Treatment of OSA: What (else) can it accomplish?
Treatment of obstructive sleep apnea improves daytime sleepiness, but does it improve other outcomes?
PRACTICE RECOMMENDATIONS
› Treat patients with symptomatic obstructive sleep apnea (OSA) with positive airway pressure (PAP) or oral appliances to reduce daytime sleepiness, improve quality-of-life scores, and modestly reduce blood pressure in patients with hypertension. A
› Consider recommending at least 4 hours of PAP every night for asymptomatic patients (those without daytime sleepiness) with severe OSA and other conditions, including resistant hypertension, atrial fibrillation, congestive heart failure, cognitive impairment, obesity, and stroke. B
› Do not screen asymptomatic patients for OSA. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
A Danish registry documented that patients treated with CPAP had higher rates of comorbidities before and during treatment; when these comorbidities were controlled, men ages ≥ 60 years had improved survival when treated with CPAP. There was no survival benefit in women.41
A recent analysis—the Sleep Heart Health Study—followed patients with obesity and severe OSA for a mean of 11.1 years and calculated a hazard ratio for all-cause mortality associated with prescribed PAP therapy of 0.58 (95% confidence interval [CI], 0.35-0.96) after propensity matching.42 The difference in mortality appeared 6 to 7 years after PAP therapy was prescribed. This delay may explain the failure of shorter-term studies to demonstrate evidence of benefit.
OSA Tx reduces motor vehicle crashes
Drowsy driving is widely accepted as a risk for motor vehicle crashes. Successful treatment of OSA with PAP has been shown to improve driving performance on a driving simulator.43 An analysis of 15 studies similarly demonstrated a significant reduction in driving accidents (incident rate ratio [IRR] = 0.45) and in near-miss accidents (IRR = 0.23) in patients with OSA treated with CPAP.44
Pulmonary hypertension: OSA Tx lowers pulmonary arterial pressure
Patients with OSA have higher than expected rates of pulmonary arterial hypertension—as high as 22%—documented by pulmonary artery catheterization findings.45 A meta-analysis of studies that examined the effect of PAP in patients with OSA and coexisting pulmonary hypertension but without other overt pulmonary or cardiac disease found significant reductions in pulmonary artery pressure.46 Whether this finding translates into improved patient-oriented outcomes is unknown.
OSA and pregnancy outcomes
A national cohort study demonstrated that OSA is an independent risk factor for multiple adverse pregnancy outcomes, including gestational diabetes, hypertensive disorders in pregnancy, intrauterine growth retardation, and stillbirth.7 OSA was also associated with the rare serious adverse outcomes of congestive heart failure, cardiomyopathy, and pulmonary embolism.7 There is little evidence to date with which to determine whether treatment of OSA improves outcomes, but PAP treatment is documented to be safe in pregnant women.8
CORRESPONDENCE
Stephen C. Sorsby, MD, MHA, University of Arkansas for Medical Sciences, 4301 West Markham, Slot 530, Little Rock, AR 72205; SCSorsby@uams.edu.
