Treatment is recommended for all patients with an AHI or respiratory-event index of ≥15 events per hour or 5–14 events per hour with symptoms of sleepiness, impaired cognition, mood disturbance or insomnia or with pre-existing conditions such as hypertension, ischaemic heart disease or a history of stroke (Veasey & Rosen, 2019).
Studies have shown evidence for body weight as an important factor in determining the evolution of sleep apnea. In the Sleep Heart Health Study, compared with a stable weight over treatment follow-up, men with a weight gain more than 10 kg had a 5.2-fold increase in AHI. For a comparable gain in weight, women had a 2.5-fold risk of AHI increase (Punjabi et al., 2008). Although weight loss is recommended (ELF, 2019) and known to decrease severity of OSA, it is commonly difficult to achieve and sustain.
There is no medication available for the treatment of OSA. Attempts to develop pharmacotherapy to increase upper airway muscle activity or target the respiratory arousal threshold or loop gain have been, and continue to be, evaluated (Osman et al., 2018).
Continuous positive airway pressure (CPAP) is the gold standard therapy to prevent upper airway collapse and reduce OSA severity. CPAP applies positive pressure to the patients’ upper airway using a nasal (figure 12) or oronasal mask (figure 13).
There is convincing evidence that CPAP treatment can reduce AHI to <5 events per hour in most patients and alleviate daytime and nighttime symptoms such as sleepiness, fatigue, intellectual impairment, restlessness and restless sleep (Veasey & Rosen, 2019).
Studies have shown that CPAP:
- markedly improves self-perception and vitality (Siccoli et al., 2008)
- reduces fatigue and daytime sleepiness (Tomfohr et al., 2011)
- reduces risk of motor vehicle accidents (MVA) (George et al., 2001)
- lowers 24-hour systolic blood pressure by 4 mm Hg (Faccenda et al., 2001)
While the effects of CPAP for cardiovascular events in obstructive sleep apnea are unclear, it is widely recognised that CPAP can result in near complete resolution of symptoms only if the patient is adherent (NICE, 2018; Slowik & Collen, 2017; Patil et al., 2019).
CPAP does require patient cooperation to position the mask correctly and adhere to the therapy and compliance is estimated to be around 75% of patients using it for >4 hours per night for >70% of nights (Veasey & Rosen, 2019).
For patients who can’t tolerate high pressure, bilevel positive airway pressure (BPAP) is an alternative to CPAP. A bilevel machine delivers a low expiratory pressure during exhalation and a higher inspiratory pressure during inhalation.
Alternative options for patients with mild OSA who decline or are unable to use CPAP may be to use an oral appliance, positional therapy or surgical correction. Referrals within the sleep centre are often made if this is the case.
These are custom-made devices inserted into the mouth to generally advance the mandible to help enlarge the upper airway. Intra-oral devices are appropriate for patients who snore or have mild to moderate OSA with normal daytime alertness. Oral appliance therapy is associated with clinically relevant decreases in the AHI (Vecchierini et al., 2016). However, adverse events such as tooth pain, changes in tooth position resulting in a different occlusion and articulation, or temporomandibular dysfunction can limit adherence to this therapy (Doff MH et al., 2012; 2013). They are not generally as effective as CPAP in reducing the AHI, but compliance is generally better (Phillips et al., 2013).
For OSA with a strong positional component (POSA), alternatives include the use of specific treatments designed to avoid the supine sleeping position. A small lightweight positional therapy device that emits gentle vibrations can be used to remind the patient not to sleep on their back (figure 14). In a randomised, prospective, multicenter trial in patients with mild to moderate POSA, compliance with the sleep position trainer device was high and efficacy of this therapy was maintained over 12 months (de Ruiter et al., 2018).
Sleep position trainer devices have been shown to reduce AHI score by 46–69%
(van Maanen et al., 2013; de Ruiter et al., 2018).
Visit the Sleep and Breathing conference 2019 section to learn more about the benefits of sleep position trainer devices for POSA. Professor Nico de Vries describes the benefits of a positional therapy device and Professor David White summarises data from a six-week crossover trial comparing positional therapy and CPAP which suggests that the sleep position trainer is as good as CPAP in reducing the AHI, with better adherence, and so should be considered a first-line therapy for POSA (J Clin Sleep Med, In press).
The most common types of surgical interventions for sleep apnea are uvulopalatopharyngoplasty (UPPP) and maxillomandibular advancement (MMA). UPPP is an invasive procedure that removes soft tissue on the back of the throat and palate and increases the width of the airway, while MMA can be used to correct certain facial problems. Surgery can be an option for patients who are unresponsive, noncompliant, or desire a permanent treatment for their OSA (Caples et al., 2010; Zaghi et al., 2016).
Surgical removal of the adenoids and tonsils is the most common treatment for paediatric OSA. In uncomplicated cases, the operation results in complete elimination of OSA symptoms in 70–90% of the time (American Sleep Apnea Association, 2017).
Another option is an implantable hypoglossal nerve stimulator which works reasonably well in very specific patients, but devices are relatively expensive. The aim is to move the tongue forwards and keep the airway open. A recent report of a 5-year follow-up of a cohort of patients who underwent this procedure showed a sustained effect with clinically relevant improvement (<20 AHI per hour and >50% reduction in AHI) in 75% of patients with rare adverse events (Woodson et al., 2018).
Visit the Sleep and Breathing conference 2019 section to learn more about treatment options for POSA. Professor Nico de Vries describes the benefits of a positional therapy device either alone or in addition to continuous positive upper airway pressure (CPAP), oral devices and upper airway surgery.
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