You are on page 1of 2

JFP_11.04_GU.

final 10/18/04 11:12 AM Page 902

Guideline Update
R E C O M M E N D AT I O N S F O R P R A C T I C E

How should we diagnose


and treat obstructive sleep apnea?
Keith B. Holten, MD
University of Cincinnati College of Medicine, Cincinnati, Ohio

■ What are the risk factors for obstructive tests; effects of treatment on apnea-hypopnea
sleep apnea (OSA)? index and other measures; patient compliance
and satisfaction with treatment; and complica-
■ What is the standard for diagnostic testing?
tions of treatment. Their rating scheme has been
■ How does management of mild OSA differ updated to comply with the SORT taxonomy.2
from severe OSA?
■ RELEVANCE AND LIMITATIONS
■ Can other illnesses complicate OSA?
OSA affects more than 12 million people in the
US, 2% of women and 4% of men aged >35 years.
The patient with OSA commonly consults a physi-
cian after a sleep partner reports loud snoring

O
bstructive sleep apnea is underdiag- and irregular breathing. The methods used to
nosed.1 These recommendations (from collect and select evidence is not stated.
the Institute for Clinical Systems
Improvement’s Respiratory Steering Committee) ■ DEVELOPMENT AND REVIEW
can help providers more accurately identify adults This guideline was accessed through the National
who have OSA through a sleep study evaluation, Guideline Clearinghouse (www.ngc.gov). The
prescribe appropriate treatment, document cases Institute for Clinical Systems Improvement is an
for appropriate follow-up, and increase patient independent, nonprofit organization sponsored by
understanding of related health risks. The target 6 Minnesota health plans.
audience is physicians, nurses, advanced practice The authors completed an electronic search
nurses, and physician assistants. The target pop- of databases. Data were analyzed by systematic
ulation is adults. review with evidence table and were validated
The evidence categories for this guideline are by clinical validation-pilot testing and internal
diagnosis, evaluation, management, risk assess- peer review. The methods used to make the
ment, and treatment. Outcomes considered are recommendations were not discussed. Quality
signs and symptoms of OSA; patient risk factors, and strength of evidence were weighted
including comorbidities; accuracy of diagnostic according to a rating scheme furnished in the
guideline. Two excellent algorithms are
Correspondence: Keith B. Holten, MD, Clinton Memorial attached to this guideline: diagnosis and treat-
Hospital/University of Cincinnati Family Practice Residency,
ment. There are 92 references.
825 W. Locust St., Wilmington, OH, 45177. E-mail:
keholtenmd@cmhregional.com.

902 NOVEMBER 2004 / VOL 53, NO 11 · The Journal of Family Practice


JFP_11.04_GU.final 10/18/04 11:12 AM Page 903

G U I D E L I N E U P D AT E

■ GUIDELINE SOURCE
Institute for Clinical Systems Improvement.
Diagnosis and Treatment of Obstructive Sleep Apnea. PRACTICE RECOMMENDATIONS
Bloomington, Minn: Institute for Clinical Systems
Grade A Recommendations
Improvement; 2003. 53 pages.
• Large neck circumference, obesity, and
hypertension are risk factors for OSA.
■ OTHER GUIDELINES ON OSA
• OSA occurs frequently in patients with
• Practice parameters for the use of auto- cardiovascular disease, coronary artery
titrating continuous positive airway pressure disease, and hypertension.
devices for titrating pressures and treating • Additional signs and symptoms of OSA
adult patients with obstructive sleep apnea syn- include reports of choking by sleep
drome. Standards of Practice Committee. Sleep partner, awakening with choking, intense
snoring, severe daytime sleepiness (with
2002; 25:143–147 [29 references]. Web access at:
driving impairment), and male gender.
www.aasmnet.org/PDF/autotitratingreview.pdf.
• Polysomography should be performed to
This is an excellent detailed guideline for the
determine the diagnosis and is the stan-
use of auto-titrating CPAP for OSA. dard for diagnosis. Unattended portable
• Practice parameters for the use of portable monitoring is a reasonable alternative
monitoring devices in the investigation of sus- when the patient has severe symptoms
pected obstructive sleep apnea in adults. requiring prompt evaluation/treatment or
for follow-up studies.
Chesson AL Jr, Berry RB, Pack A. Practice param-
• Lifestyle modification, including weight
eters for the use of portable monitoring devices in
loss, reduced alcohol consumption, and
the investigation of suspected obstructive sleep lateral sleep positioning are recommended
apnea in adults. Sleep 2003; 26:907–913 [11 refer- for treatment.
ences]. Web access at: www.aasmnet.org/ • Severity of OSA is based on magnitude
PDF/260719.pdf. of sleepiness, hypoxia, and the
Not very useful for primary care physicians. Apnea-Hypopnea Index (AHI).
Recommendations regarding 2 different types of • Mild OSA can be treated with oral
portable monitoring devices (attended and unat- appliances, positive airway pressure
tended) for the diagnosis of OSA. Not currently devices, or surgical procedures.
approved by Medicare for diagnosis. • Moderate to severe obstructive sleep
apnea should always be treated with
• Clinical practice guideline: diagnosis and
positive airway pressure devices,
management of childhood obstructive sleep continuous positive airway pressure
apnea syndrome. Pediatrics 2002; 109:704–712 (CPAP) most commonly.
[63 references]. Web access at: www.aappolicy. Grade B Recommendations
aappublications.org/cgi/content/full/pediatrics; • Unattended portable monitoring may
109/4/704. be acceptable for rural areas where
Good review of pediatric issues concerning OSA. polysomography is unavailable.
• Surgical procedures (septoplasty, nasal
REFERENCES polypectomy, tonsillectomy, turbinoplasty,
1. Strollo PJ Jr, Rogers RM. Obstructive sleep apnea. N Engl and uvulopalatopharyngoplasty) to correct
J Med 1996; 334:99–104. anatomical obstructions might be
2. Ebell M, Siwek J, Weiss BD, et al. Strength of recommen- necessary for treatment of mild OSA
dation taxonomy (SORT): A patient-centered approach to prior to a positive pressure device.
grading evidence in the medical literature. Am Fam
Physician 2004; 69:548–556. • After initiating treatment patients should
be seen in follow-up in 1 month to assess
snoring and sleepiness.

NOVEMBER 2004 / VOL 53, NO 11 · The Journal of Family Practice 903