What is the diagnosis and treatment for Obstructive Sleep Apnea (OSA)?

From the Guidelines

Obstructive Sleep Apnea (OSA) Diagnosis and Treatment Sleep apnea is a sleep disorder characterized by recurrent episodes of partial or complete upper airway obstruction during sleep, resulting in disrupted sleep and decreased oxygen saturation, as defined by the American Academy of Sleep Medicine 1. The diagnosis of OSA is based on the presence of five or more predominantly obstructive respiratory events per hour of sleep during polysomnography (PSG) or per hour of monitoring time during a home sleep apnea test (HSAT) with symptoms or comorbidities 1.

Treatment Options

Treatment options for OSA include:

• Continuous Positive Airway Pressure (CPAP) Therapy: CPAP is the standard first-line treatment for OSA, which delivers compressed air into the airway to keep it open, as recommended by the American College of Physicians 1. The pressure is typically initiated at 5-10 cmH2O and titrated to an effective pressure of 10-15 cmH2O.
• Oral Appliances: Mandibular advancement devices (MADs) are an alternative therapy to CPAP for patients who prefer MADs or have adverse effects associated with CPAP, as suggested by the American College of Physicians 1.
• Pharmacological Therapy: Medications such as acetazolamide or modafinil may be considered to help manage symptoms, although the evidence is limited 1.
• Behavioral Changes: Weight loss, increased physical activity, and avoidance of alcohol and sedatives before bedtime are recommended behavioral changes to help manage OSA symptoms 1.
• Surgical Interventions: Surgical options, such as maxillofacial surgery or otolaryngologic surgery, may be considered for specific cases, although the evidence is limited 1.

Key Considerations

• Patient Preferences: Patient preferences and adherence to treatment should be considered when selecting a treatment option 1.
• Comorbidities: The presence of comorbidities, such as hypertension or cardiovascular disease, should be considered when selecting a treatment option 1.
• Side Effects: The potential side effects of treatment options, such as CPAP or oral appliances, should be considered and monitored 1.

From the FDA Drug Label

Modafinil tablets are indicated to improve wakefulness in adult patients with excessive sleepiness associated with narcolepsy, obstructive sleep apnea (OSA), or shift work disorder (SWD). In OSA, modafinil tablets are indicated to treat excessive sleepiness and not as treatment for the underlying obstruction. If continuous positive airway pressure (CPAP) is the treatment of choice for a patient, a maximal effort to treat with CPAP for an adequate period of time should be made prior to initiating and during treatment with modafinil tablets for excessive sleepiness.

The diagnosis of Obstructive Sleep Apnea (OSA) includes:

• Excessive sleepiness or insomnia, plus frequent episodes of impaired breathing during sleep, and associated features such as loud snoring, morning headaches and dry mouth upon awakening
• Excessive sleepiness or insomnia and polysomnography demonstrating one of the following: more than five obstructive apneas, each greater than 10 seconds in duration, per hour of sleep and one or more of the following: frequent arousals from sleep associated with the apneas, bradytachycardia, and arterial oxygen desaturation in association with the apneas

The treatment for OSA includes:

• Continuous Positive Airway Pressure (CPAP) as the treatment of choice
• Modafinil tablets to improve wakefulness in adult patients with excessive sleepiness associated with OSA, but not as treatment for the underlying obstruction 2
• A maximal effort to treat with CPAP for an adequate period of time should be made prior to initiating and during treatment with modafinil tablets for excessive sleepiness 2

From the Research

Diagnosis of Obstructive Sleep Apnea (OSA)

• The diagnosis of OSA requires the objective demonstration of abnormal breathing during sleep by measuring the respiratory disturbance index (RDI, events per hour of sleep) 3.
• OSA is defined by combining symptoms and an RDI ≥5 or by an RDI ≥15 without symptoms 3.
• The apnea-hypopnea index (AHI), the frequency of apnea and hypopnea events per hour of sleep, is widely used to define OSA 3, 4.
• Minimal diagnostic criteria have been defined for OSA, including excessive daytime sleepiness and more than five obstructed breathing events per hour during sleep 4.

Treatment of Obstructive Sleep Apnea (OSA)

• Continuous positive airway pressure (CPAP) is the main therapy for OSA and has been shown to provide benefits for the respiratory, cardiovascular, and metabolic systems 5.
• CPAP has been shown to mitigate and slow the rate of cognitive decline and may reduce the risk of dementia 6.
• Other treatments for OSA, such as oral mandibular devices and hypoglossal nerve stimulation, may also be effective, but more studies are needed to further elucidate their effects 6.
• Guidelines have been developed to tailor OSA therapy to patients according to the results of their disease evaluation and their preferences 3.

Characteristics of Obstructive Sleep Apnea (OSA)

• OSA is characterized by recurrent episodes of partial or complete upper airway obstruction during sleep, resulting in a reduction in or the total cessation of airflow, despite ongoing respiratory efforts, leading to oxygen desaturation and arousal 7, 5, 4.
• Risk factors for OSA include obesity, upper airway abnormalities, male gender, menopause, and age 3.
• OSA is associated with symptoms during sleep, such as snoring, choking, and nocturia, and wakefulness, such as excessive sleepiness, fatigue, and lack of energy 3, 4.