First-line treatment for adults with obstructive sleep apnea should be continuous positive airway pressure therapy or a mandibular advancement device, according to the American College of Physicians’ clinical practice guideline published online Sept. 24 in Annals of Internal Medicine.
In contrast, no surgical procedures or pharmacologic agents should be considered as first-line treatment, because there is insufficient evidence supporting those approaches, said Dr. Amir Qaseem, director of clinical policy at the ACP, Philadelphia, and his associates on the clinical guidelines committee.
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First-line treatment for adults with obstructive sleep apnea should be continuous positive airway pressure therapy or a mandibular advancement device, according to the ACP clinical practice guideline.
Overweight and obese patients with obstructive sleep apnea (OSA) should be encouraged to lose weight, because that has been shown to improve symptoms and reduce scores on the Apnea-Hypopnea Index. Weight loss also confers many other health benefits, they added, while carrying minimal risk of adverse effects.
Those are the chief recommendations of the clinical practice guideline, which was compiled "to present information on both the benefits and harms of interventions" to all clinicians who treat adults with OSA. The guideline is based on a rigorous review of the evidence regarding OSA published in the literature from 1966 through 2012.
Overall, the evidence concerning hard clinical outcomes for any intervention for OSA was extremely limited.
Continuous positive airway pressure (CPAP) was the most extensively studied intervention for OSA, but the evidence from most studies was considered to be only of moderate quality. Studies assessed only the treatment’s effect on immediate outcomes and did not evaluate longer term outcomes such as cardiovascular illness or mortality. In addition, studies that examined CPAP’s effect on quality of life "were inconsistent and therefore inconclusive."
Nevertheless, the balance of evidence does show that CPAP is more effective than are control conditions or sham CPAP at improving scores on the apnea-hypopnea index, which measures the number of apneic and hypopneic episodes per hour of monitored sleep. CPAP also improved scores on the Epworth Sleepiness Scale, a self-administered questionnaire in which patients rate their likelihood of dozing off during various situations.
CPAP also is effective at improving oxygen saturation and reducing scores on the arousal index, which measures the frequency of arousals per hour of sleep using electroencephalography. However, there were insufficient data to compare the different types of CPAP, such as fixed CPAP, auto-CPAP, flexible bilevel CPAP, or CPAP with humidification.
There also was insufficient evidence to directly compare CPAP against other interventions, Dr. Qaseem and his colleagues said (Ann. Intern. Med. 2013;159:471-83).
The guideline recommends that mandibular or dental advancement devices to position the patient’s jaw while sleeping are a useful alternative for those who prefer this intervention to CPAP or for those who cannot tolerate or adhere to CPAP. Moderate-quality evidence showed that mandibular advancement devices improve scores on the apnea-hypopnea index and the arousal index.
However, that recommendation is considered "weak," because the overall data supporting the use of mandibular advancement devices are of low quality.
The data also were insufficient to recommend the use of any pharmacologic agents as a first-line therapy for OSA, or indeed as any therapy for the condition. Those include mirtazapine, xylometazoline, fluticasone, paroxetine, pantoprazole, steroids, acetazolamide, and protriptyline.
Only seven studies assessed surgical interventions for OSA. They were of varied quality, and their outcomes were inconsistent, so, the evidence is insufficient to support any surgery as first-line treatment. The procedures assessed in the studies included uvulopalatopharyngoplasty (UPPP); laser-assisted uvulopalatoplasty; radiofrequency ablation; and various combinations of pharyngoplasty, tonsillectomy, adenoidectomy, genioglossal advancement septoplasty, ablation of the nasal turbinates, and other nasal surgeries.
However, there was some evidence to suggest that UPPP and tracheostomy reduced mortality in patients with OSA.
The guideline strongly recommends that all OSA patients who are overweight or obese should be encouraged to lose weight. The evidence, albeit of low quality, shows that any intensive weight-loss intervention helps improve OSA symptoms and scores on the apnea-hypopnea index.
Finally, the evidence was insufficient to assess the potential benefits of positional therapy, oropharyngeal exercise, palatal implants, or atrial overdrive pacing for patients who already have dual-chamber pacemakers, Dr. Qaseem and his associates said.
The guideline was supported entirely by the American College of Physicians. The investigators had no relevant conflicts of interest.