Asleep at the wheel: Obstructive sleep apnea

Sleep disorders are a significant health issue in the U.S. One of these disorders, sleep apnea, affects an estimated 22 million Americans, with 80 percent of the moderate to severe obstructive sleep apnea (OSA) cases going undiagnosed. Sleep apnea has three forms that include the most prevalent form, OSA, which is a mechanical blockage of the airway when the tongue collapses against the soft palate, and the soft palate collapses against the back of the throat while sleeping, effectively closing off the airway.

A second form is central sleep apnea, where there is no mechanical blockage but the brain does not signal the muscles to breathe. The third form is complex sleep apnea and is a combination of the first two forms. Each apneic event partially arouses the sleeper to signal breathing to resume. In severe cases, this process may happen hundreds of times per night—most intensely during rapid eye movement (commonly known as REM) sleep. As a result, people with sleep apnea experience fragmented and poor-quality sleep along with reduced oxygenation of the blood.*

Health risks and diagnosis

Left untreated, OSA can lead to hypertension, stroke, congestive heart failure, and atrial fibrillation and is associated with type 2 diabetes and depression. Due to persistent daytime drowsiness an individual may experience before being diagnosed and treated, OSA has been implicated in heavy machinery-related injuries and motor vehicle-related injuries. OSA strikes people of any age, including infants, and is most commonly seen in overweight or obese men older than 40 years of age.*

The only definitive diagnostic tool for this condition is a sleep study performed in a sleep laboratory overnight. Very few patients undergo a formal sleep study, which is unfortunate because the presence of sleep apnea presents a challenge for both pain management and for administering anesthesia for surgical procedures. A clinical screening for OSA is strongly advised, such as the STOP-Bang Questionnaire, which examines Snoring, Tired, Observed sleep events, Pressure (hypertension), Body mass index, Age over 50, Neck size, Gender: male.

To examine the occurrence of injured motor vehicle drivers with obstructive sleep apnea contained in the National Trauma Data Bank® (NTDB®) research dataset admission year 2015, medical records were searched using the International Classification of Diseases, Ninth and 10th Revisions, Clinical Modification (ICD-9-CM/ICD-10-CM) codes. Specifically searched were records that contained either a diagnosis code of 327.23/G47.33 (obstructive sleep apnea) or G47.39 (other sleep apnea) or 780.57/G47.30 (unspecified sleep apnea). These records were then searched for motor vehicle drivers as the injured person using ICD-9 codes E810–E819 (motor vehicle traffic injury) and a post-decimal code value of 1 (injured party is the driver); or an ICD-10 diagnosis code Vxx.0xxx that contained the letter V as the first character (indicating transport injury) and a value of zero for the fourth character, signifying the driver as the injured person.

A total of 52 records were found, 50 of which contained a discharge status, including 27 patients discharged to home, nine to acute care/rehab, and 12 to skilled nursing facilities; two patients died. Of these patients, 63.4 percent were men, on average 58.5 years old, had an average hospital length of stay of 7.2 days, an intensive care unit length of stay of 5.4 days, an average injury severity score of 9.8, and were on the ventilator for an average of 4.25 days (see Figure 1).

Figure 1. Hospital discharge status

Figure 1. Hospital discharge status

Getting a good night’s sleep

Several treatment options exist for moderate to severe OSA. The most common treatment is positive airway pressure delivered by devices worn while sleeping. The shoebox-size device pushes air into the airway at a high enough pressure to prevent apnea episodes. Other treatments include avoiding sleeping on one’s back, weight loss, nighttime dental devices that push the tongue or jaw forward, as well as various surgical procedures. Whatever treatment one chooses, a good night’s sleep is far better than being asleep at the wheel while driving your car the following day.

Throughout the year, we will highlight NTDB data through brief monthly reports in the Bulletin. The NTDB Annual Report 2016 is available on the American College of Surgeons’ website as a PDF file. In addition, information is available on the NTDB web page about how to obtain NTDB data for more detailed study. To submit your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at mneal@facs.org.

Acknowledgment

Statistical support for this article was provided by Ryan Murphy, Data Analyst, NTDB.


*American Sleep Apnea Association. Sleep apnea information for clinicians. Available at: sleepapnea.org/learn/sleep-apnea-information-clinicians/. Accessed April 18, 2017.

University of Toronto. STOP-Bang Questionnaire. Available at: www.stopbang.ca/osa/screening.php. Accessed April 18, 2017.

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