Guideline recommends when to refer patients with obstructive sleep apnea for surgery
Clinicians should discuss referral to a sleep surgeon, bariatric surgeon, or both with patients who do not tolerate positive airway pressure, according to new recommendations from the American Academy of Sleep Medicine.
A new clinical practice guideline recommends referral of certain adults with obstructive sleep apnea (OSA) for surgical consultation.
The guideline provides recommendations on when to refer patients with sleep apnea for upper airway or bariatric surgery. It is an update to the American Academy of Sleep Medicine's 2010 guideline, which made recommendations for specific surgical procedures but did not address when to consider such options. It was published online by the Journal of Clinical Sleep Medicine on Aug. 5.
The guideline recommended that clinicians discuss referral to a sleep surgeon with adults who have OSA and a body mass index (BMI) less than 40 kg/m2 and who do not tolerate or accept positive airway pressure (PAP) as part of a patient-oriented discussion of alternative treatment options (strong recommendation). The discussion does not have to result in a referral and does not preclude such other treatment options as a mandibular advancement device, positional therapy, or lifestyle changes.
Similarly, the guideline recommended that clinicians discuss referral to a bariatric surgeon with adults with OSA and obesity (class II/III, BMI ≥35 kg/m2) who do not tolerate or accept PAP as part of a patient-oriented discussion of alternative treatment options (strong recommendation). Again, the discussion does not have to result in a referral and does not preclude medical weight loss strategies or other viable treatment options for OSA. For patients within the BMI range of 35 to 40 kg/m2, discussing referral to both sleep and bariatric surgeons to discuss management options is appropriate, the guideline said.
The guideline suggested discussing referral to a sleep surgeon with adults who have OSA, a BMI less than 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 (conditional recommendation). Upper airway surgery has a moderate effect in reducing minimum therapeutic continuous PAP level and increasing adherence, the guideline noted. The decision to offer referral should be based on the clinician's judgment of a patient's adherence and tolerance, as well as the patient's treatment preferences.
The guideline suggested that clinicians recommend PAP as initial therapy for adults with OSA and a major upper airway anatomic abnormality prior to consideration of referral for upper airway surgery (conditional recommendation). Major upper airway anatomic abnormalities include tonsillar hypertrophy and maxillomandibular abnormalities. Referral for initial surgical therapy should be based on the clinician's judgment of the patient's medical history, because initial surgical intervention may be justified in the setting of other surgical indications affecting the upper airway, such as chronic tonsillitis, malocclusion, abnormal lesion, or growth.
PAP is the most efficacious treatment for the majority of OSA patients if used consistently, but a substantial portion of patients do not accept or tolerate it, the guideline stated.
“A variety of alternatives to PAP for OSA treatment exist, including surgical interventions,” the guideline said. “New diagnostic tools and improved surgical techniques have proliferated over the last 10-15 years as surgeons have developed more effective and less morbid procedures better tailored to the individual patient's anatomy.”