How to Recognize Potentially Critical Sleep Disorder Cases By Orlando Ruiz-Rodriguez, MD As a pulmonary sleep disorder specialist, a common complaint I treat is snoring. It’s probably no surprise that it’s among our most prevalent sleep disorder complaints. A snoring issue may sound minor — merely an inconvenience to spouses and partners whose sleep patterns are disrupted due to resulting noise and movement. Sleep issues, however, become problems when they disrupt a person’s ability to safely and successfully perform normal activities such as working, driving or going to school. And, many cases of snoring and other sleep disturbances are associated with potentially critical cardiopulmonary medical conditions. Left untreated, severe sleep disturbances can result in cardiac-related complications including sudden cardiac death, stroke, atrial fibrillation, ventricular tachycardia and all-cause mortality, according to data from the Wisconsin Sleep Cohort, an ongoing longitudinal study of the causes, consequences and natural history of sleep disorders, particularly sleep apnea. Potentially serious sleep conditions can go undetected if not for the keen ears of an exhausted spouse or partner who, out of sheer frustration, reaches out for medical assistance, paired with the diligence of healthcare providers who know how to identify warning signs. Treatments for sleep issues, depending on their severity and potential to contribute to cardiopulmonary problems, vary. For sleeplessness, treatments may include short-term medication therapy and (preferably) talk therapy for long-term relief without the risk of drug dependencies and side effects. For more serious sleep breathing problems, treatments are more aggressive and may require sleep studies, physical therapy, supportive appliances — such as CPAP machines, MAD devices (mouth guards) and airway stents — or even nerve stimulation surgery. Here, I’ll help you identify sleep issues and triage potentially life-threatening signs that might need a referral to a pulmonary sleep specialist.
THE WIDE RANGE OF SLEEP DISORDER PATIENTS There’s not a single population that’s exclusively prone to potentially dangerous sleep disorders. In my practice, I see a very wide range of patients: from their teens into their 20s, all the way into their 90s and beyond. But, as people age, more males present with a sleep disorder spectrum. According to population data from the Wisconsin Sleep Cohort, as many as 15-30% of males and 10-30% of females meet a broad definition of obstructive sleep apnea (OSA).
LOW INCIDENCES OF SELF-REPORTING Cases are not always self-reported. Only 20% of the OSA affected population reports sleep disordered breathing to a physician. (This includes about 9% of males, 5% of females reporting 10 FLORIDA MD - MAY/JUNE 2022
a spouse or partner’s problem, and 5% of females reporting their own issues). That’s why it’s important for your practice to triage sleep disorders and identify red flags warning of potentially serious cardiac and pulmonary conditions. Because odds are, they may go unreported.
WHAT SLEEP SPECIALISTS ENCOUNTER As I mentioned earlier, initial sleep complaints — snoring, insomnia and next-day tiredness — often only scratch the surface of a potentially serious cardiopulmonary problem. An abbreviated list of sleep complaints referred to me include: • Insomnia • Snoring with difficulty sleeping • Obstructive sleep apnea (OSA) • Hypersomnia, including narcolepsy, idiopathic hypersomnia, Klein Levin Syndrome and other related disorders • Sleep Paralysis • Movement disorders • Spectrum conditions
DIAGNOSIS METHODS To diagnose a patient’s sleep disorder and rank its severity and risks for cardiopulmonary events, even if not self-reported, I triage them through precise assessment tools. In particular, I use two assessment tools: the Epworth Sleepiness Scale (ESS) and the STOP-Bang Questionnaire. The ESS is a self-administered questionnaire built on eight key questions. It asks patients questions about their levels of daytime sleepiness while engaged in eight different activities. These activities range from sitting and reading, watching television, sitting in a public place, riding in a car as a passenger and lying down, to sitting and talking with someone, sitting after a meal without alcohol consumption and sitting in a stopped car in traffic. Questions are ranked from 0-3. The higher a patient’s overall ESS score, the more likely their average sleep propensity in daily life (ASP) is high, which can signal a potential sleep disorder that prompts further evaluation. The STOP-Bang Questionnaire digs deeper into potential inpatient and outpatient medical issues such as blood pressure, breathing issues, BMI, birth gender, and more to gain a more precise assessment and objective data on a patient’s overall health risks. There also is another useful sleep disorder screening tool, known as the POPPY Study, an acronym for the Pharmacoki-
