F U N D A M E N T A L S 22
Obstructive Sleep
Apnea: Treatment Overview
and Medical Treatments
A number of considerations affect the decision to
treat a patient with obstructive sleep apnea
(OSA) (Figure F22-1). The first category is the
severity of OSA, as based on the apnea-hypopnea
index, severity of arterial oxygen desaturation,
and association with significant arrhythmias.1
The second consideration is the presence or
absence of symptoms. Symptomatic OSA should
always be treated, but the choice of treatment
may vary. Symptoms may not correlate with the
apnea–hypopnea index (AHI), and the dictum
“Treat the patient, not the AHI” should be consid-
ered. The third consideration is the impact of OSA
on the sleep of the patient’s bed partner. Loud
snoring and apnea may cause marital discord and
impair the sleep of the patient’s bed partner.2
The fourth is the potential increased risk of
death or adverse cardiovascular morbidity from
untreated OSA. The evidence for increased risk
is strongest for severe OSA (AHI >30 per hour
[hr]) and in men who are 40 to 70 years of age.3–5
The evidence is less clear for moderate OSA and
for women. However, the presence of certain
comorbid conditions such as coronary artery dis-
ease, cerebrovascular disease, arrhythmias, or con-
gestive heart failure may increase the risk even for
milder degrees of sleep apnea. Given that positive
airway pressure (PAP) treatment is safe and effec-
tive, treatment of patients with moderate and
FIGURE F22-1 n Algorithm to consider if treatment of obstructive sleep apnea is indicated.
260
severe OSA is recommended, even if patients are
asymptomatic.
CHOOSING TREATMENT
The choice of treatment modality is based on the
severity of OSA as well as patient characteristics
and preferences (Table F22-1). Treatment with
PAP (Fundamentals 24 ), surgery (Fundamentals
26) and oral appliances (Fundamentals 27) are
discussed in more detail in these chapters. Prac-
tice parameters on the use of PAP, oral appli-
ances (OAs), upper airway surgery and medical
treatments have been published.6–9 Although
weight loss is included in every category of
OSA severity, it is considered an adjunctive mea-
sure, as it requires time and weight loss mainte-
nance. For mild asymptomatic OSA, observation
may suffice, but patients should be informed that
OSA may worsen with weight gain or increasing
age. The lateral position may be effective for
postural OSA, but long-term studies of effective-
ness have yet to be performed. An OA or upper
airway surgery (uvulopalatopharyngoplasty
[UPPP]) is usually effective for mild OSA. PAP
may also be effective in symptomatic patients
who are motivated. Many patients with mild
OSA will decline surgery, and the absence of
 FUNDAMENTALS 22 OBSTRUCTIVE SLEEP APNEA 261

TABLE F22-1 Treatment of OSA by Severity

Snoring Mild OSA Moderate OSA Severe OSA
AHI 5 TO <15/HOUR 15 TO 30/HOUR >30/HOUR
Primary Observation Observation (Asx) PAP PAP
Treatment Treat nasal Lateral positioning*
congestion Oral appliance
Lateral or
positioning Upper airway surgery-2
Secondary Oral appliance PAP (if symptomatic and Oral appliance Upper airway
Treatment or motivated) or surgery-3
Upper airway Upper Airway or
surgery-1 Surgery-2 Oral appliance
Adjunctive Weight loss Weight loss Weight loss Weight loss
Lateral positioning Lateral Lateral
positioning positioning

AHI, Apnea–hypopnea index; Asx, asymptomatic; OSA; obstructive sleep apnea; PAP, positive airway pressure.
*Postural OSA present.
Upper airway surgery 1: Palatal implants, uvulopalatopharyngoplasty (UPPP), laser-assisted uvuloplasty; Upper airway
surgery 2: UPPP  genioglossus advancement, hyoid myotomy (GAHM); Upper airway surgery 3: Maxillomandibular
advancement (MMA).

reimbursement of OAs by insurance providers
may render this option unacceptable for many
patients. For moderate and severe OSA, PAP is
the treatment of choice. For moderate OSA,
OAs and upper airway surgery are secondary
treatments. Both may be effective in selected
patients, although success is less reliable than
with PAP. However, successful PAP treatment
requires adherence. Surgery such as UPPP is
listed below OA for moderate OSA treatment,
as only about 50% will achieve a significant
improvement by AHI, although a higher per-
centage may have symptomatic improvement.
For severe OSA, tracheostomy reliably bypasses
upper airway obstruction but is not acceptable to
most patients. This procedure is reserved for
patients with very severe OSA, who will not
adhere to PAP when effective treatment is
urgently needed (e.g., recurrent hypercapnic
respiratory failure) and the patient is not a candi-
date for maxillary mandibular advancement.
Complex upper airway surgery such as maxillary
mandibular advancement may be effective in
80% to 90% of patients. An OA may improve
the AHI substantially even in severe OSA,
although rarely to <15/hr. In comparing treat-
ment effectiveness, both efficacy and adherence
must be considered. If PAP reduces the AHI
from 60 to 0/hr but is used only 50% of the night,
the average AHI on treatment is 30/hr.
sleep testing), the physician ordering the study
should discuss the findings and the consequences
of untreated sleep apnea with the patient.1 Factors
that may exacerbate OSA, including weight gain,
insufficient sleep, medications, and alcohol con-
sumption, should also be addressed. Available
treatment options and the pros and cons of each
option should be discussed. Although most
patients look to the physician for ultimate recom-
mendations, involvement of the patient and spouse
in decision making is essential to improve treat-
ment outcomes. Counseling regarding drowsy
driving should be provided and documented.
Many patients have comorbid conditions such as
depression, insomnia, the restless legs syndrome
(RLS), or chronic pain that will make compliance
with PAP or other treatments more difficult.
These problems should be evaluated and treated.
FOLLOW-UP AND OUTCOMES
ASSESSMENT
Following treatment initiation, careful follow-up
is essential because OSA is a chronic disease. A
follow-up sleep study is recommended after
upper airway surgery for moderate to severe
OSA (most would also recommend for mild
OSA) and after final adjustment of an OA as
treatment for all severities of OSA.1,8

PATIENT EDUCATION BEFORE MEDICAL TREATMENT

TREATMENT
The American Academy of Sleep Medicine
Following polysomnography (PSG) or portable (AASM) has published practice parameters for
monitoring (home sleep testing, limited-channel the medical treatment of OSA (see Table F22-1).6
262 FUNDAMENTALS 22 OBSTRUCTIVE SLEEP APNEA
The treatments include weight loss, postural treat-
ment, and modafinil or armodafinil for persistent
daytime sleepiness.
Weight Loss
Obesity is a major risk factor for the development
of OSA. A body mass index (BMI) of 25 to 29.9
kilograms per square meter (kg/m2) is considered
overweight, >30 is obesity, and >40 is severe obe-
sity. In some studies, approximately 70% of
patients with OSA were obese (body weight
>120% of predicted). Peppard and colleagues10
monitored the effects of weight change on AHI.
A 10% weight gain predicted an approximate
32% increase in the AHI. A 10% weight loss pre-
dicted a 26% reduction in the AHI. A 10%
increase in weight was associated with a sixfold
increase in the risk of developing moderate to
severe OSA. Many studies have documented that
weight loss of modest proportions (5%–10% of
body weight) may produce significant improve-
ment in sleep apnea11–13 and decrease upper air-
way collapsibility.14 Even patients with mild
obesity (110%–115% of ideal body weight) may
benefit from weight reduction..
However, the effectiveness of weight loss in
reducing the AHI varies among patients. The
reason may be that a given amount of weight loss
may have more effect on upper body obesity or
upper airway anatomy in one individual than in
another. Weight loss may also be less effective
in reducing the AHI if skeletal abnormalities
BOX F22-1 American Academy of Sleep Medicine Practice Parameter Recommendations
for Medical Treatment of Obstructive Sleep Apnea
WEIGHT REDUCTION
• Successful dietary weight loss may improve the
AHI in obese patients with OSA. (Guideline)
• Dietary weight loss should be combined with pri-
mary treatment of OSA. (Option)
• Bariatric surgery may be adjunctive in treatment of
OSA in obese patients. (Option)
POSITIONAL THERAPIES
• Positional therapy, consisting of a method that
keeps the patient in a nonsupine position, is an
effective secondary therapy or can be a supplement
to primary therapies for OSA in patients who have
a low AHI in the nonsupine versus the supine posi-
tion. (Guideline)
OXYGEN SUPPLEMENTATION
• Oxygen supplementation is not recommended as a
primary treatment for OSA. (Option)
Adapted from Morgenthaler TI, Kapen S, Lee-Chiong T, et al: Practice parameters for the medical therapy of obstructive sleep
apnea, Sleep 29:1031–1035, 2006.
AHI, Apnea-hypopnea index; OSA, obstructive sleep apnea; PAP, positive airway pressure; SSRIs, selective serotonin reuptake
inhibitors.
may play a more prominent role in the pathogen-
esis of OSA in a given patients. The level of nasal
continuous PAP (CPAP) required to maintain
upper airway patency may decrease after weight
reduction. Lettieri and associates15 reported a
reduction in required CPAP from 11.5 to 8.4
centimeters of water (cm H2O) after weight loss
(BMI dropped from 51 to 32 kg/m2) in a group of
patients undergoing bariatric surgery. However,
the magnitude of this effect may vary signifi-
cantly among patients. Behavioral, surgical,
and pharmacologic approaches to weight loss
have all been successful in selected groups of
patients. The major problem, to date, has been
maintenance of weight loss. Techniques have
included a low energy diet12 and life style inter-
vention.13 Bariatric surgery has been proven to
induce weight loss, but many patients have a sig-
nificant amount of residual sleep apnea.16 OSA
may return even if patients maintain their body
weight.17 The AASM practice parameters for
use of medical treatments for OSA recom-
mended that weight loss be combined with a
primary treatment for OSA6 (Box F22-1). This
recommendation is based on the fact that weight
loss takes time, results vary among patients, and
OSA may recur even if initially improved by
weight loss. It was stated that bariatric surgery
may be adjunctive in treatment of OSA in obese
patients. This recommendation falls short of the
recommendation of bariatric surgery as a pri-
mary treatment for OSA given the variable
improvement in the AHI. Patients with OSA
NASAL CORTICOSTEROIDS
• Topical nasal corticosteroids may improve the
AHI in patients with OSA and concurrent rhinitis
and, thus, may be a useful adjunct to primary ther-
apies for OSA. (Guideline)
MODAFINIL, ARMODAFINIL
• Modafinil is recommended for treatment of resid-
ual excessive sleepiness in patients with OSA, who
have sleepiness despite effective PAP treatment
and who are lacking any other identifiable cause
for their sleepiness. (Standard)
OTHER TREATMENTS
• Protriptyline, SSRIs, aminophylline, estrogen
preparations with or without progesterone, and
short-acting decongestants. These treatments are
NOT recommended.
 FUNDAMENTALS 22 OBSTRUCTIVE SLEEP APNEA
undergoing bariatric surgery should be given an
effective treatment (usually CPAP) in the post-
operative period and during weight loss. If a
sleep study after significant weight loss docu-
ments a “cure,” stopping the primary treatment
could be considered. If significant OSA persists,
a lower level of CPAP may be effective.15 If
CPAP or other treatment for OSA is stopped,
patients should be monitored closely for signs
and symptoms of recurrence.
Posture and Positional Treatment
Many patients with OSA have a significant wors-
ening of apnea in the supine position.18–20 Some,
but not all, studies have found an increase in
upper airway size in the lateral position. Changes
in airway shape or size with changes in posture
could be caused by an effect of gravity on the tis-
sue surrounding the upper airway or to posterior
movement of the tongue in the supine position.
Reductions in lung volume in the supine position
may also reduce upper airway size. Recent
studies suggest that on assuming the supine
position, fluid may shift from the lower extrem-
ities into the neck and upper airway producing
narrowing.21
Neill and associates22 found that elevation of
the head by 30 degrees improved airway stability
(compared with the supine position) in patients
with OSA, as measured by airway occlusion dur-
ing sleep. In this study, lateral sleep positioning
had less of a stabilizing effect compared with ele-
vation of the head. This suggested that sleeping
with the head elevated may reduce the AHI more
in some patients than sleeping in the lateral posi-
tion. In the same study, CPAP was also progres-
sively elevated until apneas and hypopneas were
abolished. The mean effective pressure was
10.4 cm H2O in the supine position, 5.3 cm
H2O with the head-elevated position, and
5.5 cm H2O in the lateral position.
A considerable number of patients with a sig-
nificant overall AHI have minimal sleep apnea in
the lateral position. In fact, many of these
patients have chronically favored this position
at home. In one study, approximately 55% of a
large group of patients with sleep apnea had positional
sleep apnea, defined as an AHI at least two times
higher in the supine position than in the nonsupine
position.18
Avoiding the supine posture has been pro-
posed as a treatment for sleep apnea. To main-
tain the lateral posture during sleep, a number
of night shirts or straps with foam balls or cush-
ions are available that prevent comfortable
supine sleep.23–26 A cross-over study compared
CPAP and postural treatment (foam balls in a
backpack) and found that while postural
263
treatment was less effective than CPAP, no differ-
ence could be seen in improvement in the Epworth
Sleepiness Scale (ESS) or sleep architecture.24 Per-
mut and colleagues23 found positional treatment
to be as effective as CPAP, as assessed by one night
of PSG in a group of patients with mild and posi-
tional OSA. McEvoy and associates25 also found a
lower AHI, better oxygen saturation, and better
sleep quality in the seated sleeping posture (60
degrees) compared with the supine position. How-
ever, a study found poor adherence to the “tennis
ball technique.”26 Studies of long-term outcomes
with more comfortable positioning devices are
needed. Recently, devices with the ability to buzz
or vibrate when the patient assumes the supine
position have been developed. The buzzing or
vibration prompts the patient to change to the lat-
eral posture. These devices also measure adher-
ence and snoring.27,28 A method to document
adherence has been a limitation of positioning
devices until recently.
Postural interventions may be used to improve
CPAP treatment. An increase in the required
CPAP pressure to maintain upper airway patency
is commonly required in the supine position com-
pared with the lateral body position.19,20 Oksen-
berg and colleagues19 documented about a 3-cm
H2O difference between the supine and nonsu-
pine postures. As noted previously, Neill and
associates22 noted a significantly less PAP was
needed in the lateral position or with the head ele-
vated. In pressure-intolerant patients undergoing
CPAP treatment, one approach might be to lower
the pressure to one effective in the lateral position
and encourage patients to sleep in that position
(or use a device to discourage supine sleep), at
least during an adaptation period. Nocturnal
oximetry at home, observation of the residual
AHI recorded on the CPAP device, and a combi-
nation of both are methods to document the effi-
cacy of this approach.
Medical Therapies to Improve
Nasal Patency
The AASM practice parameters for medical
treatments6 did not recommend the use of
short-acting nasal decongestants (see Box F22-
1). The major consideration is the development
of rhinitis medicamentosa.29 A study by Kiely
and associates,30 using a placebo-controlled, ran-
domized, cross-over design, found a modest
reduction in the AHI in a group of apneic snorers
with intranasal fluticasone but no reduction in
snoring noise in nonapneic snorers. No improve-
ment was observed in objective sleep quality. Of
interest, the improvement in the AHI was corre-
lated with a reduction in the nasal resistance.
264 FUNDAMENTALS 22 OBSTRUCTIVE SLEEP APNEA
A treatment effect is likely only if intranasal ste-
roids improve nasal resistance, and this change
may not occur in all patients.
Supplemental Oxygen
Supplemental oxygen may improve nocturnal
oxygenation in patients with OSA. In a study
by Smith and coworkers,31 nocturnal supple-
mental oxygen did not improve objective day-
time sleepiness but did improve nocturnal
oxygenation in a group of patients with OSA.
In general, oxygen does not significantly reduce
the AHI or improve daytime sleepiness. Caution
is advised in the use of supplemental oxygen in
hypercapnic OSA patients because some may
develop worsening hypercapnia, especially on
high flow rates of oxygen.32,33 In some studies,
acute administration of oxygen caused prolonga-
tion of apneas.34,35 Supplemental oxygen tends
to convert central and mixed apneas to obstruc-
tive apneas.36 Loredo and colleagues37 compared
oxygen with CPAP in the treatment of OSA.
CPAP improved sleep quality, but supplemental
oxygen improved only nocturnal oxygenation. It
should also be noted that supplemental oxygen
often improves but does not normalize nocturnal
oxygen saturation in patients with severe drops in
the arterial oxygen saturation.32 In summary,
supplemental nocturnal oxygen is not the treat-
ment of choice for OSA, but individual patients
may benefit from this treatment if all other treat-
ment options fail. The AASM practice parame-
ters for medical treatment of OSA state that
supplemental oxygen is not indicated for treat-
ment of OSA.6
Persistent Daytime Sleepiness
on CPAP
A substantial number of patients with OSA con-
tinue to have daytime sleepiness despite adequate
PAP treatment.38–44 In such patients, the first
steps are to document adequate objective PAP
adherence, document effective treatment, and
try sleep extension, if indicated. Other causes
of persistent daytime sleepiness despite PAP
treatment include medications and other sleep
disorders (narcolepsy, periodic limb movement
disorder, idiopathic hypersomnia, depression).
Other sleep disorders should be ruled out, if
clinically indicated. Of note, although some
might assume 6 hours of nightly CPAP adher-
ence to be “good adherence,” in patients with
continued daytime sleepiness, the first step
would be an attempt at sleep extension to 7 hours.
This includes using CPAP during naps. Another
option would be an empirically small increase in
CPAP pressure. Adequacy of pressure should
also be documented because a surprisingly high
percentage of patients remain inadequately trea-
ted.45 Many of the current PAP devices give an
estimate of the residual AHI. However, the esti-
mated AHI is not always accurate. Finally, a
repeat PAP titration may be considered if any
suspicion exists that the current level of CPAP
is not effective. In addition, other factors such
as mouth leak or mask leak could be present that
are causing repeated arousals.
Modafinil, Armodafinil, and
Stimulants
If daytime sleepiness persists on optimized CPAP
treatment and no identifiable additional sleep dis-
order or cause of sleepiness exists, treatment with
an alerting agent (modafinil [Provigil] or armoda-
finil [Nuvigil]) is indicated.6 These medications
have been shown to improve daytime alertness
(subjective and objective) in randomized,
placebo-controlled studies in OSA patients with
residual sleepiness despite adequate PAP treat-
ment.38–44,46 The dosing and side effects of these
medications are discussed in detail in the chapter
on narcolepsy (Fundamentals 33). During treat-
ment with modafinil in patients with OSA, it is
essential to document continued adequate adher-
ence to PAP treatment. In one study evaluating
the addition of modafinil to CPAP treatment,
poorer CPAP use was noted with patients taking
modafinil compared with placebo.39 Patients with
OSA who are adherent to PAP treatment are
sometimes not able to use CPAP for various rea-
sons (e.g., upper respiratory tract infection).
A study by Williams and coworkers43 documen-
ted that use of modafinil did help the patients to
function in this circumstance.
Unfortunately, the addition of modafinil has
minimal or modest benefits in a significant num-
ber of OSA patients who are still sleepy on PAP
treatment. Kingshott and colleagues39 found no
improvement in the ESS or the multiple sleep
latency test (MSLT) with modafinil but did find
an improvement in sleep latency in the mainte-
nance of wakefulness test (MWT). Although
stimulants (methylphenidate, dextroamphet-
amine) are not approved for treatment of persis-
tent sleepiness in OSA by the U.S. Food and
Drug Administration (FDA) or the AASM prac-
tice parameters, individual patients with persis-
tent daytime sleepiness despite adequate PAP
treatment may respond better to stimulants than
to modafinil. If clinically indicated, the possibil-
ity of coexistent narcolepsy should be ruled out.
 FUNDAMENTALS 22 OBSTRUCTIVE SLEEP APNEA
Treatment with stimulants in addition to PAP
could be tried as “off-label treatment” if patients
continue to have disabling sleepiness despite
other measures. They should be educated about
the side effects and risks involved with these
medications. These medications are discussed
in detail in Patient 92.
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PATIENT 45

Patient with OSA and Weight Loss

Patient A: A 30-year-old man with sleep apnea and weight loss—height 5 feet 10 inches weight 230
pounds (lb), body mass index (BMI) 34 kilograms per square meters (kg/m2)—was diagnosed as having
severe obstructive sleep apnea (OSA) (apnea–hypopnea index [AHI] 60 per hour [hr]). He underwent a
continuous positive airway pressure (CPAP) titration, and on CPAP of 12 centimeters of water (cm
H2O), the AHI was 5/hr. Following CPAP treatment, he had a rapid resolution of symptoms. However,
he found CPAP unacceptable for his social life and began a dietary weight loss program. After 6 months,
he weighed 200 lb and stopped using his CPAP. He reported that he did not snore and that his symptoms
of sleepiness had not returned. He underwent repeat polysomnography (PSG) (Table P45-1).

TABLE P45-1 Effect of Weight Loss

Repeat PSG after
Baseline CPAP Titration Weight Loss
Weight lbs 230 230 200
CPAP (cm H2O) None 12 None
AHI no./hr 70 5 5
AHIsupine #/hr 50 n/a (no supine sleep) 25
AHInonsupine #/hr 45 5 0

AHI, Apnea–hypopnea index; CPAP, continuous positive airway pressure; hr, hour; n/a, not applicable; no sleep in this
position recorded; PSG, polysomnography.