OBSTRUCTIVE SLEEP APNEA: A MANAGEMENT PERSPECTIVE
Educational Objectives
| The goal of this program is to improve the treatment of obstructive sleep apnea (OSA) in adults and children. After hearing
and assimilating this program, the clinician will be better able to:
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 | 1. Review conservative therapies for OSA.
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| 2. Explain the difference between efficacy and effectiveness as it relates to continuous positive airway pressure
(CPAP), dental appliances, and surgical treatment of OSA.
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| 3. Describe the use of uvulopalatopharyngoplasty and surgery of the nose in the management of OSA.
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| 4. Discuss the role of sleep studies in the diagnosis and management of OSA in children.
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| 5. Summarize adenotonsillectomy as a treatment of OSA in children, including anesthetic care, perioperative respiratory
compromise, and the postoperative period.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a
proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgements
Dr. Kapur gave his lecture at Sleep Disorders 2008, held March 17-19, 2008, in Orlando, FL, presented by World Class
CME and National Sleep Foundation, and sponsored by Loma Linda University. Dr. Tunkel addressed the Chicago
Laryngological and Otological Society, November 5, 2007, in Chicago IL. The Audio-Digest Foundation thanks the
speakers and the sponsors for their cooperation in the production of this program.
| TREATMENT OF OBSTRUCTIVE SLEEP APNEA (OSA)—Vishesh K. Kapur, MD, MPH, Associate Professor of Medicine,
University of Washington School of Medicine, and Director, University of Washington Sleep Disorders Center, Seattle
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| Reasons to treat: adverse consequences, particularly hypertension and other cardiovascular diseases; symptoms, eg,
snoring, sleepiness; quality of life (QOL), eg, disturbing bed partner
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| Conservative therapies: effect not robust; usually cannot stand alone, but useful as adjunctive therapy; may be only
therapy needed in patients with mild OSA
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| Weight reduction: highly effective but difficult to achieve and maintain; Wisconsin Sleep Cohort Study—sleep studies and
weight measurement at 4-yr intervals; change in apnea-hypopnea index (AHI) compared to change in weight; as weight
increased, so did AHI, and opposite finding with decreasing weight; every 10% change in weight causes ≈30% change in
AHI; counsel all overweight patients with OSA about weight reduction, even if another primary therapy being used
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| Body positioning: sleep disordered breathing (SDB) worse when patient lying on back; patients with OSA often sleep on
side or in recliner to mitigate condition; side sleeping may be primary therapy for mild OSA that occurs only when patient
sleeps on back
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| Medications: counsel patients to avoid sedatives and other medications that may worsen OSA by blunting arousal response
to apnea or by increasing upper airway compliance, eg, alcohol, benzodiazepines, narcotics (avoid use near bedtime
in patients with untreated OSA)
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| Sleep deprivation: ≈30% of population reports not getting enough sleep; high prevalence of people getting <6 hr of sleep;
sleep deprivation worsens OSA by blunting hypoxic responses, depressing upper airway dilator activity, increasing rapid
eye movement (REM) sleep (rebound of REM sleep), and possibly lowering O2 saturation
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| Tobacco use: associated with 4 to 5 times increased risk for moderate SDB; in study, related to frequent and loud snoring
(surrogate for OSA); mechanisms by which tobacco use makes SDB worse include nasal congestion and increased airway
resistance through mucosal edema; little data to show stopping smoking reduces SDB
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| Continuous positive airway pressure (CPAP): most efficacious therapy for OSA; efficacy—theoretic; wearing
CPAP mask titrated to correct pressure resolves SDB; effectiveness—in real life, efficacious therapy may not be effective
because, eg, patient may not wear mask all night or every night; technique—CPAP administered by nasal or nasal-
oral mask to keep upper airway open; technology expanding; machines smaller, quieter, and can record data on patient;
new mask interfaces enhance usability
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| Literature on CPAP: evidence for efficacy overwhelming when CPAP compared to placebo in randomized controlled trials
(RCTs); growing body of evidence on blood pressure (BP) and developing literature on long-term outcomes, eg,
cardiovascular events; RCTs—drop in BP seen only when patient has daytime sleepiness; multicenter study that followed
patients with moderate to severe OSA over 3 mo found 30% rejected therapy or using it suboptimally
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| Conclusions: CPAP first-line therapy for OSA; trial warranted even in patients who have strong preference for other therapies;
no long-lasting negative consequences; noncompliance main factor limiting effectiveness
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| Dental appliances: mandibular advancement devices—custom fitted to upper and lower teeth; adjustable; advancement
of lower jaw changes shape of oropharynx and reduces collapsibility of upper airway; tongue-retaining devices—
rarely used
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| Efficacy: literature review by American Academy of Sleep Medicine found that ≈42% of patients achieved optimal control
(AHI <5) and ≈52% achieved reasonable control (AHI <10); factors associated with better efficacy—mild SDB;
greater protrusion of mandible; SDB worse when sleeping on back than on side; lower body mass index (BMI); factors
associated with effectiveness—many studies show improvement in subjective sleepiness; some show improvement in
objective sleepiness; key issue how often patients use device, but data sparse in this area because no objective measure
of frequency of use; based on subjective measures, adherence rates 55% to 100% for 1 to 2 yr, 48% to 90% for 2 to 5 yr
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| Comparison to CPAP: dental appliance less efficacious, and does not reduce AHI to low levels one-third of time; trials
comparing dental appliance to CPAP show similar functional outcomes in patients with mild to moderate OSA; higher
compliance may compensate for lower efficacy
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| Comparison to uvulopalatopharyngoplasty (UPPP): one RCT showed AHI <5 in 78% of patients using dental appliance,
compared to 51% of patients who underwent UPPP
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| Complications: salivation; difficulty aligning upper and lower teeth upon awakening; worsening of pain of temporomandibular
joint (TMJ) syndrome; change in bite—due to tooth movement, remodeling of TMJ complex, or adaptation of
muscular structure; may persist after device discontinued
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| Contraindications: insufficient number of teeth to hold device in place; periodontal disease; excessive bruxism; inability
to protrude lower jaw by ≥6 mm
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| Practice parameters: device should be fitted by dentist experienced with devices and dealing with negative effects seen in
some patients; evaluate SDB while patient wears appliance
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| Surgical therapy: goal to enlarge upper airway; may be primary therapy, but usually used as adjunct to other therapies;
types of surgery—turbinate reduction; septoplasty; UPPP; tongue base surgery, eg, genioglossus advancement; bariatric
surgery; maxillomandibular advancement; tracheotomy
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| Efficacy: 2007 meta-analysis in Sleep combined all studies from 2001 to 2005; tried to show that success of surgery depends
on definition; surgeons’ definition 50%; reduction in AHI and/or decrease in AHI to <20; in CPAP, AHI <5 considered
success; with appliance, AHI <10 equals success; using surgeon’s definition, efficacy ≈50%; using AHI <10,
efficacy ≈30%; using CPAP definition, efficacy ≈10%; maxillomandibular advancement—surgeon’s definition gives
≈80% success, but with CPAP definition, success only ≈45%; tell patients ≈80% chance that SDB will improve, but
only 40% chance that SDB will be as good as on any night CPAP used; radiofrequency tongue base ablation vs
CPAP—RCT found surgery much less efficacious than CPAP (based on AHI), but effectiveness roughly same because
patients used CPAP ≤4 hr per night
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| Uvulopalatopharyngoplasty: study found patients with Mallampati score of 1 and very large tonsils had 80% likelihood
of success (50% reduction in AHI) with UPPP; side effects—significant pain during weeks immediately after procedure;
difficulty swallowing, including regurgitation of liquid into nose and food sticking (problems usually resolve but
long-lasting in small group of patients); nasopharyngeal stenosis making OSA worse (rare)
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| Surgery of nose to improve CPAP compliance: studies indicate relationship between cross-sectional area of nose
and adherence to CPAP; nasal resistance—associated with rejection of CPAP; case series found patients with high resistance
who underwent surgery able to use CPAP
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| PEDIATRIC DISEASE: DIAGNOSIS AND MANAGEMENT —David Tunkel, MD, Associate Professor, Department of
Otolaryngology–Head and Neck Surgery, and Director, Division of Pediatric Otolaryngology, Johns Hopkins University
School of Medicine, Baltimore, MD
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| American Academy of Pediatrics (AAP) clinical practice guidelines: all children who snore should be
screened for OSA; complex high-risk children should be referred to specialists; children with cardiorespiratory failure
from OSA require urgent referral for treatment; sleep study still gold standard for evaluation; adenotonsillectomy (AT)
first-line treatment; CPAP good option for children who fail or are not candidates for surgery; high-risk patients should
have inpatient monitoring after surgery; some patients need reevaluation after surgery to determine whether additional
treatment required
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| Sleep apnea spectrum: from primary snoring (no gas-exchange abnormalities; ≈10% of population) to OSA (hypercarbia
and hypoxemia); hypoventilation (incomplete obstruction) makes it difficult to tell whether child just snoring or has
OSA
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| Sleep studies: survey of American Society of Pediatric Otolaryngology (ASPO) and American Academy of
Otolaryngology–Head and Neck Surgery (AAO) found that only 4.5% of children suspected of having OSA received
sleep studies; survey of ASPO members—found three-quarters of pediatric otolaryngologists used sleep studies in
<10% of children; sleep studies mostly used in children <1 yr of age and those with other abnormalities, eg, Down syndrome,
craniofacial or neuromotor anomalies; most children not observed overnight after AT; most common reasons
for admission young age or severely abnormal sleep study; ASPO members used clinical indicators (different from recommendations
in AAP and American Thoracic Society [ATS] clinical practice guidelines); Goldstein study (2004)—
developed clinical assessment score; 59 children; those with positive sleep studies underwent AT; those with negative
sleep studies randomized to AT or observation; clinical assessment repeated after 6 mo; patients who had AT had large
improvements in scores, compared to those who were observed; improvement seen even in children who had normal
sleep studies
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| Why sleep studies helpful: give definitive diagnosis of OSA; help assess severity and decide pace of work-up and treatment;
help predict risk for perioperative respiratory problems; help predict outcome of AT; give baseline data for comparison
with postoperative respiratory parameters; help with assessment of all other QOL, developmental or behavioral
problems, and other clinical signs and symptoms
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| Study data: meta-analysis of 12 articles showed that clinical evaluation of OSA inaccurate (too sensitive and not specific
enough); lack of validated thresholds for clinically significant disease; lack of screening tests with validated clinical
outcomes; Carroll study (1995)—48 children with primary snoring and 35 with OSA (both based on sleep study); parental
questionnaires showed no difference in any parameters, eg, daytime sleepiness, snoring; significant statistical
(but not clinical) differences in daytime mouth breathing, observed apneas, and having to shake child; parents of children
who snored had same worries as parents of those who had OSA
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Adenotonsillectomy
| Anesthetic care: medical comorbidities—may complicate anesthetic care; include asthma, neuromotor problems, heart
problems, craniofacial abnormalities, and obesity; airway obstruction—on extubation or induction; preparation for obstruction
key; timing of extubation should be carefully planned; induction—anesthesiologist should be aware that mask
induction may not be effective; start intravenous (IV) medications as quickly as possible; preoperative sedation—perform
judiciously in monitored setting; safety not proven; data from small study show only 2 events with use of midazolam
in 70 children; airways—nasal airways preferred by speaker for children at high risk for airway obstruction
(placed when mouth gags in place; removed in recovery room); some children need intubation or bilevel intermittent positive
airway pressure (bi-PAP); sleep study without bi-PAP done 6 wk postoperatively to determine whether still required;
sedation—steroids, narcotics, and other sedating medications used judiciously; problems usually occur early, usually on
extubation or in pediatric intensive care unit
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| Perioperative respiratory compromise: risk factors (clinical and sleep study)—young age and high respiratory
distress index (RDI) most significant; also craniofacial anomalies (eg, Down syndrome), neuromuscular disease, congenital
heart disease, and history of prematurity; McColley study—70 children with sleep study-proven OSA; 23% had postoperative
respiratory problems requiring oxygen supplementation or airway intervention (mostly younger children with
severe OSA); more likely to have failure to thrive, abnormalities on electrocardiography or echocardiography (sequelae
of severe OSA), and craniofacial abnormalities; these risk factors used as basis for admitting children for monitoring after
AT; Cincinnati study—followed large group of children for 4 yr; 6.4% developed postoperative respiratory compromise;
children <3 yr of age had twice risk of children 3 to 5 yr of age, even though older children had more medical comorbidities;
narcotics—children with OSA had depressed ventilatory drive and were more prone to apnea when spontaneously
breathing under fentanyl anesthesia; in Canadian retrospective and prospective studies, young age and reduced oxygen
saturation on sleep studies correlated with reduced morphine dose required for analgesia after AT
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| Criteria for admission after AT: young age with obstructive symptoms; neuromotor disease (eg, cerebral palsy);
highly abnormal sleep study; craniofacial disorders; obesity >120% of ideal body weight; complications of OSA
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| What to expect after AT: cure for most children on night of surgery, unless OSA severe (then improvement seen); cure
rate remains controversial; study found reduction in AHI by ≈14 events/hr and ≈83% success rate; QOL changes after
AT—study using OSA-6 questionnaire found three-quarters of children had large improvements in QOL, while 13% had
smaller improvements; sleep disturbance, caregiver concerns, and physical suffering most improved domains; smaller improvements
in emotional disturbance, speech and swallowing, and limitations in activity; AT also reduces health care utilization,
as measured by decrease in hospital admissions, emergency department visits, consultations, and prescriptions;
high-risk factors for persistent OSA after AT—obesity; severe OSA; craniofacial abnormalities; neuromotor disease
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| Powered intracapsular AT: reduces perioperative morbidity; shown to produce clinical cure of OSA and low recurrence
rate; speaker’s study of 18 children with moderate OSA used sleep studies to confirm short-term cure, and found
marked improvement in QOL (based on OSA-18 questionnaire)
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| When AT fails: UPPP performed in children with other medical problems, eg, Down syndrome; tongue resections done
if structural abnormalities present; mandibular distraction for failed AT or neonates with Pierre Robin anatomy (majority
cured, but some have persistent OSA); tracheotomy
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| Future directions: looking for clinical measure or test to assign treatment and predict perioperative risk and risk for
treatment failure; new emphasis on daytime symptoms, behavioral, cognitive, and QOL issues; new emphasis on whether
snoring itself and upper airway resistance syndrome may affect children’s behavior and cognition; natural history studies
needed on children with mild SDB
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Suggested Reading
Carroll JL et al: Behavior, cognition, and quality of lif.after adenotonsillectomy for pediatric sleep-disordered breathing:
summary of the literature. Otolaryngol Head Neck Surg 138:S19, 2008; De Serres LM et al: Impact of adenotonsillectomy
on quality of life in children with obstructive sleep disorders. Arch Otolaryngol Head Neck Surg 128:489, 2002;
Elshaug AG et al: Redefining success in airway surgery for obstructive sleep apnea: a meta analysis and synthesis of the
evidence. Sleep 30:461, 2007; Goldstein NA et al: Clinical assessment of pediatric obstructive sleep apnea. Pediatrics
114:33, 2004; Haentjens P et al: The impct of continuous positive airway pressure on blood pressure in patients with obstructive
sleep apnea syndrome: evidence from a meta-analysis of placebo-controlled randomized trials. Arch Intern Med
167:757, 2007; Hoekema A et al: Oral appliances and maxillomandibular advancement surgery: an alternative treatment
protocol for the obstructive sleep apnea-hypopnea syndrome. J Oral Maxillofac Surg 64:886, 2006; Jones DT et al: Effectiveness
of postoperative follow-up telephone interviews for patients who underwent adenotonsillectomy: a retrospective
study. Arch Otolaryngol Head Neck Surg 133:1091, 2007; Kushida CA et al: American Academy of Sleep. Practice parameters
for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep 29:240,
2006; Lin SY et al: Relief of upper airway obstruction with mandibular distraction surgery: Long-term quantitative results
in young children. Arch Otolaryngol Head Neck Surg 132:437, 2006; McColley SA et al: Respiratory compromise after
adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 118:940, 1992; Mitchell
RB et al: Outcomes and quality of life following adenotonsillectomy for sleep-disordered breathing in children. ORL J
Otorhinolaryngol Relat Spec69:345, 2007; Mitchell RB: Adenotonsillectomy for obstructive sleep apnea in children: outcome
evaluated by pre- and postoperative polysomnography. Laryngoscope 117:1844, 2007; Peppard PE et al: Longitudinal
study of moderate weight change and sleep-disordered breathing. JAMA 284:3015, 2000; Sterni LM et al:
Obstructive sleep apnea in children: an update. Pediatr Clin North Am 50:427, 2003; Tauman R et al: Persistence of obstructive
sleep apnea syndrome in children after adenotonsillectomy. J Pediatr 149:803, 2006; Weatherly RA et al: Identification
and evaluation of obstructive sleep apnea prior to adenotonsillectomy in children: a survey of practice patterns.
Sleep Med 4:297, 2003; Weatherly RA et al: Polysomnography in children scheduled for adenotonsillectomy. Otolaryngol
Head Neck Surg 131:727, 2004; Young T et al: Menopausal status and sleep-disordered breathing in the Wisconsin
Sleep Cohort Study. Am J Respir Crit Care Med 167:1181, 2003; Young T et al: Population-based study of sleep-disordered
breathing as a risk factor for hypertension. Arch Intern Med 157:1746, 1997; Zintzaras E et al: Sleep-disordered
breathing and blood pressure in children: a meta-analysis. Arch Pediatr Adolesc Med 161:172, 2007.
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