Sleep apnea differential diagnosis

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	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; 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