1. Case taking (The key to diagnosing breathing disorders during sleep is the GP’s knowledge about the OSAH syndrome)
Apart from symptoms and signs indicating breathing disorders during sleep, the most important anamnestic or heteroanamnestic information is snoring, repetitive interruption of breathing during sleep for more than 10 seconds and extreme drowsiness during the day. In such cases the Epworth’s sleepiness scale may help – score of 10 or more is pathologic; the questionnaire can be found on the internet.
It is important that the upper airway is thoroughly examined in order to find a deviation of the nasal septum, nasal polyposis, enlarged tonsils or adenoid glands, micro- or retrognathia and other facio-cranial abnormalities; such a patient may visit a specialist. Body height and weight measurements in order to define the BMI (excessive body weight above 25, obesity above 30 and extreme obesity above 40) and the volume of the neck is necessary. In case of deviations, the patient should participate in the treatment of obesity.
3. Further examination
a) Patients with extreme feeling of drowsiness during the day are not allowed to drive a car according to the regulation in Slovenia (implemented on July 1 in 2011). In such cases driving has to be prohibited (by GP) and further examination is essential. In case of professional drivers, the patient has to be examined by a specialist at the Occupational medicine institute. If OSA patients are treated properly and use CPAP appliance regularly during sleep, they undergo specific objective tests evaluating extreme drowsiness during the day at the institute for clinical neurophysiology. On the basis of test results the specialist of the Occupational medicine institute defines, whether the patient can drive a car or not. These examinations take place during daytime.
b) In case of OSA with asthma, COPD or Mb. Pickwick, the patient should visit a pulmonologist or neurologist (Clinic for sleep disorders) to exclude a potential cardiovascular disorder due to possible central sleep apneas.
c) Polysomnography (PSG) is the “golden” standard when diagnosing the OSA syndrome. OSA Syndrome is defined by the AHI (the number of apneas and hypopneas per hour of sleep). Normal AHI index ranges up to 5, whereas 5-15 defines a mild apnea, 15-30 a moderate apnea, and in case of AHI>30, an extreme sleep apnea is defined. When AHI index ranges above 20, sleep apneas have an undoubtedly negative impact on the patient’s health and general well being (8).
d) Polygraphy (PG) or mobile monitoring in a domestic environment represents an option for diagnosing of the OSA syndrome and helps less apnea syndromes to remain undiagnosed. It includes the measurement of air flow, breathing effort, pulse oxymetry, a 24-hour ECG measurement (Holter) and EEG (examination can be performed in hospital).