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Hello, my name is Dr. Christina Finch, and I’m at the University of California San Diego, where I'm a Clinical Sleep Physician in addition to being on the faculty. Today we're going to review How to Identify Residual Daytime Sleepiness in Obstructive Sleep Apnea.
So first of all, what is excessive daytime sleepiness? So this is the definition: inability to stay awake and alert during the major waking episodes of the day, resulting in periods of irrepressible need for sleep or unintended lapse into drowsiness. So this can vary in severity. Some can feel it coming. Others have kind of sleep attacks where they're taken off guard. And this is different from fatigue, where it often gets confused where fatigue is a lack of energy, either mental or physical, versus prone to sleepiness or feeling like you're going to fall asleep.
So ways that we evaluate subjectively in the clinic, is with the Epworth Sleepiness Scale. So this is considered the gold standard, self-reported scale for likelihood of dozing off or falling asleep in 8 situations of daily life. As you can see on the right, this is designed to distinguish normal subjects from patients who may have more elevated concerns for daytime sleepiness. The scores range from 0 to 14, you can see the ranking system on the right there, and over 10 total on the scoring system is considered abnormally sleepy.
So for objective evaluations of excessive daytime sleepiness, we typically reserve these when we're more concerned for narcolepsy or idiopathic hypersomnia. But in rare instances, when someone has obstructive sleep apnea, these could also be considered for further evaluation. A Multiple Sleep Latency Test is where we time someone in the laboratory for physiologic tendency to fall asleep, both in how long it takes them to fall asleep and if they reach REM sleep during any of the short nap
opportunities provided, so anything less than 8, as a mean sleep latency, or one or more REM periods reached during those naps is considered pathologic for either narcolepsy or idiopathic hypersomnia. And for a Maintenance of Wakefulness Test, this typically often isn't used clinically much. But similarly, we give them opportunities to stay awake this time in the lab, and see if they do fall asleep or if they're able to maintain their wakefulness for these kind of boring periods in the lab.
So what is residual excessive daytime sleepiness in obstructive sleep apnea? So this is the persistent subjective feeling of being sleepy, despite optimal treatment of their sleep apnea. Most patients with sleep apnea use the CPAP machine. But there are other treatment modalities that can be tested to make sure they're adequately treated. So we like to confirm that the patient has had at least 3 months of adequately treated sleep apnea with CPAP. This means looking at their data download, and making sure they're getting enough use with the device and also making sure they're sleeping, ideally, 7 to 9 is required for most adults, and that they don't have any residual sleep apnea above the threshold of 5 on their data report, and that there's no significant mask leak appreciated because all of these can detract from their treatment.
For other causes of sleepiness, we want to make sure that we aren't missing anything else, such as insufficient sleep, other medical or psychiatric comorbidities that might be contributing to daytime sleepiness, or the side effects of any medications that they may be taking. And then also ruling out any other type of sleep disorder with those tests we talked about in the last slide.
So secondary causes, we want to make sure that other sleep problems are arising like circadian rhythm wake disorders, sleep-related movement disorders, like REM behavior disorder, or periodic limb movement.
So in summary, it's important to incorporate the use of the Epworth Sleepiness Scale in routine clinical practice as an easy way to monitor for residual daytime
sleepiness in patients who are compliant with treatment for OSA for a minimum of 3 months. It's also important to rule out non-OSA causes of daytime sleepiness when considering therapy for residual daytime sleepiness in sleep apnea. Persistent subjective sleepiness, despite adequate amounts of sleep and optimal treatment of their sleep apnea and other known causes of sleep disorders should not be ignored. And this would be a good time for you to send them on to sleep medicine.
Thank you for joining me, and learning more about excessive daytime sleepiness in sleep apnea.
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