New International Consensus Document on Treating OSA

Olga Fernández Castro

August 23, 2022

The Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) has issued a new international consensus document (ICD) on obstructive sleep apnea (OSA). The objective is to improve the diagnosis and treatment of one of the most prevalent sleep disorders.

The ICD represents a collaboration of experts from 17 scientific societies and 56 specialists from various countries. It provides a series of clinical guidelines to help healthcare professionals make the best decisions for adult patients with OSA. Notably, the authors propose changing the name from sleep apnea syndrome. In recommending the term OSA, they reintroduce the term "obstructive" — to differentiate the disorder from central sleep apnea — and remove the outdated word "syndrome."

"The definition has also been changed, as it was a bit vague and difficult to understand. And there are significant changes to the treatment and to the diagnostic algorithms — one for primary care and another for sleep units," Olga Mediano, MD, told Univadis Spain. She is a SEPAR pulmonologist, first author of the ICD, and the coordinator of SEPAR 2022 Year of Intermediate Respiratory Care Units.

Diagnosis in Primary Care

The ICD indicates that all levels of care must be involved in the management of OSA, a condition in which complete or partial upper airway blockage occurs during sleep, causing the individual to stop breathing for a few seconds. These pauses, which produce hypoxia and sleep fragmentation, increase the risk of workplace and traffic accidents, affect cardiovascular health, and contribute to uncontrolled or resistant hypertension.

The recommendations in the ICD aim at increasing the role of primary care physicians so as to reduce underdiagnosis of OSA in primary care. "The vast majority of patients with OSA haven't been diagnosed. In fact, those whom we have diagnosed are the patients with the most severe cases — in other words, patients who present with the most symptoms," said Mediano. She explained that many patients with OSA don't consider it a medical condition, and so they do notgo to the doctor.

"The other big problem is that, before, there was a preconceived notion of the typical OSA patient: a middle-aged obese man who's fallen asleep in the waiting room. However, there are many other profiles: thin build, women.... Sleep has a heterogeneous profile, and all profiles need to be known," said Mediano. The difficulties in carrying out a sleep study with the various patients are an added problem that the new consensus document also seeks to resolve. "The step we've taken is to involve the primary care physician in super-simplified studies to reach more people," she said. For this, the primary care site must work in coordination with a sleep unit.

"In the super-simplified study, the patient is given a machine to use at home; they hook themselves up to it when they go to sleep. This machine records the number of apnea episodes the patient experiences during the night, as well as the oxygen level. The next day, the patient returns the machine. The data are downloaded to a computer. The software analyzes the breathing pauses that the patient had during the night and automatically gives a series of values that, if very pronounced, as the document indicates, would lead to a diagnosis of OSA. Once diagnosed by a primary care physician, the patient is referred to a sleep unit where treatment can then be assessed," explained Mediano.

Different Treatments

The new ICD's approach incorporates therapeutic alternatives, as well. Until now, many consensus documents and clinical guidelines have focused on continuous positive airway pressure therapy, in which a machine delivers continuous airflow to help keep the patient's airway open and unobstructed during sleep. Some guidelines recommend its use, and others do not. "However, in this new document, management of the patient is much more multidisciplinary. What changes, with respect to the treatment, is the philosophy. It's not one single type of treatment; rather, other therapeutic options are kept in mind," said Mediano.

First, treatment of reversible causes of OSA must be offered. The conditions that lead to OSA and that can be reversed are addressed. These include overweight and obesity; heavy drinking; tonsillar hypertrophy, or severe dental or facial alterations, for which surgery can be considered; and gastroesophageal reflux or hypothyroidism, both of which can be treated. "For example, the leading cause of sleep apnea is obesity. If we can get the patient to lose weight, that can end up making the OSA go away. What does the document say? Well, you have to try to implement intensive strategies regarding diet, exercise, etc. And if that's not enough, you need to consider using drugs or even bariatric surgery," said Mediano.

"If there's no one definitive treatment, we highly recommend that all patients implement hygienic-dietary measures and then assess all the therapeutic options. In some cases, several can be in place at the same time," she said. Various medical specialists can play a role in the treatment of OSA, said Mediano. They include otolaryngologists, maxillofacial surgeons, dentists, cardiologists, and neurophysiologists, to mention a few.

A website has been created to explain the ICD. There, visitors will be able to find the most up-to-date version of the ICD as well as related information, news, and materials.

This article was translated from Univadis Spain.

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