CE/CME
Pediatric T2DM: A Growing Threat to US Health
Although accreditation for this CE/CME activity has expired, and the posttest is no longer available, you can still read the full article.
TREATMENT OPTIONS
Because OSA is a chronic condition with no definitive cure, lifelong management and follow-up are needed to evaluate treatment adherence/response and the development or resolution of comorbidities. Treatment options for OSA consist primarily of medical (positive airway pressure, use of oral appliances, and pharmacotherapy), behavioral (weight loss, positional therapy, and substance avoidance), and surgical approaches. The patient should actively participate in the treatment and management of this chronic condition.10
Positive Airway Pressure
Regardless of OSA severity, the treatment of choice is positive airway pressure (PAP) during sleep, with continuous PAP (CPAP) being the recommended mode of delivery. PAP is delivered via a face or nasal mask attached to a machine that maintains a constant upper airway pressure, which in turn prevents pharyngeal collapse during sleep. As a result, the upper airway remains patent, and apneas and hypopneas are inhibited.4
PAP can be delivered in three different modes: CPAP, bilevel (BPAP), or autotitrating (APAP). CPAP provides PAP at a fixed rate throughout the respiratory cycle. In contrast, BPAP delivers a preset PAP that is greater during inspiration than during expiration. BPAP is used to alleviate the discomfort of exhaling against the fixed airway pressure of traditional CPAP by delivering lower pressure during expiration than during inspiration. APAP delivers fluctuating positive airway pressures according to changes in the patient’s breathing patterns and is used in patients with complex breathing patterns. CPAP is the recommended mode of airway pressure delivery; however, BPAP or APAP can be considered in patients who cannot tolerate CPAP.10,21
The amount of pressure needed to maintain airway patency is determined during PSG, and the CPAP system is titrated up to this optimal level. Patient adherence is a commonly encountered problem with CPAP therapy due to adverse effects, such as skin irritation, misfit of mask, dry mouth, nasal congestion, and rhinorrhea. Humidification, nasal saline sprays, and mask resizing can help to alleviate such symptoms.4 Follow-up in the early stages should be frequent enough to troubleshoot and remediate problems with the PAP mask, the machine, and adherence. Long-term follow-up for maintenance, adherence, and signs and symptoms of worsening OSA should be scheduled yearly.10
Oral Appliances
Oral appliances (OAs) are an alternative treatment option for OSA patients who are nonadherent with CPAP, fail CPAP or behavioral therapies, experience adverse effects from CPAP, or prefer OAs. Two types of OAs exist: mandibular repositioning appliances and tongue retaining devices. The former anteriorly displaces the mandible relative to the maxilla; the latter anteriorly displaces the tongue only. Regardless of the type selected, OAs are designed to increase the diameter of the pharynx and decrease pharyngeal collapsibility.10
Although less efficacious than traditional CPAP therapy, OAs may be considered in patients with mild-to-moderate OSA.10 Patients with severe OSA should not be offered OAs as a treatment option. Current evidence suggests that OAs can substantially reduce the severity of OSA as well as daytime sleepiness. Additionally, OAs are superior to CPAP in patient preference, which could improve long-term patient adherence to treatment.22
Prior to initiating therapy with an OA, patients should have a dental examination to assess candidacy for, and proper fit of, an OA. Regular follow-ups are required initially to ensure proper fit and comfort of the device. Patients should be instructed to make an office visit if they experience adverse effects such as temporomandibular joint discomfort, tooth tenderness, excessive salivation, and gum irritation.22 Once final adjustments have been made to the fit of the OA, a PSG should be performed to ensure maximal therapeutic efficacy. Follow-up with a dental specialist is advised every six months for the first year and yearly thereafter.10
Pharmacology
According to the practice parameters of the American Academy of Sleep Medicine (AASM), there are currently no pharmacologic agents that prevent or overcome upper airway obstruction well enough to be considered a primary treatment option for OSA.23 The most widely studied pharmacologic agents—selective serotonergic reuptake inhibitors, protriptyline, methylxanthine derivatives (aminophylline and theophylline), estrogen therapy (with or without progesterone), supplemental oxygen, and short-acting nasal decongestants—are not recommended for the primary treatment of OSA.23 Pharmacologic therapy is therefore most beneficial when used as adjuvant therapy (which targets a residual symptom) rather than primary therapy (which targets the underlying cause of the disorder).
There are currently two FDA-approved medications for the treatment of residual excessive daytime sleepiness in patients who are receiving adequate primary treatment (eg, PAP, OAs) and who do not have any other identifiable cause for the sleepiness: modafinil and armodafinil.23,24 The exact mechanism of action of these agents has not been fully characterized, but they are known to act on the central nervous system to enhance alertness (likely by enhancing dopamine signaling).24
Prior to prescribing these medications, other causes of sleepiness must be ruled out; these include suboptimal adherence with PAP, poorly fitting PAP mask, poor sleep hygiene, insufficient sleep, other sleep disorders, and depression.10 Patients should be informed that these drugs should be used in conjunction with pre-existing CPAP therapy. Common adverse effects of modafinil include headache, dizziness, gastrointestinal upset, and insomnia. This medication should be used cautiously in patients with a history of cardiovascular and/or psychologic problems because it can cause serious adverse effects, including chest pain, palpitations, hypertension, hallucinations, aggression, anxiety, depression, and severe skin reactions, such as Stevens-Johnson syndrome and toxic epidermal necrolysis.4,24
Weight Loss
Because obesity is one of the most prevalent risk factors for OSA, weight loss should be recommended for all overweight and obese OSA patients.13,23 Weight loss can be achieved by several different methods, including exercise programs, dietary programs, a combination of the two, and bariatric surgery. A recent meta-analysis found that exercise alone is less successful in reducing AHI compared to dietary modifications; however, a combination of exercise and dietary changes is superior to both individual interventions in reducing AHI.25 This meta-analysis also found that weight-loss interventions improve, but fail to normalize, AHI.25 Thus, weight-loss interventions should be an adjuvant therapy in the treatment of OSA.23
Another recent meta-analysis found that lifestyle interventions, specifically exercise training, might improve OSA severity and symptoms even in the absence of significant weight loss. According to this study, exercise training produced a 32% reduction in AHI in OSA patients and a 42% reduction in AHI when compared to OSA patients who did not partake in exercise training.26 Additionally, OSA patients experienced significant improvements in cardiorespiratory fitness, daytime sleepiness, and sleep efficiency. Because there was no significant reduction in BMI with exercise training, it is likely that there are additional benefits of exercise training that are independent of the effects on weight loss.26
Positional Therapy
Approximately 50% to 60% of OSA patients have positional OSA, which is classified as an increase of 50% or more in the AHI when sleeping in the supine position compared with nonsupine sleep positions.27 It is thought that positional therapy, consisting of any technique that maintains the patient in a nonsupine sleep position, decreases the tendency for the tongue to prolapse and for the airway to collapse.27 Several positional devices exist, including pillows, tennis balls, backpacks, and vibratory chest alarms. Additionally, sleeping in the lateral recumbent position can function as a form of positional therapy.4,21
According to the AASM, less obese, younger patients and those with less severe OSA are more likely to achieve a normalized AHI by sleeping in a nonsupine position; thus, these patients are more likely to benefit from positional therapy than their OSA counterparts.23,27 A recent study found that CPAP therapy is superior to positional therapy in reducing apneic episodes (ie, AHI) in patients with positional OSA.27 Thus, positional therapy is an effective secondary treatment that can be used as an adjuvant therapy to CPAP in patients with mild positional OSA.23,27
Substance Avoidance
All patients with OSA should be advised to avoid alcohol, as it has been shown to increase the duration and frequency of apneic episodes and lower arterial oxyhemoglobin saturation during sleep.28 Not only does alcohol exacerbate preexisting OSA, but it has also been shown to induce frank OSA in patients who snore but do not have OSA at baseline.28 Sedative medications (eg, benzodiazepines) have similar effects on the central nervous system and should also be avoided if possible. Both of these substances have inhibitory actions on the central nervous system, thereby relaxing the pharyngeal muscles and promoting upper airway collapse during sleep.
Because cigarette smoking is an independent risk factor for snoring and thus a presumed risk factor for OSA, smoking cessation is a necessary component of the treatment of OSA.13,29 Cigarette smoking is thought to increase airway inflammation, exacerbate preexisting lung conditions such as COPD and asthma, and induce sleep fragmentation due to the effects of nicotine withdrawal during sleep.29 Alcohol, sedative medications, and cigarettes have all been shown to exacerbate OSA; thus, patient education about the harmful effects of these substances and the benefits of avoiding them is a crucial aspect of OSA therapy.
Surgical Therapies
When both CPAP and OA are inadequate in the management of OSA and/or when obstructive or functional anatomic abnormalities exist, upper airway surgery can be considered for patients. There is currently no consensus about the role of surgery in OSA patients, nor are there clear guidelines or screening questionnaires that accurately predict which patients will benefit the most from upper airway surgery. The appropriate surgical procedure depends on the site of anatomic abnormality and could be a nasal, oral, oropharyngeal, nasopharyngeal, hypopharyngeal, laryngeal, or global airway procedure.10 Some of the most common surgical procedures for the management of OSA are described below.
Uvulopalatopharyngoplasty (UPPP). This surgical procedure involves resecting the entire uvula and the obstructive portion of the soft palate while resizing and reorienting the tonsillar pillars. As a sole procedure, with or without tonsillectomy, UPPP does not reliably normalize the AHI when treating moderate-to-severe OSA.30
Radiofrequency ablation (RFA). RFA is a less invasive variation of UPPP that involves using a temperature-controlled probe to deliver energy to the upper airway tissue (typically the tongue base and/or the soft palate) in an effort to induce palatal stiffening. This procedure can be considered in patients with mild-to-moderate OSA who cannot tolerate or are unwilling to adhere to PAP or OA therapies.30
Maxillo-mandibular advancement (MMA). This operation involves indirect advancement of the anterior pharyngeal tissues (ie, the soft palate, tongue base, and suprahyoid musculature) via their attachment to the maxilla, mandible, and hyoid bone. The simultaneous advancement of the maxilla and mandible are accomplished by sagittal split osteotomies that are stabilized with plates, screws, or bone grafts.31 This surgery is designed to enlarge the retrolingual airway and provide some advancement of the retropalate without directly manipulating the pharyngeal tissues. MMA is indicated for patients with severe OSA who cannot tolerate or are unwilling to adhere to PAP therapy or in whom OAs have been found ineffective.30
Tracheostomy. This procedure consists of creating an airway through the anterior neck into the upper trachea. This opening bypasses the entire upper airway obstruction and thus is 100% effective in curing OSA. However, tracheostomy is typically last-line due to the resulting undesirable alterations in the patient’s physical appearance and to the risks associated with the procedure.5 According to the AASM, this operation should only be considered when other options do not exist, have failed, or are refused, or when this operation is deemed necessary by clinical urgency.30
Hypoglossal nerve stimulation. This therapy uses a surgically implanted device, approved by the FDA in 2014, to detect the patient’s breathing pattern and stimulate the hypoglossal nerve, causing tongue protrusion during inspiration. Tongue movement is controlled, and thus, the airway remains patent during inspiration.32 It is indicated for use in patients with moderate-to-severe OSA who have refused CPAP or for whom CPAP treatment has been unsuccessful.
According to a recently published study, a 68% decrease in median AHI at 12 months postimplantation was reported among those receiving hypoglossal nerve stimulation.33 Additionally, OSA patients subjectively reported decreased sleepiness and an increased quality of life compared to baseline.
The most common adverse effects were transient tongue weakness postoperatively, discomfort related to stimulation, and tongue soreness.33 Its use is contraindicated in patients who are pregnant or plan to become pregnant and in those who will require MRI, who have other implantable devices that may interact with the stimulation system, who have any condition that may affect neurologic control of the upper airway, and who have any anatomic abnormalities that may prevent effective performance of the upper airway stimulation (eg, the presence of complete concentric collapse at the retropalatal airway during endoscopy).32,33 Although its use is promising for the treatment of OSA, hypoglossal nerve stimulation is still a novel option that is not yet readily employed.33
OUTCOMES ASSESSMENT
Clinical judgment should be used to determine the appropriate treatment(s) based on OSA severity and patient preference. Regardless of the treatment option chosen, all OSA patients should have an outcomes assessment performed after the initiation of therapy. Indicators to monitor include resolution of sleepiness, OSA-specific quality-of-life measures, adherence to therapy, avoidance of factors exacerbating OSA (eg, alcohol, tobacco, sedative medications), amount of sleep being obtained, sleep hygiene practices, weight loss, and patient and spousal satisfaction.10 Patients with all levels of OSA severity should receive ongoing management to ensure long-term resolution of symptoms and adherence to treatment. Improvements in primary care treatment, follow-up, and outcomes evaluation are becoming increasingly important to address the symptoms and complications that make OSA a major public health concern.
