Portal de Periódicos da CAPES

Updates on Definition, Consequences, and Management of Obstructive Sleep Apnea

2011; Elsevier BV; Volume: 86; Issue: 6 Linguagem: Inglês

10.4065/mcp.2010.0810

1942-5546

John G. Park, Kannan Ramar, Eric J. Olson,

Sleep and Wakefulness Research

Obstructive sleep apnea (OSA) is a breathing disorder during sleep that has implications beyond disrupted sleep. It is increasingly recognized as an independent risk factor for cardiac, neurologic, and perioperative morbidities. Yet this disorder remains undiagnosed in a substantial portion of our population. It is imperative for all physicians to remain vigilant in identifying patients with signs and symptoms consistent with OSA. This review focuses on updates in the areas of terminology and testing, complications of untreated OSA, perioperative considerations, treatment options, and new developments in this field. Obstructive sleep apnea (OSA) is a breathing disorder during sleep that has implications beyond disrupted sleep. It is increasingly recognized as an independent risk factor for cardiac, neurologic, and perioperative morbidities. Yet this disorder remains undiagnosed in a substantial portion of our population. It is imperative for all physicians to remain vigilant in identifying patients with signs and symptoms consistent with OSA. This review focuses on updates in the areas of terminology and testing, complications of untreated OSA, perioperative considerations, treatment options, and new developments in this field. Obstructive sleep apnea (OSA) is a disorder in which a person frequently stops breathing during his or her sleep. It results from an obstruction of the upper airway during sleep that occurs because of inadequate motor tone of the tongue and/or airway dilator muscles. In the United States, the prevalence of OSA is estimated to be 3% to 7% in men and 2% to 5% in women.1Punjabi NM The epidemiology of adult obstructive sleep apnea.Proc Am Thorac Soc. 2008; 5: 136-143Crossref PubMed Scopus (1545) Google Scholar Among patients with a body mass index (calculated as the weight in kilograms divided by height in meters squared) greater than 28, OSA is present in 41%.2Vgontzas AN Tan TL Bixler EO Martin LF Shubert D Kales A Sleep apnea and sleep disruption in obese patients.Arch Intern Med. 1994; 154: 1705-1711Crossref PubMed Scopus (392) Google Scholar The prevalence of OSA can be as high as 78% in morbidly obese patients who present for bariatric surgery.3Lopez PP Stefan B Schulman CI Byers PM Prevalence of sleep apnea in morbidly obese patients who presented for weight loss surgery evaluation: more evidence for routine screening for obstructive sleep apnea before weight loss surgery.Am Surg. 2008; 74: 834-838PubMed Google Scholar Up to 93% of women and 82% of men may have undiagnosed moderate to severe OSA,4Young T Evans L Finn L Palta M Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women.Sleep. 1997; 20: 705-706Crossref PubMed Scopus (1291) Google Scholar emphasizing the importance of vigilant evaluations for signs and symptoms of OSA. These may include a spouse's report of disruptive snoring, daytime sleepiness, obesity, and large neck circumference (>42 cm in men)5Dancey DR Hanly PJ Soong C Lee B Shepard Jr, J Hoffstein V Gender differences in sleep apnea: the role of neck circumference.Chest. 2003; 123: 1544-1550Crossref PubMed Scopus (156) Google Scholar (Table 1).6Epstein LJ Kristo D Strollo Jr, PJ et al.Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults.J Clin Sleep Med. 2009; 5: 263-276PubMed Google Scholar Not all patients, however, present with typical findings. For example, patients with heart failure and OSA may not present with daytime sleepiness.7Arzt M Young T Finn L et al.Sleepiness and sleep in patients with both systolic heart failure and obstructive sleep apnea.Arch Intern Med. 2006; 166: 1716-1722Crossref PubMed Scopus (323) Google Scholar Likewise, a patient may not be aware of snoring or apneic episodes. Thus, it is important to obtain collateral sleep history and recognize associated medical comorbid conditions that may implicate OSA as an underlying diagnosis. This article is intended as an update to the 2003 Concise Review for Clinicians covering OSA.8Olson EJ Moore WR Morgenthaler TI Gay PC Staats BA Obstructive sleep apnea-hypopnea syndrome.Mayo Clin Proc. 2003; 78: 1545-1552Abstract Full Text Full Text PDF PubMed Scopus (62) Google ScholarTABLE 1History and Physical Examination Findings That Should Raise Suspicion for Obstructive Sleep ApneaAdapted from/Clin Sleep Med,6Epstein LJ Kristo D Strollo Jr, PJ et al.Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults.J Clin Sleep Med. 2009; 5: 263-276PubMed Google Scholar with permission.History Disruptive snoringWitnessed apnea or snortsGasping/choking while sleepingExcessive daytime sleepinessDifficulty with concentration or short-term memory lossExcessive nocturiaDifficulty with sleep maintenanceRestless/unrefreshing sleepDecreased libidoMorning headachesIrritabilityPhysical examination ObeseLarge neck (>42 cm in men, >37 cm in women)5Dancey DR Hanly PJ Soong C Lee B Shepard Jr, J Hoffstein V Gender differences in sleep apnea: the role of neck circumference.Chest. 2003; 123: 1544-1550Crossref PubMed Scopus (156) Google ScholarRetrognathia or micrognathiaCrowded airwayEnlarged tonsilsHigh-arched hard palateNasal deformities/septal deviationComorbid conditions Resistant hypertensionRecurrent atrial fibrillationStrokeMyocardial infarctionPulmonary hypertensionChronic heart failure Open table in a new tab Diagnosis of OSA usually requires overnight polysomnography (PSG) to detect the frequency of apneic and hypopneic events9American Academy of Sleep Medicine European Respiratory Society Australasian Sleep Association American Thoracic Society Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research: the report of an American Academy of Sleep Medicine Task Force.Sleep. 1999; 22: 667-689Crossref PubMed Scopus (4792) Google Scholar (Table 2). Traditionally, this is done as a standardized, facility-based PSG, with multichannel recordings that help determine sleep time, sleep stages, respiratory effort, airflow, cardiac rhythm, oximetry, and limb movements.9American Academy of Sleep Medicine European Respiratory Society Australasian Sleep Association American Thoracic Society Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research: the report of an American Academy of Sleep Medicine Task Force.Sleep. 1999; 22: 667-689Crossref PubMed Scopus (4792) Google Scholar The apnea-hypopnea index (AHI) is the average number of disordered breathing events per hour. Other definitions of sleep-related breathing disorders are highlighted in Table 2. Typically, OSA syndrome is defined as an AHI of 5 or greater with associated symptoms (eg, excessive daytime sleepiness, fatigue, or impaired cognition) or an AHI of 15 or greater, regardless of associated symptoms.9American Academy of Sleep Medicine European Respiratory Society Australasian Sleep Association American Thoracic Society Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research: the report of an American Academy of Sleep Medicine Task Force.Sleep. 1999; 22: 667-689Crossref PubMed Scopus (4792) Google ScholarTABLE 2Definitions of Sleep-Related Breathing DisordersaAHI = apnea-hypopnea index; CPAP = continuous positive airway pressure; OSA = obstructive sleep apnea; RDI = Respiratory Disturbance Index; RERA = respiratory effort-related arousal; UARS = upper airway resistance syndrome.Data from Sleep.9American Academy of Sleep Medicine European Respiratory Society Australasian Sleep Association American Thoracic Society Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research: the report of an American Academy of Sleep Medicine Task Force.Sleep. 1999; 22: 667-689Crossref PubMed Scopus (4792) Google ScholarApneaCessation of airflow for at least 10 secondsHypopneaReduction in airflow with resultant desaturation of ≥4%RERAReduction in airflow with resultant arousal but not meeting desaturation criteria for hypopneaAHIAveraged frequency of apnea and hypopnea events per hour of sleepRDIbThe term RDI is used in 2 different contexts.Averaged frequency of apnea, hypopnea, and RERA per hour of sleep, obtained using poly-somnographyRDIbThe term RDI is used in 2 different contexts.Averaged frequency of apnea and hypopnea per hour of recording, obtained using portable monitors. This value is not the same as RDI reported in a polysomnogram report because it is based on total recording time and not sleep timeOSAAHI or RDI ≥15 from portable monitors or AHI or RDI >5 and associated with symptoms such as excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischémie heart disease, or history of stroke. The presence of respiratory efforts during these events suggests that they are predominantly obstructiveCentral sleep apneaAHI ≥5, with more than 50% of the respiratory events occurring without any respiratory effort and associated with symptoms of either excessive sleepiness or disrupted sleepComplex sleep apneaPersistence or emergence of central sleep apnea when patient receives CPAP treatment and obstructive events are eliminatedUARSAn obsolete term used to define increased RERA but with AHI 15) was associated with a higher incidence of stroke, independent of confounders (hazard ratio, 2.86-3.56).26Valham F Mooe T Rabben T Stenlund H Wiklund U Franklin KA Increased risk of stroke in patients with coronary artery disease and sleep apnea: a 10-year follow-up.Circulation. 2008; 118: 955-960Crossref PubMed Scopus (208) Google Scholar, 27Redline S Yenokyan G Gottlieb DJ et al.Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study.Am J Respir Crit Care Med. 2010; 182: 269-277Crossref PubMed Scopus (917) Google Scholar Sahlin et al28Sahlin C Sandberg O Gustafson Y et al.Obstructive sleep apnea is a risk factor for death in patients with stroke: a 10-year follow-up.Arch Intern Med. 2008; 168: 297-301Crossref PubMed Scopus (256) Google Scholar found that the risk of early death increased by 75%, independent of confounders, in those who survived stroke and had moderately severe OSA vs those who did not have OSA. Fortunately, CPAP adherence can also mitigate this excess mortality in those who have had a stroke.29Martinez-Garcia MA Soler-Cataluna JJ Ejarque-Martinez L et al.Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea: a 5-year follow-up study.Am J Respir Crit Care Med. 2009; 180: 36-41Crossref PubMed Scopus (286) Google Scholar An association between sleep apnea and epilepsy has been recognized since the early 1980s and appears to be the strongest among older adults who present with new-onset epilepsy.30Wyler AR Weymuller Jr, EA Epilepsy complicated by sleep apnea.Ann Neurol. 1981; 9: 403-404Crossref PubMed Scopus (58) Google Scholar, 31Manni R Terzaghi M Arbasino C Sartori I Galimberti CA Tartara A Obstructive sleep apnea in a clinical series of adult epilepsy patients: frequency and features of the comorbidity.Epilepsia. 2003; 44: 836-840Crossref PubMed Scopus (133) Google Scholar, 32Malow BA Levy K Maturen K Bowes R Obstructive sleep apnea is common in medically refractory epilepsy patients.Neurology. 2000; 55: 1002-1007Crossref PubMed Scopus (261) Google Scholar Prevalence of OSA among those with epilepsy can range from 10% to 45%.31Manni R Terzaghi M Arbasino C Sartori I Galimberti CA Tartara A Obstructive sleep apnea in a clinical series of adult epilepsy patients: frequency and features of the comorbidity.Epilepsia. 2003; 44: 836-840Crossref PubMed Scopus (133) Google Scholar Seizure control can be improved with adequate treatment of coexisting OSA.32Malow BA Levy K Maturen K Bowes R Obstructive sleep apnea is common in medically refractory epilepsy patients.Neurology. 2000; 55: 1002-1007Crossref PubMed Scopus (261) Google Scholar A recent meta-analysis confirmed at least a 2-fold increased risk of motor vehicle accidents among those with OSA.33Tregear S Reston J Schoelles K Phillips B Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis.J Clin Sleep Med. 2009; 5: 573-581PubMed Google Scholar As few as 2 days of CPAP use resulted in significant risk reduction.34Tregear S Reston J Schoelles K Phillips B Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis.Sleep. 2010; 33: 1373-1380PubMed Google Scholar Therefore, recent recommendations to the regulators of commercial drivers include immediate disqualification if the driver has untreated OSA, is nonadherent to therapy, has experienced excessive sleepiness while driving, or has experienced a crash associated with falling asleep while driving.35Ancoli-Israel S Czeisler CA George CFP Guilleminault C Pack AI Expert Panel Recommendations: Obstrucitve Sleep Apnea and Commercial Motor Vehicle Driver Safety. US Department of Transportation, Washington, DC2008http://www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Sleep-MEP-Panel-Recommendations-508.pdfGoogle Scholar The Expert Panel also recommended that commercial drivers who are at increased risk of OSA should only be given conditional certification until they can be evaluated by a sleep specialist.35Ancoli-Israel S Czeisler CA George CFP Guilleminault C Pack AI Expert Panel Recommendations: Obstrucitve Sleep Apnea and Commercial Motor Vehicle Driver Safety. US Department of Transportation, Washington, DC2008http://www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Sleep-MEP-Panel-Recommendations-508.pdfGoogle Scholar Primary care physicians should be aware of these recommendations and inform patients who may be affected. Obstructive sleep apnea also appears to be an independent risk factor for insulin resistance and the development of diabetes. The Sleep Heart Health Study, which enrolled 2656 patients, showed that those with moderate to severe OSA were more likely to have an elevated fasting glucose level and 2-hour glucose tolerance (adjusted odds ratio, 1.46 and 1.44, respectively).36Punjabi NM Shahar E Redline S Gottlieb DJ Givelber R Resnick HE Sleep-disordered breathing, glucose intolerance, and insulin resistance: the Sleep Heart Health Study.Am J Epidemiol. 2004; 160: 521-530Crossref PubMed Scopus (840) Google Scholar Similarly, the Wisconsin Sleep Cohort, which enrolled 1387 patients, revealed that those with moderately severe OSA were more likely to have diabetes (odds ratio, 2.30).37Reichmuth KJ Austin D Skatrud JB Young T Association of sleep apnea and type II diabetes: a population-based study.Am J Respir Crit Care Med. 2005; 172: 1590-1595Crossref PubMed Scopus (578) Google Scholar The benefits of CPAP treatment in patients with diabetes have not been extensively studied. Unrecognized OSA may lead to perioperative complications. These complications include difficult intubations,38Siyam MA Benhamou D Difficult endotracheal intubation in patients with sleep apnea syndrome [table of contents].Anesth Analg. 2002; 95: 1098-1102PubMed Google Scholar exaggerated respiratory depressions from anesthetics and analgesics,39Chung SA Yuan H Chung F A systemic review of obstructive sleep apnea and its implications for anesthesiologists.Anesth Analg. 2008; 107: 1543-1563Crossref PubMed Scopus (258) Google Scholar increased postoperative reintubations,40Gupta RM Parvizi J Hanssen AD Gay PC Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study.Mayo Clin Proc. 2001; 76: 897-905PubMed Scopus (486) Google Scholar cardiac dysrhythmias,41Mooe T Gullsby S Rabben T Eriksson P Sleep-disordered breathing: a novel predictor of atrial fibrillation after coronary artery bypass surgery.Coron Artery Dis. 1996; 7: 475-478Crossref PubMed Scopus (184) Google Scholar and longer hospital stays.40Gupta RM Parvizi J Hanssen AD Gay PC Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study.Mayo Clin Proc. 2001; 76: 897-905PubMed Scopus (486) Google Scholar Therefore, the American Society of Anesthesiologists recommends early identification and appropriate preparation for perioperative management of patients with suspected OSA.42Gross JB Bachenberg KL Benumof JL et al.Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea.Anesthesiology. 2006; 104: 1081-1093Crossref PubMed Scopus (796) Google Scholar Although it is unclear whether complications are decreased by preoperative and postoperative use of CPAP, the American Society of Anesthesiologists recommends its use during recovery if feasible.42Gross JB Bachenberg KL Benumof JL et al.Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea.Anesthesiology. 2006; 104: 1081-1093Crossref PubMed Scopus (796) Google Scholar The CPAP device is still the criterion standard for the treatment of OSA. It uses pressure to provide a pneumatic splint to maintain airway patency. Suboptimal patient adherence to CPAP has led to a number of advances in CPAP-related equipment and in other treatment options. Although CPAP use can decrease morbidity and mortality, close follow-up to ensure adherence is crucial in the management of not only OSA but also other comorbid conditions. Recognizing that the standard CPAP mask, which covers the nose or the nose and mouth, may be the most cumbersome part of the treatment, manufacturers of the device currently offer more than 100 different mask options to customize the treatment. Nasal pillows, which insert into the nostrils only, are preferred by some patients with claustrophobia. Other available masks include those that have no attached straps, cover the mouth only, or cover the entire face, the last of which are counterintuitively preferred by some claustrophobic patients. Other styles can be worn like a hat, which may be helpful for those with finger dexterity limitations. For patients who require a full face mask (that covers the nose and mouth) but have problems with skin breakdown at the bridge of the nose, a mask that combines a mouth mask with nasal pillows is an option. Cloth masks made without any plastic are available for patients who are extremely sensitive to plastic material. With such a variety of mask options, a referral back to the sleep specialist is warranted if the patient is struggling with adherence. Advances have also been made in the design of CPAP machines. Some systems have a heated wire integrated into the tubing to maximize humidity without causing excessive condensation. Machines are much smaller and quieter. The latest model is merely 1.4 kg (3 lbs) and generates less than 24 dB of noise, which is less than whisper-quiet conversation. To help patients who struggle with the pressure generated by CPAP, machines can now temporarily decrease the pressure at the beginning of exhalation to facilitate easier respiratory cycles. These devices automatically increase the pressure back up to the preset pressure before exhalation is completed, thus allowing sufficient pressure to maintain airway patency. Similarly, automatically adjusting positive airway pressure (APAP), using a proprietary algorithm, will automatically increase and decrease pressure on the basis of identified respiratory events. The APAP device is particularly useful for patients who require higher pressures in the supine than in the nonsupine position. Rather than using 1 pressure, such devices automatically adjust the pressure to meet the patient's pressure requirements during any given body position. This often results in lower average pressure throughout the night, which may contribute to better tolerance. Although most postbariatric patients may not require CPAP, a large minority (>44%) have residual AHI greater than 10.43Greenburg DL Lettieri CJ Eliasson AH Effects of surgical weight loss on measures of obstructive sleep apnea: a meta-analysis.Am J Med. 2009; 122: 535-542Abstract Full Text Full Text PDF PubMed Scopus (269) Google Scholar In such patient groups, APAP may be beneficial because the required pressure will most likely decrease with weight loss. Bilevel positive airway pressure (PAP) devices allow for separate inspiratory and expiratory pressure settings that may be more comfortable for some patients. Although studies have not shown improvements in adherence,44Gay PC Herold DL Olson EJ A randomized, double-blind clinical trial comparing continuous positive airway pressure with a novel bilevel pressure system for treatment of obstructive sleep apnea syndrome.Sleep. 2003; 26: 864-869PubMed Google Scholar select patients seem to tolerate bilevel PAP better than CPAP, particularly when high pressures are required or if patients had a prolonged period of poor initial tolerance to CPAP treatment.45Ballard RD Gay PC Strollo PJ Interventions to improve compliance in sleep apnea patients previously non-compliant with continuous positive airway pressure.J Clin Sleep Med. 2007; 3: 706-712PubMed Google Scholar In fact, AASM suggests bilevel PAP be used when CPAP pressure exceeds 15 cm H2O.46Kushida CA Chediak A Berry RB et al.Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea.J Clin Sleep Med. 2008; 4: 157-171PubMed Google Scholar Primary care physicians may be asked to certify CPAP adherence for patients covered by CMS. By CMS rules, adherence is defined as use of the CPAP device for at least 4 hours per night for at least 70% of the nights during any given consecutive 30-day period.10National Government Services, Inc. LCD for positive airway pressure (PAP) devices for the treatment of obstructive sleep apnea (L27230): American Medical Association. Center for Medicaid and Medicare, 2010http://www.nationwidemedical.com/wp-content/uploads/2010/06/LCD-for-Positive-Airway-Pressure-doc-region-b.pdfGoogle Scholar Local vendors can download the integrated adherence data from the CPAP device. Patients have 90 days after CPAP issuance to meet these criteria. Therefore, we recommend a follow-up visit within the first 30 to 60 days to allow for additional intervention if a patient is not meeting adherence criteria. Recognizing that PAP adherence can still be problematic, several investigators studied the use of a soporific. Adherence may be improved with the use of a benzodiazepine receptor agonist such as eszopiclone, particularly if baseline adherence is 4 hours or less.47Lettieri CJ Shah AA Holley AB Kelly WF Chang AS Roop SA Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial.Ann Intern Med. 2009; 151: 696-702Crossref PubMed Google Scholar Other means of improving adherence include the addition of humidity, intensive education, close follow-up, and treatment of nasal congestion. For persistently nonadherent patients with lower AHI, predominantly supine OSA, lower body mass index, or with certain facial and airway features (quantifiable by a qualified dental specialist), an oral appliance may be an option.48Schmidt-Nowara W Lowe A Wiegand L Cartwright R Perez-Guerra F Menn S Oral appliances for the treatment of snoring and obstructive sleep apnea: a review.Sleep. 1995; 18: 501-510Crossref PubMed Scopus (449) Google Scholar These custom-made devices protrude the lower jaw forward to thrust the tongue base forward, thereby enlarging the retropharyngeal region. Success rates of oral appliances are 30% to 80%, depending on the selection criteria, definition of success, and the device used.49Ferguson KA Cartwright R Rogers R Schmidt-Nowara W Oral appliances for snoring and obstructive sleep apnea: a review.Sleep. 2006; 29: 244-262PubMed Google Scholar Of the many devices available, we recommend types that are adjustable. Positional therapy is another option for those who experience mild OSA predominantly while sleeping on their back. This approach uses a barrier, such as a body pillow or tennis balls in a t-shirt, to prevent supine sleep. Although such an approach may be effective temporarily, overall adherence has been disappointing.50Bignold JJ Deans-Costi G Goldsworthy MR et al.Poor long-term patient compliance with the tennis ball technique for treating positional obstructive sleep apnea.J Clin Sleep Med. 2009; 5: 428-430PubMed Google Scholar Surgical options are also available, including removal of tissue from the posterior pharyngeal region (eg, uvulopalatopharyngoplasty) and maxillary-mandibular advancement, in which both the maxilla and the mandible are surgically advanced, thereby permanently enlarging the posterior pharyngeal region. Success rates of upper airway surgery vary from 24% to 86%, depending on severity, patient selection, definition of success, and type of surgery performed.51Khan A Ramar K Maddirala S Friedman O Pallanch JF Olson EJ Uvulopalatopharyngoplasty in the management of obstructive sleep apnea: the Mayo Clinic experience.Mayo Clin Proc. 2009; 84: 795-800Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 52Caples SM Rowley JA Prinsell JR et al.Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis.Sleep. 2010; 33: 1396-1407Crossref PubMed Scopus (356) Google Scholar Typically, a higher success rate is achieved if multilevel surgery is performed (eg, uvulopalatopharyngoplasty followed by maxillary-mandibular advancement).52Caples SM Rowley JA Prinsell JR et al.Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis.Sleep. 2010; 33: 1396-1407Crossref PubMed Scopus (356) Google Scholar The last surgical option is a tracheostomy. The AASM has published practice parameters for additional medical therapies.53Morgenthaler TI Kapen S Lee-Chiong T et al.Practice parameters for the medical therapy of obstructive sleep apnea.Sleep. 2006; 29: 1031-1035PubMed Google Scholar Neither medication nor oxygen therapy is recommended for primary treatment of OSA. Exceptions are adjunctive uses of a stimulant therapy with modafinil in those who remain adherent to OSA treatment but have residual sleepiness without any other identifiable cause and topical nasal corticosteroids in those with concurrent rhinitis. Positional therapy (in which some barrier is used to minimize supine sleep) may be acceptable as an adjunctive or secondary therapy option in those who have respiratory events predominantly in the supine position only. Some patients who appear to have OSA during the diagnostic test develop central sleep apnea on CPAP initiation (Table 2). The incidence of this form of atypical apnea, known as Complex Sleep Apnea Syndrome (CompSAS), is 10% to 20%.54Lehman S Antic NA Thompson C Catcheside PG Mercer J McEvoy RD Central sleep apnea on commencement of continuous positive airway pressure in patients with a primary diagnosis of obstructive sleep apnea-hypopnea.J Clin Sleep Med. 2007; 3: 462-466PubMed Google Scholar Patients with CompSAS tolerate CPAP very poorly because of increased sleep disruptions resulting from central sleep apnea events. Although some of those with CompSAS can eventually be treated with CPAP, up to 50% will require the use of a new PAP device known as the adaptive servo-ventilator.55Kuzniar TJ Pusalavidyasagar S Gay PC Morgenthaler TI Natural course of complex sleep apnea: a retrospective study.Sleep Breath. 2008; 12: 135-139Crossref PubMed Scopus (69) Google Scholar Because CompSAS is difficult to diagnose and treat, patients with suspected CompSAS should be referred to a sleep center for further evaluation and treatment. Recently, a new treatment device has undergone a multicenter trial to assess efficacy. Rather than using a machine to generate PAP, Provent uses a 1-way valve to maintain a constant pressure in the posterior pharyngeal region.56Rosenthal L Massie CA Dolan DC Loomas B Kram J Hart RW A multicenter, prospective study of a novel nasal EPAP device in the treatment of obstructive sleep apnea: efficacy and 30-day adherence.J Clin Sleep Med. 2009; 5: 532-537PubMed Google Scholar The attractive feature of this device is its simplicity: it is a tape-like device worn over the nostrils nightly and does not require any tubing or electricity. This product has been in the European market and has received approval by the US Food and Drug Administration; however, the results of a recently completed double-blind, prospective, multicenter trial have not yet been published. Other novel therapy devices are currently being tested but are not yet ready to be marketed. The diagnosis and treatment of OSA have been facilitated by continuous and ongoing advances in this evolving field. It is important to recognize that OSA independently affects morbidity and mortality if left untreated. Primary care physicians can assist in ensuring that OSA is properly diagnosed and treated by being more aware of this disorder and its effect on the overall health of their patients. This disorder should be suspected in obese or somnolent patients or in those who snore. Patients with OSA may also present with resistant hypertension, recurrent atrial fibrillation, or stroke or may have elevated fasting glucose values. Screening with overnight oximetry may indicate severity but is insufficient to diagnose OSA. Overnight PSG, whether facility-based or portable, is required for appropriate diagnosis. Once diagnosed, CPAP initiation is the criterion standard of treatment; however, in those with mild OSA, an oral appliance may be acceptable. Addition of humidity, nasal corticosteroids, different interface options, and/or different devices may be helpful for patients who struggle with adherence. To facilitate these interventions, patients may need referral back to the vendor or a sleep center, especially because 10% to 20% may have CompSAS, which requires an entirely different approach to treatment. Some patients may need an ear, nose, and throat or an orthodontic consultation for an evaluation of a surgical intervention if other attempts have failed. Regardless of the treatment approach, obese patients should be counseled on weight loss. Patients who are struggling to lose weight and whose obesity is causing medical complications may be considered for bariatric intervention. Novel treatment options offer alternatives to improve adherence and thus reduce the burden of OSA.