Principles of OSA Management
The degree of intervention in OSA management is based on OSA disease severity (see AHI) and mitigation of risk factors involved. Patient education is pivotal in the treatment for all forms of OSA. Health care providers should advocate for and extoll the benefits of lifestyle changes such as weight loss, maintenance of nasal patency, avoidance of respiratory depressants such as alcohol intake close to bedtime, and adjustments to sleep habits. For some patients, OSA severity is dictated by their sleep posture.
For instance, in “positional OSA,” defined as an AHI two times higher in the supine position when compared to lying on one’s side, could be managed with a number of simple, non-invasive treatments that encourage the patient to sleep more on their side. Sleeping in the supine position allows the tongue to fall backwards and can aggravate airway obstruction. Any change in sleep position away from the supine position should lead to improvements in AHI.
Weight loss strategies alone in OSA treatment have mixed results and may be better used as a stand-alone treatment in mild OSA without other comorbidities.14 Combining weight loss with non-supine sleep positioning improved non-supine AHI to normal in 22% of obese OSA patients.15
Table 1. Treatment Options for Obstructive Sleep Apnea.
Positive airway pressure – continuous vs. automatically adjustable
Mandibular advancement device – titratable vs. fixed
Lifestyle modification – weight loss, sleep position changes
Targeted hypoglossal nerve stimulation
Surgery – orthognathic, oropharyngeal
The definition of success in OSA management varies somewhat. Goalposts for success vary by different study paradigms. An example of several success goalposts include:
Reduction of AHI to less than 5
Reduction of AHI to less than 10
Reduction of AHI by 50% or better
Besides just treating the numbers, improvements in sleep quality, daytime function and blood pressure would represent notable achievements.
Surgical options aim to enhance airflow through the upper airway, thereby alleviating the symptoms of OSA. A UPPP (uvulopalatopharyngoplasty) is one such procedure. Laser-assisted uvuloplasty (LAUP) and bipolar radiofrequency volumetric reduction are two others. These surgeries have yielded mixed results.16 Maxillomandibular advancement surgeries have been shown to reduce AHI and decrease OSA severity.17