Key points

Pickwickian syndrome

With the ever-increasing media coverage of obstructive sleep apnea (OSA) and its disastrous long-term effects, it is hard to believe that this clinical entity has only been clearly identified and recognized for several decades. The first clear modern description of the syndrome was by Burwell in 1956 in the publication entitled, “Extreme Obesity Associated with Alveolar Hypoventilation: A Pickwickian Syndrome.” The report details a young obese boy whose appearance parallels Joe from Charles Dickens’ The Posthumous Papers of the Pickwick Club (1837). Its unclear if this patient truly had OSA, and it took another decade before Gastaut and colleagues in 1966 showed repeated apneas in obese patients and noted these nocturnal disturbances to possibly be linked to their daytime somnolence.

Interestingly it seems that multiple physicians, including Broadbent and Caton , alluded to a several cases in the late nineteenth century with a general understanding that obstructive apneas occur while asleep. Some physicians suspect that the early overdiagnosis of sleep disorders, such as narcolepsy, were actually cases of OSA. Luckily, in the last few decades our understanding of the pathophysiology and treatment of OSA has progressed significantly with entire medical journals focused on it.

Pickwickian syndrome

With the ever-increasing media coverage of obstructive sleep apnea (OSA) and its disastrous long-term effects, it is hard to believe that this clinical entity has only been clearly identified and recognized for several decades. The first clear modern description of the syndrome was by Burwell in 1956 in the publication entitled, “Extreme Obesity Associated with Alveolar Hypoventilation: A Pickwickian Syndrome.” The report details a young obese boy whose appearance parallels Joe from Charles Dickens’ The Posthumous Papers of the Pickwick Club (1837). Its unclear if this patient truly had OSA, and it took another decade before Gastaut and colleagues in 1966 showed repeated apneas in obese patients and noted these nocturnal disturbances to possibly be linked to their daytime somnolence.

Interestingly it seems that multiple physicians, including Broadbent and Caton , alluded to a several cases in the late nineteenth century with a general understanding that obstructive apneas occur while asleep. Some physicians suspect that the early overdiagnosis of sleep disorders, such as narcolepsy, were actually cases of OSA. Luckily, in the last few decades our understanding of the pathophysiology and treatment of OSA has progressed significantly with entire medical journals focused on it.

Increasing prevalence

This increased focus on OSA is well justified with the noted increase in its prevalence. Franklin and Linderberg showed in their review of the epidemiology of sleep apnea that the prevalence of the diagnosed entity with polysmonograms in epidemiologic studies to have increased significantly over the past 3 decades. An epidemiologic study within a select subset in the United States by Peppard and colleagues also clearly showed the increasing prevalence of OSA. OSA has truly become a major entity, so much so that in 2013 the National Healthy Sleep Awareness Project was formed. As a national campaign, it was established by a cooperative agreement between the Centers for Disease Control and Prevention and the American Academy of Sleep Medicine to help with sleep health awareness.

One of the major epidemiologic changes that have likely caused OSA rates to increase is the nationwide obesity epidemic, with rates of obesity increasing from 15% in 1990 to 36% in 2012. The increase in overweight and obese adults and children has fueled a significant increase in their medical comorbidities. Current prevalence numbers for OSA are in the realm of 36.1% in men and 11.4% in women ranging from 30 to 49 years of age. In the older subset, the author noted 60.6% in men and 36.9% in women between 50 and 70 years of age. These rates vary by study, but the literature does support an overall increase in the past decade.

Economic impact of obstructive sleep apnea

With the increasing prevalence of OSA, the economic impact of OSA cannot be overstressed. The impact can be broken down several ways. First, the cost directly to patients has been evaluated in the past. In 1999, Kapur and colleagues showed that the annual health care cost to patients directly the year before diagnosis of OSA was $1336 higher and almost double overall when compared with age- and sex-matched controls without OSA. This study went on to estimate that cost of the medical comorbidities alone in 1999 to be $3.4 billion in the United States. To date, multiple studies have shown a large increase in health care utilization in patients with OSA as well.

Not only are there direct costs to health care when considering OSA as a clinical entity but we must also consider the workday’s lost and inherent disability that OSA may cause. Data from the Integrated Benefits Institute shows individuals with sleep disturbances are also less likely to be productive at work, with an average of 7.9 more absence days and 7.5 more present days. There are also good data that shows patients with OSA and excessive daytime sleepiness are at higher risk of both recent work disability and longer-term work duty modification. These effects on work days lost and productivity for patients with OSA are just another marker of the disease’s costs.