Non-Surgical Management of OSA

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Non-Surgical Management of OSA

Adult Sleep Medicine
Author Credentials 

Cristina Baldassari, MD, FACS, FAAP
Associate Professor
Otolaryngology – Head and Neck Surgery
Department of Pediatric Sleep Medicine
Eastern Virginia Medical School, Children’s Hospital of The King’s Daughters
Norfolk, VA

Module Summary

PAP therapy is the primary treatment for adults with OSA and results in improvement in AHI and daytime sleepiness.  However, compliance with PAP therapy can be challenging.  MADs have been shown to improve PSG parameters and QOL in patients with mild to moderate OSA.  Wake-promoting medications may be used to treat OSA patients with persistent sleepiness despite adequate PAP therapy.  

Module Learning Objectives 
  1. Identify non-surgical interventions for the management of adult OSA.
  2. Recognize the indications for positive airway pressure therapy (PAP).
  3. Describe methods to improve adherence to PAP.
  4. Recognize which patients with OSA may benefit from oral appliance therapy.
  5. Cite which medications are indicated for the management of OSA and its sequelae. 

 

Anatomy

Learning Objectives 
  1. Describe the anatomical considerations that relate to outcomes of non-surgical management of OSA including the following:
  • Neck circumference; Body mass index including impact of obesity
  • Nasal anatomy
  • Dental considerations including dental crowding and lack of dentition
  • Tonsil size classification, Fujita classification, Freidman staging 
  • Facial morphology and craniofacial anatomy including retrognathia
  1. Recognize that addressing sources of nasal obstruction such as septal deviation and turbinate hypertrophy can improve PAP compliance.

 

References 
  1. Denolf PL, Vanderveken OM, Marklund ME, Braem MJ. The status of cephalometry in the prediction of non-CPAP treatment outcome in obstructive sleep apnea patients. Sleep Med Rev. 2016 Jun;27:56-73. doi: 10.1016/j.smrv.2015.05.009.
  2. Tsuiki S, Ito E, Isono S, et al. Oropharyngeal crowding and obesity as predictors of oral appliance treatment response to moderate obstructive sleep apnea. Chest. 2013 Aug;144(2):558-563. doi: 10.1378/chest.12-2609.
  3. Poirier J, George C, Rotenberg B. The effect of nasal surgery on nasal continuous positive airway pressure compliance. Laryngoscope. 2014 Jan;124(1):317-9. doi: 10.1002/lary.24131. Epub 2013 Apr 10. PMID: 23575772.
  4. Heidsieck DS1, de Ruiter MH2, de Lange J2. Management of obstructive sleep apnea in edentulous patients: an overview of the literature.  Sleep Breath. 2016 Mar;20(1):395-404.

 

Pathogenesis

Learning Objectives 

See OTOSource Module: Obstructive Sleep Apnea

Patient Evaluation

Learning Objectives 
  1. Utilize PSG to establish the diagnosis of OSA and determine disease severity prior to initiation of therapy.
  2. Identify physical exam findings such as obesity that may impact outcomes in patients being treated for OSA.
  3. Discuss the role of in-lab titration for initiation of PAP therapy. 
  4. Compare and contrast in-lab titration verses auto-titration for the initiation of PAP therapy in adults with OSA.  
  5. Identify the utility of PSG in assessing patient’s response to oral appliance therapy.
  6. Describe Drug Induced Sleep Endoscopy (DISE) and its role in patients who have failed non-surgical interventions or prefer an alternative therapy to PAP:
  • VOTE classification
References 
  1. Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2019;15(2):335–343.
  2. Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015;11(7):773–827.
  3. Sutherland K, Chan AS, Ngiam J, Dalci O, Darendeliler MA, Cistulli PA. Awake multimodal phenotyping for prediction of oral appliance treatment outcome. J Clin Sleep Med. 2018;14(11):1879–1887.
  4. Hohenhorst W. et al., Drug-induced sleep endoscopy in adults with sleep-disordered breathing: Technique and the VOTE Classification system.  Operative Techniques in Otolaryngology (2012) 23, 11-18
  5. De Vito A, Carrasco Llatas M, Vanni A, et al. European position paper on drug-induced sedation endoscopy (DISE). Sleep Breath 2014;18:453–465.
  6. Vanderveken OM, Maurer JT, Hohenhorst W, et al. Evaluation of drug induced sleep endoscopy as a patient selection tool for implanted upper airway stimulation for obstructive sleep apnea. J Clin Sleep Med 2013; 9:433–438.

 

Measurement of Functional Status

Learning Objectives 
  1. Identify instruments that may be used to screen for OSA:
  • STOP-BANG, Epworth, Berlin Questionnaire
  1. Identify instruments that may be used to evaluate OSA symptomatology: 
  • Epworth Sleepiness Scale, Berlin, Functional Outcomes of Sleep Questionnaire (FOSQ)
  1. Recognize that patients with OSA should be screened for depression:
  • Beck depression inventory or the Patient health questionnaire (PHQ-9)
  1. Describe expected sleepiness and QOL outcomes in patients with OSA treated with PAP and oral appliance therapy. 
  2. Understand the importance of considering treatment outcomes beyond the AHI in the management of OSA.

 

References 
  1. Chiu HY, Chen PY, Chuang LP.  Diagnostic accuracy of the Berlin questionnaire, STOP-BANG, and Epworth sleepiness scale in detecting obstructive sleep apnea: A bivariate meta-analysis. Sleep Med Rev. 2017 Dec;36:57-70. 
  2. Tam S, Woodson BT, Rotenberg B. Outcome measurements in obstructive sleep apnea: beyond the apnea-hypopnea index. Laryngoscope. 2014 Jan;124(1):337-43. doi: 10.1002/lary.24275.
  3. Jehan S, Auguste E, Pandi-Perumal SR, et al. Depression, Obstructive Sleep Apnea and Psychosocial Health. Sleep Med Disord. 2017;1(3):00012.
  4. Weaver TE. Outcome measurement in sleep medicine practice and research. Part 1: assessment of symptoms, subjective and objective daytime sleepiness, health-related quality of life and functional status. Sleep Med Rev. 2001 Apr;5(2):103-128.
  5. Kuhn E, Schwarz EI, Bratton DJ, et al.  Effects of CPAP and Mandibular Advancement Devices on Health-Related Quality of Life in OSA: A Systematic Review and Meta-analysis. Chest. 2017 Apr;151(4):786-794. 

 

Imaging

Learning Objectives 
  1. Describe the following imaging studies and identify their diagnostic significance
  • Cephalometric roentgenograms.
  • Computed tomography
  • Magnetic resonance imaging 

 

References 
  1. Schwab RJ. Upper airway imaging. Clin Chest Med 1998;19: 33-54. 
  2. Neelapu BC et al. Craniofacial and upper airway morphology in adult obstructive sleep apnea patients: A systematic review and meta-analysis of cephalometric studies.  Sleep Med Rev. 2017 Feb;31:79-90.
  3. Abramson Z, Susarla S, August M, Troulis M, Kaban L.  Three-dimensional computed tomographic analysis of airway anatomy in patients with obstructive sleep apnea. J Oral Maxillofac Surg. 2010 68(2):354–362.
  4. Susarla SM, Abramson ZR, Dodson TB, Kaban LB. Cephalometric measurement of upper airway length correlates with the presence and severity of obstructive sleep apnea. J Oral Maxillofac Surg. 2010 68(11):2846–2855.
  5. Barrera JE. Sleep magnetic resonance imaging: dynamic characteristics of the airway during sleep in obstructive sleep apnea syndrome. Laryngoscope. 2011 121(6):1327–1335.
  6. Bhattacharyya N, Blake SP, Fried MP. Assessment of the airway in obstructive sleep apnea syndrome with 3-dimensional airway computed tomography. Otolaryngol Head Neck Surg 2000;123:444–9.
  7. Suratt PM, Dee P, Atkinson RL, et al. Fluoroscopic and computed tomographic features of the pharyngeal airway in obstructive sleep apnea. Am Rev Respir Dis. 1983;127:487–92.

 

Treatment

Learning Objectives 
  1. Identify non-surgical treatments options for adult OSA. 
  2. Compare and contrast different outcome measures including AHI and QOL for surgical and non-surgical therapies for OSA.

Non-surgical therapy: Positive Airway Pressure STOP

  1. Identify indications for PAP therapy in adults.
  2. Become familiar with different interfaces for delivery of PAP therapy in adults with OSA. 
  3. Discuss how to effectively initiate PAP therapy in adults with OSA.
  4. Explain different interventions that can be used to improve PAP usage in adults.
  5. Understand the role of surgery in improving PAP compliance.
  6. Describe the impact of PAP on cardiovascular morbidity and mortality.
  7. Outline appropriate follow-up for OSA patients on PAP therapy. 

Non-surgical therapy: Oral Appliance

  1. Determine which patients with OSA will benefit from oral appliance therapy.
  2. Understand the advantages of a customized, titratable appliance over non-custom oral devices.
  3. Compare and contrast PAP and oral appliance therapy for the treatment of OSA in adults.
  4. Describe how patient specific OSA physiology such as loop gain and arousal threshold impact response to oral appliance therapy.

Non-surgical therapy: Positional Therapy

  1. Identify which patients with OSA are candidates for positional therapy.
  2. Describe outcomes in patients with OSA treated with positional therapy.

Medical therapy: Exercise, Lifestyle Modifications, and Other miscellaneous non-surgical therapies

  1. Describe myofunctional therapy and its role in the treatment of OSA.
  2. Identify the impact of exercise and lifestyle modifications on OSA outcomes such as AHI and daytime sleepiness.

 

 

 

 

 

References 
  1. Epstein LJ, Kristo D, Strollo PJ, Friedman N, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5(3):263–276.
  2. Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015;11(7):773–827.
  3. Woods CM, Gunawardena I, Chia M, et al. Long-term quality-of-life outcomes following treatment for adult obstructive sleep apnoea: comparison of upper airway surgery, continuous positive airway pressure and mandibular advancement splints.  Clin Otolaryngol. 2016 Dec;41(6):762-770.
  4. Robinson S, Chia M, Carney AS, et al. Upper airway reconstructive surgery long-term quality-of-life outcomes compared with CPAP for adult obstructive sleep apnea.  Otolaryngol Head Neck Surg. 2009 Aug;141(2):257-263.

Non-surgical therapy: Positive Airway Pressure STOP

  1. Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2019;15(2):335–343.
  2. Chai CL, Pathinathan A, Smith B. Continuous positive airway pressure delivery interfaces for obstructive sleep apnoea. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005308.
  3. Wozniak DR, Lasserson TJ, Smith I.  Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev. 2014 Jan 8;(1):CD007736. 
  4. Smith I1, Lasserson TJ. Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD003531.
  5. Yu J, Zhou Z, McEvoy RD, Anderson CS, Rodgers A, Perkovic V, Neal B. Association of Positive Airway Pressure With Cardiovascular Events and Death in Adults With Sleep Apnea: A Systematic Review and Meta-analysis. JAMA. 2017 Jul 11;318(2):156-166.
  6. Durán-Cantolla J, Aizpuru F, Montserrat JM, et al. Continuous positive airway pressure as treatment for systemic hypertension in people with obstructive sleep apnoea: randomised controlled trial. BMJ. 2010 Nov 24;341:c5991.
  7. Friedman M, Soans R, Kakodkar S, et al. The effect of multilevel upper airway surgery on continuous positive airway pressure therapy in obstructive sleep apnea/hypopnea syndrome.  Laryngoscope. 2009 Jan;119(1):193-6. 
  8. Camacho M, Riaz M, Capasso R, Ruoff CM, Guilleminault C, Kushida CA, Certal V. The effect of nasal surgery on continuous positive airway pressure device use and therapeutic treatment pressures: a systematic review and meta-analysis. Sleep. 2015 Feb 1;38(2):279-86.

Non-surgical therapy: Oral Appliance

  1. Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015;11(7):773–827.
  2. Doff MH, Hoekema A, Wijkstra PJ, et al. Oral appliance versus continuous positive airway pressure in obstructive sleep apnea syndrome: a 2-year follow-up. Sleep. 2013 Sep 1;36(9):1289-96. 
  3. Anandam A, Patil M, Akinnusi M, et al. Cardiovascular mortality in obstructive sleep apnoea treated with continuous positive airway pressure or oral appliance: an observational study. Respirology. 2013 Nov; 18(8):1184-90.
  4. Bratton DJ1, Gaisl T1, Wons AM1, Kohler M2. CPAP vs Mandibular Advancement Devices and Blood Pressure in Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. JAMA. 2015 Dec 1;314(21):2280-93.
  5. Edwards BA, Andara C, Landry S, et al. Upper-Airway Collapsibility and Loop Gain Predict the Response to Oral Appliance Therapy in Patients with Obstructive Sleep Apnea. Am J Respir Crit Care Med. 2016;194(11):1413-1422.
  6. Sharples L, Glover M, Clutterbuck-James A, et al. Clinical effectiveness and cost-effectiveness results from the randomised controlled Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and long-term economic analysis of oral devices and continuous positive airway pressure. Health Technol Assess.2014 Oct;18(67):1-296.

Non-surgical therapy: Positional Therapy

  1. Epstein LJ; Kristo D; Strollo PJ; Friedman N; Malhotra A; Patil SP; Ramar K; Rogers R; Schwab RJ; Weaver EM; Weinstein MD. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5(3):263- 276.
  2. Ravesloot MJL, White D, Heinzer R, et al. Efficacy of the New Generation of Devices for Positional Therapy for Patients With Positional Obstructive Sleep Apnea: A Systematic Review of the Literature and Meta-Analysis.J Clin Sleep Med. 2017 Jun 15;13(6):813-824.

Medical therapy: Exercise, Lifestyle Modifications, and Other miscellaneous non-surgical therapies

  1. Camacho M, Certal V, Abdullatif J, et al. Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Sleep. 2015;38(5):669-75. Published 2015 May 1.
  2. Aielloa KD, Caugheya WG, Nellurib B, et al. Effect of exercise training on sleep apnea: A systematic review and meta-analysis. Respir Med. 2016 Jul;116:85-92.
  3. Neumannova K, Hobzova M, Sova M, et al. Pulmonary rehabilitation and oropharyngeal exercises as an adjunct therapy in obstructive sleep apnea: a randomized controlled trial. Sleep Med. 2018 Dec;52:92-97. 

 

 

 

 

 

 

Pharmacology

Learning Objectives 
  1. List medications that are indicated for the treatment of daytime sleepiness in adults with OSA.
  2. Identify which patients with OSA would benefit from wake promoting agents such as Modafinil.
  3. Recognize that medical therapy for allergy can improve PAP compliance and sleep quality in patients with OSA and nasal obstruction.

 

References 
  1. Charakorn N, Hirunwiwatkul P, Chirakalwasan N, et al. The effects of topical nasal steroids on continuous positive airway pressure compliance in patients with obstructive sleep apnea: a systematic review and meta-analysis. Sleep Breath. 2017 Mar;21(1):3-8.
  2. Hirshkowitz M, Black J. Effect of adjunctive modafinil on wakefulness and quality of life in patients with excessive sleepiness-associated obstructive sleep apnoea/hypopnoea syndrome: a 12-month, open-label extension study. CNS Drugs. 2007;21(5):407-16.
  3. Sukhal S, Khalid M, Tulaimat A.  Effect of Wakefulness-Promoting Agents on Sleepiness in Patients with Sleep Apnea Treated with CPAP: A Meta-Analysis. J Clin Sleep Med. 2015 Oct 15;11(10):1179-86.
  4. Morgenthaler TI; Kapen S; Lee-Chiong T et al. Practice parameters for the medical therapy of obstructive sleep apnea. SLEEP 2006;29(8):1031-1035.

 

Surgical Therapies

Learning Objectives 

See OTOSource module: Surgical Treatment of OSA 

Complications

Learning Objectives 
  1. Recognize that surveillance is required for dental-related side effects or occlusal changes in patients with OSA treated with oral appliance devices.
  2. Recognize complications of PAP therapy that can lead to decreased compliance.

 

References 
  1. Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015;11(7):773–827.
  2. Baltzan MA1, Elkholi O, Wolkove N. Evidence of interrelated side effects with reduced compliance in patients treated with nasal continuous positive airway pressure Sleep Med. 2009 Feb;10(2):198-205.

 

Review

Review Questions 
  1. Which patients with OSA may benefit from MAD therapy?
  2. What strategies can be utilized to improve PAP therapy compliance in patients with OSA?
  3. Which patients with OSA are candidates for wake-promoting medications?

 

Resources 

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  1. Annual Meeting Webcast (AMW):
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