Treatment for Mild, Moderate, or Severe OSA
Key Points:
- The treatment of OSA includes oral devices and various positive airway pressure devices
- A CPAP with heated humidity is strongly suggested for patients with a past history of ear, nose and throat (ENT) surgeries, taking drying medications, or have chronic nasal congestion. In all other patients, it may be cost effective and increase comfort and adherence to order CPAP with heated humidity.
- Surgical interventions may be helpful in the treatment of OSA.
For patients who have not responded to lifestyle modification, additional treatment options are available and are based on the severity of OSA.
There are three options for treatment of mild OSA. A combination of the treatment options listed below may be necessary to adequately manage the symptoms of OSA.
Positive Airway Pressure (PAP) Devices
CPAP
Positive pressure is the most efficacious (next to tracheostomy) for treating OSA. CPAP is currently the most commonly used positive airway pressure device. It is a non-invasive/non-pharmacologic method of applying positive pressure to the upper airway via a blower and mask/interface to pneumatically splint the airway thereby preventing collapse. Therapeutic CPAP pressures are generally determined by manual titration during a polysomnogram resulting in a final fixed pressure that eliminates apneic and hypopneic episodes in all stages of sleep and body positions, diminishes sleep fragmentation, snoring, and oxygen desaturations, thereby improving daytime function. Self-titrating CPAP (AutoPAP) can also be utilized for determining an effective CPAP pressure (see below) [A].
The success of any positive airway pressure device therapy depends primarily on patient adherence, which can be enhanced by education, proper mask/interface fit, frequent follow-up by the clinician and durable medical equipment (DME) provider, and finally, A.W.A.K.E. (Alert Well And Keeping Energetic) meetings. (See Appendix B, "Management Tips to Improve Adherence with Therapy" in the original guideline document.) A heated humidifier is strongly suggested in patients with the following circumstances:
- The patient is currently taking drying medications
- Past history of ENT surgeries
- Chronic nasal congestion
In all other patients, it may be cost effective and still improve comfort and adherence to order CPAP with heated humidity.
Flexible CPAP is an option that may improve adherence for patients who have difficulty with CPAP [C].
AutoPAP (AutoPAP, Self-titrating CPAP, Auto-adjust CPAP)
AutoPAP is a positive pressure apparatus designed to vary pressures to meet the needs of the patient's sleep-disordered breathing. Pressure changes are determined by monitoring variably a combination of apneas, hypopneas, inspiratory flow limitation, and snoring. Instead of constant maximal pressure, these systems provide the minimal pressure necessary to stabilize the upper airway. The pressures found by these machines generally agree well with those established by skilled technicians [A], [D].
AutoPAP may be used as an alternative therapy for patients who are intolerant of pressures in conventional CPAP therapy and may be used for an unattended in-home CPAP titration after a positive sleep study or when follow-up indicates a need for CPAP pressure change [A]. It is important to follow-up with patients to determine treatment effectiveness.
The success of any positive airway pressure device therapy depends primarily on patient adherence, which can be enhanced by education, proper mask/interface fit, frequent follow-up by the clinician and durable medical equipment (DME) provider, and finally, A.W.A.K.E. meetings. (See Appendix B, "Management Tips to Improve Adherence with Therapy" in the original guideline document) [R].
Bi-level PAP
Bi-level PAP is a non-invasive respiratory device which delivers different levels of inspiratory (IPAP) and expiratory (EPAP) pressure to a spontaneously breathing patient to keep the upper airway open. By applying a lower pressure during the expiratory phase, the total pressure applied on the airway can then be reduced, thereby achieving closer to normal physiologic breathing.
Bi-level devices have additional flow delivery methods to meet the ventilatory needs of patients with varied respiratory problems and have been shown therapeutic for OSA. Theoretical advantages of bi-level devices include reducing the work of breathing, lowering of mean treatment pressure, and a more physiologic breathing pattern. These possible advantages make a trial of bi-level devices an appropriate intervention for selected OSA patients who do not tolerate continuous pressure or auto-titrating devices. Patients with concurrent or more severe chronic obstructive pulmonary disease or hypoventilation syndromes may also benefit, particularly if they have awake hypercapnia, but very specific criteria must be met to enable Medicare reimbursement. Although selected patients may benefit, the use of bi-level devices as initial treatment for OSA is not encouraged, since bi-level devices have not been demonstrated to be superior to CPAP in improving adherence, symptom scores, nasal discomfort, or patient complaints regarding therapy. If used, the therapeutic IPAP and EPAP pressures must be achieved by manual titration during an attended polysomnogram and many patients can resume CPAP if retitration reveals improvement in sleep-disordered breathing with adjustment of pressure [A], [C].
Bi-level is applied to the patient via nasal mask interface or a full-face interface. Bi-level is indicated not only to correct OSA, but may be used as an alternate therapy for patients who are intolerant of conventional CPAP at higher pressures. Bi-level reduces the work of breathing and lowers the mean pressure delivered in the airway.
The success of any positive airway pressure device therapy depends primarily on patient adherence, which can be enhanced by education, proper mask/interface fit, frequent follow-up by the clinician and DME provider, and finally, A.W.A.K.E. meetings. (See Appendix B, "Management Tips to Improve Adherence with Therapy" in the original guideline document) [R].
Oral Appliances
Oral appliances are a recommended treatment for patients with mild OSA who have not responded to lifestyle modification or who are intolerant of positive airway pressure devices (described above), though they are not as effective.
Mandibular repositioning devices are a successful treatment modality for patients with mild OSA with obstruction in the oropharynx and tongue base region.
Tongue retaining devices are helpful for patients with limited or loose natural dentition, temporomandibular disorders, and limited mouth opening.
To locate a dentist or orthodontist with special training in sleep apnea who can fit oral appliances, consider contacting your local dental society, or check the following Internet Web site: www.dentalsleepmed.org.
Surgical Procedures
The following is a list of surgical procedures available for the treatment of symptomatic anatomical obstructions of the upper airway that contribute to or result in mild clinical obstructive sleep apnea syndrome. It may be necessary to correct the anatomical obstruction before prescribing an oral appliance or positive airway pressure device. The work group developed this list as examples of the surgical procedures available and it is not meant to be all-inclusive of the different types of procedures available.
Septoplasty -- intranasal operation performed to straighten a deviated nasal septum (cause of substantial nasal obstruction). This procedure has a very high rate of success in improving the nasal airway if the nasal septal deviation is the major etiology of the nasal obstruction. There are, however, no controlled studies that evaluate the long-term effect of septoplasty on OSA.
Nasal polypectomy -- intranasal operation to remove nasal polyps
Tonsillectomy -- surgical procedure that involves the transoral resection of the pharyngeal tonsils. Typically this is reserved for clinically obstructing tonsillar hypertrophy of the oropharynx. There are no studies that evaluate the long-term effect of tonsillectomy on OSA.
Turbinoplasty -- intranasal operation performed to reduce the size of obstructing nasal turbinates. This procedure may consist of partial surgical resection of the inferior turbinates or reduction of the inferior turbinates using other methods including electrocautery, laser ablation, and radiofrequency reduction. The results of all these methods are similar. There are no studies demonstrating a beneficial effect of turbinoplasty on OSA.
Tracheostomy -- the creation of an airway through the anterior neck into the upper trachea. This airway bypasses the entire upper airway and therefore is 100% successful in curing sleep apnea. However, this method of treatment has significant social stigmata due to the presence of a tracheostomy tube and the associated care of the tracheostomy site. This is typically the treatment of last resort for patients with sleep apnea [D].
Uvulopalatopharyngoplasty (UPPP) -- the surgical resection of the obstructive portion of the velar musculature of the soft palate and the entire uvula. This surgical procedure has an approximately 52.3% rate of long-term reduction of RDI or AHI of greater than 50% of patients with mild or moderate sleep apnea.
Pillar Procedures -- the surgical procedure of inserting plastic rods into the palate area of the mouth to prevent the collapse of the soft palate. Small, short-term studies have shown these devices can treat mild OSA in selected patients [D].
Radiofrequency ablation of the soft palate and tongue base -- the administration of microwave radiofrequencies to the treated tissue of the soft palate and/or the tongue base with a needle-implanted probe. This modality has been predominantly used for the treatment of snoring by treating the soft palate. Multiple treatments are performed and complications consist of tissue erosion and perforation [C].
Radiofrequency ablation of the tongue base has been described, but there are no studies demonstrating the efficacy of this method in the treatment of OSA.
Hyoid suspension --- surgical procedure that results in the hyoid bone being suspended, usually to the mandible, pulling the hyoid bone anteriorly and superiorly. The purpose of the procedure is to pull the tongue base forward, resulting in a larger hypopharyngeal airway. Complications consist of dysphagia post-treatment. There are no controlled studies evaluating this method for the treatment of OSA.
Mandibular advancement, genioglossus advancement, and/or maxillary advancement - orthognathic surgery, a procedure to permanently reposition the jaws, widely accepted for growth deformities and for masticatory dysfunction. The complications are low, and the results reliable. A great deal of established research in orthognathic surgery allows surgeons to use accepted techniques to help this patient population. Maxillomandibular advancement (MMA) is successful for patients with base of tongue obstruction, severe OSA, morbid obesity, and failure of other treatments. Skeletal movement of the maxilla and mandible has a broad effect on the upper airway without cicatricial scarring and has demonstrated positive results. With careful evaluation, results with MMA surgery equal those of nasal CPAP. The Stanford group has outlined a specific surgical protocol that is phased and tailored to the specific anatomical abnormalities in each patient. MMA surgery is usually a two-phase surgical procedure [D], [M], [R].