Treatments for Obstructive Sleep Apnea

From the Center for Narcolepsy, Sleep and Health Research, Department of Biobehavioral Health Science, University of Illinois at Chicago, Chicago, IL.

Abstract

• Objective: To review the efficacy of current treatment options for adults with obstructive sleep apnea (OSA).
• Methods: Review of the literature.
• Results: OSA, characterized by repetitive ≥ 10-second interruptions (apnea) or reductions (hypopnea) in airflow, is initiated by partial or complete collapse in the upper airway despite respiratory effort. When left untreated, OSA is associated with comorbid conditions, such as cardiovascular and metabolic diseases. The current “gold standard” treatment for OSA is continuous positive air pressure (CPAP), which pneumatically stabilizes the upper airways. CPAP has proven efficacy and potential cost savings via decreases in health comorbidities and/or motor-vehicle crashes. However, CPAP treatment is not well-tolerated due to various side effects, and adherence among OSA subjects can be as low as 50% in certain populations. Other treatment options for OSA include improving CPAP tolerability, increasing CPAP adherence through patient interventions, weight loss/exercise, positional therapy, nasal expiratory positive airway pressure, oral pressure therapy, oral appliances, surgery, hypoglossal nerve stimulation, drug treatment, and combining 2 or more of the aforementioned treatments. Despite the many options available to treat OSA, none of them are as efficacious as CPAP. However, many of these treatments are tolerable, and adherence rates are higher than those of the CPAP, making them a more viable treatment option for long-term use.
• Conclusion: Patients need to weigh the benefits and risks of available treatments for OSA. More large randomized controlled studies on treatments or combination of treatments for OSA are needed that measure parameters such as treatment adherence, apnea-hypopnea index, oxygen desaturation, subjective sleepiness, quality of life, and adverse events.

Obstructive sleep apnea (OSA), characterized by repetitive ≥ 10-second interruptions (apnea) or reductions (hypopnea) in airflow (measured as events/hour, called the apnea-hypopnea index [AHI]), is initiated by partial or complete collapse in the upper airway despite respiratory effort [1]. Current estimates of the prevalence of OSA (AHI ≥ 5 and Epworth Sleepiness Scale > 10) in American men and women (aged 30–70 years) are 14% and 5%, respectively, with prevalence rates increasing due to increasing rates of obesity, a risk factor for developing OSA [2]. Hypoxemia/hypercapnia, fragmented sleep, as well as exaggerated fluctuations in heart rhythm, blood pressure, and intrathoracic pressure are some of the acute physiological effects of untreated OSA [1]. These acute effects can develop into long-term sequelae, such as hypertension and other cardiovascular comorbidities [2,3], decrements in cognitive function [4,5], poor mood, reduced quality of life [6,7], and premature death [8,9]. In economic terms, health care cost estimates of OSA and its associated comorbidities rival that of diabetes [10]. Additionally, in the year 2000, more than 800,000 drivers were involved OSA-related motor-vehicle collisions, of which more than 1400 fatalities occurred [11].

Front-line treatment of OSA relies on mechanically stabilizing the upper airway with a column of air via continuous positive airway pressure (CPAP) treatment. Though CPAP is the “gold standard” treatment for OSA with proven efficacy and potential cost savings via decreases in health comorbidities and/or motor-vehicle crashes [10–12], CPAP treatment is not well-tolerated due to various side effects [13–15]. Adherence among OSA subjects can be as low as 50% in certain populations [16–18]. Improved strategies for current and innovative treatments have emerged in the last few years and are the subject of this review.