Treatment of Obstructive Sleep Apnea

Treatment of Obstructive Sleep Apnea- Overview 

Obstructive Sleep Apnea(OSA) is a common disorder involving collapse of the upper airway during sleep. This repetitive collapse results in sleep fragmentation, hypoxemia, hypercapnia, increased sympathetic activity. As specialists in upper airway anatomy, physiology and surgery, Otolaryngologists are uniquely qualified to treat patients with OSA. In the Clinical Guidelines for Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults, it is  recommended that evaluation for primary surgical treatment be considered in select patients who have severe obstructing anat¬omy that is surgically correctible (e.g., tonsillar hypertrophy obstructing the pharyngeal airway) and in patients in whom continuous positive airway pressure (CPAP) therapy is inadequate.(Epstein, EJ, Evidence Based Clinical Guideline)

Surgical treatment of pediatric sleep disordered breathing with tonsillectomy and adenoidectomy is the recommended first line treatment.  In the pediatric population, resolution of OSA occurs in 82% of patients who are treated with tonsillectomy and adenoidectomy. (Breitzke,S, Meta-analysis)

In most patients with moderate to severe OSA, continuous positive airway pressure (CPAP) is the first line treatment.  Successful long term treatment of OSA with CPAP is difficult to achieve and fewer than 50% of patients on CPAP are adequately treated, as defined by 4 hours of use 70% of nights.(Weaver, TE, Level 2 evidence and Kribbs, NB, Level 2 evidence) Other treatment options must be available to patients with OSAS.

“Surgical pro¬cedures may be considered as a secondary treatment for OSA when the outcome of PAP therapy is inadequate, such as when the patient is intolerant of CPAP, or CPAP therapy is unable to eliminate OSA (Consensus). Surgery may also be considered as a secondary therapy when there is an inadequate treatment out¬come with an oral appliance (OA), when the patient is intolerant of the OA, or the OA therapy provides unacceptable improvement of clinical outcomes of OSA (Consensus). Surgery may also be considered as an adjunct therapy when obstructive anatomy or functional deficiencies compromise other therapies or to improve toler¬ance of other OSA treatments (Consensus)”(Epstein, EJ) Surgery for OSAS has been shown to improve important clinical outcomes including survival and quality of life. (Weaver, EM. Level 2 evidence)

References
1. Epstein,EJ,(Chair), Kristo,D, Strollo, Jr.PJ, Clinical Guidelines for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults. J Clin Sleep Med 5(3):263-79, 2009.

2. Brietzke S, Gallagher D, The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: A meta-analysis
Otolaryngol Head Neck Surg, 134(6), 979-984, 2006.

3. Weaver TE, Grunstein RR; Adherence to continuous positive airway pressure therapy: the challenge to effective treatment, Proc Am Thorac Soc. 5(2):173-8, 2008

4. Kribbs NB, Pack AI, Kline LR, et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis. 147:887-95.1993.

5. Weaver EM, Maynard C, Yueh B. Survival of veterans with sleep apnea: continuous positive airway pressure versus surgery. Otolaryngol Head Neck Surg 130(6):659-65. 2004.

Adopted 5/3/2010

Guidelines are not a substitute for the experience and judgment of a physician and are developed to enhance the physicians' ability to practice evidence-based medicine.

Important Notice

The American Academy of Otolaryngology-Head and Neck Surgery, Inc. and Foundation (AAO-HNS/F) Policy Statements are guidelines only. In no sense do they represent a standard of care. The applicability of an indicator for a procedure, and/or of the process or outcome criteria, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these guidelines will not ensure successful treatment in every situation. The AAO-HNS emphasizes that these policies should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results.