Dr. Nabili received his undergraduate degree from the University of California, San Diego (UCSD), majoring in chemistry and biochemistry. He then completed his graduate degree at the University of California, Los Angeles (UCLA). His graduate training included a specialized fellowship in public health where his research focused on environmental health and health-care delivery and management.
Doctor Verneuil grew up in Orange County and played high school water polo. He attended UCLA for his undergraduate degree in Kinesiology. Doctor Verneuil graduated from Mayo Medical School. He completed six years of Internship and Residency training in head and neck surgery at UCLA. He is Board Certified with the American Board of Otolaryngology.
Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
How is obstructive sleep apnea diagnosed and evaluated?
History and physical examination
Obstructive sleep apnea can be diagnosed and evaluated
by subjective (perceived or biased) and objective (factual, based on empirical
data) methods. An example of a subjective method that measures the effects
of obstructive sleep apnea on patients is the Epworth Sleepiness Scale.
The Epworth Sleepiness Scale is a self-report test that establishes the severity of sleepiness. A person rates the likelihood of falling asleep during specific activities. Using the scale from 0-3 below, the risk of dozing can be ranked from the chart below.
0 = Unlikely to fall asleep
1 = Slight risk of falling asleep
2 = Moderate risk of falling asleep
3 = High likelihood of falling asleep
Situation
Risk of Dozing
Sitting and reading
Watching television
Sitting inactive in a pubic place
As a passenger in a car riding for an hour with no breaks
Lying down to rest in the afternoon
Sitting and talking with someone
Sitting quietly after lunch without alcohol
In a car while stopped for a few minutes in traffic
After ranking each category, the total score is calculated. The range is 0-24, with higher scores suggesting greater sleepiness.
Scoring:
0-9 = Average daytime sleepiness
10-15 = Excessive daytime sleepiness
16-24 = Moderate to severe daytime sleepiness
Breaking it down further, excessive daytime sleepiness is greater than 10.
Primary snorers usually have a score less than 10, and individuals with moderate to severe sleep apnea usually have a score greater than 16. Self reported, subjective measures such as the Epworth Sleepiness Scale usually are combined with a thorough medical history. The history includes questions about:
work performance,
daytime sleepiness,
driving and accident history,
napping,
falling asleep during meetings, and
decreased memory.
Next a physical examination is performed to examine the
areas of possible airway collapse.
In the nose, this includes the septum,
turbinates, nasal polyps, adenoid hypertrophy, and
nasopharynx (back of
the nose).
In the mouth, the
palate, tonsils, uvula, pharyngeal
walls, and neck circumference are all examined.
A flexible nasopharyngoscopy is usually
performed to examine the airway during active breathing and simulated snoring
maneuvers. (The nasopharyngoscope is a fiber-optic, flexible tube approximately
18 inches in length and an eighth of an inch in diameter with a camera on its end. The camera end is inserted through
the nasal passage to the upper throat or
pharynx where the actions of the tongue
and palate can be observed.)
Polysomnography
The primary objective test for obstructive sleep apnea
is polysomnography, also referred to as a sleep study. This test measures
different physical and physiological parameters while a subject is asleep.
During attended polysomnography, a technician observes a person sleeping and
monitors recording equipment in the setting of a sleep laboratory. A typical
polysomnography test includes:
The EEG (electroencephalogram) monitors brain waves and
can be used to determine the level of sleep or wakefulness. It is helpful for
determining if an event (respiratory or limb movement) disrupts the level of sleep.
An EOG (electro-oculogram) measures eye movements using sticker electrodes placed next to each eye. During
REM sleep (dreaming sleep), the eyes typically move from side-to-side. This
measurement can help determine the duration of REM sleep.
An EMG (electromyogram) measures muscle movements.
Frequently, an additional monitor is placed on the chin to measure muscle
relaxation (tone). During stage 1-4 sleep there is a baseline muscle tone;
however, during REM sleep all muscles relax. The EMG also helps to determine the
duration of REM sleep. An EMG of the legs can be used to detect "restless legs
syndrome" or periodic leg movements during sleep.
Oral and nasal
airflow can be measured by several different methods to help determine the size
and frequency of breaths during sleep. Chest and abdominal movements occur with
each attempt to breathe and can be used to distinguish between central sleep
apnea and obstructive sleep apnea.
(During central sleep apnea, the signal to take a breath is not given, so the muscles
do not attempt to take a breath. During obstructive sleep apnea, the muscles
attempt to take a breath, but no air moves.)
Measurement of the loudness of
snoring can be used to quantify snoring. (Sometimes a measurement is needed to
convince someone that they have a snoring problem.) It can also be used to
measure changes after treatments for snoring.
Oximetry is used to measure the decreases in oxygen in
the blood during apneas and hypopneas.
The video monitor is most helpful for
detecting movement disorders, parasomnias, or
seizures during sleep. (Often a
patient will not remember sleepwalking, sleep talking,
or other parasomnias, so a video is helpful to review the events with the
patient.)
After polysomnography is completed the data are
analyzed by a board certified sleep specialist. The number of apneas, hypopneas,
leg movements, and desaturations as well as sleep levels are all recorded in a formal
report, and a diagnosis is made.
Although the primary objective test for obstructive sleep apnea is the sleep study (polysomnography);
other tests for obstructive sleep apnea include the:
Multiple Sleep Latency Test (MSLT) and
Maintenance
of Wakefulness Test (MWT)
Multiple Sleep Latency Test
For someone who reports being sleepy during the day, it
is sometimes helpful to measure how sleepy they are. Also, after treatment of
sleep problems the doctor may want to measure improvement in daytime sleepiness.
Sleepiness can be measured with a Multiple Sleep Latency Test (MSLT).
Basically,
the MSLT measures how fast someone falls asleep during the day. It must be done
after an overnight sleep study (polysomnography), which documents adequate opportunity
for sleep the night before. The test is composed of four to five naps that last 20
minutes and are spaced two hours apart. The person is instructed to try and fall
asleep. The average time to fall asleep is calculated for all four or five tests.
Normal time would be greater than 10 minutes to fall asleep. Excessive
sleepiness is less than five minutes to fall asleep.
Maintenance of Wakefulness Test
The Maintenance of Wakefulness Test (MWT) also measures daytime sleepiness.
The person in this test is instructed to try to stay awake. This is repeated
for four 40 minute sessions two hours apart. Not falling asleep in all four tests is
the strongest objective measure of no daytime sleepiness.
Some agencies use these tests to ensure that their employees are not
excessively sleepy while at work. Specifically, airline pilots and truck drivers
who have sleepiness need to be tested. This is done for public safety and
work productivity. Unfortunately, there is no test that will guarantee that
someone will not fall asleep at his or her job or while driving.
Severity levels in obstructive sleep apnea
Obstructive sleep apnea can be categorized as mild, moderate, or severe. This
stratification assists in determining the direction of treatment. For example, some
treatments that are excellent for mild sleep apnea nearly always will fail for
severe sleep apnea.
The severity level is measured with polysomnography. In
one grading scale using the apnea-hypopnea index, mild obstructive sleep apnea is 5-15 events
per hour, moderate obstructive sleep apnea is
15-30 events per hour, and severe obstructive sleep apnea is more than 30 events
per hour.
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. A poor blood supply resulting from congestive heart failure may cause the body's organ systems to fail, leading to a weakened heart muscle and fluid accumulation in the lungs and body tissue. There are many diseases that can impair pumping efficiency and symptoms of congestive heart failure including fatigue, diminished exercise capacity, shortness of breath, and swelling. Treatments include lifestyle modifications, medications, heart transplant, and therapy.
High blood pressure, also known as hypertension, is a repeatedly
elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above
140 with a diastolic pressure above 90. There are two causes of high blood pressure, primary and secondary. Primary high blood pressure is much more common that secondary and its basic causes or underlying defects are not always known. It is known that a diet high in salt increases the risk for high blood pressure, as well as high cholesterol. Genetic factors are also a primary cause. Secondary high blood pressure is generally caused by another condition such as renal hypertension, tumors, and other conditions. Treatment for high blood pressure is generally lifestyle changes and if necessary, diet.
Sinus infection (sinusitis) signs and symptoms include headache, fever, and facial tenderness, pressure, or pain. Treatments of sinus infections are generally with antibiotics and at times, home remedies.
Hypothyroidism is any state in which thyroid hormone production is below normal. Normally, the
rate of thyroid hormone production is controlled by the brain at the pituitary.
Hypothyroidism is a very common condition and the symptoms of hypothyroidism are
often subtle.
A stroke results from impaired oxygen delivery to brain cells via the bloodstream. A stroke is also referred to as a CVA, or cerebrovascular incident. Symptoms of stroke include: sudden numbness or weakness of the face, arm or leg. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing in one or both eyes, sudden trouble walking, dizziness, or loss of balance, and/or sudden severe headache with no known cause. A TIA, or transient ischemic attack is a short-lived temporary impairment of the brain caused by loss of blood supply. Stroke is a medical emergency.
Heart attack happens when a blood clot completely obstructs a coronary
artery supplying blood to the heart muscle. A heart attack can cause chest pain, heart failure, and electrical
instability of the heart.
Temporomandibular joint disorder, or TMJ, is a disorder of the temporomandibular joint(s) that causes signs and symptoms including ear pain, bite problems, headaches, dizziness, clicking sounds in the jaw, tinnitus and/or locked jaws. Behaviors or conditions that can lead to TMJ include teeth grinding or clenching, fingernail biting, habitual gum chewing, trauma to the jaw, stress, and occupational hazards. Treatment for TMJ may include heat, ice, a soft diet, antiinflammatory medications, physical therapy, stress management, occlusal therapy, correction of bite abnormalities, and surgery.
Polycythemia (elevated red blood cell count) causes are either primary (aquired or genetic mutations) or secondary (diseases, conditions, high altitude). Treatment of polycythemia depends on the cause.
Insulin resistance is the diminished ability of cells to respond to the action of insulin in transporting glucose (sugar) from the bloodstream into muscle and other tissues. Causes of insulin can include conditions such as stress, obesity, metabolic syndrome, and steroid use. Some of the risk factors for insulin resistance include fatty liver, heart disease, strokes, peripheral vascular disease, high cholesterol, and smoking. Treatment for insulin resistance are lifestyle changes and if necessary, medication.
It is thought that the tonsils and adenoids assist the body in fighting incoming bacteria and viruses by helping the body form antibodies. This is thought to be important only during the first year of life. Acute tonsillitis, strep throat, mononucleosis (mono), chronic tonsillitis, peritonsillar abscess, and hypertrophic tonsils and adenoids are all common problems involving the tonsils and adenoids. Treatment of tonsillitis and adenoids include antibiotics and other medications depending on the cause. In some cases, a tonsillectomy or adenoidectomy (the removal of the tonsils or adenoids) may be necessary.
Marfan syndrome is hereditary condition affecting connective tissue. A person with Marfan syndrome may exhibit the following symptoms and characteristics: dislocation of one or both lenses of the eye; a protruding or indented breastbone; scoliosis; flat feet; aortic dilatation; dural ectasia; stretch marks; hernia; and lung collapse. Though there is no cure for Marfan syndrome, there are treatments that can minimize and sometimes prevent some complications.
Heart rhythm disorders vary from minor palpitations, premature atrial contractions (PACs), premature ventricular contractions (PVCs), sinus tachycardia, and sinus brachycardia, to abnormal heart rhythms such as tachycardia, ventricular fibrillation, ventricular flutter, atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), Wolf-White-Parkinson syndrome, brachycardia, or heart blocks. Treatment is dependant upon the type of heart rhythm disorder.
Heart disease (coronary artery disease) is caused by a buildup of cholesterol deposits in the coronary arteries. Risk factors for heart disease include smoking, high blood pressure, heredity, diabetes, peripheral artery disease, and obesity. Symptoms include chest pain and shortness of breath. There are a variety of tests used to diagnose coronary artery disease. Treatment includes life-style changes, medications, procedures, or surgery.
Pulmonary hypertension is an abnormal elevation of the pressure in the pulmonary circulation caused by the constriction of the blood vessels that supply blood to the lungs. Shortness of breath and dizziness are symptoms of pulmonary hypertension. Treatment involves diuretics, blood thinners, calcium channel blockers, and using supplemental oxygen to increase blood oxygen levels.
Snoring, like all other sounds, is caused by vibrations that cause particles in the air to form sound waves. While we are asleep, turbulent air flow can cause the tissues of the nose and throat to vibrate and give rise to snoring. Any person can snore. Snoring is believed to occur in anywhere from 30% of women to over 45% of men. People who snore can have any body type. In general, as people get older and as they gain weight, snoring will worsen. Snoring can be caused by a number of things, including the sleep position, alcohol, medication, anatomical structure of the mouth and throat, stage of sleep, and mouth breathing.
Obesity is the state of being well above one's normal weight. A person has traditionally been
considered to be obese if they are more than 20 percent over their ideal weight.
That ideal weight must take into account the person's height, age, sex, and
build.
High blood pressure (hypertension) means high pressure (tension) in the arteries. Treatment for high blood pressure include lifestyle modifications (alcohol, smoking, coffee, salt, diet, exercise), drugs and medications such as ACE inhibitors, angiotensin receptor blockers, beta blockers, diuretics, calcium channel blockers (CCBs), alpha blockers, clonidine, minoxidil, and Exforge.
Insomnia is the perception or complaint of inadequate or poor-quality sleep because of difficulty falling asleep; waking up frequently during the night with difficulty returning to sleep; waking up too early in the morning; or unrefreshing sleep. Secondary insomnia is the most common type of insomnia. Treatment for insomnia include lifestyle changes, cognitive behavioral therapy, and medication.
Fatigue can be described in various ways. Sometimes fatigue is described as feeling a lack of energy and motivation (both mental and physical). The causes of fatigue are generally related to a variety of conditions or diseases for example, anemia, mono, medications, sleep problems, cancer, anxiety, heart disease, drug abuse, and more. Treatment of fatigue is generally directed toward the condition or disease that is causing the fatigue.
Sudden cardiac arrest is an unexpected, sudden death caused by sudden cardiac arrest (loss of heart function). Causes and risk factors of sudden cardiac arrest include (not inclusive): abnormal heart rhythms (arrhythmias), previous heart attack, coronary artery disease, smoking, high cholesterol, Wolff-Parkinson-White Syndrome, ventricular tachycardia or ventricular fibrillation after a heart attack, congenital heart defects, history of fainting, and heart failure, obesity, diabetes, and drug abuse. Treatment of sudden cardiac arrest is an emergency, and action must be taken immediately.
Narcolepsy, a chronic disease of the central nervous system causes have not been fully determined. Some theories include abnormalities in hypocretin neurons in the brain or an autoimmune disorder. Symptoms of narcolepsy include excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, sleep paralysis, disturbed nocturnal sleep, and automatic behavior. Diagnosis of narcolepsy is based on a clinical evaluation, specific questionnaires, sleep logs or diaries, and the results of sleep laboratory tests. Treatments of narcolepsy symptoms include medication and lifestyle changes.
Seizures are divided into two categories: generalized and partial. Generalized seizures are produced by electrical impulses from throughout the brain, while partial seizures are produced by electrical impulses in a small part of the brain. Seizure symptoms include unconsciousness, convulsions, and muscle rigidity.
Sleepwalking is a condition in which an individual walks or does other activities while asleep. Factors associated with sleepwalking include genetic, environmental, and physiological. Episodes of sleepwalking may include quiet walking to agitated running. Conditions that may have similar symptoms of sleepwalking, but are not include night terrors, confusional arousals, and nocturnal seizures. Treatment of sleepwalking generally include preventative measures. Medication may be prescribed if necessary.
A deviate septum is a condition in which the bone and cartilage that divide the nasal cavity of the nose in half (nasal septum) is significantly off center or crooked. The causes of a deviated septum can be congenital, or develop after a trauma or injury to the nose. Symptoms of a deviated septum include nasal congestion, recurrent sinus infections, nosebleeds, headache, facial pain, postnasal drip, snoring, and loud breathing. A deviated septum can be relieved with medications, and if necessary surgery, called a septoplasty.
Heart failure is caused by many conditions including coronary artery disease, heart attack, cardiomyopathy, and conditions that overwork the heart. Symptoms of heart failure include congested lungs, fluid and water retention, dizziness, fatigue and weakness, and rapid or irregular heartbeats.
Urinary incontinence in children (enuresis) is twice as common in boys as in girls and may occur during the daytime or nighttime. Nighttime urinary incontinence is also called bedwetting and sleepwetting. The cause of nighttime incontinence in children is unknown. Daytime incontinence in children may be caused by an overactive bladder. Though many children overcome urinary incontinence naturally, it may be necessary to treat incontinence with medications, bladder training and moisture alarms, which wake the child when he or she begins to urinate.
Hypersomnia is a condition where a person has excessive daytime sleepiness and trouble staying awake during the day. Treatment for hypersomnia includes medication, CPAP machines, and lifestyle changes.
When sleepiness interferes with daily routines and activities, or reduces the ability to function, it is called "problem sleepiness." A person can have problem sleepiness without realizing it. Symptoms of problem sleepiness include: consistently don't get enough sleep, or poor quality sleep, fall asleep while driving, struggle to stay awake when inactive (like watching TV or reading), have difficulty paying attention or concentrating at work, school, or home, have poor performance problems at work or school, have difficulty remembering things, have slowed responses, have difficulty controlling your emotions, and/or if you have to take naps on most days.
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