Obstructive sleep apnea - management update

Abstract

Obstructive sleep apnea (OSA) is a highly significant condition based both on the high prevalence in community and significant consequences. Obstructive sleep apnea syndrome (OSAS), OSA together with hypersomnolence, is seen in 4% of middle-aged men and 2% of middle-aged women. OSA is associated with impaired quality of life and increased risks of motor vehicle accidents, cardiovascular disease (including hypertension and coronary artery disease), and metabolic syndrome. There is some evidence for the use of conservative interventions such as weight loss and position modification. CPAP remains the mainstay of treatment in this condition with high-level evidence supporting its efficacy. Continuous positive airway pressure (CPAP) is an intrusive therapy, with long-term adherence rates of less than 70%. Dental appliances have been shown to be effective therapy in some subjects but are limited by the inability to predict treatment responders. Alternative treatments are discussed but there is little role for upper airway surgery (except in a select few experienced institutions) or pharmacological treatment. The current levels of evidence for the different treatment regimens are reviewed.

Keywords: obstructive sleep apnea; review; treatment.

Figure 1

Five-minute epoch of supine Stage II sleep in a subject with severe OSA. Cessation (apnea) in breathing (a) result in arterial oxygen desaturation (b) and EEG arousal from sleep (c). Chest wall motion continues during the apneas indicating that the events are due to upper airway obstruction.

Figure 2

Subject demonstrating the principle of nasal CPAP. The flow generator (a) delivers air through a smooth tube (b) to the mask (c) from which the air is vented (d) generating pressure in the mask which is transmitted to the upper airway.

Figure 3

Proportion of patients continuing CPAP over time. The proportion adhering to CPAP continues to fall over the first 4 years of therapy. Reprinted from McArdle N, Devereux G, Heinarnejad H, et al. 1999. Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med, 159:1108–14. Copyright © 1999, with permission from American Thoracic Society.

Figure 4

Mandibular advancement splints showing both adjustable appliance (a) which uses a hinge to adjust mandibular advancement or one-piece mono-block appliance (b) with fixed mandibular advancement.