Sleep apnea and family physicians

Roger Ladouceur

Some articles are little gems, and we take great pleasure in rereading them. Such is Howard Tandeter’s Reflection published in Canadian Family Physician this month on page 74. In it he tells us how he managed to diagnose himself as suffering from sleep apnea. It took him 20 years and he had to endure many jeers and setbacks before a serious automobile accident gave him the evidence he needed. One day, for example, when he was returning home on the subway, he didn’t wake up at his stop and found himself back where he started! Nice one, Howard!

He who sleeps forgets his hunger

After reading the Reflection, I asked myself (as will a great many others who read it) if I could be suffering from sleep apnea or hypopnea, commonly called obstructive sleep apnea-hypopnea syndrome (OSAHS). Well, it appears that I snore while I sleep, and I am often asked (to tell the truth, ordered!) to turn on my side so that this din will cease ... but I am certainly not the only snorer in the country in this situation. It is true also that I often feel very tired, to the point of having to take a nap at work sitting in my chair. But with the pace of life today, who doesn’t? Often, when I drive my car, I can hardly keep my eyes open, and I have to pull over to the side of the road for a little snooze. Surely this is also normal since my passengers are already sleeping soundly.

Two years ago, when I went to see Pirates of the Caribbean III with my daughter, I remembered absolutely nothing about it because I slept through the whole thing to her great despair. She kept nudging me, embarrassed that I would disturb the entire audience. But I regularly see people sleeping in the theatre. Simply put, just like Tandeter, I have every reason in the world, as do many of you, to deny that I am suffering from OSAHS. Moreover, from what I hear about my nighttime activities, I do not actually stop breathing during my sleep.

Polysomnography

Fortunately, when you suspect the presence of OSAHS without being really sure that’s what it is, there is a simple way to increase your index of suspicion: measure the circumference of your patient’s neck. According to the guidelines, it seems that a neck circumference greater than 43 cm and symptoms suggestive of OSAHS should prompt you to recommend nocturnal polysomnography. Incidentally, it’s a long time since I measured the size of my neck, but I will rely on the size of my shirt collars to get an approximation of it. Any size larger than 16½ inches should raise my suspicion. Sixteen and a half inches! Are there any Canadians who can still button their collars? I understand now why no one wears a tie!

I should at this point turn to the evidence. It is certainly possible that I suffer from OSAHS (as many others probably do no doubt), and many among us would do well to undergo nocturnal polysomnography. The problem is that, at the hospital where I work (and I practise in downtown Montreal), I have been told that the waiting time for such a test is many months. As for private laboratories, they charge between $750 and $1500 for an ambulatory test.

When all is said and done, even if OSAHS is a frequently seen disorder affecting 4% of men and 2% of women between the ages of 30 and 60, and even if several learned societies recommend the use of decision-making algorithms based on probabilities before testing, arterial oxygen saturation during sleep, and ambulatory polysomnography to increase the sensitivity of the test, most family physicians find the diagnosis difficult to make. It’s hardly surprising that it is often missed or hidden. Even without considering the fact that sleeping with a mask on is something no one is keen to do.

Zzzzzz

Thinking about all this, I suddenly feel a great fatigue coming upon me. I am going to go and take a little nap. And I believe that I am going to teach myself to sleep on my side!

Good night.