Diagnosis and treatment of obstructive sleep apnea in adults

Abstract

O bstructive sleep apnea (OSA) is characterized by recurring episodes of cessation (apnea) or reduction (hypopnea) in airflow during sleep caused by obstruction of the upper airway. In recent population-based studies, the estimated prevalence of moderate to severe sleep-disordered breathing ranges from 3% to nearly 50% depending on age group and sex. 1,2 A survey conducted by the Public Health Agency of Canada in 2009 found that 26% of Canadian adults reported symptoms and risk factors that are associated with a high risk of OSA; 3 however, prevalence data in Canada are limited by the absence of studies using objective sleep testing. Obstructive sleep apnea may be underdiagnosed; only 3% of Canadians aged 18 years or older reported a formal diagnosis despite high rates of symptom reporting; 3 yet, high-quality prospective studies have shown clear benefit of treatment for patients with sleepiness, cognitive or psychological dysfunction, or poor quality of life owing to obstructive sleep apnea. 4-6 Large population-based studies have shown that untreated moderate or severe OSA is associated with serious complications. 7-9 We review signs, symptoms and morbidity associated with OSA, along with diagnostic options, treatments and considerations for long-term follow-up, based on evidence and recommendations from clinical guidelines, systematic reviews and primary studies (Box 1). What signs, symptoms and risk factors should prompt consideration of obstructive sleep apnea? About 25% of patients with OSA report daytime sleepiness; a greater proportion report unrefreshing sleep or fatigue. 10 Other symptoms include frequent nocturnal waking due to choking or gasping, nocturia, morning headaches, poor concentration, irritability and erectile dysfunction. 11-13 Bed partners may report snoring or witnessed apneas. Atypical symptoms, which are more frequently reported by women, include insomnia, impaired memory, mood disturbance, reflux and nocturnal enuresis. 14 However, the correlation of symptoms with disease severity is poor, 15 which is why it is important for physicians to be alert to milder symptoms. There are many underlying risk factors, predisposing conditions and associated comorbidities for OSA; they are summarized in Appendix 1, available at www.cmaj.ca/ lookup/suppl/

Treatment options for obstructive sleep apnea

“…Rotenberg and Pang, who are proponents of ear, nose and throat surgery for sleep apnea, 1 and from Dr. Cheryl Laratta and colleagues, 2 who maintain that continuous positive air pressure (CPAP) remains the gold standard and first choice of treatment for this "epidemic" sleep disorder, in response to the recent review article in CMAJ. 3 Obstructive sleep apnea affects about 50% of Canada's over-50 population. 3 As the then director of member services for the British Columbia Dental Association, I was tasked with reviewing the proposed standards and guidelines of the College of Dental Surgeons of BC in the spring of 2013 for the prescribing, fabrication, fitting and titration of mandibular repositioning appliances for the treatment of obstructive sleep apnea.…”

“…3 Obstructive sleep apnea affects about 50% of Canada's over-50 population. 3 As the then director of member services for the British Columbia Dental Association, I was tasked with reviewing the proposed standards and guidelines of the College of Dental Surgeons of BC in the spring of 2013 for the prescribing, fabrication, fitting and titration of mandibular repositioning appliances for the treatment of obstructive sleep apnea. I quickly discovered that the proposed regulatory rules I was reviewing followed standards and guidelines similar to those that were being formulated by the College of Physicians and Surgeons of British Columbia and by a committee of the American Academies of Sleep Medicine and Dental Sleep Medicine.…”

Addressing challenges with current therapies for obstructive sleep apnea

“…We read with interest the responses to our recent review of the diagnosis and treatment of obstructive sleep apnea (OSA). 1 We agree that challenges with current therapies for OSA necessitate the study of newer and personalized treatments to improve clinical outcomes, treatment adherence and patient satisfaction. As indicated by Dr. Pupko, 2 the use of dronabinol in the treatment of OSA is one of several such approaches to improve OSA severity and sleepiness.…”

Rendimiento de los cuestionarios de sueño en el diagnóstico de síndrome de apneas obstructivas del sueño en población chilena. Subestudio de la Encuesta Nacional de Salud, 2016/17

“…l síndrome de apneas hipopneas obstructivas del sueño (SAHOS) constituye un problema clínico prevalente que ocasiona morbilidad y mortalidad significativas en la población adulta [1][2][3][4] . En los estudios poblacionales, se estima una prevalencia de SAHOS de 22% (rango: 9-37%) en varones y 17% (rango: 4-50%) en mujeres 5 .…”