Obstructive sleep apnea: A diagnostic and treatment guide

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Obstructive sleep apnea: A diagnostic and treatment guide

J Fam Pract. 2013 October;62(10):565-568, 570-572

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References

1. Dempsey JA, Veasey SC, Morgan BJ, et al. Pathophysiology of sleep apnea. Physiol Rev. 2010;90:47-112.

2. Jenkinson C, Stradling J, Petersen S. Comparison of three measures of quality of life outcome in the evaluation of continuous positive airways pressure therapy for sleep apnoea. J Sleep Res. 1997;6:199-204.

3. Satela MJ. Neuropsychological impairment and quality of life in obstructive sleep apnea. Clin Chest Med. 2003;24:249-259.

4. Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002;165:1217-1239.

5. Yaggi HK, Concato J, Kernan W, et al. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005;353:2034-2041.

6. Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046-1053.

7. Young T, Finn L, Peppard PE, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep. 2008;3:1071-1078.

8. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:136-143.

9. Coughlin SR, Mawdsley L, Mugarza JA, et al. Obstructive sleep apnoea is independently associated with an increased prevalence of metabolic syndrome. Eur Heart J. 2004;25:735-741.

10. Basta M, Vgontzas AN. Metabolic abnormalities in obesity and sleep apnea are in a continuum. Sleep Med. 2007;8:5-7.

11. Peppard PE, Young T, Palta M, et al. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA. 2000;284:3015-3021.

12. Parish JM, Adam T, Facchiano L. Relationship of metabolic syndrome and obstructive sleep apnea. J Clin Sleep Med. 2007;3:467-472.

13. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004;291:2013-2016.

14. Skomro RP, Gjevre J, Reid J, et al. Outcomes of home-base diagnosis and treatment of obstructive sleep apnea. Chest. 2010;138:257-263.

15. Iber C, Ancoli-Israel S, Chesson AL Jr, et al. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Westchester, IL: American Academy of Sleep Medicine; 2007.

16. Johns MW. Sensitivity and specificity of the multiple sleep maintenance tests, the maintenance of wakefulness tests and the Epworth sleepiness scale: failure of the MSLT as a gold standard. J Sleep Res. 2000;9:5-11.

17. Hesselbacher S, Subramanian S, Allen J, et al. Body mass index, gender, and ethnic variations alter the clinical implication of the Epworth sleepiness scale in patients with suspected of obstructive sleep apnea. Open Respir Med J. 2012;6:2020-2027.

18. Ahmadi N, Chung S, Gibbs A, et al. The Berlin questionnaire for sleep apnea in a sleep clinic population: relationship to polysomnographic measurement of respiratory disturbance. Sleep Breath. 2008;12:38-45.

19. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108:812-821.

20. Shneerson J, Wright J. Lifestyle modification for obstructive sleep apnoea. Cochrane Database Syst Rev. 2001;(1):CD002875.

21. Barvaux VA, Aubert G, Rodenstein DO. Weight loss as treatment for obstructive sleep apnea. Sleep Med Rev. 2000;4:435-452.

22. Buchwald H, Avidor H, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-1737.

23. Dixon JB, Schachter LM, O’Brien PE, et al. Surgical vs. conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial. JAMA. 2012;308:1142-1149.

24. Greenburg A, Lettieri C, Arn E. Effects of surgical weight loss on measures of obstructive sleep apnea: a meta-analysis. Am J Med. 2009;122:535-542.

25. Sagawa Y, Kondo H, Matsubuchi N. Alcohol has a dose-related effect on parasympathetic nerve activity during sleep. Alcohol Clin Exp Res. 2011;35:2093-2100.

26. Vakulin A, Baulk SD, Catcheside PG, et al. Effects of alcohol and sleep restriction on simulated driving performance in untreated patients with obstructive sleep apnea. Ann Intern Med. 2009;151:447-455.

27. Patel SR, White DP, Malhotra A, et al. Continuous positive airway pressure therapy for treating sleepiness in a diverse population with obstructive sleep apnea: results of a meta-analysis. Arch Intern Med. 2003;163:565-571.

28. Giles TL, Lasserson TJ, Smith BH, et al. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev. 2006;(3):CD001106.

29. Simantirakis EN, Schiza SI, Marketou ME, et al. Severe bradyarrhythmias in patients with sleep apnoea: the effect of continuous positive airway pressure treatment: a long-term evaluation using an insertable loop recorder. Eur Heart J. 2004;25:1070-1076.

30. Marshall NS, Barnes M, Travier N, et al. Continuous positive airway pressure reduces daytime sleepiness in mild to moderate obstructive sleep apnoea: a meta-analysis. Thorax. 2006;61:430-434.

31. Findley L, Smith C, Hooper J, et al. Treatment with nasal CPAP decreases automobile accidents in patient with sleep apnea. Am J Respir Crit Care Med. 2000;161:857-859.

32. Barbe F, Sunyer J, de la Pena A, et al. Effects of continuous positive airway pressure on the risk of road accidents in sleep apnea patients. Respiration. 2007;74:44-49.

33. Sin DD, Mayers I, Man GC, et al. Long Term compliance rates to continuous positive airway pressure in obstructive sleep apnea: a population based study. Chest. 2002;121:430-435.

34. Cormican LJ, Williams A. Sleep disordered breathing and its treatment in congestive heart failure. Heart. 2005;91:1265-1270.

35. Lindberg E, Berne C, Elmasry A, et al. CPAP treatment of a population-based sample—what are the benefits and the treatment compliance? Sleep Med. 2006;7:553-560.

36. Engleman HM, Wild MR. Improving CPAP use by patients with the sleep apnea-hypopnea syndrome (SAHS). Sleep Med. 2003;7:81-99.

37. Blau A, Minx M, Peter JG, et al. Auto bi-level pressure relief-PAP is as effective as CPAP in OSA patients—a pilot study. Sleep Breath. 2012;16:773-739.

38. Chan AS, Lee RW, Cistulli PA. Dental appliance treatment for obstructive sleep apnea. Chest. 2007;132:693-699.

39. Kushida CA, Morgenthaler TI, Littner MR, et al. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep. 2006;29:240-243.

40. Sundaram S, Bridgman SA, Lim J, et al. Surgery for obstructive sleep apnoea. Cochrane Database Syst Rev. 2005;(4):CD001004.

41. Caples SM, Rowley JA, Prinsell JR, et al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep. 2010;33:1396-1407.

42. Smith I, Lasserson TJ, Wright JJ. Drug therapy for obstructive sleep apnea in adults. Cochrane Database Syst Rev. 2006;():CD003002. Review.

43. Mason M, Welsh EJ, Smith I. Drug therapy for obstructive sleep apnoea in adults. Cochrane Database Syst Rev. 2013;(5): CD003002.

Avoidance of alcohol. Alcohol has adverse effects on sleep: It shortens sleep latency, increases slow-wave sleep, suppresses REM and parasympathetic nerve activity,²⁵ and can exacerbate OSA. Driving simulation studies have found that, compared with healthy individuals, those with untreated OSA are more susceptible to the effects of alcohol and at higher risk for accidents after just one drink.²⁶

CPAP improves sleep, but some problems persist
CPAP supplies a flow of positive air pressure, adjusted to the level needed to keep the airway open, delivered through a facial device best suited to the patient’s anatomy, physiology, and comfort.

Multiple studies have demonstrated the effectiveness of CPAP in reducing symptoms of moderate to severe OSA, compared with placebo and other treatment modalities such as oral devices, surgical procedures, and medications. CPAP reduces AHI, blood pressure, and cardiac arrhythmias. It improves sleep efficiency, oxygen saturation, and self-reported sleep and well-being.^27-30 While it ameliorates many of the harmful effects of OSA, it does not improve or reverse all of them. (See “Peripheral neuropathy linked to obstructive sleep apnea?”)

A Cochrane review of 36 randomized controlled trials with a combined total of more than 1700 patients demonstrated the superiority of CPAP vs control in several measures, such as subjective daytime sleepiness, quality of life, cognitive function, and blood pressure.²⁸ On specific parameters of OSA, such as snoring and EDS, studies yielded mixed results.

CPAP has been found to decrease work-related injuries and morbidity and mortality associated with motor vehicle accidents linked to EDS.^30-32 However, no study of CPAP Try bilevel positive airway pressure if a patient is unable to tolerate CPAP. has demonstrated a long-term reduction in morbidity and mortality. And no standards define the minimum number of sleep hours and/or frequency of CPAP use that is required to obtain specific benefits.

Patient compliance is poor. Part of the problem is that CPAP is difficult to use, which affects compliance. Poor patient compliance is a major barrier to evaluating its long-term benefits. (The video below, "CPAP Patients Tips from the FDA", can help ensure that patients use CPAP safely and effectively.) Studies estimate that 65% to 89% of patients with CPAP devices use them for at least 4 hours a night for 70% of nights, but that about half of those for whom CPAP is prescribed stop using it after 2 to 3 years.^33-36 Several risk factors and comorbid conditions, including advanced age, diabetes, obesity, smoking, and especially, depression, are associated with decreased compliance.¹³

Improving CPAP compliance continues to be a challenge, highlighting the importance of treating not only OSA but all comorbidities, particularly depression. Short-term studies have found behavioral modification to be a promising means of improving CPAP compliance.^33-36

Although not a first-line therapy, bilevel positive airway pressure (BiPAP), which delivers both inspiratory and expiratory pressure via a face device, can be tried in patients unable to tolerate CPAP.³⁷ Studies are limited and it has been used in patients with complex OSA.

Oral appliances are a CPAP alternative
Mandibular repositioning devices (MRDs) and tongue-retaining devices are alternatives to CPAP.³⁸ Although both types of oral appliance are beneficial, they are less effective than CPAP.²⁸

MRDs, which are more commonly used than tongue-retaining devices, are available in several models. An MRD can be custom-made to hold the lower jaw in a forward position during sleep, enlarge the space behind the tongue, and put tension on the walls of the pharynx and the palate to reduce collapse.³⁸

Tongue-retaining devices—splints that hold the tongue in place to keep the airway open—can be used for mild to moderate OSA, and for patients unable to tolerate CPAP.^38,39

Studies comparing MRDs and tongue-retaining devices found no statistically significant difference in their ability to reduce AHI, but patients tolerated MRDs better.^38,39 Nonetheless, both devices can cause dental discomfort, temporomandibular joint pain, dry mouth or excessive salivation, gum irritation, bruxism, and long-term occlusal changes.³⁸

Is surgery an option?
Numerous surgical techniques are available for treating OSA, all aimed at relieving the obstruction by removing or bypassing it or increasing airway size. These include uvulopalatopharyngoplasty, which resects the uvula, retrolingual, and palatine tonsillar tissue; septoplasty; rhinoplasty; nasal turbinate reduction; nasal polypectomy palatal advancement pharyngoplasty; tonsillectomy; adenoidectomy; palatal implants; tongue reduction; genioglossus advancement; and maxillomandibular advancement.

The choice of modality depends on the patient’s anatomy and physiology, and is selected only after a full evaluation by a head and neck surgeon who specializes in surgical treatment of OSA.^40,41 There is a paucity of reliable studies on the results of such procedures, but a Cochrane review of the existing literature concluded that surgery is only indicated for severe cases of sleep apnea in patients who have an anatomic obstruction.⁴⁰