Obstructive Sleep Apnea

 

 

 

 

 

 

 

 

 

 

What is Sleep Apnea

 

Obstructive sleep apnea (OSA) is a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort. It is the most common type of sleep-disordered breathing and is characterized by recurrent episodes of upper airway collapse during sleep.  These episodes are associated with recurrent oxyhemoglobin desaturations and arousals from sleep.  Generally, symptoms of OSA begin insidiously and are often present for years before the patient is referred for evaluation.

Nocturnal symptoms may include the following: Snoring, usually loud, habitual, and bothersome to others Witnessed apneas, which often interrupt the snoring and end with a snort Insomnia; restless sleep, with patients often experiencing frequent arousals and tossing or turning during the night

 

What are the symptoms of Sleep Apnea 

Daytime symptoms may include the following: Nonrestorative sleep (ie, “waking up as tired as when they went to bed”) Morning headache, dry or sore throat Excessive daytime sleepiness that usually begins during quiet activities (eg, reading, watching television); asthe severity worsens, patients begin to feel sleepy during activities that generally require alertness (eg, school, work, driving). Patients begin to experience daytime fatigue/tiredness, Cognitive deficits; memory and intellectual impairment (short-term memory, concentration) Decreased vigilance, Morning confusion Personality and mood changes, including depression and anxiety Sexual dysfunction, including impotence and decreased libido Gastroesophageal reflux and Hypertension

 

I snored while I was in service but never complained about it 

 

A sleep-related breathing disorder (SRBD) continuum has been described and is supported by research.  OSA can be thought of as occupying a range of this continuum The idea of the SRBD continuum was first described by Elio Lugaresi: “There is a continuum of intermediate clinical conditions between trivial snoring and the most severe forms of OSAS (which we prefer to call heavy snorers disease). This fact should be taken into consideration for any meaningful approach to the clinical problems posed by snoring. Many issues, however, remain unsettled.”

The SRBD continuum suggests that snoring is the initial presenting symptom, and it increases in severity over time and it increases in association with medical disorders that may serve to exacerbate the disorder, such as obesity. Snoring has a constellation of pathophysiological effects.   As the disease progresses, SRBD patients begin to develop increased UA resistance that results in a new hallmark symptom: sleepiness. Sleepiness is caused by increased arousals from sleep.

 

Sleep disorder secondary to PTSD or pain

 

Scientists at the Madigan Army Medical Center have recently studied the incidence of sleep apnea in military personnel    They observed that Sleep disturbances, however, are increasing in frequency and are commonly diagnosed during deployment and when military personnel return from deployment (redeployment).   Recent evidence suggests the increased incidence of sleep disturbances in redeployed military personnel is potentially related to PTSD, depression, anxiety, or mTBI. .

short sleep duration (SSD)  was highly prevalent in the study, with a self-reported sleep duration average of 5.74 h of nightly sleep and 41.8% sleeping 5 h or less per night. This finding is consistent with prior studies of military personnel who habitually report SSD. Compared with civilian reports, these findings are substantially higher than the 9.3% prevalence reported in the adult population in the United States.

Medical comorbidities were frequently identified in military personnel undergoing PSG, with 58.1% having one or more service-related illnesses. The percentages of military personnel with PTSD (13.2%) and mTBI (12.8%) are similar to previous reports, whereas a larger percentage of those in the study’s study had depression (22.6%) and anxiety (16.8%).   A potential reason is that insomnia often precedes anxiety and depression, resulting in the referral for sleep evaluation. The relationship of insomnia to PTSD, however, may not be solely as a symptom or a comorbid disorder. Disturbed sleep prior to a traumatic event is a risk factor for the development of PTSD. Persistent insomnia 4 mo after deployment predicts changes in depression and PTSD symptoms. Further, the sleep disturbances of insomnia and nightmares can persist despite appropriate therapy for PTSD

Military personnel with the diagnosis of pain syndromes were more likely to have insomnia. Poor sleep is a recognized symptom in individuals who have medical disorders associated with pain. Previous studies using both questionnaires and PSGs have reported patients with pain have difficulties initiating and maintaining sleep, supporting the association of pain syndromes with insomnia.,   In the study’s  cohort, 24.7% were identified as taking medications for pain.

 

The usefulness of IMO to establish rating for sleep apnea secondary to PTSD 

 

In a recent decision by the BVA (FEB 2 8 2014 DOCKET NO. 11-09 193) the board reiterated the importance of an IMO supported by medical literature in establishing service-connected disability for sleep apnea secondary to PTSD the board held:

“The Veteran had a VA examination in October 2009. The Veteran reported sleep apnea with an onset two to three months earlier. The VA examiner opined that, per medical literature review, sleep apnea is not caused by or aggravated by the Veteran’s PTSD. The VA examiner stated that the basis of the opinion was the review of medical literature. The literature was not specified.
At the Board hearing in March 2012, the Veteran testified that his therapist has told him that PTSD aggravates sleep apnea because he has nightmares and dreams in his sleep. The Veteran testified that he has anxiety attacks in his sleep that keep him from catching his breath. The Veteran testified that he has used a CPAP machine for about four years.
In this case, there is positive medical evidence which links the Veteran’s current sleep apnea to service-connected PTSD via aggravation. The most probative opinion is that of Dr. T which not only provided a link between the Veteran’s PTSD and sleep apnea (by aggravation) but also was supported by submitted medical literature. Despite the negative VA opinion, in light of the positive medical opinions from the private psychologist, the Board finds the evidence is at least in equipoise regarding whether the Veteran’s sleep apnea is aggravated by service- connected PTSD. Accordingly, resolving all reasonable doubt in the Veteran’s favor, service connection for sleep apnea is warranted. – Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b).
ORDER
Secondary service connection for sleep apnea is granted.”