From the Guidelines
Patients with sleep apnea should be referred to a sleep surgeon or a bariatric surgeon, depending on their BMI and tolerance to PAP therapy, as part of a patient-oriented discussion of alternative treatment options. According to the American Academy of Sleep Medicine clinical practice guideline 1, referral to a sleep surgeon is recommended for adults with OSA and BMI <40 kg/m2 who are intolerant or unaccepting of PAP therapy.
Key Considerations
- The guideline suggests discussing referral to a sleep surgeon with adults with OSA, BMI <40 kg/m2, and persistent inadequate PAP adherence due to pressure-related side effects as part of a patient-oriented discussion of adjunctive or alternative treatment options 1.
- For adults with OSA and obesity (class II/III, BMI ≥35 kg/m2) who are intolerant or unaccepting of PAP, referral to a bariatric surgeon is recommended 1.
- The primary care physician should initiate the referral after identifying risk factors or symptoms such as loud snoring, observed breathing pauses during sleep, excessive daytime sleepiness, morning headaches, or difficulty concentrating.
Treatment Options
- The sleep specialist will typically order a sleep study (polysomnography) either in a sleep lab or at home to confirm the diagnosis.
- They can then recommend appropriate treatment options such as continuous positive airway pressure (CPAP) therapy, oral appliances, lifestyle modifications, or in some cases, surgical interventions.
Importance of Early Referral
- Early referral is important as untreated sleep apnea can lead to serious health consequences including hypertension, heart disease, stroke, and diabetes due to the intermittent hypoxia and sleep fragmentation that characterize the condition.
From the Research
Diagnosis and Referral of Sleep Apnea
To determine which specialty to refer a patient for sleep apnea, it is essential to understand the diagnosis and management of obstructive sleep apnea (OSA).
- OSA is a common disorder that affects quality of life and is associated with comorbidities such as hypertension, atrial fibrillation, heart failure, coronary heart disease, type 2 diabetes mellitus, and stroke 2.
- The U.S. Preventive Services Task Force states that there is insufficient evidence to recommend routine screening for OSA in the absence of symptoms 2.
- OSA should be considered in patients with excessive daytime fatigue, unrestful sleep, persistent snoring, and nocturnal awakenings with gasping or choking 2.
Referral to Specialty Care
Patients with suspected OSA can be referred to various specialties, including:
- Sleep medicine specialists: for diagnosis and management of OSA, including polysomnography and home sleep apnea testing 3, 4.
- Pulmonologists: for management of respiratory complications associated with OSA 5.
- ENT (ear, nose, and throat) specialists: for surgical evaluation and treatment of upper airway obstruction 5.
- Primary care physicians: for initial assessment and management of uncomplicated OSA, with referral to specialists as needed 6.
Diagnostic Testing
Diagnostic testing for OSA includes:
- Polysomnography (PSG): the gold standard for diagnosis, which measures sleep variables, including apnea-hypopnea index (AHI) 4.
- Home sleep apnea testing (HSAT): a useful diagnostic option for patients with symptoms consistent with moderate to severe OSA without significant cardiopulmonary comorbidities 2.
- STOP-BANG questionnaire: a sensitive screening tool for OSA 2.
Treatment Options
Treatment options for OSA include:
- Positive airway pressure (PAP) therapy: the first-line treatment for adults with OSA 2.
- Weight loss: a beneficial adjunct to treatment through intensive lifestyle modification, medications, or bariatric surgery 5, 2.
- Oral appliances: such as mandibular advancement devices, for patients intolerant of or nonadherent to PAP therapy 2.
- Hypoglossal nerve stimulation: for select patients with a body mass index less than 32 5.