Obstructive sleep apnea (OSA) affects persons of all ages, and rates are likely increasing because of higher rates of obesity, which is a risk factor for OSA. Management is based on type and severity of symptoms and on patient education about the benefits vs. adverse effects associated with the treatment options. The American College of Physicians (ACP) has developed a guideline to assist physicians in choosing the best initial treatment for adults with OSA.

Recommendations

Continuous positive airway pressure (CPAP) is the recommended initial treatment for OSA in addition to weight loss. It improves Epworth Sleepiness Scale scores, reduces apnea-hypopnea index and arousal index scores, and increases oxygen saturation. Studies show that CPAP is more effective than control treatments or sham CPAP, although there were no data on long-term outcomes, such as death or cardiovascular illness, and inconsistent data regarding the effects on quality of life. Evidence shows that fixed CPAP, auto-CPAP, and C-Flex are similar in adherence and effectiveness, although data were insufficient to compare other CPAP modifications.

Use of a mandibular advancement device is an alternative treatment for those who prefer it or if CPAP leads to adverse effects (e.g., discomfort, skin irritation, noise, claustrophobia). Using this device has been shown to lower apnea-hypopnea index scores and reduce sleepiness, although CPAP more effectively decreases apnea-hypopnea index scores and increases minimum oxygen saturation. Evidence was limited about which patients would benefit from either CPAP or a mandibular advancement device. Patients with more severe OSA may more readily adhere to CPAP treatment. Other factors that may increase the likelihood of adherence to CPAP are younger age, snoring, lower CPAP setting, higher body mass index, greater mean oxygen saturation, and the sleepiness domain on the Grenoble Sleep Apnea Quality of Life test.

Evidence was insufficient to compare the effectiveness of other treatments, such as positional therapy, oropharyngeal exercise, palatal implants, surgery, pharmacologic therapy, and atrial overdrive pacing. Physicians should encourage all persons with OSA who are overweight or obese to lose weight. Intensive weight loss in these patients has been shown to reduce apnea-hypopnea index scores and improve OSA symptoms.

Guideline source: American College of Physicians

Evidence rating system used? Yes

Literature search described? Yes

Guideline developed by participants without relevant financial ties to industry? Yes

Published source: Annals of Internal Medicine, October 1, 2013.

Available at: http://annals.org/article.aspx?articleid=1742606