Book Review

Sleep Apnea: Current Diagnosis and Treatment

N Engl J Med 2007; 356:1899-1900May 3, 2007

Article

Sleep Apnea: Current Diagnosis and Treatment
(Progress in Respiratory Research. Vol. 35.) Edited by Winfried J. Randerath, Bernd M. Sanner, and Virend K. Somers. 243 pp., illustrated. Basel, Switzerland, Karger, 2006. $171. ISBN: 978-3-8055-8049-6

The rapid growth of sleep-disorder medicine as a subspecialty, and with it the growing number of patients in all medical settings who have received diagnoses of sleep disorders, has created the need for reference works accessible to the clinician seeking a focused and succinct introduction to the field. This is particularly true for the sleep apnea syndromes, as those are arguably the sleep disorder diagnoses having the largest effect on the rest of medicine. In addition, the recent inclusion of training in sleep-disorder medicine as a formal requirement of fellowship programs in pulmonary and critical-care medicine has highlighted a serious deficit in didactic texts that include both basic clinical science and pragmatic clinical guidelines.

Sleep-disorder medicine already has its share of “definitive” texts. At more than 1000 pages in length, however, these books represent a serious commitment for physicians with looming board exams and students with a still-fledgling interest in the subject. In addition, these books are necessarily broad in scope, covering all of sleep medicine — from common disorders to rare ones — thereby limiting depth in any one area. Enter Sleep Apnea, a slender book (just shy of 250 pages) that is part of the Progress in Respiratory Research series from Karger. Its modest heft makes it a reasonable addition to a briefcase or backpack. Despite the easy lifting, however, this book aspires to provide a comprehensive introduction to sleep apnea syndromes, with chapters covering everything from basic sleep physiology to the clinical features of sleep-disordered breathing in pregnancy.

Although the book falls short of its promise in a number of ways, there is still much to recommend, and I have already found this book to be a valuable resource in the clinic, in the laboratory, and in the classroom. The chapters on the physiology of breathing during sleep and the clinical presentation of obstructive sleep apnea are particularly good — pitched perfectly for students and residents who do not have extensive pulmonary training. The last several chapters, covering sleep apnea syndromes in special populations (such as children, the elderly, and pregnant women), are valuable as well. Although problematically terse in places, these chapters provide clinicians with an accessible introduction to these important overlapping areas. For example, the chapter on sleep-related breathing disorders in children includes a beautifully brief summary of the clinical approach to a child with sleep apnea and the factors that should be weighed in considering surgical treatment.

The identified need, however, was for a book that could serve in the classroom, in the fellowship program, or on the reference shelf of the nonspecialist. Against this measure, the book falls short. The problems lie in several key areas. First, several chapters are already out-of-date. Although it is true that the gestation period for a book of this kind is an inherent barrier to currency, there are a few chapters that are so dated or incomplete that students should be advised against reading them. It is difficult to imagine, for example, that a chapter titled “Physiology of Sleep and Dreaming” written in the past 6 years could omit mention of the ventrolateral preoptic nucleus of the hypothalamus. First described in 1996, by 2001 it was understood for its preeminent role in the control of sleep, but the anatomy and physiology of this structure escape mention in the chapter. A look at the references hints that the problem with this crucial chapter may be less currency than focus — there are current references on the modeling of sleep–wake regulation, for example. As it stands, however, this is not a useful introduction to the neurobiology of sleep for those new to the field. The problems with the chapter on the genetics of sleep apnea are more understandable, given the focus of recent research on this topic. The authors of this chapter concentrate on a review of the genes that may be involved in the development of obesity or variations in craniofacial structure, an approach that has not been particularly productive in understanding the pathophysiology of sleep apnea. Promising findings from more empirical, population-based studies have appeared only within the past few years.

The other major disappointment lies in the selection of chapter topics. The preparation of a collaborative book such as this one always requires compromises between the ideal table of contents and the authors who are available (and willing) to write. Here, the tension between the two may be the explanation for some perplexing choices. Continuous positive airway pressure (CPAP), the treatment of choice for most patients with obstructive sleep apnea, is covered thoroughly in chapters dealing with both theory and practice. Alternative therapies are addressed in a series of much shorter chapters that include two extremely brief discussions of cardiac pacemaker therapy and electrical upper-airway muscle stimulation (surgical revision procedures, which have yielded some impressive results, are not covered). Another chapter is devoted to pharmacology and behavior modification. A single chapter dealing with alternative approaches, in which the strengths and weaknesses of each could be contrasted and the selection criteria reviewed, would have been far more valuable to the clinician. Almost as frustrating is the inclusion of an entire chapter on humidification in CPAP therapy but only a few paragraphs on the broader clinical problem of ensuring patients' compliance with this problematic but effective therapy. Other chapters seem to belong on the editorial page rather than in a teaching resource. One hopes the authors of the chapter “Oxidative Stress — The Culprit of Obstructive Sleep Apnea Syndrome” do not come to regret the omission of a question mark from its title by the time the next edition of the book is due.

So, still lacking a book I can recommend without reservation to students, residents, and colleagues newly interested in sleep, I slipped this book into a very narrow space on my bookshelf, realizing that sometimes slender is just another word for thin.

Gary S. Richardson, M.D.
Henry Ford Hospital, Detroit, MI 48104