Sleep apnea differential diagnosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Saarah T. Alkhairy, M.D.
Overview
Sleep apnea must be differentiated from other diseases that cause loud snoring, fatigue, choking, coughing, and daytime sleepiness. To differentiate obstructive sleep apnea (OSA) and central sleep apnea, a polysomnogram should be performed. OSA will demonstrate evidence of thoracoabdominal effort, whereas central sleep apnea will not.
Differential Diagnosis
The table below summarizes the findings that differentiate sleep apnea from other conditions that cause loud snoring, fatigue, choking, coughing, and/or somnolence.
| Disease/Condition | Differentiating Signs/Symptoms | Differentiating Tests |
| Cheyne-Stokes breathing (CSB) | Recurrent episodes of apnea with absence of respiratory effort; CSB is associated with cerebrovascular disease, CHF, and/or renal failure[1] | In CSB, a crescendo-decrescendo change in breathing amplitude interpersed by episodes of central sleep apnea or hypoapnea would be seen |
| Narcolepsy | Level of sleepiness in narcolepsy may be higher in Epworth Sleepiness Scale[2]; may have cataplexy hypnagogic hallucincations, and sleep paralysis | A polysomnography should be performed to rule out OSA; a multiple sleep latency test (MLST) can assess for naroclepsy |
| Insufficient sleep | Difficult to differentiate clinically | A polysomnography should be performed to rule out OSA; a sleep diary should used |
| Inadequate sleep hygiene | Irregular sleep schedule with frequent napping; frequent use of alcohol, nicotine, and caffeine; poor bedroom environment | A polysomnography should be performed to rule out OSA; diagnosis is usually clinical |
| Periodic limb movement disorder | Patients describe an urge to move legs due to discomfort during periods of inactivity (including sleep); patients have excessive sleepiness | A polysomnography should demonstrate limb movements and rule out OSA |
| Nocturnal gastroesphageal reflux | Results in nocturnal restlessness, choking episodes during sleep, frequent awakening, and labored breathing | A polysomnography should be performed to rule out OSA |
| Nocturnal asthma | Can present with nocturnal choking, gasping, coughing, or dyspnea | A polysomnography should be performed to rule out OSA; pulmonary function tests (PFTs) should be performed |
| Primary snoring | More common than OSA | A polysomnography should be performed to rule out OSA |
| Nocturnal panic attacks | Can present with nocturnal choking, gasping, coughing, or dyspnea | A polysomnography should be performed to rule out OSA; a psychiatric history should be performed |
| Congestive heart failure | Can present with nocturnal choking, gasping, coughing, or dyspnea | A polysomnography should be performed to rule out OSA; EKG, chest x-ray, blood tests, stress testing, and cardiac catheterization should be performed |
| Sleep-related laryngospasm | Can present with nocturnal choking, gasping, coughing, or dyspnea | A polysomnography should be performed to rule out OSA |
| Chronic fatigue syndrome | Daytime fatigue is usually the only complaint | A polysomnography should be performed to rule out OSA |
| Depression | Can present with fatigue and feelings of hopelessness | A polysomnography should be performed to rule out OSA; a psychiatric history should be performed |
| Pseudocentral sleep apnea | These patients with diaphragmatic paralysis depend on accessory muscles during breathing and may have apnea during REM sleep (sleep apnea is mostly observed during non-REM sleep); history of neuromuscular disease | A polysomnography should be performed to rule out OSA; various neuromuscular disease tests should be performed |