Sleep Disorders | Sleep Review
A new clinical practice guideline developed by the American Academy of Sleep Medicine (AASM) provides recommendations for referring adults with obstructive sleep apnea for surgical advice. Surgical treatment for OSA can be an option for patients who have difficulty with CPAP therapy and others with certain anatomical features.
The guideline, available online as an accepted paper in the Journal of Clinical Sleep Medicine, provides recommendations for referral to upper respiratory tract or bariatric surgery for patients with sleep apnea who cannot tolerate CPAP therapy or who cannot accept persistent inadequate CPAP adherence have or have obvious upper airway anatomical abnormalities that may be amenable to surgery. This is a 2010 update of the AASM guideline that provides recommendations for certain surgical procedures but does not address when such options should be considered.
“While CPAP is considered the gold standard in the treatment of obstructive sleep apnea, its effectiveness can be compromised if patients fail to adhere to treatment or receive adequate benefit,” said David Kent, MD, chairman of the AASM Task Force, and assistant professor and director of Sleep surgery in the Department of ENT Surgery Head and Neck Surgery at Vanderbilt University in Nashville, Tenn, in a press release. “Our review has shown that surgery for obstructive sleep apnea results in clinically significant reductions in excessive sleepiness, snoring, blood pressure and multiple measures of sleep apnea severity, and improves quality of life.”
The guideline makes two strong recommendations for the management of adults with obstructive sleep apnea who are intolerant or unwilling to accept CPAP treatment that clinicians should follow in most cases.
If such a patient has a body mass index below 40, the sleep doctor should discuss referral to a sleep surgeon with the patient. If such a patient has a BMI of 35 or greater, the sleep doctor should discuss referral to a bariatric surgeon with the patient. Referrals to both providers can be discussed for patients with a BMI between 35 and 40.
The guideline provides a conditional recommendation for discussing referral to a sleep surgeon for adults with sleep apnea, a BMI below 40, and persistent inadequate CPAP adherence due to pressure-related side effects that requires stronger clinical judgment, as the available evidence suggests that surgery should upper airway can help reduce CPAP pressure needs and improve patient compliance. It is also conditionally recommended that CPAP be used as the initial treatment for sleep apnea in patients with a major anatomical abnormality of the upper respiratory tract, such as: Large tonsils, before considering a referral for upper airway surgery. Other indications for surgery may warrant surgery prior to the CPAP study.
The guideline was developed by a working group made up of experts in sleep medicine, ENT medicine and bariatric surgery and approved by the board of the AASM. The process included a systematic literature review, meta-analyzes and the assessment of the evidence using the GRADE methodology. A draft of the guideline has been made available for public comment.
“The guideline illustrates common clinical scenarios where the discussion of referral for sleep or bariatric surgery can benefit the patient,” says Kent. “Nonetheless, recommendations for surgical referral should be based on the patient’s individual circumstances and should not rule out other treatment options.”
The recommendations are based on an overall assessment of the quality of the evidence, the beneficial and harmful effects, patient values and preferences, and resource consumption. The final assessment of a particular treatment must be made by the attending physician and the patient, taking into account the patient’s individual circumstances, available treatment options, and resources.
The guideline has been endorsed by the American Society for Metabolic and Bariatric Surgery and the Alliance of Sleep Apnea Partners and confirmed by the American Academy of Otolaryngology – Head and Neck Surgery.
Kent is listed as the inventor on patent applications for the surgical treatment of sleep apnea owned and licensed by Vanderbilt University. The licensed treatments do not currently exist in prototype or commercial form and have not been included in the task force’s review and analysis.
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