Sleep Apnea: Comorbidities, Racial Disparities, Weight Guidelines, and Alternatives to CPAP

Publish date: October 5, 2023

Slideshow below.

Obstructive sleep apnea (OSA) is a disorder in which the upper airway repeatedly collapses during sleep, resulting in hypoxemia and sleep disruption. Approximately 9-17% of women and 25-30% of men in the United States are diagnosed with OSA.^1,2 Patients may present with a range of symptoms, including daytime sleepiness, snoring, breathing pauses, or unexplained awakenings from sleep.¹ OSA severity is classified according to the apnea-hypopnea index (AHI), and defined by the presence of either ≥ 15 events per hour or 5-14 events per hour with symptoms such as excessive daytime sleepiness, insomnia, or impaired sleep-related quality of life.¹ OSA has been associated with stroke, hypertension, atrial fibrillation, coronary artery disease, heart failure, and mood disorders.³ Continuous positive airway pressure (CPAP) is the standard of care for treating OSA in most patients and is highly cost-effective.⁴

Unfortunately, racial disparities exist in sleep apnea, as with sleep health generally. Black individuals have disproportionately high rates of OSA and higher OSA severity in comparison with White patients.⁵ Racial inequity also exists in disease outcomes and sleep apnea-related mortality.^5,6 CPAP adherence may be lower in marginalized racial groups, with Black patients demonstrating lower nightly CPAP usage.⁴ Initiatives are needed to improve sleep health equity, such as through increased access to sleep care through telehealth, lessening barriers to sleep apnea diagnostics, and reducing structural inequities associated with CPAP treatment including cost.

Obesity is a well-established risk factor for sleep apnea, and all patients whose body mass index (BMI) is elevated should be counseled on weight loss.^7,8 For patients unable to acclimate to CPAP, alternatives are available; there was increased reliance upon these during the recent major CPAP recall.⁹ Some alternatives include mandibular advancement devices, positional therapy, and hypoglossal nerve stimulation therapy.⁹ Emerging research is exploring the possibility of drug therapy to manage sleep apnea in the future.⁹

For patients who need further assistance, anti-obesity pharmacotherapy and/or bariatric surgery should be considered. This includes anti-obesity pharmacotherapy for BMI ≥ 27 and consideration of bariatric surgery referral for BMI ≥ 35.
ATS, American Thoracic Society

References

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CPAP adherence curbs severe cardiovascular disease outcomes

Sleep Apnea: Comorbidities, Racial Disparities, Weight Guidelines, and Alternatives to CPAP

References

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