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Obstructive Sleep Apnea (OSA)

By

Kingman P. Strohl

, MD, Case School of Medicine, Case Western Reserve University

Medically Reviewed Oct 2022
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Topic Resources

Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of apnea or hypopnea > 10 seconds) followed by arousals and hyperpnea. Symptoms can include excessive daytime sleepiness, restlessness, snoring, recurrent awakening, and morning headache. Diagnosis is based on sleep history and polysomnography. Treatment is with nasal continuous positive airway pressure, oral appliances, and, in refractory cases, surgery. Prognosis is good with treatment. Untreated patients are at risk for hypertension, atrial fibrillation and other arrhythmias, heart failure, and injury or death due to motor vehicle crashes and other accidents resulting from hypersomnolence.

General references

Pathophysiology of Obstructive Sleep Apnea (OSA)

Obstructive sleep apnea involves a compromise in upper airway anatomy during sleep. Sleep destabilizes patency of the upper airway, leading to partial or complete obstruction of the nasopharynx, oropharynx, or both. Airway patency tends to oscillate causing recurrent periods of apnea and recovery.

Obstruction causes multiple episodes of apnea or hypopnea, which lead to hypoxia and hypercapnia, all of which disrupt normal sleep, with partial or complete arousals from nonrapid eye movement (NREM) and rapid eye movement (REM) sleep (1 Pathophysiology references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ). Inspiratory efforts against a closed upper airway cause swings in intrathoracic pressure that affect cardiac performance. Endothelial and neurotransmitter dysfunction occur. All factors interact to produce significant morbidity and mortality.

Related disorders

Less severe forms may not produce oxygen desaturation, but they interrupt sleep.

Obstructive sleep hypopnea is a condition in which inspiratory flow is diminished, but not absent, in a high resistance airway.

Upper airway resistance syndrome is crescendo snoring terminated by snorts and respiratory effort-related arousals (RERAs). Breathing reductions do not meet strict criteria for obstructive apneas and hypopneas. Patients with upper airway resistance syndrome are typically younger and have less obesity than those with OSA. Patients are more often female, report fatigue, and complain of insomnia. Snoring and upper airway airflow resistance cause noisy inspiration but without arousals from sleep lasting > 2 seconds. Symptoms, diagnostic evaluation, and treatment of snoring and upper airway resistance syndrome are similar to those of OSA.

Complications

Obstructive sleep apnea is the leading medical cause of excessive daytime sleepiness. A more correct term is wake-time excessive sleepiness, because people who work during the night may be excessively sleepy during night hours. The excessive sleepiness actively increases risk of automobile crashes, difficulties at work, and sexual dysfunction. There is often some degree of cognitive impairment and also increased risk of injury (eg, when operating heavy machinery or engaging in other activities during which unintentional sleep episodes would be hazardous). Relationships with bed partners, roommates, and/or housemates may also be adversely affected because such people may have difficulty sleeping because of the patient's noisy, restless sleep. Severe OSA (apnea-hypopnea index > 30 per hour) increases the risk of death in middle-aged men.

OSA also has medical risks unrelated to excessive sleepiness. Hypertension is strongly associated with OSA (2 Pathophysiology references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ). Normotensive patients with untreated OSA are more likely to develop hypertension within 5 years of diagnosis. Repetitive nocturnal hypoxia and sleep disruption are associated with increased risk of medical disorders, including heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular (LV) failure causes shortness of breath and fatigue, and right ventricular (RV) failure causes peripheral and abdominal... read more Heart Failure (HF) , atrial fibrillation Atrial Fibrillation Atrial fibrillation is a rapid, irregularly irregular atrial rhythm. Symptoms include palpitations and sometimes weakness, effort intolerance, dyspnea, and presyncope. Atrial thrombi may form... read more (even after catheter ablation) and other arrhythmias, nonalcoholic fatty liver Nonalcoholic Fatty Liver Disease (NAFLD) Fatty liver is excessive accumulation of lipid in hepatocytes. Nonalcoholic fatty liver disease (NAFLD) includes simple fatty infiltration (a benign condition called fatty liver), whereas nonalcoholic... read more , and stroke Overview of Stroke Strokes are a heterogeneous group of disorders involving sudden, focal interruption of cerebral blood flow that causes neurologic deficit. Strokes can be Ischemic (80%), typically resulting... read more Overview of Stroke (3 Pathophysiology references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ). The risk of stroke and all-cause mortality is increased even when controlling for other risk factors (eg, hypertension Hypertension Hypertension is sustained elevation of resting systolic blood pressure (≥ 130 mm Hg), diastolic blood pressure (≥ 80 mm Hg), or both. Hypertension with no known cause (primary; formerly, essential... read more Hypertension , diabetes Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more ) (4 Pathophysiology references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ). However, the contribution of OSA to these common disorders (and thus its cost to society) is often underappreciated (5 Pathophysiology references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ).

In addition, perioperative complications, including cardiac arrest, occur with unrecognized OSA, because moderate and general anesthesia is a risk for airway obstruction. Patients should inform an anesthesiologist of the diagnosis before undergoing any surgery and should receive continuous positive airway pressure (CPAP) when they receive preoperative drugs and during recovery.

Pathophysiology references

Etiology of Obstructive Sleep Apnea (OSA)

Anatomic risk factors for obstructive sleep apnea include

  • An oropharynx “crowded” by a short or retracted mandible

  • A prominent tongue base or tonsils

  • A rounded head shape and a short neck

  • A neck circumference > 43 cm (> 17 in)

  • Thick lateral pharyngeal walls and parapharyngeal fat pads

Such risk factors may not predict severity.

Other identified risk factors include postmenopausal status, aging, obesity, and alcohol or sedative use (1 Etiology references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ). Medical disorders that can cause or contribute to OSA include nocturnal gastroesophageal reflux Gastroesophageal Reflux Disease (GERD) Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain. Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia... read more Gastroesophageal Reflux Disease (GERD) , acromegaly Gigantism and Acromegaly Gigantism and acromegaly are syndromes of excessive secretion of growth hormone (hypersomatotropism) that are nearly always due to a pituitary adenoma. Before closure of the epiphyses, the result... read more Gigantism and Acromegaly , hypothyroidism Hypothyroidism Hypothyroidism is thyroid hormone deficiency. Symptoms include cold intolerance, fatigue, and weight gain. Signs may include a typical facial appearance, hoarse slow speech, and dry skin. Diagnosis... read more Hypothyroidism , and prior stroke Overview of Stroke Strokes are a heterogeneous group of disorders involving sudden, focal interruption of cerebral blood flow that causes neurologic deficit. Strokes can be Ischemic (80%), typically resulting... read more Overview of Stroke . Nocturnal angina confers a 15-fold increased risk for OSA. OSA and obesity-hypoventilation syndrome frequently coexist.

A family history of OSA is present in 25 to 40% of adult cases, reflective of polygenic risks affecting ventilatory drive or anatomy; genetic risks may vary by ethnicity (2 Etiology references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ). Likelihood of OSA in a given family member is proportional to the number of other affected family members.

Etiology references

  • 1. Patel SR: Obstructive sleep apnea. Ann Intern Med 171(11):ITC81-ITC96, 2019. doi: 10.7326/AITC201912030

  • 2. Yi M, Tan Y, Pi Y, et al: Variants of candidate genes associated with the risk of obstructive sleep apnea. Eur J Clin Invest 52(1):e13673, 2022. doi: 10.1111/eci.13673

Symptoms and Signs of Obstructive Sleep Apnea (OSA)

  • Choking, gasping, or snorting during sleep

  • Restless and unrefreshing sleep

  • Difficulty staying asleep

Most patients are asleep and are unaware of these symptoms until informed by bed partners, roommates, or housemates. In the morning, some patients have a sore throat, dry mouth, or headache.

During daily activities, patients may experience intrusive sleepiness, fatigue, and impaired concentration. The frequency of sleep complaints and the degree of daytime sleepiness do not correlate well with number of events or arousals from sleep. However, those with sleepiness are at greater risk of cardiovascular complications. Not all patients are sleepy.

Physical examination may show signs of nasal obstruction, tonsillar hypertrophy, and abnormalities of pharyngeal structure. Anatomic risk factors for OSA should be noted.

Symptoms and signs references

  • 1. Lee JJ, Sundar KM: Evaluation and management of adults with obstructive sleep apnea syndrome. Lung 199(2):87-101, 2021. doi: 10.1007/s00408-021-00426-w

  • 2. Strohl KP, Redline S. Recognition of obstructive sleep apnea. Am J Respir Crit Care Med 154(2 Pt 1):279-89, 1996. doi: 10.1164/ajrccm.154.2.8756795. PMID: 8756795.

Diagnosis of Obstructive Sleep Apnea (OSA)

  • Suspected by clinical evaluation

  • Confirmation by sleep studies

In addition to the patient, bed partners, roommates, and/or housemates are all sources for risk assessment information. Snoring loudly enough to be heard in the next room confers a 10-fold increase in the likelihood of having an apnea-hypopnea index > 5 per hour.

At-risk patients who might need more detailed evaluation include those who

Questionnaires, such as STOP-Bang, Berlin Questionnaire (BQ), and Epworth Sleepiness Scale (ESS), can be used by nonspecialists to assess risk. However, when compared to the more accurate results of sleep studies, these questionnaires have low specificity and high false-positive rates and should not be used to make a diagnosis or to direct therapy. The multimodal STOP-Bang and the BQ are more specific than the ESS for risk of OSA and have good negative predictive value (2 Diagnosis references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ).

Accountable care organizations and medical insurance companies have a symptomless risk score to estimate likelihood of disease, but the score lacks specificity at the individual patient level (3 Diagnosis references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ). (See also Centers for Medicare & Medicaid Services: Accountable Care Organizations.) Multivariate analyses of symptoms, comorbidities, and testing results are now suggesting ways to individualize management and help calculate individual risk if sleep apnea is untreated (4 Diagnosis references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ).

Research is beginning on using artificial intelligence to analyze clinical history together with physiologic inputs from wearable devices to suggest disease probability (5 Diagnosis references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ). This technology could be educationally valuable and beneficial, given the prevalence of poor sleep, snoring, and sleep apnea, and the consequences of untreated disease. However, diagnosis and treatment should be based on symptoms.

Patients whose symptoms, screening questionnaires, and/or risk factors suggest a higher likelihood of OSA should typically have sleep monitoring Sleep studies Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more to determine the apnea-hypopnea index (AHI) or some surrogate like Respiratory Disturbance Index (RDI), which is needed to confirm the syndrome and grade severity. Patients who report only snoring, without other symptoms or cardiovascular risks, do not need an extensive evaluation for OSA, and can respond by increasing fitness, losing weight, improving sleep hygiene, and treating nasal allergies.

The apnea-hypopnea index (AHI) represents the total number of episodes of apnea and hypopnea occurring during sleep divided by the hours of sleep time; it is expressed as the number of apneic episodes occurring per hour. The more events that occur, the more severe the OSA and the greater the likelihood of adverse effects. AHI values can be computed for different sleep stages and body positions (side or back).

Criteria for diagnosis of OSA include daytime symptoms, nighttime symptoms, and sleep monitoring results that show an AHI ≥ 5 per hour in patients with symptoms, or ≥ 15 per hour in the absence of symptoms. Symptoms should include ≥ 1 of the following:

  • Unrefreshing sleep

  • Daytime sleepiness*, fatigue

  • Unintentional sleep episodes

  • Difficulty staying asleep

  • Awakening with breath holding, gasping, or choking

  • Reports by a bed partner of loud snoring, breathing interruptions, or both

*Sleepiness that is active (ie, intrusive into daily activities or producing crashes or errors) is particularly significant.

The differential diagnosis includes many other conditions and factors that reduce the quantity or quality of sleep or cause daytime sedation or sleepiness. These include

Measurement of thyroid-stimulating hormone can be useful in those in whom hypothyroidism is clinically suspected but should not be done routinely. No other adjunctive testing (eg, upper airway imaging, facial photographs, biomarkers like cancer-related fatigue) has sufficient specificity to be recommended routinely.

Sleep studies

Sleep studies include

  • Traditional polysomnography conducted in a sleep laboratory

  • Portable diagnostic tools that can be used by patients at home in their own bed

Polysomnography Testing Almost half of all people in the US report sleep-related problems. Disordered sleep can cause emotional disturbance, memory difficulty, poor motor skills, decreased work efficiency, and increased... read more records and helps classify stages of sleep and the occurrence and duration of apneic and hypopneic periods. It is ideal for confirming the diagnosis of OSA and quantifying the severity of OSA. However, it requires an overnight stay in a sleep laboratory and is thus complicated and expensive. Polysomnography typically includes

  • Continuous measurement of sleep architecture by EEG (electroencephalography)

  • Chin electromyography to detect hypotonia

  • Electro-oculography to assess the occurrence of rapid eye movements.

  • Airflow sensors at the nose and mouth to detect apneas and hypopneas

  • Chest and/or abdominal sensors to detect respiratory effort

  • Oxygen saturation by pulse oximetry

  • ECG monitoring to detect arrhythmias associated with apneic episodes

The patient is also observed by video.

Other variables evaluated include limb muscle activity (to assess nonrespiratory causes of sleep arousal, such as restless legs syndrome and periodic limb movements disorder) and body position, because apnea may occur predominantly in the supine position.

The apnea-hypopnea index (AHI) is the total number of episodes of apnea and hypopnea occurring during sleep divided by the hours of sleep time. It is a common measure of respiratory disturbance during sleep and is used to classify the severity of OSA. Note the AHI alone does not determine need for treatment.

OSA is graded as:

  • Mild: AHI ≥ 5 and < 15 per hour

  • Moderate: AHI ≥ 15 and ≤ 30 per hour

  • Severe: AHI > 30 per hour

Some patients may have a very high AHI (> 60).

The respiratory disturbance index (RDI) is a related measure that includes the number of arousals related to respiratory effort (called respiratory effort-related arousals or RERAs) plus the number of apnea and hypopnea episodes per hour of sleep.

The arousal index, which is the number of arousals per hour of sleep, can be computed if EEG monitoring is used. The arousal index is loosely correlated with the apnea-hypopnea index and respiratory disturbance index; about 20% of apneas and desaturation episodes are not accompanied by arousals, or other causes of arousals are present.

However, the apnea-hypopnea index, arousal index, and respiratory disturbance index are only moderately associated with a patient’s symptoms. Some patients with a high or extremely high AHI (eg, > 60) have few or no symptoms. Additional metrics and combinations of metrics may prove useful in diagnosis (6 Diagnosis references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ). Furthermore, studies now show that it is a composite of clinical and polysomnographic data (not just AHI) that are linked to outcome and to cardiovascular risk and mortality, for instance, sleepiness regardless of AHI is linked to excess cardiovascular disease.

Home sleep testing using portable diagnostic tools uses a limited subset of polysomnographic measures, typically just heart rate, pulse oximetry, respiratory effort, position, and nasal airflow to detect apnea and estimate its severity. Their role is expanding (7 Diagnosis references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ) because of their convenience and decreased cost and their ability to provide a reasonably accurate estimate of respiratory disturbances during sleep.

However, portable tools have some limitations. They do not actually detect the presence of sleep and instead depend on patients to self-report sleeping, which can be inaccurate; if patients were not sleeping during part of the study and they did not report this, sleep-disordered breathing will be underestimated. Also, coexisting sleep disorders (eg, restless legs syndrome Periodic Limb Movement Disorder (PLMD) and Restless Legs Syndrome (RLS) Periodic limb movement disorder (PLMD) and restless legs syndrome (RLS) are characterized by abnormal motions of and, for RLS, usually sensations in the lower or upper extremities, which may... read more , seizures, REM behavior disorder, confusional arousals) are not detected. Follow-up polysomnography may still be needed to characterize these disorders as well as to accurately provide AHI and RDI values in the different stages of sleep and with changes in position, especially when surgery or therapy other than positive airway pressure is being considered.

Portable tools are often used in combination with questionnaires (eg, STOP-Bang, Berlin Questionnaire). If questionnaire results indicate a higher pre-test probability of disease, the sensitivity and specificity of the portable tools is higher.

Diagnosis references

  • 1. Gupta A, Quan SF, Oldenburg O, et al: Sleep-disordered breathing in hospitalized patients with congestive heart failure: a concise review and proposed algorithm. Heart Fail Rev 23(5):701-709, 2018. doi:10.1007/s10741-018-9715-y

  • 2. Gamaldo C, Buenaver L, Chernyshev O, et al: Evaluation of clinical tools to screen and assess for obstructive sleep apnea. J Clin Sleep Med 14(7):1239-1244, 2018. doi:10.5664/jcsm.7232

  • 3. Keenan BT, Kirchner HL, Veatch OJ, et al: Multisite validation of a simple electronic health record algorithm for identifying diagnosed obstructive sleep apnea. J Clin Sleep Med 16(2):175–183, 2020. doi: 10.5664/jcsm.8160

  • 4. Keenan BT, Kim J, Singh B, et al: Recognizable clinical subtypes of obstructive sleep apnea across international sleep centers: a cluster analysis. Sleep 41(3):zsx214, 2018. doi: 10.1093/sleep/zsx214

  • 5. Lovejoy CA, Abbas AR, Ratneswaran D: An introduction to artificial intelligence in sleep medicine. J Thorac Dis 13(10):6095-6098, 2021. doi:10.21037/jtd-21-1569

  • 6. Malhotra A, Ayappa I, Ayas N, et al: Metrics of sleep apnea severity: beyond the apnea-hypopnea index. Sleep 44(7):zsab030, 2021. doi: 10.1093/sleep/zsab030

  • 7. Collop NA, Anderson WM, Boehlecke B, et al: Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med 3(7):737-47, 2007.

Prognosis for Obstructive Sleep Apnea (OSA)

Prognosis for obstructive sleep apnea is excellent provided treatment is instituted, accepted, and effective. Untreated or unrecognized OSA is accompanied by a lower quality of life, and increased risk of hypertension and injuries from falling asleep while engaging in potentially hazardous activities. Treated OSA is accompanied by better sleep, daytime alertness, and quality of life.

Treatment of OSA results in a modest 2 to 3 mm Hg decrease in blood pressure (1 Prognosis reference Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ), with larger effects in those with resistant hypertension. There may be reduced prevalence of stroke and a shallower decline in renal function. Treatment may lessen excessive daytime sleepiness and its attendant consequences and can decrease snoring and restless sleep. However, there is no strong evidence yet that treatment reduces heart failure or arrhythmias, but it may make these conditions easier to manage. Mortality effects are mixed in controlled trials of CPAP, generally attributed to the poor (about 50%) adherence in the treated groups.

Although the associations between hypertension, short sleep duration, insomnia, restless legs syndrome (RLS) diabetes, etc, and OSA are identified by multiple studies, their causative role is not proven.

Prognosis reference

  • 1. Bratton DJ, Gaisl T, Wons AM, et al: CPAP vs mandibular advancement devices and blood pressure in patients with obstructive sleep apnea: a systematic review and meta-analysis. JAMA 314(21):2280-2293, 2015. doi:10.1001/jama.2015.16303

Treatment of Obstructive Sleep Apnea (OSA)

  • Control of risk factors such as obesity, hypertension, alcohol use, and sedative use

  • Continuous positive airway pressure (CPAP) or oral appliances

  • Sometimes surgery, or nerve stimulation

An apnea-hypopnea index (AHI) Diagnosis Obstructive sleep apnea (OSA) is episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation. Symptoms include snoring and sometimes restless... read more ≥ 5 per hour defines a diagnosis of obstructive sleep apnea; treatment is given only to patients who have symptoms (sleepiness with fatigue, nonrestorative sleep, and snoring/gasping/choking). An AHI value ≥ 15 indicates at least a moderate level of sleep apnea and is considered a threshold to treat in the absence of symptoms.

Pending treatment, sleepy patients should be warned of the risks of driving, operating heavy machinery, or engaging in other activities during which unintentional sleep would be hazardous.

  • Reduce episodes of hypoxia and sleep fragmentation

  • Restore sleep continuity and architecture

  • Avoid episodic asphyxia

There are many available approaches to treatment. Patient and clinician should engage in shared decision making to match the degree and nature of the disorder with feasible interventions and the outcomes most important to the patient.

Treatment is directed at both risk factors and OSA itself. First-line direct therapy includes use of a continuous positive airway pressure (CPAP) device or an oral appliance. For anatomic encroachment or for disease that does not respond to these devices, surgery or nerve stimulation is considered. Success is defined as a resolution of symptoms with AHI reduction, usually to < 10 per hour and ideally to < 5 per hour.

Control of risk factors

Initial treatment aims to control risk factors such as obesity, hypertension, alcohol use, and sedative use. Exercise decreases the AHI and increases alertness, independent of any effect on body mass index (BMI).

Continuous positive airway pressure (CPAP)

There are many different CPAP devices available, including those that cover the nose, nose and mouth, or the whole face. All have cushions to provide an air seal, which is essential for maintaining a pressure gradient. Cushions may be inflatable or made of silicone, foam, or gel. Proper fit and comfort vary widely among patients but must be optimized for both efficacy and adherence.

CPAP improves upper airway patency by applying positive pressure to the collapsible upper airway segment. Effective pressures typically range from 3 to 15 cm H2O. Pressure requirements are not correlated with disease severity. Many CPAP devices monitor CPAP efficacy and titrate pressures automatically, according to internal algorithms. If necessary, polysomnographic monitoring can be used to guide manual titration of pressure.

Although a reduction in AHI is one of the treatment goals, CPAP will reduce cognitive impairment and improve quality of life regardless of improvement in the AHI. CPAP also may reduce blood pressure. If CPAP is withdrawn, symptoms recur over several days, though short interruptions of therapy for acute medical conditions are usually well tolerated. Duration of therapy is indefinite.

If clinical improvement is not apparent, CPAP adherence should be reviewed, and patients should be reassessed for a second sleep disorder (eg, upper airway obstruction) or a comorbid disorder. If patients have septal deviation or polyps, nasal surgery may make CPAP treatment more successful but inconsistently “treats” OSA.

Adverse effects of nasal CPAP include discomfort resulting from a poorly fitting mask, and dryness and nasal irritation, which can be alleviated in some cases with the use of warm humidified air. However, newer mask designs have improved comfort and ease of use.

Adherence is difficult for many people and is lower in patients who do not experience sleepiness. Overall, about 50% of patients adhere to use of CPAP long term. Adherence can be improved by efforts to foster a positive attitude towards device use combined with early attention to any problems, particularly mask fit, and close follow-up by a committed caretaker, with reinforcement by the primary care physician. There is also a need to recognize and address the decreased long-term CPAP adherence among patients who do not have obesity and have low respiratory arousal threshold (ie, awaken easily) and thus a propensity for increased arousals and irregular breathing.

Even when adherence is adequate, results may become unsatisfactory if patient factors change (eg, weight gain, nasal obstruction develops).

CPAP can be augmented with inspiratory assistance (bilevel positive airway pressure) to increase tidal volume in patients with comorbid obesity-hypoventilation syndrome.

Oral appliances

Oral appliances are designed to advance the mandible or, at the very least, prevent retrusion and tongue prolapse during sleep (6 Treatment references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more , 7 Treatment references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more , 8 Treatment references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ). Some appliances are designed to pull the tongue forward. These appliances are now considered mainstream treatments of both snoring and mild to moderate OSA. Comparisons of appliances to CPAP show equivalent effectiveness in mild to moderate OSA, but cost-effectiveness studies are focused on fixed initial costs of fabrication, rather than replacement and follow-up costs.

Surgery

Surgical procedures to correct anatomic factors, such as enlarged tonsils and nasal polyps contributing to upper airway obstruction (called anatomic procedures), should be considered (8 Treatment references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more , 9 Treatment references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ). Surgery for macroglossia or micrognathia is also an option. Surgery is a first-line treatment if specific anatomic encroachment is identified. However, in the absence of encroachment, evidence to support surgery as a first-line treatment is lacking.

Uvulopalatopharyngoplasty (UPPP) was previously the most common procedure. It involves resection of pharyngeal tissue. UPPP has been largely replaced by less aggressive approaches that attempt to stabilize the lateral walls of the pharynx and/or enlarge the velopharyngeal area without risk of altering speech or swallowing. Equivalence with CPAP was shown in one study using CPAP as a bridge to surgery, but the interventions have not been directly compared. Results are less predictable in patients who have severe obesity or anatomic narrowing of the airway. The procedure may reduce intrusive snoring, although apneic episodes may remain as severe (although silent) as before surgical intervention.

Other surgical procedures include midline glossectomy, hyoid advancement, and mandibulomaxillary advancement. Mandibulomaxillary advancement is sometimes offered as a 2nd-stage procedure if soft tissue approaches are not curative. The optimal multistage approach is not known.

Tracheostomy is the most effective therapeutic maneuver for OSA but is done as a last resort. It bypasses the site of obstruction and is indicated for patients most severely affected (eg, those with cor pulmonale Cor Pulmonale Cor pulmonale is right ventricular (RV) enlargement secondary to a lung disorder that causes pulmonary artery hypertension. Right ventricular failure follows. Findings include peripheral edema... read more Cor Pulmonale ).

Upper airway stimulation

Upper airway stimulation using an implanted device to stimulate a branch of the hypoglossal nerve (10 Treatment references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more , 11 Treatment references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ) can activate muscles that protrude the tongue and other muscles that help open the airway. This therapy is now mainstream, being successful in selected patients with moderate to severe disease. It is used mainly in those who are unable to tolerate CPAP therapy and in whom oral appliances are ineffective. The procedure may also be tried in those in whom mandibulomaxillary advancement is contemplated. Improvements in AHI to < 10 per hour occur in about 65% of these selected patients, but symptoms may improve without achieving efficacy in an AHI < 20 per hour.

Adjunctive treatments

Various adjunctive treatments are sometimes used but have no proven benefit for OSA.

Supplemental oxygen improves blood oxygenation and may reduce AHI and arousal index among patients who did not respond to upper airway surgery (12 Treatment references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ), but a beneficial clinical effect is mainly in those with high gain (tendency to have repeated apnea or hypopnea after an initial episode) and effects are hard to predict. Also, oxygen may provoke respiratory acidosis and morning headache.

A number of other drugs have been tried, including tricyclic antidepressants, theophylline, dronabinol, combined atomoxetine plus oxybutynin (16 Treatment references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ), but cannot be recommended because of factors including limited experience, a low therapeutic index, lack of replication of results, and lack of adequate trials. Better methods to recognize sleep apnea subtypes may allow better selection of patients for this line of treatment.

Exercises for upper airway muscles (myofunctional therapy) have been proposed on the theory that improved muscle strength and tone might help improve airway patency during sleep (17 Treatment references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ). There are a number of exercises that seem to reduce AHI and symptoms, making this approach interesting, particularly because it is noninvasive and with no adverse effects. However, this approach is not yet a mainstream recommendation, because of the wide variety of techniques proposed and the uncertainly about their mechanism of action and efficacy, combined with the great practical difficulties with adherence.

Nasal dilatory devices and throat sprays sold over-the-counter for snoring have not been studied sufficiently to prove value in OSA.

Laser-assisted uvuloplasty, uvular splints, and radiofrequency tissue ablation have been used to treat snoring in patients without OSA. Although they may transiently decrease snoring loudness, efficacy in treating OSA is neither predictable nor durable.

Patient education and support

An informed patient and family are better able to cope with an OSA treatment strategy, including tracheostomy. Patient support groups provide helpful information and effectively support timely treatment and follow-up. There is now organized investigation on the role of patient support groups and digital support tools for management (18 Treatment references Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more ).

Treatment references

  • 1. Strohl KP, Cherniack NS, Gothe B: Physiologic basis of therapy for sleep apnea. Am Rev Respir Dis 134(4):791-802, 1986. doi: 10.1164/arrd.1986.134.4.791

  • 2. Joosten SA, Hamilton GS, Naughton MT: Impact of weight loss management in OSA. Chest 152(1):194-203, 2017. doi: 10.1016/j.chest.2017.01.027

  • 3. Kuna ST, Reboussin DM, Strotmeyer ES, et al: Effects of weight loss on obstructive sleep apnea severity. Ten-year results of the Sleep AHEAD study. Am J Respir Crit Care Med 203(2):221-229, 2021. doi: 10.1164/rccm.201912-2511OC

  • 4. Labarca G, Saavedra D, Dreyse J, et al: Efficacy of CPAP for improvements in sleepiness, cognition, mood, and quality of life in elderly patients with OSA: systematic review and meta-analysis of randomized controlled trials. Chest 158(2):751-764, 2020. doi: 10.1016/j.chest.2020.03.049

  • 5. Wang G, Goebel JR, Li C, et al: Therapeutic effects of CPAP on cognitive impairments associated with OSA. J Neurol 267(10):2823-2828, 2020. doi: 10.1007/s00415-019-09381-2

  • 6. Ng JH, Yow M: Oral appliances in the management of obstructive sleep apnea. Sleep Med Clin 14(1):109-118, 2019. doi: 10.1016/j.jsmc.2018.10.012

  • 7. Ramar K, Dort LC, Katz SG, et al: Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 11(7):773-827, 2015. doi: 10.5664/jcsm.4858

  • 8. Randerath W, Verbraecken J, de Raaff CAL, et al: European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea. Eur Respir Rev 30(162):210200, 2021. doi: 10.1183/16000617.0200-2021

  • 9. Halle TR, Oh MS, Collop NA, et al: Surgical treatment of OSA on cardiovascular outcomes: a systematic review. Chest 152(6):1214-1229, 2017. doi: 10.1016/j.chest.2017.09.004

  • 10. Woodson BT, Strohl KP, Soose RJ, et al: Upper airway stimulation for obstructive sleep apnea: 5-year outcomes. Otolaryngol Head Neck Surg 159(1):194-202, 2018. doi:10.1177/0194599818762383

  • 11. Baptista PM, Costantino A, Moffa A, et al: Hypoglossal nerve stimulation in the treatment of obstructive sleep apnea: Patient selection and new perspectives. Nat Sci Sleep 12:151–159, 2020. doi: 10.2147/NSS.S221542

  • 12. Joosten SA, Tan M, Wong AM, et al: A randomized controlled trial of oxygen therapy for patients who do not respond to upper airway surgery for obstructive sleep apnea. J Clin Sleep Med 17(3):445-452, 2021. doi: 10.5664/jcsm.8920

  • 13. Lal C, Weaver TE, Bae CJ, et al: Excessive daytime sleepiness in obstructive sleep apnea. Mechanisms and clinical management. Ann Am Thorac Soc 18(5):757-768, 2021. doi: 10.1513/AnnalsATS.202006-696FR

  • 14. Black JE, Hirshkowitz M: Modafinil for treatment of residual excessive sleepiness in nasal continuous positive airway pressure-treated obstructive sleep apnea/hypopnea syndrome. Sleep 28(4):464-471, 2005. doi:10.1093/sleep/28.4.464

  • 15. Hirshkowitz M, Black JE, Wesnes K, et al: Adjunct armodafinil improves wakefulness and memory in obstructive sleep apnea/hypopnea syndrome. Respir Med 101(3):616-627, 2007. doi:10.1016/j.rmed.2006.06.007

  • 16. Taranto-Montemurro L, Messineo L, Wellman A: Targeting endotypic traits with medications for the pharmacological treatment of obstructive sleep apnea. A review of the current literature. J Clin Med 8(11):1846, 2019. doi: 10.3390/jcm8111846

  • 17. Camacho M, Certal V, Abdullatif J, et al: Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis. Sleep 38(5):669-75, 2015. doi: 10.5665/sleep.4652

  • 18. Aardoom JJ, Loheide-Niesmann L, Ossebaard HC, et al: Effectiveness of eHealth interventions in improving treatment adherence for adults with obstructive sleep apnea: meta-analytic review. J Med Internet Res 22(2):e16972, 2020. doi: 10.2196/16972

Key Points

  • Obesity, anatomic abnormalities in the upper airway passages, family history, certain disorders (eg, hypothyroidism, stroke), and use of alcohol or sedatives increase the risk of obstructive sleep apnea (OSA).

  • Patients typically snore, have restless and unrefreshing sleep, and often feel daytime sleepiness and fatigue.

  • Most people who snore do not have OSA.

  • Disorders that occur more commonly in patients with OSA include hypertension, stroke, diabetes, gastroesophageal reflux disease, nonalcoholic steatohepatitis, nocturnal angina, heart failure, and atrial fibrillation or other arrhythmias.

  • Confirm the diagnosis by polysomnography or, if uncomplicated OSA, home sleep testing.

  • Control modifiable risk factors and treat most patients with continuous positive airway pressure and/or oral appliances designed to open the airway.

  • Consider surgery for abnormalities causing airway encroachment or if the disorder is intractable.

More Information

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

  • Lee JJ, Sundar KM: Evaluation and management of adults with obstructive sleep apnea syndrome. Lung 199(2):87-101, 2021. doi: 10.1007/s00408-021-00426-w

Drugs Mentioned In This Article

Drug Name Select Trade
Provigil
SUNOSI
Elixophyllin, Quibron T, Quibron T/SR, Respbid, Slo-Bid, Slo-Phyllin, Theo X, Theo-24, Theo-Bid Duracap, TheoCap, Theochron, Theo-Dur, Theo-Dur Sprinkle , Theolair, Theolair SR, Theovent LA, T-Phyl, Uni-Dur, Uniphyl
Strattera
Ditropan, Ditropan XL, Gelnique , Oxytrol, Oxytrol for Women
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