Diagnosis and Treatment of Obstructive Sleep Apnea in Adults

 

Am Fam Physician. 2016 Sep 1;94(5):355-360.

  Patient information: See related handout on obstructive sleep apnea, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Obstructive sleep apnea is a common disorder that causes patients to temporarily stop or decrease their breathing repeatedly during sleep. This results in fragmented, nonrestful sleep that can lead to symptoms such as morning headache and daytime sleepiness. Obstructive sleep apnea affects persons of all ages, with an increasing prevalence in those older than 60 years. The exact prevalence is unknown but is estimated to be between 2% and 14%. There are many health conditions associated with obstructive sleep apnea, including hypertension, coronary artery disease, cardiac arrhythmias, and depression. Loud snoring, gasping during sleep, obesity, and enlarged neck circumference are predictive clinical features. Screening questionnaires can be used to assess for sleep apnea, although their accuracy is limited. The diagnostic standard for obstructive sleep apnea is nocturnal polysomnography in a sleep laboratory. Home sleep apnea tests can be performed for certain patients but are generally considered less accurate. Continuous positive airway pressure is the first-line treatment; adherence rates are variable and seem to improve with early patient education and support. Other treatment modalities include weight reduction, oral appliance therapy, and surgery to correct anatomic obstructions, although there is insufficient evidence to support these types of surgeries. Bariatric surgery can improve sleep parameters and symptoms in obese patients with obstructive sleep apnea and can result in remission in many patients.

Obstructive sleep apnea (OSA) is a common, chronic disorder that disrupts breathing during sleep. It affects persons of all ages but especially those middle-aged and older.1 Patients with OSA temporarily stop or decrease their breathing (apnea or hypopnea, respectively) repeatedly during sleep.25 This cessation or decrease in breathing is the result of repetitive partial or complete obstruction of the airway caused by narrowing of the respiratory passages.4,68 These breathing disruptions can awaken a person or prevent deep, restful sleep. The effects of fragmented sleep on daytime fatigue and sleepiness are widely recognized.3,6

WHAT IS NEW ON THIS TOPIC: OBSTRUCTIVE SLEEP APNEA

In patients with obstructive sleep apnea, continuous positive airway pressure lowers blood pressure and rates of arrhythmia and stroke, improves left ventricular ejection fraction in patients with heart failure, and reduces fatal and nonfatal cardiovascular events.

A recent meta-analysis demonstrated similar rates of blood pressure lowering between continuous positive airway pressure and mandibular advancement devices.

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BEST PRACTICES IN SLEEP MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not perform positive airway pressure retitration studies in asymptomatic, adherent patients with sleep apnea and stable weight.

American Academy of Sleep Medicine

Do not routinely order sleep studies (polysomnogram) to screen for/diagnose sleep disorders in workers with chronic fatigue/insomnia.

American College of Occupational and Environmental Medicine


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN SLEEP MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not perform positive airway pressure retitration studies in asymptomatic, adherent patients with sleep apnea and stable weight.

American Academy of Sleep Medicine

Do not routinely order sleep studies (polysomnogram) to screen for/diagnose sleep disorders in workers with chronic fatigue/insomnia.

American College of Occupational and Environmental Medicine


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Although the American Academy of Sleep Medicine advocates for physicians to ask all patients about signs and symptoms of OSA, the U.S. Preventive Services Task Force has no position on this issue, and there are no good outcome studies of net benefit for screening unselected populations.

C

6

Overnight polysomnography performed in a sleep laboratory in the presence of an attendant is considered the diagnostic standard for OSA.

C

4, 6, 7, 11, 2224

In obese patients with OSA, bariatric surgery can result in improvement and remission.

A

57, 58


OSA = obstructive sleep apnea.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For

The Authors

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MICHAEL SEMELKA, DO, FAAFP, is the family medicine department chair and director of the Family Medicine Residency Program at Excela Health Latrobe (Pa.) Hospital....

JONATHAN WILSON, MD, is a faculty member in the Family Medicine Residency Program at Excela Health Latrobe Hospital.

RYAN FLOYD, MD, is a faculty member in the Family Medicine Residency Program at Excela Health Latrobe Hospital. At the time the article was submitted, Dr. Floyd was a third-year family medicine resident at Excela Health Latrobe Hospital.

Author disclosure: No relevant financial affiliations.

Address correspondence to Michael Semelka, DO, Excela Health Latrobe Hospital, One Mellon Way, Latrobe, PA 15650 (e-mail: msemelka@excelahealth.org). Reprints are not available from the authors.

REFERENCES

show all references

1. Qaseem A, et al. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013;159(7):471–483....

2. Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and treatment of obstructive sleep apnea in adults. Comparative Effectiveness Review no. 32. AHRQ publication no. 11-EHC052-EF. Rockville, Md.: Agency for Health Care Research and Quality; July 2011.

3. Greenstone M, Hack M. Obstructive sleep apnoea. BMJ. 2014;348:g3745.

4. Qaseem A, et al. Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(3):210–220.

5. Bratton DJ, Stradling JR, Barbé F, Kohler M. Effect of CPAP on blood pressure in patients with minimally symptomatic obstructive sleep apnoea: a meta-analysis using individual patient data from four randomised controlled trials. Thorax. 2014;69(12):1128–1135.

6. Balachandran JS, Patel SR. In the clinic: obstructive sleep apnea. Ann Intern Med. 2014;161(9):ITC1–ITC15.

7. Myers KA, Mrkobrada M, Simel DL. Does this patient have obstructive sleep apnea? The rational clinical examination systematic review. JAMA. 2013;310(7):731–741.

8. Mohsenin V. Obstructive sleep apnea and hypertension: a critical review. Curr Hypertens Rep. 2014;16(10):482.

9. Krishnan V, Dixon-Williams S, Thornton JD. Where there is smoke… there is sleep apnea: exploring the relationship between smoking and sleep apnea. Chest. 2014;146(6):1673–1680.

10. Bixler EO, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001;163(3 pt 1):608–613.

11. Zancanella E, et al. Obstructive sleep apnea and primary snoring: diagnosis [published correction appears in Braz J Otorhinolaryngol. 2014;80(5):457]. Braz J Otorhinolaryngol. 2014;80(1 suppl 1):S1–S16.

12. Raghuram A, Clay R, Kumbam A, Tereshchenko LG, Khan A. A systematic review of the association between obstructive sleep apnea and ventricular arrhythmias. J Clin Sleep Med. 2014;10(10):1155–1160.

13. Qin B, Sun Z, Liang Y, Yang Z, Zhong R. The association of 5-HT2A, 5-HTT, and LEPR polymorphisms with obstructive sleep apnea syndrome: a systematic review and meta-analysis. PLoS One. 2014;9(4):e95856.

14. Hartenbaum N, Collop N, Rosen IM, et al. Sleep apnea and commercial motor vehicle operators: statement from the joint task force of the American College of Chest Physicians, the American College of Occupational and Environmental Medicine, and the National Sleep Foundation. Chest. 2006;130(3):902–905.

15. Povitz M, Bolo CE, Heitman SJ, Tsai WH, Wang J, James MT. Effect of treatment of obstructive sleep apnea on depressive symptoms: systematic review and meta-analysis. PLoS Med. 2014;11(11):e1001762.

16. Lee W, et al. Epidemiology of obstructive sleep apnea: a population-based perspective. Expert Rev Respir Med. 2008;2(3):349–364.

17. Shahar E, Whitney CW, Redline S, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001;163(1):19–25.

18. Wheaton AG, Perry GS, Chapman DP, Croft JB. Sleep disordered breathing and depression among U.S. adults: National Health and Nutrition Examination Survey, 2005–2008. Sleep. 2012;35(4):461–467.

19. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004;291(16):2013–2016.

20. Kasai T, Floras JS, Bradley TD. Sleep apnea and cardiovascular disease: a bidirectional relationship. Circulation. 2012;126(12):1495–1510.

21. Drager LF, Brunoni AR, Jenner R, Lorenzi-Filho G, Benseñor IM, Lotufo PA. Effects of CPAP on body weight in patients with obstructive sleep apnoea: a meta-analysis of randomised trials. Thorax. 2015;70(3):258–264.

22. Walia R, et al. Are at-home sleep studies performed using portable monitors (PMs) as effective at diagnosing obstructive sleep apnea (OSA) in adults as sleep laboratory-based polysomnography (PSG)? J Okla State Med Assoc. 2014;107(12):642–644.

23. Epstein LJ, Kristo D, Strollo PJ Jr, et al.; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. 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.

24. John M. Eisenberg Center for Clinical Decisions and Communications Science. Comparative effectiveness of diagnosis and treatment of obstructive sleep apnea in adults. August 8, 2011. In: Comparative Effectiveness Review Summary Guides for Clinicians. Rockville, Md.: Agency for Healthcare Research and Quality (US); 2011. http://www.ncbi.nlm.nih.gov/books/NBK63965/. Accessed January 15, 2016.

25. Veloro LV, Sarte MA, Castañeda SS. Collar size as predictor of obstructive sleep apnea. Philipp J Otolaryngol Head Neck Surg. 2008;23(2):14–16.

26. Flemons WW, et al. Likelihood ratios for a sleep apnea clinical prediction rule. Am J Respir Crit Care Med. 1994;150(5 pt 1):1279–1285.

27. Chung F, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812–821.

28. Nagappa M, et al. Validation of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea among different populations: a systematic review and meta-analysis. PLoS One. 2015;10(12):e0143697.

29. Chung F, Yang Y, Liao P. Predictive performance of the STOP-Bang score for identifying obstructive sleep apnea in obese patients. Obes Surg. 2013;23(12):2050–2057.

30. Fenton ME, Heathcote K, Bryce R, et al. The utility of the elbow sign in the diagnosis of OSA. Chest. 2014;145(3):518–524.

31. Centers for Medicare & Medicaid Services. Decision memo for continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA) (CAG-00093R2). Baltimore, Md.: Centers for Medicare & Medicaid Services; 2008. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=204. Accessed May 19, 2016.

32. Collop NA, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007;3(7):737–747.

33. El Shayeb M, et al. Diagnostic accuracy of level 3 portable sleep tests versus level 1 polysomnography for sleep-disordered breathing: a systematic review and meta-analysis. CMAJ. 2014;186(1):E25–E51.

34. Chai-Coetzer CL, Antic NA, Rowland LS, et al. A simplified model of screening questionnaire and home monitoring for obstructive sleep apnoea in primary care. Thorax. 2011;66(3):213–219.

35. Shelton KE, Woodson H, Gay S, Suratt PM. Pharyngeal fat in obstructive sleep apnea. Am Rev Respir Dis. 1993;148(2):462–466.

36. Schwartz AR, et al. Effect of weight loss on upper airway collapsibility in obstructive sleep apnea. Am Rev Respir Dis. 1991;144(3 pt 1):494–498.

37. Randerath WJ, et al.; European Respiratory Society task force on non-CPAP therapies in sleep apnoea. Non-CPAP therapies in obstructive sleep apnoea. Eur Respir J. 2011;37(5):1000–1028.

38. Bignold JJ, Deans-Costi G, Goldsworthy MR, et al. Poor long-term patient compliance with the tennis ball technique for treating positional obstructive sleep apnea. J Clin Sleep Med. 2009;5(5):428–430.

39. de Vries GE, et al. Usage of positional therapy in adults with obstructive sleep apnea. J Clin Sleep Med. 2015;11(2):131–137.

40. Gay P, Weaver T, Loube D, Iber C; Positive Airway Pressure Task Force; Standards of Practice Committee; American Academy of Sleep Medicine. Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep. 2006;29(3):381–401.

41. Chai CL, Pathinathan A, Smith B. Continuous positive airway pressure delivery interfaces for obstructive sleep apnoea. Cochrane Database Syst Rev. 2006;(4):CD005308.

42. Quinnell TG, Clutterbuck-James AL. Alternatives to continuous positive airway pressure 2: mandibular advancement devices compared. Curr Opin Pulm Med. 2014;20(6):595–600.

43. Wolkove N, Baltzan M, Kamel H, Dabrusin R, Palayew M. Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea. Can Respir J. 2008;15(7):365–369.

44. Sin DD, Mayers I, Man GC, Pawluk L. Long-term compliance rates to continuous positive airway pressure in obstructive sleep apnea: a population-based study. Chest. 2002;121(2):430–435.

45. Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;5(2):173–178.

46. 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;(1):CD007736.

47. Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365(9464):1046–1053.

48. Phillips CL, Grunstein RR, Darendeliler MA, et al. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med. 2013;187(8):879–887.

49. Iftikhar IH, Valentine CW, Bittencourt LR, et al. Effects of continuous positive airway pressure on blood pressure in patients with resistant hypertension and obstructive sleep apnea: a meta-analysis. J Hypertens. 2014;32(12):2341–2350.

50. Kaneko Y, Floras JS, Usui K, et al. Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea. N Engl J Med. 2003;348(13):1233–1241.

51. Littner M, Hirshkowitz M, Davila D, et al. Practice parameters for the use of auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome. An American Academy of Sleep Medicine report. Sleep. 2002;25(2):143–147.

52. Chan AS, Lee RW, Cistulli PA. Non-positive airway pressure modalities: mandibular advancement devices/positional therapy. Proc Am Thorac Soc. 2008;5(2):179–184.

53. Colrain IM, Black J, Siegel LC, et al. A multicenter evaluation of oral pressure therapy for the treatment of obstructive sleep apnea. Sleep Med. 2013;14(9):830–837.

54. Ramar K, Dort LC, Katz SG, et al. 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.

55. Bratton DJ, Gaisl T, Wons AM, Kohler M. CPAP vs mandibular advancement devices and blood pressure in patients with obstructive sleep apnea: a systematic review and meta-analysis. JAMA. 2015;314(21):2280–2293.

56. Sundaram S, Bridgman SA, Lim J, Lasserson TJ. Surgery for obstructive sleep apnoea. Cochrane Database Syst Rev. 2005;(4):CD001004.

57. Sarkhosh K, Switzer NJ, El-Hadi M, Birch DW, Shi X, Karmali S. The impact of bariatric surgery on obstructive sleep apnea: a systematic review. Obes Surg. 2013;23(3):414–423.

58. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis [published correction appears in JAMA. 2005;293(14):1728]. JAMA. 2004;292(14):1724–1737.

59. Strollo PJ Jr, Soose RJ, Maurer JT, et al.; STAR Trial Group. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med. 2014;370(2):139–149.

60. Victor LD. Treatment of obstructive sleep apnea in primary care. Am Fam Physician. 2004;69(3):561–569.


 

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