Obstructive Sleep Apnea Updates: Prevalence, Predictors, Diagnosis and Therapy October 2, 2013 Tina Waters, MD Objectives • Describe the prevalence of obstructive sleep apnea (OSA) • Identify clinical features that should prompt a suspicion for OSA • Understand the importance of incorporating screening tools with testing to diagnose OSA • Review the current therapies available for OSA Obstructive Sleep Apnea (OSA) Characterized by recurrent episodes of upper airway collapse and obstruction associated with arousals and/or oxyhemoglobin desaturation. This is a polysomnographic (PSG) finding. Obstructive Sleep Apnea Syndrome (OSAS) • When OSA is associated with daytime symptoms, such as excessive daytime sleepiness, it is labeled the obstructive sleep apnea syndrome. Obstructive Sleep Apnea • PSG reveals > 5 obstructive events/hr on PSG and at least 1 of the following - Daytime sleepiness, sleep attacks, unrefreshing sleep, fatigue or insomnia - Waking with breath holding, gasping or choking - Observer reports loud snoring, breathing interruptions or both OR • PSG reveals > 15 obstructive events/hr International Classification of Sleep Disorders, 2nd ed. American Academy of Sleep Medicine. 2005. Sleep Apnea Severity Grading Mild AHI 5 -<15 Sa02 (%) >85 EKG Mild tachybradycardia Moderate 15 -<30 75-85 Severe >30 <75 Prominent tachybradycardia, Asystole <3 sec Asystole >3 sec, VT Apnea-hypopnea index (AHI) - primary grading parameter AHI = apneas + hypopneas total sleep time (hrs) American Academy of Sleep Medicine Task Force Sleep 1999;22:667-689 Types of Apnea • Apnea = complete airway obstruction • Drop in thermal sensor excursion >90% for > 10 sec - Obstructive: Continued effort during period of absent airflow - Central: Absent effort during period of absent airflow - Mixed: Absent effort initially followed by resumption of effort Iber C et al, AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, 2007. Obstructive Apneas Hypopneas Evolving Hypopnea Definition • Hypopnea = partial airway obstruction • 2007 Scoring Manual1 - Recommended: Drop in nasal pressure excursion by >30% for >10 sec w/ >4% desaturation - Alternate: Drop in nasal pressure excursion by >50% for >10 sec w/ >3% desaturation or arousal • 2012 Revised Scoring2 - Drop in nasal pressure excursion by >30% for >10 sec w/ >3% desaturation or arousal 1Iber C et al, AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, 2007; Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications Version 2.0, 2012. 2AASM Impact of Hypopnea Scoring on AHI 3 recognized hypopnea definitions produce markedly different AHIs Ruehland WR et al. SLEEP 2009;32:150-157. OSA • Clinically recognized more than 40 years ago • Awareness of this condition was slow to develop until population based studies were performed and uncovered a high prevalence of OSA in adults Guilleminault el al. Annu Rev Med 1976;27:465-484 Population-based OSA and OSAS prevalence studies Study # subjects AHI>=5 AHI >=15 OSAS Methods WI, 1993 M=352 W=250 (age 30-60) M=24% W=9% M=9% W=4% M=4% W=2% PA, 1998, 2001 M=741 W=1000 (age 20-100) M=17% W=5% M=7% W=2% M=3.3% PSG W=1.2% Spain, 2001 M=325 W=235 (age 30-70) M=26% W=28% M=14% W=7% M=3.4% W=3% PSG Australia, 1995 M=294 (age 40-65) M=25.9% M=10% (AHI≥10) M=3.1% W=n/a HST Hong M=153 W=106 (age M=8.8% Kong, 30-60) W=3.7% 2001, 2004 M=5.3% W=1.2% M=4.1% PSG W=2.1% Korea, 2004 M=309, W=148 (age 40-69) M=27% W=16% M=10.1% W=4.7% M=4.5% PSG or HST W=3.2% India, 2006 M=88 W=63 (age 30-60) M=19.7% W=7.4% n/a M=4.9% PSG W=2.1% PSG Adapted from Lee et al. Expert Rev Respir Med 2008;2:349-364 Ethnicity • Similar prevalence in Asian populations when compared to Western societies - Despite lower BMI in Asians - Could be attributed to cephalometric differences • Limited data on prevalence of OSA in Hispanics Ip et al. Chest 2001;119:62-69 Ip et al. Am J Respir Crit Care Med 2001;163:A636 Ip et al. Chest 2004;125:127-134 O’Connor et al. Sleep 2003;26:74-79 Ethnicity • Population based studies suggest that OSA prevalence is as high or higher in African Americans compared with Caucasians. • For community dwelling African Americans >65 years, the odds of having severe OSA was 2.5x greater relative to Caucasians. Ancoli-Israel et al. Am J Respir Crit Care Med 1995;1946-1949 Ethnicity • Cleveland Family Study: - OSA prevalence is higher in African Americans <25 years than Caucasians • Other investigators reported disproportionately higher severity of OSA in young and elderly African Americans compared to Caucasians • Sleep Heart Health Study: - Similar OSA prevalence African Americans compared to other ethnic groups Redline. Semin Respir Crit Care Med, 1998;19:113-122 Young, Peppard, Gottlieb, Am J Respir Crit Care Med 2002 Lee et al. Expert Rev Respir Med 2008;2:349-364 Young, et al. Arch Intern Med 2002;893-900 Redline et al. Am J Respir Crit Care Med 1997;155:186-192 OSA- Women • Differences in clinical presentation (compared to men) - ↓ snoring and apneas - ↑ insomnia - ↑ EDS and fatigue • ↓ survival rates compared to men with similar AHIs Redline, et al. Am J Respir Crit Care Med 1994; 149:722-26 Collop, et al. Chest Med 2004;25:257-268 Young, et al. Thorax 1998;53(Suppl 3):S16-19 OSA-Women • Differences in PSG features (compared to men) - Lower AHI (when matched for body weight) • Less collapsibility of upper airway - Less supine position dependency of respiratory events - Commonly cluster during REM sleep O’Connor, et al. Am J Respir Crit Care Med 2000;161:1465-1472 OSA - Women • OSA is less common in premenopausal women than in men - Risk of OSA increases in women during menopause - Lower prevalence of OSA among postmenopausal women who use HRT compared to women not on HRT Young et al. Am J Respir Crit Care Med 2003;167:1181-1185 Shahar et al. Am J Respir Crit Care Med 2003;167:1186-1192 OSA - Aging • Several studies found OSA to be highly prevalent in people >65 years • Prevalence for moderate OSA (AHI≥15) varies from 7- 44% Duran, et al. Am J Respir Crit Care Med 2001;163:685-689 Bixler, et al. Am J Respir Crit Care Med 1998;157:144-148 Bixler, et al. Am J Respir Crit Care Med 2001;163:608-613 Aging • For ages 65-95 years - HST – 427 people - OSA defined as an AHI ≥ 10 occurred in 70% of men and 56% of women • 3x higher than middle age prevalence estimates • For ages 71-100 years - Spain cohort - AHI ≥5: 81% men and 80% women • 3x higher than middle age - AHI ≥ 15: 57% men and 49% women • 4x higher than middle age Ancoli-Israel et al. Sleep 1991;14:486-495 Durán, et al. World Conference Space Odyssey, 2001 Aging • MrOs Sleep Study - AHI ≥ 15, prevalence estimate of 21.4%-26.4% - Prevalence increased with increasing age • 22.8% <72 years • 30.1% >=80 years • Cleveland Family Study - Higher prevalence for AHI ≥ 15 if >60 years compared with 25-60 years - Men: 42% vs 22%; Women: 32% vs 4% • Sleep Heart Health Study - AHI ≥ 15, 1.7 fold higher proportion in older (60-99 years) vs younger (40-60 years) Mehra, et al. JAGS 2007;55:1356-1364 Redline, Semin Respir Crit Care Med 1995 Young et al. Arch Intrn Med, 2002 From: Predictors of Sleep-Disordered Breathing in Community-Dwelling Adults: The Sleep Heart Health Study Arch Intern Med. 2002;162(8):893-900. doi:10.1001/archinte.162.8.893 Figure Legend: Smoothed plot (5-year moving average) of the prevalence of an apnea-hypopnea index (AHI) of 15 or greater by age. Date of download: 4/11/2013 Copyright © 2012 American Medical Association. All rights reserved. OSA and Aging • Risk factors - Increased weight Reduced lung function Impaired ventilatory control Increased upper airway collapsibility • Soft palate gets longer • Pharyngeal fat pads increase in size • Response of genioglosus muscle to negative pressure stimulation diminishes - Impaired thyroid function - Reduced slow wave sleep Incidence of OSA Study N Years of f/u Definition Incidence Wisconsin 554 4 AHI <5 to AHI ≥ 5 10.6% Cleveland Family 286 5 AHI <5 to AHI ≥ 15 15% men 8.2% women Sleep Heart Health 2968 5 AHI <5 to AHI ≥ 15 11.1% men 4.9% women Adapted from Lee et al. Expert Rev Respir Med 2008;2:349-364 Tishler et al. JAMA 2003;289:2230-2237 Peppard et al. JAMA 2000;284:3015-3021 Newman et al. Arch Intern Med 2005;165:2408-2413 OSA Progression N Baseline AHI f/u AHI 8-yr AHI increase 95% CI for increase All 282 2.5 5.1 2.7 ± 8.2 (1.7, 3.6) Women 121 1.5 3.8 2.3 ± 6.1 (1.2, 3.4) Men 161 3.3 6.3 3.0 ± 9.4 (1.5, 4.5) BMI<30 179 1.5 3.0 1.6 ± 5.4 (0.8, 2.3) BMI>30 103 4.8 10.1 5.2 ± 12 (2.8, 7.7) 3.4 7.0 3.7 (1.0) obese – non-obese 30-45 yrs 137 1.8 3.4 1.7 ± 6.5 (0.6, 2.7) 45-60 yrs 145 3.3 6.9 3.7 ± 9.5 (2.1, 5.2) 1.5 3.5 2.0 (1.0) Old-young Not-habit snore 134 1.3 2.6 1.3 ± 5.1 (0.6, 2.0) Habit snore 148 5.5 11.8 6.3 ± 9.7 (4.1, 8.4) 4.2 9.2 5.9 (1.0) Habit – nonhabit snore Wisconsin Sleep Cohort Adapted from Terry et al. Am J Respir Crit Care Med, 2002 OSA Progression • Wisconsin Sleep Cohort - 282 participants - Significant increase in OSA severity over 8 year interval • Cleveland Family Study - Similar trends to Wisconsin Sleep Cohort - After 5 years, mean AHI increased from 2.0 (SD=1.4) to 6.2 (SD=7.9) Prevalence of OSA in diseases OSA defined as either AHI ≥ 10 or 15. Each bar in the figure represents an individual study. Prevalence of OSA in diseases - references Netzer, et al. Ann Intern Med 1999;131:485-491 Punjabi, et al. Sleep 2000;23:471-480 Punjabi, et al.Am R Respir Crit Care Med 2002;165:677-682 Frey, Pilcher. Obes Surg 2003;13:676683 Rasheid, et al. Obes Surg 2003;13:58-61 Worsnop, et al. Am J Respir Crit Care Med 1998; 157:111-115 Javaheri, et al. Circulation 1998;97:2154-2159 Javaheri, et al. Ann Intern Med 1995; 122:487-492 Javaheri, et al. Int J Cardiol 2006;106:21-28 Oldenburg et al. Eur J Heart Fail 2007;9:251-257 Andreas, et al. Coron Artery Dis 1996;7:541-545 Dyken, et al. stroke 1996;27:401-407 Turkington, et al. Stroke 2002;33:20372042 Foster et al. Sleep 2005;28:A606 West, et al. Thorax 2006;61:945-950 Fogel, et al. J Clin Endocrinol Metab 2001;86:1175-1180 Vgontzas, et al. J Clin Endocrinol Metab 2001;86:517-520 Mooe, et al. Chest 1996;109:659-663 Mooe, et al. Am J Med 1996;101:251256 Parra, et al. Am J Respir Crit Care Med 2000;161:375-380 Bassetti, et al. Stroke 2006;37:967-972 Hui, et al. Chest 2002;122:852-860 Prevalence of OSA in diseases • Over 80% of individuals with moderate to severe OSA are estimated to be undiagnosed - Implies unaddressed risk factors for cardiovascular diseases, stroke, and DM-II Young et al. Sleep 1997;20:705-6 Kapur et al. Sleep Breath 2002;6:49-54 Common Symptoms Nighttime Daytime • Snoring • Gasping/snorting • Witnessed apneas • Restless Sleep • Nocturia • Night sweats • Excessive daytime sleepiness • Fatigue • Morning headaches • Memory problems • Irritability Risk Factors Modifiable Non-Modifiable • Obesity • Medications - opiates - benzodiazepines - alcohol • Smoking • Nasal congestion • Gender • Genetic predisposition • Race • Aging • Menopause • Craniofacial anatomy Young et al. JAMA 2004;291:2013-2016 Anatomic Risk Factors for OSA • Obesity - Increased visceral fat; parapharyngeal fat pads - Increased neck size • Increased size of upper airway soft tissue structures - Macroglossia, elongated soft palate, increased lateral pharyngeal walls, adeno-tonsillar hypertrophy Anatomic Risk Factors for OSA • Recessed mandible - Retrognathia • Nasal airway restriction - Septal deviation - Allergic rhinitis - Nasal polyps Friedman palate position Class 1 Class 2 Class 3 Class 4 Class 1, soft palate, fauces, uvula, anterior and posterior pillars visible Class 2, soft palate, fauces and uvula visible Class 3, soft palate and base of uvula visible Tsai et al AJRCCM 2003 Class 4, soft palate not visible Mallampati et al Can Anaest Soc J, 1985 Physical Exam Elongated Uvula and enlarged tonsils Physical Exam Macroglossia and tongue ridging Retrognathia High-arched palate and overjet Nasal exam What a deal! 25 cents Neck circumference • Patients with OSA have significantly increased neck circumference compared to non-apneic snorers • Measure at superior border of cricothyroid membrane • > 40 cm (15.7 inches) has been shown to be predictive of OSA with 61% sensitivity and 93% specificity, regardless of sex Katz et al. Am Rev Respir Dis 1990;141:1228-1231 Kushida et al. Ann Intern Med 1997;127:581-587 AASM Adult OSA Task Force – Physical findings that may suggest OSA presence • Increased neck circumference: >17in for men, >16in for women • BMI ≥ 30kg/m2 • Friedman Class III or greater • Nasal abnormalities (turbinate hypertrophy, septal deviation, etc) • Retrognathia • Lateral peritonsillar narrowing • Macroglossia • Tonsillar hypertrophy • Elongated/enlarged uvula • High-arched/narrow hard palate • Overjet Epstein et al. J Clin Sleep Med 2009;5(3)263-276 OSA screening • In addition to history and examination, a number of self-report screening instruments are available to assist in recognition of patients with suspected OSA • Inexpensive and time-efficient Epworth Sleepiness Scale • How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? • This refers to your usual way of life in recent times. • Even if you have not done some of these things recently try to work out how they would have affected you. • Use the following scale to choose the most appropriate number for each situation: - 0 = would never doze or sleep - 1 = slight chance of dozing or sleeping - 2 = moderate chance of dozing or sleeping - 3 = high chance of dozing or sleeping Johns Sleep 1991;14(6):540-545 Johns Sleep 1992;15:376-81 Epworth Sleepiness Scale 0 = would never doze or sleep 1 = slight chance of dozing or sleeping 2 = moderate chance of dozing or sleeping 3 = high chance of dozing or sleeping • • • • • • • • Sitting and reading Watching TV Sitting inactive in a public place Being a passenger in a motor vehicle for an hour or more Lying down in the afternoon Sitting and talking to someone Sitting quietly after lunch (no alcohol) Stopped for a few minutes in traffic while driving EDS and OSA • Sleep Heart Health Study - Significant, progressive increase in ESS score with increasing AHI • ESS = 7.2 (AHI<5) • ESS = 9.3 (AHI ≥ 30) - % subjects with excessive daytime sleepiness increased from 21% in those with AHI<5 to 35% in those with AHI>30 Gottlieb, et al. Am J Respir Crit Care Med 1999;159:502-507 STOP-BANG • Developed and validated in preoperative patients • Sensitive screening tool for OSA Chung, et al. Anesthesiology 2008;108:812-821 STOP-BANG Questionnaire Answer - either yes or no: 1. Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)? 2. Do you often feel TIRED, fatigued or sleepy during the daytime? 3. Has anyone OBSERVED you stop breathing during your sleep? 4. Do you have or are you being treated for high blood PRESSURE? 5. BMI more than 35? 6. AGE over 50 years? 7. NECK circumference > 15.75 inches (40cm)? 8. Male GENDER? STOP • ≥ 2 yes answers: High risk of OSA • < 2 yes answers: Low risk of OSA • Sensitivity: - 65.6% for AHI ≥ 5 - 74.3% for AHI ≥ 15 - 79.5% for AHI ≥ 30 STOP-BANG • ≥ = 3 yes answers: High-risk for OSA • < 3 yes answers: Low-risk for OSA • Sensitivity: - 83.6% for AHI ≥ 5 - 92.9% for AHI ≥ 15 - 100% for AHI ≥ 30 Sensitivity increases from 74 to 93% using STOP-BANG Indications for In-Lab PSG • Sleep-related breathing disorders - OSA, CSA, Complex SA - Hypoventilation - Nocturnal desaturation • Narcolepsy and other hypersomnias • Abnormal motor activity/behaviors in sleep - Seizures - Limb movements - Parasomnias International Classification of Sleep Disorders, 2nd ed. American Academy of Sleep Medicine. 2005. In-Lab PSG • • • • Gold standard for evaluation of OSA 8-hr attended night study Established scoring criteria Tailored based on clinical history - PAP, OA Titration - Oxygen therapy - Expanded EEG/EMG • Aim to record NREM/REM, supine/off-supine sleep Iber C et al, AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, 2007. In-Lab PSG Parameters • • • • • • • • • • EEG: bilateral frontal, central, occipital EOG: bilateral outer canthi EMG: submental and leg ECG Nasal-oral airflow Thoraco-abdominal effort Oxygen saturation Carbon dioxide Body position Snore Iber C et al, AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, 2007. Staging Sleep on PSG Each 30 sec epoch assigned a stage allowing for identification of state-dependency of respiratory events Normal Adult Hypnogram Slow wave sleep (OSA protective) predominates in first 1/3 REM sleep (OSA exacerbating) increases in last 1/3 Sleep Study Monitoring Devices • Type 1: In-lab, attended, overnight PSG • Type 2: Comprehensive portable, min 7 ch - EEG, EOG, chin EMG, ECG, airflow, effort, SPO2 • Type 3: Modified portable, min 4 ch - 2 effort channels or effort + airflow, ECG, SPO2 • Type 4: Single or dual parameter, 1-2 ch - SPO2 or airflow In March 2008, CMS approved CPAP coverage based on a diagnosis of OSA by HST Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. A joint project by the AASM, ATS, and ACCP SLEEP 2003;26(7):907-913; CMS. 2008; http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6048.pdf.. HST Indications • 18-65 yrs of age • High pre-test probability mod-to-severe OSA • Absence of co-morbid sleep/medical disorders that compromise accuracy • Patients who otherwise could not complete in-lab PSG due to safety, immobility or critical illness • May be indicated to monitor response to nonPAP therapies (oral appliances, surgery, weight loss) Should not be used for screening asymptomatic patients Collop NA et al. For AASM Task Force on PM. JCSM 2007;3(7):737-747. HST Contraindications • Co-morbid sleep disorders - Central sleep apnea, Sleep hypoventilation Periodic limb movements Insomnia Circadian rhythm disorders Parasomnias Narcolepsy • Co-morbid medical conditions - Mod-severe Heart failure • LVEF <45, pulmonary edema, NYHA class III or IV - Other mod-severe cardiac disease - Symptomatic neurological disease • Neuromuscular, PD, active epilepsy, stroke - Mod-severe pulmonary diseases • Use nocturnal O2, resting wake PO2< 60 or PCO2> 45 Collop NA et al. For AASM Task Force on PM. JCSM 2007;3(7):737-747. HST Methodology • 4-7 channel devices including airflow (thermal & nasal pressure), effort (inductive plethysmography) & oximetry • Tech applies sensors/directly educates patient • Raw data display w/editing & manual scoring Raw data review by sleep specialist • AHI based on recording time -> underestimates AHI • Follow-up to review results Collop NA et al. For AASM Task Force on PM. JCSM 2007;3(7):737-747; CMS. 2008; http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6048.pdf.. The HomePAP Study RCT comparing HST/Auto-PAP titration & In-lab PSG/CPAP titration for high probability mod-to-severe OSA (adjusted neck circumference >43 cm and ESS score >12) Rosen CL et al. SLEEP 2012;35:757-767. HomePAP Results • Only 53% of subjects eligible w/AHI >15 • At 3 mo, nightly PAP use greater (4.7+2.1 vs. 3.7+2.4 hr) & PAP adherence higher (63+29 vs. 49+36 %nights) in Home vs. Lab arm • Significant improvements within groups in all outcomes* w/PAP therapy • Similar PAP acceptance (93 vs. 94%), time to treatment, outcomes* between groups * Included Epworth Sleepiness Scale, Functional Outcomes of Sleep Quality (FOSQ),Sleep Apnea Quality of Life Instrument (SAQLI), SF 36 Rosen CL et al. SLEEP 2012;35:757-767. What about Split Night Studies? • Diagnostic PSG (2 hr) followed by PAP titration if criteria met • AASM recommends split for AHI >401 • Position & state dependency of events often precludes splitting • Providers may request split at lower cutoff (i.e. AHI >15) 1Chesson AL et al. SLEEP 1997;20:406-422. Nocturnal Oximetry as an OSA Screening Tool? • Type 4 study- doesn’t identify respiratory events or confirm sleep • Lacks specificity & sensitivity • Excessive false positives Chesson AL et al. SLEEP 1997;20:406-422; Epstein L et al. Chest 1998;113:97-103. In-lab PSG vs. HST Which Procedure is Right? • In newly presenting patients w/ OSA symptoms, two main questions should be considered: - How severe is the patient’s OSA likely to be? - Does the patient have a medical condition or co-morbid sleep disorder that would make HST unsafe, misleading or substantially incomplete? Decision Tree for Mod-to-Severe OSA Does pt have high pre-test prob of modsevere OSA? Evaluate for other sleep disorders; consider in-lab PSG N Y Does pt have signs/symptoms of co-morbid medical disorders? Y N N Does pt have signs/symptoms of co-morbid sleep disorders? N Y OSA diagnosed? In-lab PSG Y N Sleep study PM or in-lab PSG PM PM: Portable monitoring OSA diagnosed? Y Treatment Adapted from Collop NA et al. For AASM Task Force on PM. JCSM 2007;3(7):737-747. Limitations of Testing for OSA • First night effect – sleep architecture changes induced by artificial environment - Prolonged sleep & REM latency - Increased light sleep, arousals & awakenings - Reduced REM & deep NREM (stage N3) sleep • Night-to-night variability esp. for milder cases • Stage & position dependent OSA - Reduced detection on in-lab PSG - May miss entirely on HST OSA Nasal CPAP Pathophysiology of OSA The Starling resistor offers a pathophysiology of obstructive sleep apnea, based on collapsibility of the airway, and which can be reversed by positive airway pressure therapy. The Starling resistor model The pharyngeal airway is represented as a collapsible segment between rigid nasal and tracheal segments. OSA Nasal CPAP Overview of OSA Treatment Before CPAP CPAP 5 cmH2O Effective Troubleshooting Outcomes Pressure tolerance Humidification Interface Follow up Orientation Compliance Data % days use 100 95 90 85 80 75 70 65 60 95.2 92.9 90.5 85.4 2 weeks Sin et al. Chest 2002 4 week 3 month 6 month Oral Appliances • 52% of patients treated with OA reduce their AHI to < 10 per hour • Favorable effects on sleepiness and quality of life were demonstrated • Improvements in other neurocognitive outcomes were not consistent • OA less efficacious in reducing the AHI • OA may have better compliance and are usually preferred over CPAP Ferguson et al. SLEEP 2006;29(2):244-262 Adjustable OA vs CPAP • 70.3%, 47.6%, and 41.4% of patients with mild, moderate, and severe disease achieved an AHI < 5 respectively with an aOA • 70.1% achieved an AHI < 5 using CPAP compared with 51.6% for an aOA (P < .001) • aOA is comparable to CPAP for mild OSA • CPAP is superior for moderate to severe OSA • On multivariate analysis, a lower AHI was the only predictor of a successful aOA titration Holley et al. CHEST 2011; 140(6):1511–1516 Surgery in OSA Caples, Rowley et al. Sleep 2010;33:1396-407. Surgery • UPPP rarely achieves a surgical cure • 50% of UPPP have a 50% reduction in AHI • Hard to assess candidates for the procedure • UPPP may decrease future adherence to CPAP Khan et al. Mayo Clin Proc 2009; 84:795 Aboussouan et al. Chest 1995;107:946-51 Maxillomandibular advancement www.sleepapneasurgery.com Substantial and consistent reductions in AHI with MMA Caples, Rowley et al. Sleep 2010;33:1396-407. Conclusion • OSA is characterized by repeated episodes of complete or partial obstruction of the upper airway during sleep • OSA syndrome prevalence is 4% in men and 2% in women across geographical regions and ethnic groups • A simple upper airway exam and quick validated screening tools can be used to aid in the diagnosis of OSA Conclusion • In-lab PSG is recommended for most sleep disorders including OSA in presence of comorbid sleep/medical disorders • HST is a confirmatory test for adults 18-65 yr w/ high pre-test probability of mod-tosevere OSA without co-morbidities • HST is not recommended for screening asymptomatic populations • OSA therapy options include PAP, oral appliances and surgery