MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA

Members:
Racho, Kim Szydney
Ramos, Celber Vic
Reburon, Eva Maricon
Sarno, Myrem Jesame
Sibayan, Danyka Danielle
Tabin, Charmaine
Tjakrapawira, Agnes
Ujano, Stephen
Upano, Celimar Monette
Objectives for the topic:
To know the general management of obstructive sleep apnea
To explain the uses of the different specific treatment modalities of obstructive sleep apnea
WHOM TO TREAT
Treatment improves symptoms, sleepiness, driving, cognition, mood, quality of life, and blood
pressure in patients who have:
Epworth Score >11, troublesome sleepiness while driving or working,
Epworth Score >15 apneas +hypopneas per hour of sleep.
For those with similar degrees of sleepiness and 515 events per hour of sleep,
RCTs indicate improvements in symptoms, including subjective sleepiness, with
less strong evidence indicating gains in cognition and quality of life. There is no evidence of
blood pressure improvements in this group.
There is no robust evidence that treating nonsleepy subjects improves their
symptoms, function, or blood pressure, and so treatment cannot be advocated for this large
group, although this may change with further RCTs or less obtrusive therapy.
HOW TO TREAT (GENERAL MANAGEMENT)
All patients diagnosed with OSAHS should have the condition and its significance
explained to them and their partners.
accompanied by written and/or Web-based information and a discussion of the implications of
the local driving regulations.
Rectifiable predispositions should be discussed; this often includes weight loss and
alcohol reduction both to reduce weight and because alcohol acutely decreases upper-airway
dilating muscle tone, thus predisposing to obstructed breathing.
Sedative drugs, which also impair airway tone, should be carefully withdrawn
Continuous Positive Airway Pressure (CPAP)
works by blowing the airway open during sleep, usually with pressures of 520 mmHg
shown in randomized placebo-controlled trials to improve breathing during sleep, sleep
quality, sleepiness, blood pressure, vigilance, cognition,and driving ability as well as
mood and quality of life in patients with OSAHS

 An overnight monitored trial of CPAP is used to identify the pressure required to keep the
patients airway patent. The development of pressure-varying CPAP machines has made
an in-lab CPAP night trial unnecessary, but treatment must be initiated in a supportive
environment. Patients can be treated with fixed-pressure CPAP machines set at the
determined pressure or with a self-adjusting intelligent CPAP device.
Initiation;
finding the most comfortable mask from the ranges of several manufacturers and trying
the system for at least 30 min during the day to prepare for the overnight trial
Side effect: airway drying, which can be countered by using an integral heated
humidifier CPAP use is imperfect, but around 94% of patients with severe OSAHS are
still using their therapy after 5 years on objective monitoring
MRS
SURGERY
Four forms of surgery in OSAHS
Bariatric surgery - curative in the morbidly obese
Tonsillectomy - highly effective in children but rarely in adults
Tracheostomy - bypasses the site of upper airway obstruction
- makes speech difficult and is reserved for only the most severe cases and for
patients with concomitant hypoventilation syndromes that do not respond to noninvasive forms
of PAP
Jaw advancement surgery (maxillomandibular osteotomy)
- effective in those with retrognathia (posterior displacement of the mandible)
- should be considered particularly in young and thin patients
Uvulopalatopharyngoplasty
Procedures to reduce uvular or palatal tissue
not recommended as first-line therapy to treat symptomatic OSA patients
References: Harrisons Principles of Internal Medicine,18th edition
Goldmans Cecil Medicine, 24th edition

Drug Therapy
- Unfortunately, there are no drugs clinically useful for prevention or reduction of apneas or
hypopneas. Though...
Modafinil (Provigil)
- Classification: Wakefulness-promoting agent or Eugeroic
- It is believed to work by changing the amounts of certain natural substances (monoamines) in
the area of the brain that controls sleep and wakefulness. (MedLine Plus, 2016)
- Promotes marginal improvement in sleepiness in patients who remain sleepy despite CPAP

- Clinical value is debatable and financial cost is significant

- Classified as category IV controlled substances, indicating that they have a potential for abuse
and can lead to physical or psychological dependence. (US National Library of Medicine, LiverTox:
Clinical and Research Information on Drug-Induced Liver Injury, 2014)

Choice of Treatment
CPAP and MRS are the two most widely used and best evidence-based therapies.
Studies show better outcomes with CPAP in terms of apneas and hypopneas, nocturnal
oxygenation, symptoms, quality of life, mood, and vigilance.
Adherence to CPAP is better than MRS, and there is evidence that CPAP improves
driving.
CPAP is the current treatment of choice.
MRSs are evidence-based second-line therapy in those who fail CPAP.
In younger, thinner patients, maxillomandibular advancement should be considered.