Obstructive sleep apnea

Each puzzle piece

One year before diagnosis (BD), at age 37, I suffered from severe daytime sleepiness. Every afternoon while driving from one place of work to another, I used to fight to keep my eyes open. One day my eyes won and I fell asleep. I woke up on the other side of the road when I hit a tree. The car was completely destroyed. I was lucky that I survived and that no one else had been hit or killed. Although the relationship between motor vehicle accidents and OSA is well recognized today, my conclusion at that time was less “medical.” I believed my tiredness and the crash were the result of too much work.

Two years BD, I was waking up 2 to 3 times every night to urinate, which was strange for me. I was only 36 years old and too young to have an enlarged prostate. Today’s literature recognizes that many awakenings due to patients’ “pressure to urinate” might be a result of OSA. At the time, however, I was unaware of this.

Four years BD (age 34), I was falling asleep at every afternoon meeting in the clinic. I was known among my colleagues as “the tired guy” because of my heavy workload. None of my peers (physicians) ever suggested to me that I might have a medical problem. Although excessive daytime sleepiness is one of the most common signs of OSA, I did not think that my behaviour was “a medical problem” or that I needed a medical consultation.

Eight years BD (age 30), I suffered a severe depressive episode and received treatment for a couple of years. Today depressive disorders are recognized as more prevalent among OSA patients; however, neither I nor the physicians who treated me thought about that possibility at that time.

Twelve years BD (age 26), my wife was complaining about my loud snoring. Sometimes she had to move to another room because the noise was unbearable. Sometimes she was quite scared, as I would choke and gasp for air. She also witnessed long and scary apneas during my sleep. Because snoring is so common in the general population, it is seldom seen by patients as a possible medical problem with associated comorbidities.

Twenty years BD (age 18), I was not performing well in my first year of medical school. Teaching was frontal, in a big amphitheatre, and about 15 minutes into the lecture I was already asleep! The student sitting next to me usually woke me up, not because I wasn’t paying attention to the lecture but because I was snoring! Obstructive sleep apnea causes cognitive, behavioural, and personality disturbances, intellectual impairment, memory loss, and poor study achievements. Today I know that I was suffering from a treatable medical condition, but that does not help the fact that I used to give the impression of being a bad student.

Twenty-one years BD (age 17), my brother was throwing pillows at his obese brother (me) to make him stop snoring. Who could think this a medical problem?

Throughout the years, I was experiencing the classic signs of OSA. I, however, did not recognize the signs as a “medical” problem or as requiring consultation. In the past, the medical system was less aware of OSA than today, and I did not know much about it.

Pieced together

Today I sleep with a CPAP machine. I do not snore. My wife sleeps better, as the CPAP machine is less noisy than my previous snoring. I see others falling asleep at noon while I am awake and fresh. I do not have to wake up at night to urinate. I am not depressed and no longer use medication. And, even though my work schedule is just as busy as at the time of my car accident, I can drive without being tired.

At present, I see OSA as a puzzle built in retrospect: When the puzzle is complete, the picture is clear. But in the beginning, when the puzzle pieces are seen one by one, it is difficult to predict the final picture they will form.

We do not know the “natural history” of OSA. When do symptoms appear? When do they become “clinically significant”? When do they become a “medical matter”? When do patients begin to see these symptoms as reasons to visit their physicians? And when do physicians start thinking of OSA as a possible explanation for their patients’ complaints?

Thinking about my past, I wonder how my life could have been different if my OSA had been diagnosed earlier. I was the typical Pickwickian obese kid. I was tagged as a “bad student” because I fell asleep in class and had poor grades. My wife could not sleep because of my snoring. I had a depressive episode (possibly related to OSA). I suffered from nocturia (clearly related to OSA). I had a life-threatening experience falling asleep at the wheel.

As a family physician I help many of my patients by recognizing their symptoms of OSA earlier and sending them for diagnosis and treatment. I hope that personal stories like mine will help other primary care physicians recognize, diagnose, and treat this common syndrome at an early stage, preventing not only severe medical complications but also the burden of suffering.