Management

The main aim of treatment is to improve the symptoms (especially sleepiness) rather than the diminution of vascular risk (1).

When to start treatment? (2)

SIGN guideline suggest that

• treatment is beneficial in symptomatic patients with AHI ≥15 or a 4% oxygen saturation dip rate at the level of >10/hour
• some evidence of benefit in symptomatic individuals with AHI of 5-14
• patients with five or fewer respiratory events per hour may need to be treated if they complain of sleepiness and fatigue, or have secondary medical complications such as heart failure

Treatment options

The main treatment options include

• behavioural interventions
  • weight loss - should be encouraged in all patients with obesity contributing to their OSAHS. Attempts at weight loss should not delay the initiation of further treatment. Weight loss should also be encouraged as an adjunct to CPAP or intra-oral devices as it may allow discontinuation of therapy
  • alcohol and sedatives or sleeping tablets which aggravates OSAS should be avoided
  • cessation of smoking
  • positional treatment e.g. - non-sleepy snorers should be discouraged from sleeping on their backs
  • spending adequate time in bed - sleep deprivation increases a person's tendency to snore
  • raising the head of the bed
• non-surgical options
  • continuous positive airway pressure (CPAP)
    • is the first choice therapy for patients with moderate or severe OSAS that is sufficiently symptomatic to require intervention.
    • randomised controlled trials show that CPAP improves subjective and objective sleepiness cognitive function, vigilance, mood and quality of life measures
    • for more detail see linked item
  • oral appliances
    • used to advance the mandible or tongue which in turn enlarges the upper airway or reduce the upper airway collapsibility by increasing muscle tone
    • useful in patients with mild to moderate OSAS or who are intolerant to CPAP
    • not recommended in severe OSAS, or in patients with severe sleepiness or noticeable nocturnal desaturation
    • NICE recommends that soft-palate implants should not be used in the treatment of this condition (3)
  • pharmacological
    • comparison of drugs for excessive daytime sleepiness (EDS) in OSA (4)
      • found solriamfetol, armodafinil-modafinil and pitolisant reduced daytime sleepiness for patients with OSA already on conventional therapy, with solriamfetol likely superior
      • adverse events probably increased discontinuation risk of armodafinil-modafinil & solriamfetol
    • there is no convincing evidence that other drugs which have been used in obstructive sleep apnoea, including aminophylline, buspirone, clonidine, medroxyprogesterone and theophylline, offer benefit to patients (5)
• surgical options
  • could be considered in patients for whom CPAP or oral appliances have failed, or if such treatments are contraindicated by claustrophobia or dental disease, respectively
  • available surgical options include:
    • tonsillectomy
    • laser palatoplasty
    • uvulopalatopharyngoplasty
    • radiofrequency ablation of the tongue base
    • suspension of the hyoid bone (1,2)

Reference:

• (1) Greenstone M, Hack M. Obstructive sleep apnoea. BMJ. 2014;348:g3745
• (2) Scottish Intercollegiate Guidelines Network (SIGN) 2003. Management of obstructive sleep apnoea/hypopnoea syndrome in adults
• (3) National Institute for Health and Clinical Excellence (NICE) 2007. Soft-palate implants for obstructive sleep apnoea
• (4) Pitre T et al. Comparative Efficacy and Safety of Wakefulness-Promoting Agents for Excessive Daytime Sleepiness in Patients With Obstructive Sleep Apnea: A Systematic Review and Network Meta-analysis. Ann Intern Med. [Epub 9 May 2023]. doi:10.7326/M22-3473
• (5) Drug and Therapeutics Bulletin 2004; 42(7):52-6