Saptarshi Bhattacharya ( Department of Endocrinology, Max Hospital, Patparganj, New Delhi, India )
Viny Kantroo ( Department of Pulmonology, Critical Care and Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, India )
Atulya Atreja ( Department of Pulmonology, Aarogym Hospital, Karnal )
Sanjay Kalra ( Department of Endocrinology, Bharti Hospital & BRIDE, Karnal, India. )
This communication describes the screening and diagnostic tools that can be used to identify obstructive sleep apnoea (OSA). It highlights the need to screen for OSA in all persons with metabolic syndrome and uses the term ’somnometabolic syndrome’ to emphasise this. Somnometabolic syndrome can be easily screened at the primary care level, and should be an integral part of diabetes care.
Keywords: Diabetes, Metabolic syndrome, Obesity, Obstructive sleep apnoea, Sleep.
Obstructive sleep apnoea (OSA) is a sleep-related breathing disorder which presents with repetitive episodes of a complete or partial collapse of the upper airway during sleep, dry mouth or sore throat upon awakening, and cognitive impairment. Though termed a sleep-related disorder, OSA is a multi-system metabolic syndrome.1 OSA is associated with metabolic and cardiovascular morbidity2 and can be a cause of “refractory” or difficult-to-manage diabetes and hypertension.
This has led to the conceptualization of somnometabolic syndrome, which is defined as a clinical condition, where OSA is associated with one or more of the various components of metabolic syndrome, as defined by multiple international authorities. The association between OSA and metabolic syndrome, suggests that we must screen for it in every patient presenting with diabetes. If done at the primary care level, it can identify more patients who are in need of effective management of the condition.
Screening and Substantiation
There are several screening questionnaires available for OSA3 (Table-1). However, Berlin, STOP, STOP-BANG and ESS have been validated in several studies and are used commonly in clinical setting. Berlin, STOP and STOP-BANG screen OSA, whereas, ESS is used as a complimentary tool to gauge day-time sleepiness, which is an important day-time symptom of OSA. Patients found to be high risk can be diagnosed using sleep studies4 (Table-2). Type 4 sleep studies are commonly being used for substantiation of diagnosis, as they are economical, easy to use, and effective.
Positive airway pressure (PAP) device is the standard treatment of OSA along with life style modification which includes cessation of smoking, reduction of alcohol intake, weight loss and exercise. PAP devices like AirSense 10 Autoset and AirCurve VAuto come under the category of automated PAP which can adjust airway pressure based on patient requirement.4 These devices help in the alleviation of vasculo-metabolic disorders in addition to treatment of OSA.5 These should be prescribed at specialized centres equipped to offer long term monitoring and support.
Newer drugs like SGLT2i and GLP1RA improve OSA symptomatology, along with their beneficial effects on glucose control and cardiovascular outcomes.6 Hence, their use should be encouraged in diabetes with OSA.
OSA is a significant comorbidity of diabetes, and must be screened for at the primary care level. The availability of validated questionnaires and person-friendly type 4 sleep studies have made it easier to suspect, screen and substantiate its diagnosis, thereby facilitating timely therapeutic intervention.
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2. Yeghiazarians Y, Jneid H, Tietjens JR, Redline S, Brown DL, El-Sherif N, et al. Obstructive sleep apnea and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2021;144: e56-67.
3. Su YJ, Yang JX, Hu YL, Liu YP, Xu HH, Hu SL, et al. A review of potential methods for screening obstructive sleep apnea during pregnancy jing wai ke za zhi. Chinese journal of otorhinolaryngology head and neck surgery. 2021;56:1361-5.
4. Lee JJ, Sundar KM. Evaluation and management of adults with obstructive sleep apnea syndrome. Lung. 2021;199:87-101.
5. Labarca G, Schmidt A, Dreyse J, Jorquera J, Enos D, Torres G, et al. Efficacy of continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) and resistant hypertension (RH): systematic review and meta-analysis. Sleep Med. Rev.. 2021; 58:101446.
6. Schütz SG, Dunn A, Braley TJ, Pitt B, Shelgikar AV. New frontiers in pharmacologic obstructive sleep apnea treatment: A narrative review. Sleep Med. Rev.. 2021; 57:101473.