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). One other recent publication of specific interest for otolaryngologists is a large multicenter retrospective review on the treatment outcomes for OSA after an adenotonsillectomy. This review included 578 children of which 90 percent of the children were less than 13 years of age. Fifty percent of the children were obese (BMI > 95%). Only 27% of the children had complete resolution of OSA (AHI < 1 total sleep time) while 21.6% had an AHI>5/hr TST. Surgical success was variable and depended upon outcome measures selected. So success is as low as 27% (AHI of < 1) or as high as 78% (AHI <5). Fifty nine percent of the obese children had an AHI>5/hr TST. An analysis of factors which were associated with an elevated post-operative AHI in order of influence were age > 7 years, elevated BMI, presence of asthma and more severe OSA pre-operatively.
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)
- Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, Mitchell RB, Promchiarak J,Simakajornboon N, Kaditis AG, Splaingard D, Splaingard M, Brooks LJ, Marcus CL,Sin S, Arens R, Verhulst SL, Gozal D. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med. 2010 Sep 1;182(5):676-83. Epub 2010 May 6. PubMed PMID: 20448096.
- 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.
- 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.
- 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
- 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.
- 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.
Important Disclaimer Notice
Position statements are approved by the American Academy of OtolaryngologyHead and Neck Surgery, Inc. or Foundation (AAO-HNS/F) Boards of Directors and are typically generated from AAO-HNS/F committees. Once approved by the Academy or Foundation Board of Directors, they become official position statements and are added to the existing position statement library. In no sense do they represent a standard of care. The applicability of position statements, as guidance for a procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical position statements will not ensure successful treatment in every situation. As with all AAO-HNS/F guidance, this position statement 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.