Pulmonary

Management of Obstructive Sleep Apnea

SUMMARY

Obstructive sleep apnea is the most common sleep-related breathing disorder, with a continuing increase in prevalence in recent decades. OSA is responsible for significant health consequences including increased all-cause mortality, CV disease, stroke, cognitive impairment, and excessive daytime sleepiness leading to workplace accidents and motor vehicle collisions. The backbone of treatment for OSA is positive airway pressure with sleep, though adherence to therapy can be poor.

DIAGNOSIS

Diagnosis and severity of OSA should be based on objective testing with either polysomnography or home sleep apnea testing
- Screening tests for OSA (e.g., STOP-BANG questionnaire) are not sufficient for initiating OSA therapies
Patient education on OSA diagnosis, severity and health effects is paramount to improving patient adherence to PAP therapy
For more information on OSA screening and diagnosis see related topics below
Therapy should be offered to all patients diagnosed with OSA

THERAPY

Medical Devices

Positive Airway Pressure (PAP)
- Most studied therapy for OSA and recommended as first line therapy
- PAP treatment has been shown to reduce daytime symptoms (e.g., sleepiness) and reduce nighttime apnea and hypopnea episodes
- May be delivered via: CPAP (recommended) | BiPAP (if coexisting central hypoventilation is present or patient needs assistance exhaling against a high fixed pressure) | APAP (good for patients initiating therapy at home and not during sleep study)
- Evidence is insufficient to determine long term benefit of PAP on OSA related diseases such as: Hypertension | CV disease | Diabetes
- Device and mode used depends on patient’s preference as studies have shown similar efficacy and adherence (e.g., nasal vs oral masks | humidified air vs not)
- Follow up should be done with weeks of starting PAP to discuss adherence and troubleshoot any problems
- Telemonitoring is an acceptable and recommended form of follow up after PAP initiation

Oral appliances (OA)
- Recommended as alternative therapy for patients who cannot tolerate PAP
- Includes: Mandibular advancement devices | Tongue retaining devices
- To ensure benefit from oral appliances, patients should undergo repeat sleep study with the OA in place after final adjustments of fit have been done
- Reported adverse effects of MAD include: Tooth loosening | Dental crown damage | TMJ pain

Behavior and lifestyle modifications

All overweight and obese patients diagnosed with OSA should be encouraged to lose weight
- Weight loss is not recommended as monotherapy, and should be combined with primary treatment for OSA (e.g., positive airway pressure during sleep)
- For those who qualify, bariatric surgery referral or pharmacotherapy for weight loss should be offered
- Repeat sleep study is recommended for any patients who have substantial weight loss (≥ 10% body weight)
Avoid substances and medications that can worsen OSA: Alcohol | Opiates | Benzodiazepines | First generation antihistamines | Sedating antidepressants
Sleep positioning
- Keeping the patient in a non-supine position is effective in patients who have a low apnea-hypopnea index in the non-supine vs supine position
Patient education has been shown to improve adherence and hours of PAP use each night
Patients receiving cognitive behavioral therapy also more likely to adhere to PAP use

Surgical treatments

Surgeries to treat OSA include: Tonsillectomy | Nasal procedures (e.g., Septoplasty, rhinoplasty) | Tongue reduction | Epiglottis correction | Maxillomandibular advancement | Hypoglossal nerve stimulation | Tracheostomy
Associated with more risks and harms then medical device/PAP therapy
Insufficient evidence on their benefits and must be tailored to specific patient
Currently not recommended as first line therapy for OSA treatment

Pharmacotherapy

Currently there are no medications that are recommended for the primary treatment of OSA
- Modafinil (Provigil) can be used for excessive daytime sleepiness due to OSA that fails to improve with PAP therapy
- Intranasal steroids can be used for patients with OSA and concomitant allergic rhinitis to improve nasal airflow
Prior studies have demonstrated a lack of efficacy with: SSRIs | Protriptyline | Methylxanthine derivatives (e.g., theophylline) | Estrogen therapy | Oxymetazoline (Afrin) | Supplemental O2

KEY POINTS

OSA treatment should only be initiated after diagnosis is made based on polysomnography or at home sleep apnea testing
The cornerstones of OSA therapy are weight loss, when indicated, and positive airway pressure with sleep
PAP use has been shown to decrease nighttime apnea/hypopnea episodes and daytime sleepiness, but evidence is lacking on long term improvement in OSA associated comorbidities (e.g., hypertension, CV disease)
Patient education and follow up are critical for improving PAP adherence