Dec 112013

The American College of Physicians released a new clinical practice guideline for the management of obstructive sleep apnea, published in Annals of Internal Medicine. ACP advises people with obstructive sleep apnea should use CPAP therapy or other airway opening devices such as mandibular advancement devices, and should be encouraged and assisted in losing weight.

The guideline was developed through a systematic evidence review sponsored by the Agency for Healthcare Research and Quality (AHRQ). They looked at hundreds of studies, most of which were poor quality. The final product was three evidence-based recommendations:

  • All overweight and obese patients diagnosed with OSA should be encouraged to lose weight. (strong recommendation; low-quality evidence)
  • Continuous positive airway pressure treatment should be used as initial therapy for patients diagnosed with OSA. (strong recommendation; moderate-quality evidence)
  • Mandibular advancement devices as an alternative therapy to continuous positive airway pressure treatment for patients diagnosed with OSA who prefer mandibular advancement devices or for those with adverse effects associated with continuous positive airway pressure treatment. (weak recommendation; low-quality evidence)

A few pearls from their evidence review that didn't make it above the fold:

  • Weight loss can cure mild obstructive sleep apnea. 22 of 35 patients (63%) with mild sleep apnea who lost an average of 25 pounds had an AHI < 5 on follow-up sleep studies. Patients in the weight loss intervention arm improved AHI (by -4 to -23 events/hour) in all randomized studies examined.
  • There is no good evidence that surgery improves OSA, compared to control (no treatment). The 7 studies examined were too inconsistent in design and measured outcomes to establish any benefit. Surgery has also been compared to CPAP in at least 12 studies, almost all poor-quality, with no conclusions possible. Positional therapy likewise has insufficient evidence to recommend its use.
  • CPAP has been shown to be better than mandibular advancement devices as treatment for obstructive sleep apnea.
  • The more severe someone's sleep apnea (higher AHI and Epworth Sleepiness Scores), the more likely they are to adhere to (use) CPAP consistently.
  • No interventions to increase CPAP adherence have been convincingly shown to work. Cognitive-behavioral improved adherence with CPAP in one trial; telemonitoring programs were helpful in 2 out of 3 trials. One low-quality study suggested seeing a sleep doctor rather than a primary care physician improved adherence. Giving eszopiclone (Lunesta) also improved CPAP adherence in 2 randomized trials.

Amir Qaseem et al. Management of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 24 September 2013doi:10.7326/0003-4819-159-7-201310010-00704

See also:

Perioperative management of obstructive sleep apnea review

CPAP cures metabolic syndrome paper retracted from NEJM

Home testing for sleep apnea bankrupting sleep centers

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Management of obstructive sleep apnea: New guideline from ACP