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Challenges of Treating OSA

Providers face several hurdles in caring for patients with obstructive sleep apnea.

Many are the hurdles associated with obstructive sleep apnea (OSA). It is only by recognizing them head-on that sleep providers can ferret out strategies and solutions, which indeed include educating other providers of the sheer numbers and dangers associated with OSA. Here are five of the challenges we must confront in order to bring about better outcomes for patients with OSA.

Challenge 1: Recognition of OSA 
About 25% of middle age males have apneas and  hypopneas five  times per hour of sleep. (The statistic is about half that number in females.) Prevalence of apneas and hypopneas associated with consequences = OSA syndrome; 4% to 5% in males and 2% in females. The sad fact remains that there far are more people undiagnosed with OSA than are actually diagnosed.

Sleep professionals must remain vigilant and at the front of the charge to address the unmet need to recognize those who have OSA-a potentially fatal disease.

Complications of OSA Include hypertension, coronary artery disease including heart attacks and sudden death, arrhythmias especially atrial fibrillation, strokes, uncontrolled diabetes, severe daytime sleepiness with consequences such as motor accidents (three  times greater than in those without OSA), cognitive effects (e.g., misdiagnosed with depression but also memory issues, poor concentration, irritability, etc.), economic impact (decreased productivity) and even higher divorce rate in OSA patients.

Challenge 2: Patient Compliance
Most challenging to good outcomes is the ability to educate a patient to fully accept the impact that OSA can have on their health. Only when a patient truly "gets it" can enhanced compliance with therapy be achieved. It's easier for patients to adhere to compliance when they can appreciate the impact of CPAP on how they especially the relief of excessive daytime sleepiness (EDS).  Some patients have severe OSA but do not feel sleepy, yet the risk of cardiovascular and other complications remains. In these patients compliance may be more difficult to attain so patient education and explanation of the health impact of OSA is critical.

SEE ALSO: First Sleep Apnea App

Also critical to compliance is close attention to detail at the time of CPAP set up and careful follow-up to ensure interface comfort. Several strategies are available to enhance compliance and in this regard a highly skilled therapist/technician knowledgeable in this area is vital. An empathetic patient approach needs to be part of the therapist's attitude, especially in dealing with the elderly patient who may need more TLC in acclimating to a therapy with which he/she is completely unfamiliar.

A team effort involving patient, physician and therapist is crucial. It is therefore equally crucial to carefully select a DME company which will not only initiate PAP therapy, but also will continue to follow the patient. I am completely opposed to the all-too-familiar situation where an out-of-state DME company assumes the role of the provider of services. Sometime this is insurance (third party payer) driven, but at other times it may occur when a local company goes out of business or is no longer a Medicare-approved supplier. Suddenly, a sleep center receives a request to sign an order allowing the new vendor (usually out of state) to be the new supplier of PAP equipment and supplies. It is a situation to be avoided when possible.

Challenge 3: Out-of-Center Sleep Testing (OCST)
OCST is now an accepted diagnostic test for OSA, and while it has earned a definite place in the workup of OSA, it must be used intelligently and only after a full sleep history.  The problem I observe is that OCST often underestimates the severity of OSA (which in turn may result in under treatment) and poor data capture. Further, OCST may miss some sleep disorders, such as PLMS.

There are two related issues that rear their problematic heads: (a) third-party payers often will insist in OCST even when a sleep specialist feels PSG or a split night study in the lab is in the best interest of the patients; and (b) primary care physicians (PCPs) are encouraged to incorporate OCST into their practices (by independent vendors) and they may then reflexively prescribe auto-PAP for patients without considering alternative treatments (e.g. an oral appliance) or additional important issues (e.g., severe hypoxemia should mandate a lab titration to ensure normal oxygenation. Presence of central apneas, even if the minority of events may result in CPAP-induced central sleep apnea,  should mandate a lab titration, while severely obese patients may need BiPAP.)

Sleep medicine professionals must deliver the message to third-party payers that there are situations where a lab test is preferable even in patients who, in their opinion, meet criteria for using OCST. Furthermore, they must educate PCPs about making appropriate referrals following diagnosis for long-term care by a sleep specialist. Such orders should not be ignored.

Challenge 4: Alternative Treatments
Treatment for moderate and severe OSA, or even for milder OSA with significant sequelae (e.g., sleepy driving) or co-morbidities (e.g., HT, A Fib, CAD, CVA) should be PAP therapy. Every effort should be made to ensure compliance (see above).

There will be patients who, despite such attempts, still can't tolerate PAP treatment. Alternative surgical approaches would include palatal surgery (but overall success is only 40-50%), base of tongue procedures or mandibular advancement procedures (maxillary-mandibular advancement carries 90% success rate but surgery is extensive and reserved for severe OSA in patients intolerant of PAP therapy).

Non-surgical alternatives to CPAP include oral/dental appliances to advance the tongue or mandible, (there are dentists certified by the American Academy of Dental Sleep Medicine with special proficiency in fitting OAs for OSA), nasal valves (which I personally have not found to be particularly effective), and the most recent innovation: transcutaneous submental electrical stimulation of the genioglossus muscle (Inspire) whereby a power generator is implanted under the skin with electrodes implanted into the genioglossus muscle and with a second breathing sensor lead. There are specific patient phenotypes for which this form of treatment is indicated.

Weight reduction remains a major challenge, but can be very successfully overcome. It may be worth considering incorporating a dietician into the sleep practice. Bariatric surgery may need to be considered.

Challenge 5: From My Soapbox
Sleep medicine professionals are challenged to encourage PCPs to routinely evaluate for OSA, but especially in the high-risk groups e.g. those with a history of CHF or CAD. Asking a few simple questions: Do you snore? Do you wake gasping or choking at night? Has anyone noted you quit breathing in your sleep? Are you tired/sleepy fatigued in the day? Obesity and a neck size greater than 17 inches in men and greater than 16 inches in women add to the predictability. Utilizing the STOP-BANG screening protocol and the Epworth Sleepiness Scale should be routine.

Subspecialists who may encounter high risk patients should ask the same questions and use the same screening tools. These would include cardiologists, orthopedists (for example in their obese patients needing hip or knee surgery), anesthesiologists, psychiatrists whose patients remain depressed on anti-depressants or nephrologists who encounter patients with difficult-to-control hypertension. Urologists whose patients have unexplained nocturia (i.e. no BPH) should consider OSA as the cause.

We also need to make professionals aware of other sleep disorders, e.g. narcolepsy, restless leg syndrome and shift work disorder and to screen for these conditions. They should also utilize sleep specialists to assist in diagnosis and management. Sleep specialists in turn should be available (e.g. by email or cell phone) to discuss problem patients and give advice. Such cooperative and reciprocal efforts often result in better utilization of services.

Dr. David E. Westerman is medical director, Northside Hospital Sleep Disorders Center, Atlanta.

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