pulmonary disorders
Obstructive Sleep Apnea (OSA)
Treatment of Obstructive Sleep Apnea (OSA)
Control of risk factors such as obesity, hypertension, alcohol use, and sedative use Continuous positive airway pressure (CPAP) or oral appliances Sometimes surgery, or nerve stimulation An Diagnosis ≥ 5 per hour defines a diagnosis of obstructive sleep apnea; treatment is given only to patients who have symptoms (sleepiness with fatigue, nonrestorative sleep, and snoring/gasping/choking). An AHI value ≥ 15 indicates at least a moderate level of sleep apnea and is considered a threshold to treat in the absence of symptoms. Pending treatment, sleepy patients should be warned of the risks of driving, operating heavy machinery, or engaging in other activities during which unintentional sleep would be hazardous. The aims of treatment ( Treatment references ) are to Reduce episodes of hypoxia and sleep fragmentation Restore sleep continuity and architecture Avoid episodic asphyxia There are many available approaches to treatment. Patient and clinician should engage in shared decision making to match the degree and nature of the disorder with feasible interventions and the outcomes most important to the patient. Treatment is directed at both risk factors and OSA itself. First-line direct therapy includes use of a continuous positive airway pressure (CPAP) device or an oral appliance. For anatomic encroachment or for disease that does not respond to these devices, surgery or nerve stimulation is considered. Success is defined as a resolution of symptoms with AHI reduction, usually to < 10 per hour and ideally to < 5 per hour. Initial treatment aims to control risk factors such as obesity, hypertension, alcohol use, and sedative use. Exercise decreases the AHI and increases alertness, independent of any effect on body mass index (BMI). Daytime sleepiness can be reduced by good Insomnia and Excessive Daytime Sleepiness (EDS) , including sleeping longer and discontinuing sedative drugs, particularly antihistamines or antidepressants. (≥ 15%) may result in clinically meaningful improvement ( Treatment references , CPAP is the treatment of choice for most patients with OSA and subjective daytime sleepiness, including those in whom it causes cognitive impairment ( Treatment references , There are many different CPAP devices available, including those that cover the nose, nose and mouth, or the whole face. All have cushions to provide an air seal, which is essential for maintaining a pressure gradient. Cushions may be inflatable or made of silicone, foam, or gel. Proper fit and comfort vary widely among patients but must be optimized for both efficacy and adherence. CPAP improves upper airway patency by applying positive pressure to the collapsible upper airway segment. Effective pressures typically range from 3 to 15 cm H2O. Pressure requirements are not correlated with disease severity. Many CPAP devices monitor CPAP efficacy and titrate pressures automatically, according to internal algorithms. If necessary, polysomnographic monitoring can be used to guide manual titration of pressure. Although a reduction in AHI is one of the treatment goals, CPAP will reduce cognitive impairment and improve quality of life regardless of improvement in the AHI. CPAP also may reduce blood pressure. If CPAP is withdrawn, symptoms recur over several days, though short interruptions of therapy for acute medical conditions are usually well tolerated. Duration of therapy is indefinite. If clinical improvement is not apparent, CPAP adherence should be reviewed, and patients should be reassessed for a second sleep disorder (eg, upper airway obstruction) or a comorbid disorder. If patients have septal deviation or polyps, nasal surgery may make CPAP treatment more successful but inconsistently “treats” OSA. Adverse effects of nasal CPAPinclude discomfort resulting from a poorly fitting mask, and dryness and nasal irritation, which can be alleviated in some cases with the use of warm humidified air. However, newer mask designs have improved comfort and ease of use. Adherenceis difficult for many people and is lower in patients who do not experience sleepiness. Overall, about 50% of patients adhere to use of CPAP long term. Adherence can be improved by efforts to foster a positive attitude towards device use combined with early attention to any problems, particularly mask fit, and close follow-up by a committed caretaker, with reinforcement by the primary care physician. There is also a need to recognize and address the decreased long-term CPAP adherence among patients who do not have obesity and have low respiratory arousal threshold (ie, awaken easily) and thus a propensity for increased arousals and irregular breathing. Even when adherence is adequate, results may become unsatisfactory if patient factors change (eg, weight gain, nasal obstruction develops). CPAP can be augmented with inspiratory assistance (bilevel positive airway pressure) to increase tidal volume in patients with comorbid obesity-hypoventilation syndrome. Oral appliances are designed to advance the mandible or, at the very least, prevent retrusion and tongue prolapse during sleep ( Treatment references , Surgical procedures to correct anatomic factors, such as enlarged tonsils and nasal polyps contributing to upper airway obstruction (called anatomic procedures), should be considered ( Treatment references , Uvulopalatopharyngoplasty (UPPP) was previously the most common procedure. It involves resection of pharyngeal tissue. UPPP has been largely replaced by less aggressive approaches that attempt to stabilize the lateral walls of the pharynx and/or enlarge the velopharyngeal area without risk of altering speech or swallowing. Equivalence with CPAP was shown in one study using CPAP as a bridge to surgery, but the interventions have not been directly compared. Results are less predictable in patients who have severe obesity or anatomic narrowing of the airway. The procedure may reduce intrusive snoring, although apneic episodes may remain as severe (although silent) as before surgical intervention. Other surgical procedures include midline glossectomy, hyoid advancement, and mandibulomaxillary advancement. Mandibulomaxillary advancement is sometimes offered as a 2nd-stage procedure if soft tissue approaches are not curative. The optimal multistage approach is not known. Tracheostomy is the most effective therapeutic maneuver for OSA but is done as a last resort. It bypasses the site of obstruction and is indicated for patients most severely affected (eg, those with Cor Pulmonale ). Upper airway stimulation using an implanted device to stimulate a branch of the hypoglossal nerve ( Treatment references , Various adjunctive treatments are sometimes used but have no proven benefit for OSA. Supplemental oxygen improves blood oxygenation and may reduce AHI and arousal index among patients who did not respond to upper airway surgery ( Treatment references ), but a beneficial clinical effect is mainly in those with high gain (tendency to have repeated apnea or hypopnea after an initial episode) and effects are hard to predict. Also, oxygen may provoke respiratory acidosis and morning headache. ) may be used to counteract excessive sleepiness that occurs with OSA or in the 20% of treated patients who have residual sleepiness ( Treatment references , ( Treatment references ), but cannot be recommended because of factors including limited experience, a low therapeutic index, lack of replication of results, and lack of adequate trials. Better methods to recognize sleep apnea subtypes may allow better selection of patients for this line of treatment. Exercises for upper airway muscles (myofunctional therapy) have been proposed on the theory that improved muscle strength and tone might help improve airway patency during sleep ( Treatment references ). There are a number of exercises that seem to reduce AHI and symptoms, making this approach interesting, particularly because it is noninvasive and with no adverse effects. However, this approach is not yet a mainstream recommendation, because of the wide variety of techniques proposed and the uncertainly about their mechanism of action and efficacy, combined with the great practical difficulties with adherence. Nasal dilatory devices and throat sprays sold over-the-counter for snoring have not been studied sufficiently to prove value in OSA. Laser-assisted uvuloplasty, uvular splints, and radiofrequency tissue ablation have been used to treat snoring in patients without OSA. 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