Each recommendation is rated based on the level of the recommendation. Definitions of the levels of the evidence (levels I-V) and levels of the recommendations (Standard, Guideline, Option) are presented at the end of the "Major Recommendations" field.
Weight Reduction
Successful dietary weight loss may improve the apnea-hypopnea index (AHI) in obese obstructive sleep apnea (OSA) patients. (Guideline)
This parameter is based on one Level I, one Level II, and 2 Level III papers.
Dietary weight loss should be combined with a primary treatment for OSA. (Kushida et al., 2005; Kushida et al., 2006; American Sleep Disorders Association, 1996) (Option)
Bariatric surgery may be adjunctive in the treatment of OSA in obese patients. (Option)
There are no Level I-III studies of bariatric surgery for OSA specifically. However, many non-randomized, uncontrolled investigations are now available, show improvements in AHI with weight loss, and therefore there is consensus among members of the Task Force and the Standards of Practice Committee that bariatric surgery may play a role in the treatment of morbidly obese OSA patients as an adjunct to less invasive and rapidly active first-line therapies such as positive airway pressure (PAP).
Pharmacologic Agents
Selective serotonergic uptake inhibitors (SSRIs) are not recommended for treatment of OSA. (Standard)
The above recommendation is derived from 2 Level II publications and one level V using paroxetine and fluoxetine.
Protriptyline is not recommended as a primary treatment for OSA. (Guideline)
Three Level II and one Level V papers form the basis of this recommendation.
Methylxanthine derivatives (aminophylline and theophylline) are not recommended for treatment of OSA. (Standard)
For this recommendation, there are 3 Level II publications, all of which report similar negative findings.
Estrogen therapy (estrogen preparations with or without progesterone) is not indicated for the treatment of OSA. (Standard)
This recommendation is based on the results of 4 Level I, 3 Level II, and one Level V publications.
Modafinil is recommended for the treatment of residual excessive daytime sleepiness in OSA patients who have sleepiness despite effective positive airway pressure (PAP) treatment and who are lacking any other identifiable cause for their sleepiness. (Standard)
All five studies included in the review (3 Level I, one Level II, and one Level V) attest to the partial effectiveness of modafinil in the management of residual sleepiness in patients with treated OSA who have no other identifiable reason for hypersomnolence.
Supplemental Oxygen
Oxygen supplementation is not recommended as a primary treatment for OSA. (Option)
There are 2 Level II and 2 Level III studies that show oxygen administration improves oxygenation parameters in patients with OSA.
Medical Therapies Intended To Improve Nasal Patency
Short-acting nasal decongestants are not recommended for treatment of OSA. (Option)
One level II study showed little additive effect of oxymetazoline to positional therapy in improving AHI.
Topical nasal corticosteroids may improve the AHI in patients with OSA and concurrent rhinitis, and thus may be a useful adjunct to primary therapies for OSA. (Guideline)
This recommendation is based upon the results of one level I study that demonstrated an improvement in mean AHI from 20 to 12 events/hr using fluticasone nasal spray.
Positional Therapies
Positional therapy, consisting of a method that keeps the patient in a non-supine position, is an effective secondary therapy or can be a supplement to primary therapies for OSA in patients who have a low AHI in the non-supine versus that in the supine position. (Guideline)
Patients who normalize their AHI when they sleep in a nonsupine position tend to have less severe OSA, to be less obese, and to be younger. Three Level II studies form the basis for this practice parameter, one of which compared supine with an upright position.
Definitions:
American Academy of Sleep Medicine Classification of Evidence
Level I Randomized well-designed trials with low alpha and beta levels*
Level II Randomized trials with high alpha and beta levels*
Level III Nonrandomized concurrently controlled studies
Level IV Nonrandomized historically controlled studies
Level V Case series
*Alpha (type I error) refers to the probability that the null hypothesis is rejected when in fact it is true (generally acceptable at 5% or less, or p<0.05). Beta (Type II error) refers to the probability that the null hypothesis is mistakenly accepted when in fact it is false (generally trials accept a beta error of 0.20). The estimation of Type II error is generally the result of a power analysis. The power analysis takes into account the variability and the effect size to determine if sample size is adequate to find a difference in means when it is present (Power generally acceptable at 80-90%).
American Academy of Sleep Medicine Levels of Recommendations
Standard This is a generally accepted patient-care strategy, which reflects a high degree of clinical certainty. The term standard generally implies the use of Level I Evidence, which directly addresses the clinical issue, or overwhelming Level II Evidence.
Guideline This is a patient-care strategy, which reflects a moderate degree of clinical certainty. The term guideline implies the use of Level II Evidence or a consensus of Level III Evidence.
Option This is a patient-care strategy, which reflects uncertain clinical use. The term option implies either inconclusive or conflicting evidence or conflicting expert opinion.
