Treatment Algorithm for OSA

Abstract

To the Editor: I appreciate the opportunity to respond to Dr. Loube's letter concerning my review of the treatment of obstructive sleep apnea (OSA).1Hudgel DW Treatment of obstructive sleep apnea: a review.Chest. 1996; 109: 1346-1358Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Dr. Loube contends that weight loss and medications should not be recommended as a first line of treatment for OSA. He would recommend either nasal continuous positive airway pressure (CPAP) or upper airway surgery as the initial treatment option discussed with a new untreated sleep apnea patient. In the military where Dr. Loube practices, extremely obese OSA patients likely are not encountered. However, in the civilian population, obesity is quite common in OSA patients. Several studies have shown an improvement in upper airway function and a decrease in apnea with weight loss. These findings are discussed in the review.1Hudgel DW Treatment of obstructive sleep apnea: a review.Chest. 1996; 109: 1346-1358Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Obviously, we would be remiss if we did not strongly encourage our obese OSA patients to lose weight. Although the medical treatment of obstructive sleep apnea is in its infancy, some promising results are available. The relationship between serotonin abnormalities and sleep apnea is not totally clarified, but studies have provided initial promising results. Tryptophan, fluoxetine, and buspirone–agents that increase brain serotonin activity by different mechanisms–all improve sleep apnea in some patients. Although it is not yet clear which patients are the best candidates for this therapy, the use of medications can be more convenient than CPAP, if they are as effective. Surely, this area needs further research; in the future, we hope to have more specific indications for medications in the treatment of sleep apnea. The use of oral appliances is addressed in my review,1Hudgel DW Treatment of obstructive sleep apnea: a review.Chest. 1996; 109: 1346-1358Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar but at this time there is insufficient data to know where to place this mode of therapy in the treatment algorithm. Since my review was submitted, the manuscript by Ferguson et al was published2Ferguson KA Ono T Lowe AA et al.A randomized crossover study of an oral appliance versus nasal continuous positive airway pressure for the treatment of mild-moderate obstructive sleep apnea.Chest. 1996; 109: 1269-1275Abstract Full Text Full Text PDF PubMed Scopus (390) Google Scholar and shows promising results. As supportive evidence grows, this form of therapy may become one of our first line treatments. Surely, CPAP is often prescribed initially for the treatment of OSA. However, studies documenting that patient compliance is often considerably less than ideal influenced the placement of CPAP in my recommended algorithm. Surgery for sleep apnea is not successful enough to be a first line treatment at this time. New findings about pharyngeal surgery, discussed in the review, are worrisome. First, the pharynx size may revert to the original caliber several months after surgery. Second, late uvulopalatopharyngoplasty failures are being reported. Third, pharyngeal surgery is often performed without preoperative identification of the site of obstruction. In summary, I am aware that there are multiple approaches to treating the OSA patient. In spite of the treatment chosen, the response to a given treatment choice should be objectively measured, be it by monitoring CPAP machine timer, repeat polysomnogram following a few weeks of drug therapy, or documentation of improvement in apnea following surgery. When there is not an adequate response, the therapy should be changed based on this objective evidence. Our goal is to have the sleep apnea patient's health improved with a form of treatment that is effective over time, and with which the patient is satisfied. Treatment Algorithm for OSACHESTVol. 111Issue 2PreviewTo the Editor: Full-Text PDF