Obstructive Sleep Apnea (OSA)

Epidemiology

Prevalence: OSA affects about 10-17% of US population (depending on criteria used) [MEDLINE]
Sex: 2-3x more common in adult men than adult women
- May be related to hormonal differences, differential fat deposition, craniofacial morphology, and genioglossus muscle activation
- OSA prevalence increases after menopause
Age: OSA has 2-4x higher prevalence in elderly than in middle age
- Some studies have shown the prevalence (using AHI 5/hr) is as high as 80% in patients >71 y/o

Risk Groups

Long-Distance Commercial Truck Drivers
- Examination of OSA Prevalence Rates in Long-Distance Commercial Truck Drivers (Sleep, 2012) [MEDLINE]: 41% of long-distance heavy vehicle drivers were likely to have sleep apnea by in-home diagnostic testing (importantly, patient self-report measures showed poor agreement with the in-home detected sleep apnea)
  - 36% of drivers were overweight/50% of drivers were obese
  - 49% of drivers were cigarette smokers

Risk Factors/Clinical Predictors

Acid Maltase Deficiency: OSA has been reported
Acromegaly (see Acromegaly, [[Acromegaly]]): OSA occurs in 60-70% of cases
- Most cases are due to anterior pituitary somatotrophin-secreting adenoma
- Best screening test is serum insulin growth factor level (GH levels can be elevated, due to increased dietary carbohydrate intake)
Age: prevalence of OSA increases from young adulthood through the 6th-7th decade of life, then plateaus
Chronic Lung Disease
- Asthma (see Asthma, [[Asthma]])
- Chronic Obstructive Pulmonary Disease (COPD) (see Chronic Obstructive Pulmonary Disease, [[Chronic Obstructive Pulmonary Disease]]): 10-15% of COPD patients have OSA
- Idiopathic Pulmonary Fibrosis (IPD) (see Idiopathic Pulmonary Fibrosis, [[Idiopathic Pulmonary Fibrosis]])
Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]])
Craniofacial/Upper Airway Abnormalities
- Macroglossia: due to acromegaly, etc
End-Stage Renal Disease (ESRD) (see Chronic Kidney Disease, [[Chronic Kidney Disease]])
Gender: OSA is 3x more common in males, as compared to females
Hypothyroidism (see Hypothyroidism, [[Hypothyroidism]])): causes or worsens OSA
Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident, [[Ischemic Cerebrovascular Accident]])
Marfan Syndrome (see Marfan Syndrome, [[Marfan Syndrome]])
Menopausal/Post-Menopausal Status: xxx
Nasal Congestion: xxx
Obesity (see Obesity, [[Obesity]])
- Growing rates of obesity are associated with increasing OSA prevalence
- Neck Circumference >XXXXX
Opiate Use (see Opiates, [[Opiates]])
- Methadone (see Methadone, [[Methadone]]): studies report an association between chronic methadone use and sleep-disordered breathing, with obstructive sleep apnea being observed more commonly than central sleep apnea (Drug Alcohol Depend, 2010) [MEDLINE]
Polycystic Ovary Syndrome (PC) (see Polycystic Ovary Syndrome, [[Polycystic Ovary Syndrome]])
Pregnancy (see Pregnancy, [[Pregnancy]])
Testosterone (see Testosterone, [[Testosterone]])
Tobacco Abuse (see Tobacco, [[Tobacco]]) (Archives 1994: 154: 2219-2224)

Physiology

Pulmonary hypertension due to upper airway obstruction
Hypoventilation leads to hypoxia/acidosis (with resultant pulmonary vasoconstriction)

Diagnosis

Arterial Blood Gas (ABG) (see Arterial Blood Gas, [[Arterial Blood Gas]])

Chronic Hypoventilation
- Normal A-A Gradient Hypoxemia (see Hypoxemia, [[Hypoxemia]])
- Hypercapnia (see Hypercapnia, [[Hypercapnia]])

Pulmonary Function Tests (PFT’s) (see Pulmonary Function Tests, [[Pulmonary Function Tests]])

May demonstrate restrictive pattern (if obesity is present)

Actigraphy (see Actigraphy, [[Actigraphy]])

Technique: assesses sleep/wake cycle

Sleep Study (see Sleep Study, [[Sleep Study]])

Attended Polysomnography

Technique
- Multi-Channel Polysomnographic Study (Including EEG Channels)
Advantages
- EEG Channel Allows Assessment for Sleep During the Study
Disadvantages
- More Expensive

Unattended Portable Sleep Study

Technique
- 4-Channel Device
Advantages
- Less Expensive
Disadvantages
- Unattended/Portable Sleep Studies Do Not Assess for Actual Sleep: they are therefore not definitive in terms of ruling out sleep-disordered breathing

Echocardiogram (see Echocardiogram, [[Echocardiogram]])

May Be Useful to Assess for Concomitant Congestive Heart Failure or Pulmonary Hypertension

Clinical Manifestations

Cardiovascular Manifestations

Hypertension (see Hypertension, [[Hypertension]])

Strong Association of Obstructive Sleep Apnea and Hypertension
- Longitudinal Sleep Heart Health Study in Adults 40-98 (2009) [MEDLINE]: odds ratios for the presence of hypertension increased with increasing AHI levels
- Longitudinal Wisconsin Sleep Cohort Study in Adults 30-60 (2008) [MEDLINE]: for even small baseline AHI elevations (1 to 5), there was an increased likelihood of developing hypertension at the 4 and 8-year time points
- 70-80% of Patients with Treatment-Resistant Hypertension Have OSA
- 30% of patients in essential hypertension clinics have OSA
- Age/male sex/AHI/BMI are all associated with hypertension, but snoring is not in OSA patients (however, in Upper Airways Resistance Syndrome, snoring is associated with HTN)

Increased Risk of Coronary Artery Disease (CAD) (see Coronary Artery Disease, [[Coronary Artery Disease]])

Epidemiology

Increased Risk of Post-Operative Cardiac Complications [MEDLINE] [MEDLINE]

Epidemiology

Endocrinologic Manifestations

Impaired Glucose Tolerance/Diabetes Mellitus (DM) (see Diabetes Mellitus, [[Diabetes Mellitus]])

Epidemiology: impaired glucose tolerance and insulin resistance are observed in OSA (independent of age and obesity): probably due to sleep deprivation and sleep-associated hypoxemia

Gastrointestinal Manifestations

Increased Risk of Hepatic Steatosis/Non-Alcoholic Fatty Liver Disease (NAFLD) (see Non-Alcoholic Fatty Liver Disease, [[Non-Alcoholic Fatty Liver Disease]])

General Comments: OSA with chronic intermittent hypoxemia results in increased lipogenesis, increased triglyceride levels, and decreased hepatic beta oxidation
Study Reporting an Association Between OSA and Elevated Liver Function Tests/Fatty Liver (2013) [MEDLINE]
Study Reporting an Association Between OSA and Hepatic Steatosis in Patients with Median BMI 34.2 (2014) [MEDLINE]: 61.5% of referred OSA patients exhibited moderate or severe steatosis (with 38% manifesting borderline or possible non-alcoholic steatohepatitis)
- Risk Factors for Hepatic Steatosis
  - Nocturnal Cumulative Time Spent <90% SaO2: dose-response relationship was observed between nocturnal hypoxemia and liver injury in subset of patients with BMI >37.8
  - Presence of Insulin Resistance
  - Triglyceride Level
Study Reporting an Association Between OSA and Hepatic Steatosis in Patients with BMI <35 (2014) [MEDLINE]: OSA syndrome with sleepiness was strongly associated with NASH and fibrosis >1 (independent of known clinical risk factors such as age, gender, BMI, diabetes, and ALT levels)

Neuropsychiatric Manifestations

Excessive Daytime Somnolence (EDS) (see Excessive Daytime Somnolence, [[Excessive Daytime Somnolence]])

Epidemiology: common
Diagnosis
- Epworth Sleepiness Scale
  - Epworth sleepiness scores correlate with risk for motor vehicle accidents
- xxxxx
Clinical
- Cognitive Impairment
- Fatigue (see Fatigue, [[Fatigue]])
- Impaired Daytime Concentration
- Increased Probability of Motor Vehicle and Other Accidents
  - Swedish Traffic Accident Registry Data Examining OSA and Risk of Motor Vehicle Accidents (2015) [MEDLINE]: OSA increased the risk of motor vehicle accidents with a risk ratio of 2.45, as compared with controls (p <0.001)

Increased Risk of Cerebrovascular Accident (CVA)

Epidemiology
- Sleep Heart Health Study (Am J Resp Crit Care Med, 2010) [MEDLINE]: there is a strong adjusted association between ischemic stroke and obstructive apnea-hypopnea index in community-dwelling men with mild-moderate sleep apnea

Sleep Disruption/Frequent Arousals

xxx

Pulmonary Manifestations

Chronic Hypoventilation (see Chronic Hypoventilation, [[Chronic Hypoventilation]])

Epidemiology

Habitual Snoring

xxx

Increased Risk of Post-Operative Respiratory Complications [MEDLINE] [MEDLINE]

xxx

Observed Apneas During Sleep

xxx

Pulmonary Hypertension/Cor Pulmonale (see Pulmonary Hypertension, [[Pulmonary Hypertension]]))

Pulmonary hypertension (usually mild) occurs in 15-20% of OSA patients (usually moderate-severe OSA)
Pulmonary hypertension is believed to be associated with nocturnal hypoxemic events (therefore, in upper airway resistance syndrome, where hypoxemic events do not occur, pulmonary HTN is absent)
There are no clinical differences between OSA patients with and without pulmonary hypertension

Snoring

Epidemiology: xxx

Nocturnal Oxygen Desaturations

xxx

Other Manifestations

Decreased Quality of Life [MEDLINE]

xxx

Treatment

Positive Airway Pressure (PAP)

Modalities

Continuous Positive Airway Pressure (CPAP) (se Continuous Positive Airway Pressure, [[Continuous Positive Airway Pressure]])
Bilevel Positive Airway Pressure (BPAP) (see Bilevel Positive Airway Pressure, [[Bilevel Positive Airway Pressure]])

Technique of CPAP/BPAP Titration (American Academy of Sleep Medicine, Guidelines, 2008) (J Clin Sleep Med, 2008) [MEDLINE]

CPAP (or IPAP and/or EPAP for BPAP) Should Be Increased Until Respiratory Events are Eliminated: oxygen desaturations without associated obstructive respiratory events should not be considered in the decision to increase CPAP in adult patients
- Apneas
- Hypopneas
- Respiratory Effort-Related Arousals (RERA’s)
- Snoring
Starting CPAP Should Be 4 cm H2O in Adults: higher starting CPAP may be used in patient with elevated BMI or for retitration studies
- Higher BMI Has Been Demonstrated to be Associated with Higher CPAP Pressures to Abolish Apneas
- CPAP Should Be Increased By at Least 1 cm H2O No More Often than q5 min
Increase in CPAP Pressures to Target Respiratory Events
- CPAP Should Be Increased if at Least 2 Obstructive Apneas are Observed for Patients >12 y/o
- CPAP Should Be Increased if at Least 3 Hypopneas are Observed for Patients >12 y/o
- CPAP Should Be Increased if at Least 5 RERA’s are Observed for Patients >12 y/o
- CPAP Should Be Increased if at Least 3 min of Loud or Unambiguous Snoring is Observed for Patients >12 y/o
- “Exploration” of CPAP Above the Pressure at Which Respiratory Events are Controlled Should Not Exceed 5 cm H2O
- Maximum CPAP Should Be 20 cm H2O in Patients >12 y/o
“Down” Titration of CPAP
- If Patient Awakens and Complains that Pressure is Too High, CPAP Should Be Restarted at a Lower Pressure Which Patient Finds Comfortable
- Down Titration May Be Considered, But is Not Required: due to a “hysteresis” phenomenon, during upward titration, the pressure level at which flow limitation disappears is 2-5 cm H2O higher than the pressure level at which it reappears during downward titration
Split-Night Titration Study: same protocol should be used as for full-night titration study
- Split-Night Study is Comparable to Full-Night Titration Study, in Most Cases: except that pressures determined from split-night studies may be lower for patients with mild-to-moderate OSA who may not manifest the maximal severity of their condition during the first portion of the night
Switch to BPAP
- If Patient is Uncomfortable/Intolerant of CPAP or if There are Continued Obstructive Respiratory Events at CPAP 15 cm H2O During a Titration Study, BPAP May Be Tried
Use of BPAP
- Starting BPAP Pressures Should Be 8/4 in Adult Patients
  - Minimum EPAP should be 4 cm H2O or the level of CPAP pressure at which obstructive events were eliminated
  - Higher starting IPAP/EPAP may be used in patient with elevated BMI or for retitration studies
- IPAP and/or EPAP (Depending on Type of Obstructive Respiratory Evente) Should Be Increased By at Least 1 cm H2O in Both IPAP and EPAP No More Often than q5 min
- Maximum IPAP Should Be 30 cm H2O in Patients >12 y/o: IPAP exceeding 30 cm H2O increases the risk of barotrauma and other morbidities
  - Minimum IPAP-EPAP Differential Should Be 4 cm H2O
  - Maximum IPAP-EPAP Differential Should Be 10 cm H2O
Increase in BPAP Pressures to Target Respiratory Events
- IPAP and EPAP Should be Increased if at Least 2 Obstructive Apnea are Observed for Patients ≥12 y/o
- IPAP Should be Increased if at Least 3 Hyopneas are Observed for Patients ≥12 y/o
- IPAP Should be Increased if at Least 5 RERA’s are Observed for Patients ≥12 y/o
- IPAP Should be Increased if at Least 3 min of Loud or Unambiguous Snoring is Observed for Patients >12 y/o
- “Exploration” of IPAP Above the Pressure at Which Respiratory Events are Controlled Should Not Exceed 5 cm H2O
“Down” Titration of BPAP
- If Patient Awakens and Complains that Pressure is Too High, IPAP Should Be Restarted at a Lower Pressure Which Patient Finds Comfortable
- Decrease in IPAP or Setting BPAP in Spontaneous-Timed (ST) Mode with Backup Rate May Be Helpful if Treatment-Emergent Central Sleep Apneas Complex Sleep Apneas) Develop
- Down Titration May Be Considered, But is Not Required:
Quality of Titration
- “Optimal” Titration: decrease in RDI to <5/hr for at least 15 min duration and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings
- “Good” Titration: decrease in RDI to ≤10/hr (or by 50% if baseline RDI was <15/hr) and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings
- “Adequate” Titration: one which does not decrease RDI to ≤10/hr but does decrease RDI by 75% from baseline (especially in severe OSA) or if “optimal” or “good” criteria are met but supine REM sleep did not occur at the selected pressure
Leak Management: mask fit or readjustment should be performed when any unintentional leak is observed
- Intentional Leak: controlled leak from the port on mask interfaces that washes out CO2 and prevents rebreathing
- Mouth Leak: pressurized air escaping via the mouth when a nasal mask is used
- Mask Leak: pressurized air escaping between the mask and the face when a nasal mask or full-face mask is used
Supplemental Oxygen (see Oxygen, [[Oxygen]])
- Supplemental Oxygen Should Be Added to PAP Titration When Supine SpO2 on Room Air is ≤88%: start at 1L/min and titrate up to target a SpO2 88-94%
- Supplemental Oxygen May Be Added to PAP Titration When Supine SpO2 is ≤88% for ≥5 min in the Absence of Obstructive Respiratory Events: start at 1L/min and titrate up to target a SpO2 88-94%
Adaptive Servo Ventilation (ASV) (see Adaptive Servo Ventilation, [[Adaptive Servo Ventilation]])
- ASV May Be Considered if Patient is Observed to Have Cheyne-Stokes Respiration or if Treatment-Emergent Central Sleep Anea (Complex Sleep Apnea) During the Titration Study is Not Eliminated by Down Titration of Pressure

Clinical Benefits of Continuous Positive Airway Pressure (CPAP)

CPAP is Highly Effective in the Treatment of OSA: however, many patients may not be adherent (for various reasons)
CPAP Has Beneficial Effects on Atrial Fibrillation (see Atrial Fibrillation, [[Atrial Fibrillation]])
- Use of CPAP (>4 hrs/nt) in OSA patients with AF has been shown to decrease recurrence of AF after cardioversion (42% recurrence rate vs. 82% recurrence rate): may be related to effects of OSA on nocturnal hypoxemia, hypercapnia, sympathetic drive, and changes in intrathoracic pressure
CPAP Has Beneficial Effects on Pulmonary Hypertension (see Pulmonary Hypertension, [[Pulmonary Hypertension]]): CPAP decreases PA pressures
- This occurs independent on changes in hypoxemia, suggesting that PA pressure changes are related to changes in endothelial function, rather than merely a reversal of hypoxic pulmonary arterial vasoconstriction
CPAP Has Beneficial Effects on Systemic Hypertension (see Hypertension, [[Hypertension]])
- Systematic Review/Meta-Analysis of Effects of Positive Pressure Therapy on Hypertension Associated with OSA (J Clin Sleep Med, 2012) [MEDLINE]: positive pressure therapy results in modest, but significant, decreases in systolic and diastolic blood pressure
- However, data indicate that the effects of CPAP are less clear in the treatment of OSA without sleepiness
CPAP Has Beneficial Effects on Sleep Apnea-Related Risk of Motor Vehicle Accidents (Sleep, 2015)
- Swedish Traffic Accident Registry Data Examining OSA and Risk of Motor Vehicle Accidents (2015) [MEDLINE]: in patients with OSA, CPAP use ≥4 hr/night was associated with a reduction in the incidence of motor vehicle accidents (7.6 -> 2.5 accidents/1,000 drivers/yr)
CPAP Has Beneficial Effects on Post-Traumatic Stress Disorder (PTSD)
- Study of Effects of CPAP on PTSD in Veterans with OSA (J Clin Sleep Med, 2014) [MEDLINE]: in veterans with PTSD and OSA, CPAP therapy reduces PTSD-associated nightmares and improves overall PTSD symptoms
CPAP Therapy Alone Does Not Result in Weight Loss
- Effect of CPAP on Cardiometabolic Parameters in OSA (Thorax, 2012) [MEDLINE]: CPAP alone does not lead to weight loss or improvement in insulin sensitivity
CPAP Therapy Alone Does Not Result in Improvement in Depression

Autotitrating Continuous Positive Airway Pressure (CPAP) (see Continuous Positive Airway Pressure, [[Continuous Positive Airway Pressure]])

Rationale: autotitrating CPAP devices may be used in lieu of an in-laboratory CPAP titration study in some patients (and insurers may deny the in-laboratory study, instead requiring that an autotitrating CPAP be used)
Contraindications
- Lack of Respiratory Drive: since the pressure delivered is triggered by respiratory effort
Technique
- From the Autotitration Report, it is Generally Accepted to Choose the T90 or T95 Pressure (Which is the Pressure the Patient is at or Below 90-95% of the Time)
- Due to Limitations of These Devices, Patients Need Follow-Up to Ensure that this is the Correct Setting: if symptoms persist, in-laboratory titration may be required
Factors Which May Decrease Auto-PAP Adherence
- Air Leak: auto-PAP systems are very sensitive to air leaks
Clinical Efficacy
- Study of Auto-PAP Therapy for OSA (Sleep, 2011) [MEDLINE]
  - Air Leak was Associated with Poor Adherence with Auto-PAP
  - Adherence to Auto-PAP Therapy was Strongly Correlated with Subsequent Adherence to CPAP Therapy
- Residual Sleep-Disordered Breathing During Autotitrating CPAP Therapy (Eur Resp J, 2012) MEDLINE]
  - Residual OSA (AHI ≥10 Events/hr) was Observed in 24% of Patients During Autotitration: for this reason, clinicians should be aware of the limitations of auto-PAP devices

Continuous Positive Airway Pressure (CPAP) Adherence

Chronic CPAP Adherence is Predicted by the Initial First Few Days of Use by the Patient [MEDLINE]
Factors Which May Decreased CPAP Adherence
- Air Leak
- Nasal Dryness
- Post-Traumatic Stress Disorder (PTSD) (see Post-Traumatic Stress Disorder, [[Post-Traumatic Stress Disorder]])
  - In soldiers with OSA, co-morbid PTSD is associated with significantly decreased CPAP adherence [MEDLINE]
  - In veterans with PTSD and OSA, CPAP therapy reduces PTSD-associated nightmares and improves overall PTSD symptoms [MEDLINE]
- Rhinorrhea (see Rhinorrhea, [[Rhinorrhea]])
Measures/Factors Which May Enhance CPAP Adherence
- Cognitive Behavioral Therapy
- Education
- Family Involvement
- More Severe Sleep Apnea Indices
- Short Course of Eszopiclone (Lunesta) During the First 2 Weeks of CPAP Therapy [MEDLINE] (see Eszopiclone, [[Eszopiclone]]): improves adherence and results in Fewer patients discontinuing CPAP therapy

Complications of Continuous Positive Airway Pressure (CPAP)

Treatment-Emergent Central Sleep Apnea (Complex Sleep Apnea) (see Central Sleep Apnea, [[Central Sleep Apnea]]): refers to the development of central sleep following the application of CPAP or a dental appliance
- History: recently added to the International Classification of Sleep Disorders, 3rd ed (Chest, 2014) [MEDLINE]
- Epidemiology: these central events cannot be attributed to another identifiable comorbidity such as Cheyne-Stokes breathing or use of opiates
- Mechanism: may be related to hypocapnia or mask leak (J Clin Sleep Med, 2013) [MEDLINE]
- Clinical
  - Usually Observed When the Patient Has Frequent Arousals from Sleep
  - Occurs After the Obstructive Events are Controlled During NREM Sleep
- Treatment
  - May Resolve Over Time in Some Cases: should reassess patient on CPAP in 2-3 mo
    - Complex Sleep Apnea Resolution Study (Sleep, 2014) [MEDLINE]: central sleep apnea improves or resolves spontaneously in approximately 66% of patients who continue on CPAP for 90 days
  - Adaptive Servo Ventilation (ASV) (see Adaptive Servo Ventilation, [[Adaptive Servo Ventilation]]): may be useful, as it treats both obstructive and central apneas
    - ASV is a form of bi-level positive airway pressure that provides variable pressure support via a servo mechanism-based assessment of the patient’s respiratory output
    - When There are Hypopneas: ASV increases the pressure support (difference between expiratory PAP and inspiratory PAP)
    - When There are Hyperpneas: ASV decreases the pressure support (difference between expiratory PAP and inspiratory PAP)
    - When Central Sleep Apneas Occur: ASV utilizes a backup rate and the EPAP maintains airway patency
    - ASV increases the mortality rate in patients with central sleep apnea in association with systolic congestive heart failure and EF <45% (NEJM, 2015) [MEDLINE]
  - Bilevel Positive Airway Pressure (BPAP) with Backup Rate (see Bilevel Positive Airway Pressure, [[Bilevel Positive Airway Pressure]])
    - Avoid Using BPAP without a Backup Rate: may worsen the apnea-hypopnea index (AHI)

Implantable Upper Airway Stimulation Device (Hypoglossal Nerve Stimulator)

Indications
- OSA with Inability to Tolerate CPAP: device increases upper airway patency (but does not correct central sleep apnea)
  - Device has not been tested in treatment emergent central sleep apnea (complex sleep apnea)
Studies
- STAR Trial of Hypoglossal Nerve Stimulator in Moderate-Severe OSA (2014) [MEDLINE]: multi-center, prospective, single group, cohort design trial (n = 126) of surgically implanted upper-airway stimulation device (from Inspire Medical Systems) in moderate-severe OSA patients intolerant of CPAP (BMI <32, no major underlying cardiopulmonary disease, no other sleep disorders, no psychiatric disease) -> 68% decrease in the apnea-hypopnea index score at 12 mo, less oxygen desaturation, and improved quality of life
  - Patients used the device for at least part of the night on 86% of the nights
  - Procedure-Related Serious Adverse Events: <2% of cases

Transtracheal Oxygen (see Oxygen, [[Oxygen]])

Decreases hypoxemia and AHI (possibly due to delivery of oxygen below site of obstruction with increase in mean airway pressure and improved hypoxemia)

Avoid Sedatives

These can increase the number of apneas in OSA

Treatment of Underlying Diseases

Treatment of Acromegaly (see Acromegaly, [[Acromegaly]]): surgical resection of pituitary adenoma or octreotide both improve OSA
Treatment of Obesity (see Obesity, [[Obesity]]): weight loss

Dental Appliance (Most are Mandibular Advancement Devices)

Variety of Appliances

There are >80 Dental Appliances Available
- Mandibular Advancement Devices: accounts for most of the available devices
- Tongue Retaining Devices: accounts for remainder of devices

Indications

xxx

Studies

Randomized Trial Comparing CPAP with Mandibular Advancement Device in Moderate-Severe OSA (2013) [MEDLINE]
- CPAP was more efficacious than mandibular advancement device in reducing AHI
- Compliance was higher with mandibular advancement device than with CPAP
- Neither treatment improved blood pressure
- Sleepiness, driving simulator performance, and disease-specific quality of life improved on both treatments by similar amounts
- Mandibular advancement device was superior to CPAP in terms of improving four general quality-of-life

Complications

Treatment Emergent Central Sleep Apnea (Complex Sleep Apnea): refers to the development of central sleep following the application of CPAP or a dental appliance
- See Above

Prognosis

Obstructive Sleep Apnea Increases Mortality Rate (1988) [MEDLINE]: patients with an average of >20 apneas/hr were found to have an 8-year cumulative mortality of 37% compared with 4% in those with an index <20 apneas/hr
Wisconsin Sleep Cohort Study (2008) [MEDLINE]: untreated sleep-disordered breathing increases mortality, independent of age/sex/BMI
- Results Were Similar Even After Accounting for Symptoms of Daytime Sleepiness
Busselton Health Study (2008) [MEDLINE]: moderate-severe OSA is associated with increased all-cause mortality
Sleep Heart Health Study (2009) [MEDLINE]: sleep-disordered breathing increased all-cause mortality (and specifically that due to coronary artery disease), particularly in males age 40-70
Database Study (2012) [MEDLINE]: increased OSA severity (quantified by AHI/apnea index/desaturation index) is independently associated with all-cause mortality in patients <50 y/o (after adjustment for confounding factors)

References

General

Mortality and apnea index in obstructive sleep apnea: experiences in 385 male patients. Chest. 1988;94:9-14 [MEDLINE]
The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993; 328:1230-5 [MEDLINE]
Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc. 2001;76:897-905 [MEDLINE]
Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med 2007;3(7):737-747 [MEDLINE]
A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg. 2008;107:1543-63 [MEDLINE]
Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin Sleep Cohort. Sleep. 2008;31:1071-8 [MEDLINE]
Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med. 2009;6:e1000132 [MEDLINE]
Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med. 2009;10:753-8 [MEDLINE]
Are sleep studies appropriately done in the home? Respir Care 2010;55(1):66-75 [MEDLINE]
Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study. Am J Respir Crit Care Med. 2010 Jul 15;182(2):269-77. doi: 10.1164/rccm.200911-1746OC. Epub 2010 Mar 25 [MEDLINE]
A prospective polysomnographic study on the evolution of complex sleep apnoea. Eur Respir J 2011;38(2):329-337 [MEDLINE]
Assessing sleepiness and sleep disorders in Australian long-distance commercial vehicle drivers: self-report versus an “at home” monitoring device. Sleep 2012;35:469-475 [MEDLINE]
Obstructive sleep apnea is associated with fatty liver and abnormal liver enzymes: a meta-analysis. Obes Surg 2013;23(11): 1815-1825 [MEDLINE]
Nonalcoholic fatty liver disease, nocturnal hypoxia, and endothelial function in patients with sleep apnea. Chest 2014;145(3):525-533 [MEDLINE]
Risk of obstructive sleep apnea with daytime sleepiness is associated with liver damage in non-morbidly obese patients with nonalcoholic fatty liver disease. PLoS One 2014;9(4):e96349 [MEDLINE]
Diagnosis of obstructive sleep apnea in adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med 2014;161:210-220 [MEDLINE]
International classification of sleep disorders-third edition: highlights and modifications. Chest. 2014 Nov;146(5):1387-94. doi: 10.1378/chest.14-0970 [MEDLINE]
Sleep apnea related risk of motor vehicle accidents is reduced by continuous positive airway pressure: Swedish Traffic Accident Registry Data. Sleep 2015;38:341-349 [MEDLINE]

CPAP

Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. An American Academy of Sleep Medicine report. Sleep 2008;31(1): 141-147 [MEDLINE]
Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med. 2008 Apr 15;4(2):157-71 [MEDLINE]
Portable monitoring and autotitration vs polysomnography for the diagnosis and treatment of sleep apnea. Sleep 2008;31(10):1423-1431 [MEDLINE]
Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial. Ann Intern Med. 2009 Nov 17;151(10):696-702. doi: 10.7326/0003-4819-151-10-200911170-00006 [MEDLINE]
A systematic review of CPAP adherence across age groups: Clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev 2011;15(6):343-356 [MEDLINE]
Air leak is associated with poor adherence to autoPAP therapy. Sleep. 2011 Jun 1;34(6):801-6. doi: 10.5665/SLEEP.1054 [MEDLINE]
Residual sleep-disordered breathing during autotitrating continuous positive airway pressure therapy. Eur Respir J 2012;39(6): 1391-1397 [MEDLINE]
Cardiometabolic changes after continuous positive airway pressure for obstructive sleep apnoea: a randomised sham-controlled study. Thorax 2012;67:1081-1089 [MEDLINE]
The effect of continuous positive airway pressure treatment on blood pressure: a systematic review and meta-analysis of randomized controlled trials. J Clin Sleep Med 2012;8:587-596 [MEDLINE]
The impact of posttraumatic stress disorder on CPAP adherence in patients with obstructive sleep apnea. J Clin Sleep Med 2012;8(6):667-72. doi: 10.5664/jcsm.2260 [MEDLINE]
Health Outcomes of Continuous Positive Airway Pressure versus Oral Appliance Treatment for Obstructive Sleep Apnea. Am J Respir Crit Care Med. 2013 Apr 15;187(8):879-87 [MEDLINE]
The effect of continuous positive air pressure (CPAP) on nightmares in patients with posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA). J Clin Sleep Med 2014;10(6):631-636. doi: 10.5664/jcsm.3786 [MEDLINE]
Sleep apnea related risk of motor vehicle accidents is reduced by continuous positive airway pressure: Swedish Traffic Accident Registry Data. Sleep 2015;38:341-349 [MEDLINE]

Adaptive Servo Ventilation

Efficacy of adaptive servoventilation in treatment of complex and central sleep apnea syndromes. Chest. 2007;132:1839–1846 [MEDLINE]
Adaptive servoventilation improves cardiac function and respiratory stability. Clin Res Cardiol. 2011;100:107–115 [MEDLINE]
A prospective polysomnographic study on the evolution of complex sleep apnoea. Eur Respir J 2011;38(2):329-337 [MEDLINE]
Therapy for sleep hypoventilation and central apnea syndromes. Curr Treat Options Neurol 2012;14(5):427-437 [MEDLINE]
Adaptive servoventilation for treatment of sleep-disordered breathing in heart failure: a systematic review and meta-analysis. Chest. 2012;142:1211–1221 [MEDLINE]
Air leak during CPAP titration as a risk factor for central apnea. J Clin Sleep Med 2013;9(11):1187-1191 [MEDLINE]
The complex sleep apnea resolution study: a prospective randomized controlled trial of continuous positive airway pressure versus adaptive servoventilation therapy. Sleep. 2014 May;37(5):927-34 [MEDLINE]
SERVE-HF Trial. Adaptive servo-ventilation for central sleep apnea in systolic heart failure. N Engl J Med 2015;373:1095-1105 [MEDLINE]

Mandibular Advancement Device

Health Outcomes of Continuous Positive Airway Pressure versus Oral Appliance Treatment for Obstructive Sleep Apnea. Am J Respir Crit Care Med. 2013 Apr 15;187(8):879-87 [MEDLINE]

Implantable Upper Airway Stimulation Device

Treating obstructive sleep apnea with hypoglossal nerve stimulation. Sleep 2011;34(11):1479-1486. doi: 10.5665/sleep.1380 [MEDLINE]
STAR Trial Group. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med 2014;370:139-149 [MEDLINE]
Randomized controlled withdrawal study of upper airway stimulation on OSA: short- and long-term effect. Otolaryngol Head Neck Surg 2014;151:880-887 [MEDLINE]

Prognosis

Sleep disordered breathing and mortality: 18-year follow-up of the Wisconsin sleep cohort. Sleep 2008;31:1071-1078 [MEDLINE]
Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep 2008;31:1079-1085 [MEDLINE]
Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med 2009;6:1-9 [MEDLINE]
All-cause mortality and obstructive sleep apnea severity revisited. Otolaryngol Head Neck Surg 2012;Epub ahead of print Jun 11 2012 [MEDLINE]