"Treatment of Obstructive Sleep Apnea in Primary Care" (My Synopsis)

Treatment of Obstructive Sleep Apnea in Primary Care
LYLE D. VICTOR, M.D., M.B.A., Oakwood Hospital and Medical Center, Dearborn, Michigan
Am Fam Physician. 2004 Feb 1;69(3):561-569.

     A good friend of mine called me and said that his wife thinks that he has sleep apnea. "Is that bad?", he said. I gave him a brief overview, and then decided that it would be a good topic to review today. SO AWAY WE GO!
     OSA is a partial or complete airway obstruction which causes breathing to stop during sleep. It is seen in overweight patients who snore. They will often be sleepy during the day. Disease severity can be measured with an "apnea-hypopnea index". If the number of apneic or hypopneic episodes equal 20 or more per hour, then treatment is recommended. 
     First line therapy is sleep hygiene. Patients should allot enough time to dedicate to sleep. Deprivation of sleep can cause snoring. Things that affect nasal outflow (rhinitis, polyps, septal deviation) and mouth breathing are risk factors for OSA. Patients with OSA should avoid alcohol and sedatives because they can increase snoring by relaxing the tongue and parapharyngeal muscles. Most patients with OSA are overweight or obese. Weight loss of 20-30 lbs. will lead to significant improvement. Patients may also get relief if they sleep at an elevated position. 
     If sleep hygiene is not fully effective, then the patient will need CPAP. This is a mask that the patient wears when they go to bed. It pushes air into the nostrils to keep the pharyngeal airway open. Patients usually require 6-12 cm of pressure to reduce the number of episodes each night. The pressure may be reduced slightly after a month of use or if the patient has some weight loss. Many patients have a hard time tolerating the mask while sleeping. One way to address this is to uses bilevel pressure ventilation, which lowers the pressure upon exhalation. This will reduce the work of breathing.  Other strategies to help with patient compliance is to make sure the mask fits right, using nasal pillows, using a full face mask, adding a humidifier, or giving the patient a nasal steriod spray. Complications of CPAP include air leakage, claustrophobia, skin irritation, and conjunctivitis. 
     Surgery is another option if the patient cannot tolerate CPAP. Uvulopalatoplasty removes part of the soft palate and uvula. Jaw surgery attempts to advance the maxillomandibular bone. Another technique moves "the anterior tip of the mandible forward along with its lingual attachments". Another approach, which uses maxillary and mandibular osteotomies, is more invasive. Tracheostomy is a last resort treatment, used in respiratory failure or in severe apnea. 
     Oxygen is partially effective by treating desaturation, but it does not reverse the obstruction.