Treatment of Sleep Apnea: To Cut May Not Always Be To Cure

How effective is upper airway surgery in treating obstructive sleep apnea?

The fallout from the growing obesity epidemic includes obstructive sleep apnea (OSA) syndrome. Although OSA may be considered a "specialty disease" (managed by pulmonologists, sleep specialists, otolaryngologists, and bariatric surgeons), the primary care physician bears the brunt of providing ongoing care. This chronic disease is associated with multiple comorbidities (eg, heart failure and hypertension).

After OSA is diagnosed, treatment options include continuous positive airway pressure (CPAP), control of weight and alcohol intake, and surgery. The specific surgical procedure for OSA, uvulopalatopharyngoplasty, removes potentially obstructive airway tissue that can hamper breathing. This tissue comprises the uvula and parts of the palate and pharynx. A number of questions arise when physicians are confronted with OSA. Should certain treatments, such as CPAP, be implemented before others (eg, bariatric or airway surgery) or should they be used in combination? Is surgery a first or last resort? A recent paper addresses these questions.

WHAT THE DATA SHOW
Elshaug and coworkers¹ performed an extensive review to assess the benefits and risks of upper airway surgery for OSA. They searched Medline, the Cochrane Library, and the International Health Technology Assessment Database. As an example of their findings, none of 5 systematic reviews (including 2 performed by the authors themselves) demonstrated a clear benefit for surgery as an OSA treatment. These were "robust" trials: one contained a total of 412 patients followed up postoperatively by polysomnography in order to obtain objective evidence of improvement. Other studies have also suggested that limited benefits accrue from surgery. In fact, one review of more than 20,000 patients found that adverse events occurred in about 60% of those who underwent airway surgery. Many of the patients later regretted having the surgery.²

However, some patients (those younger than 40 years of age, with a body mass index of less than 40 and an apnea-hypopnea index of less than 40 measured by polysomnography) are still prime candidates for surgical intervention because they have better outcomes than with nonsurgical therapy. Also, some patients who are not cured of OSA by surgery nonetheless benefit from lower CPAP pressures after the procedure.²IMPLICATIONS FOR YOUR PRACTICE
Surgery is not first-line therapy for all persons with OSA and should perhaps be limited to a more select population. Certain patients will not be cured of OSA with surgery, but their condition may improve and the CPAP pressure can then be lowered. Thus, when patients ask whether they should have surgery or try an alternate route (CPAP), you can offer in select instances an answer that combines both caution and optimism.

References:

REFERENCES:

1.

Elshaug AG, Moss JR, Hiller JE, Maddern GJ. Upper airway surgery should not be first line treatment for obstructive sleep apnea in adults. BMJ. 2008;336:44-45.

2.

Gever J. Surgery disparaged as first-line treatment for sleep apnea. Available at:

http://www.medpagetoday.com/Pulmonary/SleepDisorders/tb/7845

. Accessed January 7, 2008.