For adults with obstructive sleep apnea, using CPAP therapy or other airway-opening devices are one of the best courses of action to treat their sleep disorder. Overweight and obese adults with sleep apnea should also be encouraged and helped to lose weight as part of treating sleep apnea.
These are the messages from new clinical guidelines announced by the American College of Physicians. The ACP announced its new recommendations to doctors for treating obstructive sleep apnea -- and a summary of the research that led to these guidelines -- in a report published in its journal, Annals of Internal Medicine. The guidelines emphasize the importance of achieving and maintaining a healthy weight as a strategy to alleviate OSA. They also point to CPAP and, alternatively, to mandibular advancement devices (MAD) as effective treatments for sleep apnea after initial diagnosis. Both CPAP and MAD are designed to diminish or eliminate the episodes of interrupted and shallow breathing that are the hallmark symptoms of OSA. Mandibular advancement devices are worn inside the mouth and help to keep the airway from collapsing during sleep. In contrast, the CPAP device is a machine connected to a mask worn over the face during sleep, which pushes a constant stream of air through the airway, keeping it open.
Two other treatment options -- drug therapy and surgery -- were not recommended by the ACP, which found insufficient evidence that these options provide benefits to OSA patients compared to other treatments.
The ACP used published scientific research from the years 1966-2010 in developing these guidelines. Their review of this nearly 50-year body of evidence formed the basis for the ACP's three recommendations to physicians diagnosing and treating obstructive sleep apnea:
Weight loss can have a positive impact on obstructive sleep apnea. Rates of OSA are on the rise, according to the ACP report, and so are rates of obesity and other weight-influenced diseases such as Type 2 diabetes. Being overweight is one of the most significant risk factors for developing obstructive sleep apnea. The ACP's first recommendation to doctors is that they encourage their overweight and obese patients with sleep apnea to lose weight.
CPAP is the most effective initial treatment for sleep apnea -- but many patients don't use it once prescribed. The ACP review of evidence found that overall CPAP remains the best first option for treating sleep apnea after an initial diagnosis. The most significant downside to CPAP therapy is that people often are uncomfortable wearing the device's mask during sleep. Discomfort with the CPAP device often leads people to use the treatment inconsistently, or abandon it altogether. Because of its overall effectiveness, the ACP recommends CPAP as the first option for initial treatment of sleep apnea.
MAD can be used instead of CPAP in initial treatment. For sleep apnea patients who find they cannot tolerate the CPAP, mandibular advancement devices are an alternative that the ACP recommends. The ACP review of research found that overall, CPAP has demonstrated greater effectiveness than MAD to treat sleep apnea. However, evidence does show MAD can be effective in treating OSA. The ACP recommends mandibular advancement devices for initial treatment of sleep apnea in patients who have adverse reactions to CPAP.
With estimates suggesting that more than 18 million adults or more are suffering from obstructive sleep apnea, these guidelines will apply broadly to physicians across the U.S. Research also indicates that sleep apnea remains significantly under-diagnosed, especially in women. I hope that these new guidelines, beyond providing directions to primary care and other physicians about treatment, will also spur some much-needed attention toward the prevalence of sleep apnea and sleep-disordered breathing.
Sweet Dreams,
Michael J. Breus, PhD
The Sleep Doctor®
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