Sleep apnea differential diagnosis: Difference between revisions

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{{Sleep apnea}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Sleep_apnea]]
{{CMG}}; {{AE}} {{JH}}
{{CMG}} {{AE}} Saarah T. Alkhairy, M.D.


==Overview==
==Overview==
Sleep must be differentiated from other diseases that cause loud snoring, fatigue, or daytime sleepiness.
Sleep apnea must be differentiated from other diseases that cause loud snoring, [[fatigue]], choking, coughing, and daytime sleepiness. To differentiate obstructive sleep apnea (OSA) and central sleep apnea, a [[polysomnogram]] should be performed. OSA will demonstrate evidence of thoracoabdominal effort, whereas central sleep apnea will not.


==Differential Diagnosis==
==Differential Diagnosis==
The table below summarizes the findings that differentiate sleep apnea from other conditions that cause loud snoring, fatigue, choking, coughing, and/or somnolence.


*Sleep fragmentation
{| {{table}}
*Fatigue
*Usage of long-acting opioid medication<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
Asthma
Chronic Obstructive Pulmonary Disease
Depression
Gastroesophageal Reflux Disease
Hypothyroidism
Narcolepsy
Periodic Limb Movement Disorder


Pseudocentral sleep apnea: Patients with diaphragmatic paralysis and other neuromuscular diseases, who are dependent on accessory muscles of breathing to maintain ventilation, may appear to have central apneas during rapid eye movement (REM) sleep. This is due to the REM atonia of skeletal muscles. Many of these patients actually have obstructive sleep apnea but do not have enough diaphragmatic excursions to be recorded by the piezoelectric belts used during routine PSG. A history of neuromuscular disease and worsening of central apneas during REM sleep should alert to the possibility of pseudocentral apnea.
| align="center" style="background:#f0f0f0;"|'''Disease/Condition'''


Sleep-related hypoventilation syndrome: Sleep-related hypoventilation with central sleep apneas can be observed in many conditions, such as neuromuscular weakness or chronic obstructive pulmonary disease. These conditions are characterized by a history of a preexisting disorder of hypoventilation, elevated resting PaCO2, and severe oxygen desaturation during sleep, which is more prominent during REM sleep in contrast to primary centralSLEEP APNEA and Cheyne-Stokes breathing-central sleep apnea (CSB-CSA), which are mostly observed during NREM sleep.
| align="center" style="background:#f0f0f0;"|'''Differentiating Clinical Features'''


| align="center" style="background:#f0f0f0;"|'''Differentiating Tests'''
|-
| '''Cheyne-Stokes breathing (CSB)'''||Recurrent episodes of apnea with absence of respiratory effort; CSB is associated with [[cerebrovascular disease]], [[CHF]], and/or [[renal failure]]<ref name="pmid1509783">{{cite journal| author=Lieber C, Mohsenin V| title=Cheyne-Stokes respiration in congestive heart failure. | journal=Yale J Biol Med | year= 1992 | volume= 65 | issue= 1 | pages= 39-50 | pmid=1509783 | doi= | pmc=PMC2589377 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1509783  }} </ref> ||In CSB, a crescendo-decrescendo change in breathing amplitude interpersed by episodes of central sleep apnea or hypoapnea would be seen
|-
| '''Narcolepsy'''||Level of sleepiness in narcolepsy may be higher in [[Epworth Sleepiness Scale]]<ref name="pmid19750928">{{cite journal| author=Vernet C, Arnulf I| title=Narcolepsy with long sleep time: a specific entity? | journal=Sleep | year= 2009 | volume= 32 | issue= 9 | pages= 1229-35 | pmid=19750928 | doi= | pmc=PMC2737581 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19750928  }} </ref>; may have [[cataplexy]]  hypnagogic hallucincations, and sleep paralysis||A [[polysomnography]] should be performed to rule out OSA; a [[multiple sleep latency test]] (MLST) can assess for naroclepsy
|-
| '''Insufficient sleep'''||Difficult to differentiate clinically from sleep apnea||A [[polysomnography]] should be performed to rule out OSA; a sleep diary should used
|-
| '''Inadequate sleep hygiene'''||Irregular sleep schedule with frequent napping; frequent use of  alcohol, nicotine, and caffeine; poor bedroom environment||A [[polysomnography]] should be performed to rule out OSA; diagnosis is usually clinical
|-
| '''Periodic limb movement disorder'''||Urge to move legs due to discomfort during periods of inactivity (including sleep); patients have excessive sleepiness||A [[polysomnography]] should demonstrate limb movements and rule out OSA
|-
| '''Nocturnal gastroesphageal reflux'''||[[Nocturnal]] restlessness, choking episodes during sleep, frequent awakening, and labored breathing||A [[polysomnography]] should be performed to rule out OSA
|-
| '''Nocturnal asthma'''||[[Nocturnal]] choking, gasping, coughing, or dyspnea||A [[polysomnography]] should be performed to rule out OSA; [[pulmonary function tests]] (PFTs) should be performed
|-
| '''Primary snoring'''||More common than OSA||A [[polysomnography]] should be performed to rule out OSA
|-
| '''Nocturnal panic attacks''' ||[[Nocturnal]] choking, gasping, coughing, or dyspnea||A [[polysomnography]] should be performed to rule out OSA; a psychiatric history should be performed
|-
| '''Congestive heart failure'''||[[Nocturnal]] choking, gasping, coughing, or dyspnea||A [[polysomnography]] should be performed to rule out OSA; [[EKG]], [[chest x-ray]], blood tests, [[stress testing]], and [[cardiac catheterization]] should be performed
|-
| '''Sleep-related laryngospasm'''||[[Nocturnal]] choking, gasping, coughing, or dyspnea||A [[polysomnography]] should be performed to rule out OSA
|-
| '''Chronic fatigue syndrome'''||Daytime [[fatigue]] is usually the only complaint||A [[polysomnography]] should be performed to rule out OSA
|-
| '''Depression'''||[[Fatigue]] and feelings of hopelessness||A [[polysomnography]] should be performed to rule out OSA; a psychiatric history should be performed
|-
| '''Pseudocentral sleep apnea''' ||Patients with diaphragmatic paralysis depend on accessory muscles during breathing and may have [[apnea]] during REM sleep (sleep apnea is mostly observed during non-REM sleep); history of [[neuromuscular disease]]||A [[polysomnography]] should be performed to rule out OSA; various neuromuscular disease tests should be performed
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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[[Category:Sleep disorders]]
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Latest revision as of 00:12, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Saarah T. Alkhairy, M.D.

Overview

Sleep apnea must be differentiated from other diseases that cause loud snoring, fatigue, choking, coughing, and daytime sleepiness. To differentiate obstructive sleep apnea (OSA) and central sleep apnea, a polysomnogram should be performed. OSA will demonstrate evidence of thoracoabdominal effort, whereas central sleep apnea will not.

Differential Diagnosis

The table below summarizes the findings that differentiate sleep apnea from other conditions that cause loud snoring, fatigue, choking, coughing, and/or somnolence.

Disease/Condition Differentiating Clinical Features Differentiating Tests
Cheyne-Stokes breathing (CSB) Recurrent episodes of apnea with absence of respiratory effort; CSB is associated with cerebrovascular disease, CHF, and/or renal failure[1] In CSB, a crescendo-decrescendo change in breathing amplitude interpersed by episodes of central sleep apnea or hypoapnea would be seen
Narcolepsy Level of sleepiness in narcolepsy may be higher in Epworth Sleepiness Scale[2]; may have cataplexy hypnagogic hallucincations, and sleep paralysis A polysomnography should be performed to rule out OSA; a multiple sleep latency test (MLST) can assess for naroclepsy
Insufficient sleep Difficult to differentiate clinically from sleep apnea A polysomnography should be performed to rule out OSA; a sleep diary should used
Inadequate sleep hygiene Irregular sleep schedule with frequent napping; frequent use of alcohol, nicotine, and caffeine; poor bedroom environment A polysomnography should be performed to rule out OSA; diagnosis is usually clinical
Periodic limb movement disorder Urge to move legs due to discomfort during periods of inactivity (including sleep); patients have excessive sleepiness A polysomnography should demonstrate limb movements and rule out OSA
Nocturnal gastroesphageal reflux Nocturnal restlessness, choking episodes during sleep, frequent awakening, and labored breathing A polysomnography should be performed to rule out OSA
Nocturnal asthma Nocturnal choking, gasping, coughing, or dyspnea A polysomnography should be performed to rule out OSA; pulmonary function tests (PFTs) should be performed
Primary snoring More common than OSA A polysomnography should be performed to rule out OSA
Nocturnal panic attacks Nocturnal choking, gasping, coughing, or dyspnea A polysomnography should be performed to rule out OSA; a psychiatric history should be performed
Congestive heart failure Nocturnal choking, gasping, coughing, or dyspnea A polysomnography should be performed to rule out OSA; EKG, chest x-ray, blood tests, stress testing, and cardiac catheterization should be performed
Sleep-related laryngospasm Nocturnal choking, gasping, coughing, or dyspnea A polysomnography should be performed to rule out OSA
Chronic fatigue syndrome Daytime fatigue is usually the only complaint A polysomnography should be performed to rule out OSA
Depression Fatigue and feelings of hopelessness A polysomnography should be performed to rule out OSA; a psychiatric history should be performed
Pseudocentral sleep apnea Patients with diaphragmatic paralysis depend on accessory muscles during breathing and may have apnea during REM sleep (sleep apnea is mostly observed during non-REM sleep); history of neuromuscular disease A polysomnography should be performed to rule out OSA; various neuromuscular disease tests should be performed

References

  1. ↑ Lieber C, Mohsenin V (1992). "Cheyne-Stokes respiration in congestive heart failure". Yale J Biol Med. 65 (1): 39–50. PMC 2589377. PMID 1509783.
  2. ↑ Vernet C, Arnulf I (2009). "Narcolepsy with long sleep time: a specific entity?". Sleep. 32 (9): 1229–35. PMC 2737581. PMID 19750928.

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