Sleep apnea is common but rarely diagnosed: most patients with sleep apnea do not know they have the disorder but, when asked, will acknowledge the symptoms. Thus health care professionals in pain medicine can play a key role in reaching the undiagnosed by asking pain patients about sleep apnea symptoms. It is especially important for health care professionals to consider whether their patients have sleep apnea before the patients undergo sedation or any type of anesthesia and before the patients are given pain medications that can affect their respiratory drive or relax their muscles.
Asking on a pain questionnaire if the pain patient has sleep apnea is important, but given that most apneics are undiagnosed, it is crucial to ask additional screening questions of the patient— with the bedpartner present if possible.
Two key questions to ask patients are:
- Do you snore?
yes no don’t know
- Do you ever fall asleep easily and/or sometimes inappropriately?
yes no
Three other good questions to include are:
- Do you feel tired or groggy on awakening?
yes no
- Do you have morning headaches?
yes no
- Do you wake frequently during the night?
yes no
The risk factors and presenting symptoms of sleep apnea should also be considered. Risk factors may include the following:
- A family history of sleep apnea
- Excess weight
- A large neck
- A recessed chin
- Male sex
- Abnormalities in the structure of the upper airway
- Alcohol use
- Age
Yet sleep apnea can affect both males and females of all ages (including children) and of any weight.
Presenting symptoms may include the following:
- Loud snoring
- Excessive daytime sleepiness (i.e., falling asleep easily and sometimes inappropriately)
- High blood pressure and other cardiovascular complications
- Morning headaches
- Memory problems
- Feelings of depression
- Reflux
- Nocturia
- Impotence
When suspicious of the presence of sleep-disordered breathing, the patient should be treated as if the disorder is present until the diagnosis is confirmed or ruled out. (For more information about sleep studies, read the ASAA’s publications "Being Evaluated for Sleep Apnea" and "Having Your Child Evaluated for Sleep Apnea".) When pain patients diagnosed and treated for sleep apnea need pain medications that affect the respiratory drive and/or the patency of the airway, treatment for sleep apnea can be adjusted accordingly. However, it must be remembered, when treating the pain, that most pain patients with sleep apnea are not diagnosed and treated for the disorder.
Appropriate monitoring and follow-up of patients with sleep apnea are key to safe and effective pain management; what is appropriate depends upon the medication given and/or procedure done, as well as the patient’s medical history. For in-patients, many facilities can implement ambulatory monitoring of respiratory effort, airflow and arterial oxygen saturation (via pulse oximetry). The patient may be monitored at home with the same ambulatory equipment if that level of monitoring is deemed safe.
Because sleep apnea is associated with fragmented sleep, the perception of pain may be altered in those with untreated sleep apnea. Studies in non-complaining sleepers have shown that experimentally fragmenting their sleep to mimic those arousal patterns seen in sleep apnea leads to increased complaint of arthralgias and non-restorative sleep. Therefore, treating the underlying sleep apnea may allow the patient’s pain to diminish.
For more information about sleep apnea, including treatment options and treatment compliance, visit http://www.sleepapnea.org/info/practitioner/anespain.html.
The American Sleep Apnea Association is proud to be a member of the Partners for Understanding Pain.
This publication was originally written for its Pain Awareness Month held in September 2003.
11/03
