Philippine Clinical Practice Guidelines on the Diagnosis

and Management of OSA in Adults (2015)

Philippine Society of Sleep Medicine (PSSM)

Philippine College of Chest Physicians Council of Sleep Medicine
(PCCP)
Philippine Academy of Sleep Surgeons

Diego A Estigoy, MD
Year II Pulmonary Fellow
SUMMARY OF RESEARCH QUESTIONS
ADDRESSED
 Index case
• 33/M
• Single
• Quezon City
• Physician

• Chief complaint: Loud snoring for 10

years
History of present illness
• > 10 Years
• Loud snoring
• Witnessed apnea and choking during sleep
• Un-refreshing sleep
• Excessive daytime sleepiness
• Decreased concentration and forgetfulness
• No episodes of falling asleep at red traffic lights
• Has not been involved in any road accidents because of falling asleep
while driving
Sleep schedule and sleep hygience
• Goes to bed at 12AM and wakes up at 6AM
• Takes 10 minutes to fall asleep without medications
• Does not wake up at night
• Does shift work (24hours duty every 3 days)
• 30-minute naps during the day

• No cataplexy
• No sleep paralysis
• No vivid dreams
• No restless legs

• ESS: 9/24
• STOPBANG: 4
Medical history
• Not known hypertensive and diabetic
• No asthma, allergic rhinitis or history of PTB treatment
• No GERD
• No surgeries to nose, throat or jaw

• FAMILY HISTORY
• Hypertension, Type 2 DM
• Breast and Colon Cancer
• Sibling and father: loud snorer
• No relative diagnosed with sleep apnea
Social history
• Occasional alcoholic beverage drinker
• Non-smoker
• Drinks 1 cup of coffee and cola per day occasionally
Physical examination
• BP 120/80 mmHg
• HR 92 bpm, regular rhythm
• RR 18 cpm, O2 sat 98% at room air

• Height: 175 cm; Height: 85 kg

• BMI: 27.7 kg/m2
• Neck circumference: 40 cm (15.7 in)
• No goiter
• Mallampati IV
• (+) Overbite
• (+) Micrognathia
Assessment

• T/c Obstructive Sleep

Apnea
 Polysomnogram
• AHI 26.4 (Moderate)
• Lowest O2 sat: 89%
• (+) snoring
SLEEP ARCHITECTURE DIAGNOSTIC THERAPEUTIC
Sleep onset 4.1 minutes 1.5 minutes
REM absent 33 minutes
TST 116 minutes 359 minutes
Efficiency 54 % 85.07 %
Lowest oxygen 89% 95%
Snoring present No snoring
RDI 26.4/hour 1.3/hour
Final diagnosis

• Obstructive Sleep Apnea,

Moderate
• Improved with CPAP 10
cm H2O
 Discussion
I. Definition
II. Epidemiology
III. Pathophysiology
IV. CPG
A. SCREENING
B. DIAGNOSIS
C. MANAGEMENT
A breathing disorder characterized
by narrowing of the upper airway
that impairs normal ventilation
during sleep
• The prevalence of OSA in North America has
been estimated to be 15% of men and 5% of
women
• Global estimates suggest rates of 936 million
people worldwide with mild to severe OSA, and
425 million people worldwide with moderate to
severe OSA, between the ages of 30 and 69 years.
• Prevalence of OSA in Asia is similar to that in the
US, despite lower rates of obesity.
• No prevalence data for OSA in the Philippines
• Extrapolated prevalence is approximately 3.8M
• The prevalence appears to be increasing and may
relate to the increasing rates of obesity or
increased detection rates of OSA
Pathophysiology
Pathophysiology
 WHEN SHOULD OSA BE SUSPECTED?
• OSA should be suspected in
patients with witnessed apneas,
chronic snoring, and excessive
daytime sleepiness not explained
by other factors.
• Presence of risk factors such as
obesity, diabetes, dyslipidemia
and hypertension along with the
triad strengthens the suspicion of
OSA.
• Physical findings suspicious for
OSA include obesity, increased
neck circumference, and
narrowed pharyngeal airway
 Clinical Triad

A. CHRONIC SNORING
Greatest sensitivity
30-50% of adults above 50 years old
Not enough to carry out sleep sleep test
B. WITNESSED APNEAS
Greatest specificity
C. EXCESSIVE DAYTIME SLEEPINESS
Marks the clinical intensity of OSA
OSA symptom most responsive to
treatment
Its presence is sufficient to carry out
sleep test
 Patients at High Risk for Obstructive Sleep Apnea (OSA) who must be Evaluated for OSA

Symptoms

• (Morbid) Obesity (BMI ≥30)

• Congestive heart failure or cardiac insufficiency
• Refractory hypertension
• Type 2 Diabetes Mellitus
• Nocturnal dysrhythmias or atrial fibrillation
• Stroke
• Pulmonary hypertension
• Individuals at high risk for accidents such as long haul drivers, pilots
• Preoperative for bariatric surgery
• Chronic respiratory diseases with greater hypoxemia or hypercarbia deterioration
than (clinically) expected
 RISK FACTORS
• Older age
• Male sex
• Obesity
• Craniofacial and upper
airway abnormalities
• Smoking
• Family history of snoring
or OSA
• Nasal congestion
Physical findings suggestive of OSA
• Increased neck circumference (M: >17 in., F >16)
• BMI ≥ 30 (*BMI ≥ 27.5 for Asians)
• modified Mallampati score of 3 or 4
• Retrognathia
• lateral peritonsillar narrowing
• Macroglossia
• Tonsillar hypertrophy/ elongated/enlarged uvula
• High arched/narrow hard palate
• Overjet
• Nasal abnormalities such as septal deviation, nasal polyps, congestion or enlargement of
turbinates
 SCREENING
WHEN SHOULD WE SCREEN FOR OSA? • Because they poses or considered as commercial
populations where OSA poses a public health hazard
• Routine health maintenance evaluation
• Pre-operative evaluation
• PUV drivers, long haul drivers, pilots

Questions about OSA that should be included in Routine

Health Maintenance Evaluation:
• Is the patient obese?
• Is the patient retrognathic?
• Does the patient complain of daytime sleepiness?
• Does the patient snore?
• Does the patient have hypertension?
 SCREENING
WHAT IS THE UTILITY OF QUESTIONNAIRES AND
CLINICAL PREDICTION RULES FOR THE
DIAGNOSIS OF OSA?
• Use to screen patients for further testing for
OSA.
• No single questionnaire/physical finding can
be used to diagnose OSA.
• Ruling out OSA than for ruling in the
diagnosis.
• Use to identify those with low likelihood in
whom PSG should be avoided or those with
high likelihood of disease who will require
full nocturnal PSG
As far as QUESTIONNAIRES AND CLINICAL
PREDICTION RULES FOR THE DIAGNOSIS OF
OSA is concern,.
• No questionnaire or PE finding can be
used to diagnose OSA. Hence, aggregation
of signs and symptoms using clinical
questionnaires or prediction rules may be
helpful in screening those suspected with
OSA.
• For the most part, clinical questionnaires
are more useful for ruling out OSA than
for ruling in the diagnosis.
Questionnaires
• BERLIN QUESTIONNNAIRE
• Snoring, non-restorative sleep, sleepiness
while driving, apneas during sleep, Different questionnaires have different
hypertension, and BMI intents and use:
• Predicting the risk for OSA ξ The Berlin Questionnaire may be
used in predicting risk for OSA
• High risk: ≥ 2 ξ The STOP questionnaire and
its extended version, the
STOP-Bang may be used for
OSA screening in surgical
• STOP-BANG patients
ξ The Epworth Sleepiness Scale
• Screening OSA in surgical patients (ESS) may be used for
• Snoring, Tiredness, Observed apneas, blood monitoring symptoms of
excessive daytime
Pressure sleepiness.
• BMI, Age, Neck circumference, Gender (male)
• High risk: ≥ 3
 Diagnosis
The diagnosis of OSA cannot be made based on
• Attended, in-laboratory compatible clinical signs or symptoms
polysomnogram The diagnosis can only be made with certainty using
polysomnography

- Gold standard The presence of OSA must be confirmed and its severity
determined before initiating treatment.

• PSG should be done either

overnight or during the subject’s
usual sleep schedule
• No less than 6.5 hours including at
least 3 hours of sleep
Polysomnography
Polysomnography generally includes monitoring of the following:
electroencephalogram (EEG), electro-oculogram (EOG), chin
electromyogram, airflow, oxygen saturation, respiratory effort,
electrocardiogram (ECG), and limb movements.

An attended study requires the constant presence of a trained individual

who can monitor for technical adequacy, patient compliance, and relevant
patient behavior.

The PSG (compared to PM) provides the most comprehensive information

needed to make the diagnosis of OSA to reliably distinguish between the
various sleep stages; to compute for the frequency of respiratory events
during sleep (the so-called AHI or apnea-hypopnea index); to assess the
quality and continuity of sleep; and also to rule out the presence of other
sleep disorders.
 Diagnosis
The use of Portable Monitors (PM) (at
least type 3) is recommended as an
alternative to Polysomnography for
diagnostic testing in patients
suspected of OSA provided all of the
following conditions are met:
• High risk for moderate to severe
OSA
• Absence of serious co-morbidities
such as congestive heart failure,
COPD, restrictive lung disease
• Other sleep disorders are not a
consideration
• With a prior comprehensive sleep
evaluation by a sleep specialist
The issue is The Respiratory disturbance index (RDI)
has been defined differently when used with portable
monitors. In the standard PSG, RDI is defined as apnea
+hypopnea/total sleep time while the RDI in the PM is the
number of apneas + hypopneas /total recording time.iv As
a result, portable monitors are likely to underestimate
the severity of respiratory events compared with
PSG. The other disadvantages of PM include its inability
to evaluate the quality of sleep, and other non-respiratory
sleep disorders.
However, PM testing may be used for the diagnosis of
OSA in patients for whom in-laboratory PSG is not
possible due to immobility, safety or critical illness and to
monitor response to non-CPAP therapies
 Diagnosis
The following are NOT RECOMMENDED to diagnose OSA:
• Type 4 Portable Monitors
• Overnight oximetry
• Auto-titrating Positive Airway Pressure (APAP)
• Multiple Sleep Latency Test (MSLT)
• Actigraphy
 SLEEP STUDIES
TYPE 1 TYPE 2 TYPE 3 TYPE 4
Continuous
Standard PSG- PM for sleep
Description Standard PSG single or dual
research apnea
bio-parameter
Minimum 7 Minimum 7 Minimum 4 Minimum one
Measures
channels channels channels channel
The American Academy of Sleep Medicine
(AASM) classifies sleep studies into 4 types
Body Position Measured Can measure Can measure Not measured Type I monitors are facility-based PSG
overseen by a technician. The rest,. type 2 3
Leg and 4,. all are unattended
Measured Measured Can measure Not measured Type 2 monitors are portable, measure most
Movement of the same channels as type I and can
differentiate between sleep and awake states
Personnel Attended Unattended Unattended Unattended but with no technician present.
Type 3 monitors also measure at least 2
respiratory channels but cannot reliably
distinguish between sleep and awake states.
Type 4 monitors are super simplified studies
with a 1-2 channel apparatus
 Diagnosis
CRITERIA FOR THE DIAGNOSIS OF OSA

• Using the gold standard of POLYSOMNOGRAPHY:

• Greater than 5 obstructive events per hour (apneas, hypopneas, and respiratory event
related arousals) plus any of the following:
Sleepiness, Non-restorative sleep, Fatigue, Insomnia, wakes up with breath holding, gasping, or
choking, Habitual loud snoring, Breathing interruptions, or both during the patient’s sleep
Or one or more of these conditions: hypertension, T2DM, CHF or CAD, has AF, stroke, mood
disorder, or cognitive dysfunction OR

• Greater than 15 events/hour even in the absence of sleep related symptoms.

 RESPIRATORY EVENTS
APNEA
• Drop in the peak signal excursion by ≥ 90% of pre-event baseline + ≥ 10 seconds
• No minimum desaturation or microarousal requirement for scoring of an apnea

HYPOPNEA meets ALL of the ff criteria:

• Peak signal excursions drop ≥ 30% of pre-event baseline
• Duration of the ≥ 30% drop in signal excursion is ≥ 10 seconds
• ≥ 3% oxygen desaturation from pre-event baseline or the event is associated with an
arousal

RESPIRATORY EFFORT RELATED AROUSAL (RERA)

• sequence of breaths lasting ≥ 10 seconds that does not meet criteria for apnea or hypopnea,
characterized by increasing respiratory effort leading to arousal from sleep
RESPIRATORY EVENTS
So these are what the Respiratory events waves looks like..

APNEA

Drop in the peak signal excursion by ≥ 90% of pre-event

baseline + ≥ 10 seconds

HYPOPNEA

Peak signal excursions drop ≥ 30% of pre-event baseline

by ≥ 10 seconds plus

≥ 3% oxygen desaturation from pre-event baseline or the

event is associated with an arousal

Respiratory Effort-Related Arousal (RERA)

sequence of breaths lasting ≥ 10 seconds that does not

meet

criteria for apnea or hypopnea, characterized by increasing

respiratory effort leading to arousal from sleep

Obstructive, if there is continued or increasing respiratory

effort throughout the event
Central, if effort is absent throughout the entire event
Mixed, if effort is initially absent, then resumes in the latter
part of the event
 Diagnosis
WHAT IS THE SEVERITY CLASSIFICATION FOR OSA?

𝑹𝒆𝒔𝒑𝒊𝑫𝒊𝒔𝒕𝒖𝒓𝒃𝒂𝒏𝒄𝒆𝑰𝒏𝒅𝒆𝒙 = (𝐴𝑝𝑛𝑒𝑎 + 𝐻𝑦𝑝𝑜𝑝𝑛𝑒𝑎 + 𝑅𝐸𝑅𝐴)/𝑇𝑜𝑡𝑎𝑙𝑆𝑙𝑒𝑒𝑝𝑇𝑖𝑚𝑒

𝑨𝒑𝒏𝒆𝒂 − 𝑯𝒚𝒑𝒐𝒑𝒏𝒆𝒂𝑰𝒏𝒅𝒆𝒙 = (𝐴𝑝𝑛𝑒𝑎 + 𝐻𝑦𝑝𝑜𝑝𝑛𝑒𝑎)/𝑇𝑜𝑡𝑎𝑙𝑆𝑙𝑒𝑒𝑝𝑇𝑖𝑚𝑒
• MILD: RDI/AHI 5-14/hour
• MODERATE: RDI/AHI 15-30/hour
• SEVERE: RDI/AHI > 30/hour

vThe severity classification similar to the diagnostic cut-offs for OSA is

recommended by the International Classification of Sleep Disorders (ICSD)
and is generally used by all the sleep societies worldwide.
WHAT ARE THE INDICATIONS FOR
DOING FOLLOW-UP PSG?
• For assessment of treatment
results after surgical treatment
for moderate to severe OSA
• To assess treatment result on
CPAP after substantial weight
loss (10% of body weight);
substantial weight gain with
return of symptoms while on
CPAP
• When clinical response is
insufficient or when symptoms
recur despite good initial
response to CPAP.
Follow-up PSG is not routinely indicated in patients
treated with CPAP whose symptoms continue to be
resolved with treatment.
• However there are situations where in Follow up PSG is
indicated..
• For assessment of treatment results after surgical
procedure
• for moderate to severe OSA
• To assess treatment result on CPAP after
substantial weight loss or substantial weight gain
with return of symptoms while on CPAP
• When clinical response is insufficient or when
symptoms recur despite good initial response to
CPAP.
 Management
WHAT IS THE PRIMARY TREATMENT FOR
OBSTRUCTIVE SLEEP APNEA IN ADULTS?

• CPAP at a fixed pressure is the

standard initial treatment of choice
for OSA in adults. It is strongly
recommended for moderate to
severe OSA and recommended only
for mild OSA.
• CPAP should be used for at least 4
hours during sleep daily for optimal
benefits.
 Management
WHEN SHOULD OSA BE MANAGED?
• Management using a
multidisciplinary approach should
commence once the diagnosis and
severity classification of OSA has
been established.

Team:
• Sleep specialist
• Allied healthcare (dentist,
respiratory therapist, sleep
technician, nursing personnel)
 Management
WHAT ARE THE GOALS OF THERAPY FOR OSA?
1. To improve symptoms (excessive sleepiness,
concentration, snoring), quality of life and sexual intimacy.
2. To decrease AHI to <5 events/hour with no
desaturations nor arousals
3. Improvement of associated comorbidities such as
hypertension, arrhythmia, heart failure, stroke, and
hyperglycemia
4. To prevent or minimize the risk for cardiovascular
events and traffic accidents
 CPAP

The rationale for using PAP in OSA is that it provides pneumatic splinting of the
upper airway and is effective in reducing AHI.
As you can see in this illustration, air entry is compromised in patient with OSA
without PAP,. compared with CPAP,. there is now improvement of air entry..
 Benefits of CPAP use
• Associated with modest but significant
reductions in diurnal and nocturnal
SBP and DBP
• Improves LV ejection fraction among
patients with OSA and heart failure
• 42% reduction in recurrence of atrial
fibrillation
• Reduces the risk of fatal and non-fatal
cardiovascular events
• Improved insulin sensitivity
• Improved intimate and sexual
relationships (severe OSA)
• Improved driver performance
 MILD OSA
Conservative or medical
management
• Weight loss
• Positional therapy
• Nasal corticosteroids (allergic
rhinitis)
• Dental appliance,Mandibular
advancement device or splint,
position appliance
• Surgery
(Uvulopalatopharyngoplasty)
• CPAP > Dental appliance > Surgery
 Management
WHAT MEASURES CAN BE USED TO INCREASE CPAP COMPLIANCE?
1. the addition of heated humidifaction - decreased the occurrence
of upper airway symptoms (dry throat and nose)
2. Use of BIPAP is an option in CPAP-intolerant patients - Alleviate
discomfort of exhaling against a fixed pressure
3. Pressure waveform modification technologies (ie. pressure
relief) - Reduces pressure on exhalation

vGenerally, most studies have considered good adherence as use

of the device for a minimum number of hours per night (approx 4
hours in the literature) for 70% of the nights of the week.
 Management
WHAT IS THE ROLE OF AUTO-TITRATING CPAP (APAP) IN THE
MANAGEMENT OF OSA?

• Auto-titrating CPAP is recommended as an alternative

treatment to fixed CPAP for OSA in patients who are
poorly tolerant of fixed CPAP, and those with
position-related and REM-related OSA.
• Caution on its use must be exercised among those
with chronic cardiopulmonary disease (ie COPD,
restrictive chest disorders, congestive heart failure)
because there are no studies on these populations.
 Management
CAN AUTO-TITRATING APAP use to determine a fixed CPAP pressure
CPAP (APAP) BE USED is currently not recommended since studies
are few and have not consistently shown
IN DETERMINING that APAP is equivalent to the standard
CPAP PRESSURE IN titration.
LIEU OF FORMAL AASM recommends that certain APAP devices
CPAP TITRATION? may be used during attended titration with
polysomnography to identify a single
pressure for use with standard CPAP for
• Not recommended treatment of moderate to severe OSA.
 Management
WHAT IS THE ROLE OF THE FOLLOWING INTERVENTIONS FOR THE
MANAGEMENT OF OSA?

1. Behavioral and Lifestyle Modifications

• All overweight and obese patients diagnosed with OSA should be
encouraged to lose weight as medically supervised weight loss
may improve the AHI.
Ø10% weight loss = 26% decrease in AHI
Ø10% weight gain = 32% increase in AHI
• Alcohol intake and routine use of sedatives among patients with
OSA is discouraged.
 Management
Positional Therapy
• Strategies that keep the patient in a non-supine position can be used as adjunctive
treatment for positional OSA.
• Tennis ball, vests, positional alarms, verbal instruction and (orthopedic) pillows
• Moderate reduction in AHI but inferior to CPAP
• Long-term compliance is poor

Oxygen Therapy
• Not recommended as a sole treatment for OSA.
• Prolong apnea duration
• Increase the severity of hypercarbia and acidosis
• Minimal to no effect on blood pressure and daytime sleepiness
 Management
Pharmacologic
Therapy
• There is no
accepted
pharmacological
treatment for OSA.
• Address other
comorbidites
 Oral appliance therapy
• The use of prefabricated non-custom,
non-titratable oral appliance for OSA is
not recommended.
• The decision to use custom fitted
titratable oral appliance must be made
by a sleep specialist in conjunction
with a dentist trained in sleep
medicine.
• Protrude and help stabilize the
mandible in order to maintain a patent
upper airway during sleep
• Most effective in mild to moderate OSA
• Treatment alternative for patients with
severe OSA
• Prescribed and fitted by a dentist who
has sleep medicine experience
 Management
Other Treatment Options (unproven
therapies)
Nasal sprays, nasal strips and nose clips.
anti-snore” clothing or pillows
Buteyko breathing exercise
• Developed by Russian physician Dr
Konstantin Buteyko
• Breathing exercises is specifically aimed at
treating hyperventilation
• Some evidence of efficacy in asthma;
currently not recommended due to limited
clinical data on the use of this technique
for OSA.
 Management
WHEN IS SURGERY INDICATED FOR OSA?

• Generally, surgery is not recommended for

OSA.
• Recommendation to perform surgery must
be made by multidisciplinary team which
includes the referring physician, sleep
specialist, and a qualified surgeon.
• Site-directed surgical treatment may be
used as primary intervention when the site
of obstruction can be excised or corrected
surgically
Ø Enlarged tonsils — Tonsillectomy
Ø Nasal obstruction — straightening deviated
septum, reducing enlarged turbinates or
removal of nasal polyps
 Management

WHICH PATIENTS REQUIRE URGENT TREATMENT FOR OSA?

• Any patient with known or suspected OSA with

severe/unstable comorbid conditions may benefit from
a referral to a sleep specialist for evaluation and/or
possible initiation of CPAP or NIV

• Among patients with suspected OSA, a definitive PSG is

recommended after stabilization of co-morbid condition
to confirm the diagnosis of OSA.
CTS guidelines recommend laboratory evaluation must be done within 4 weeks for patients with unstable or severe co morbid conditions
 Follow-up evaluation
• Resolution of sleepiness
• OSA specific quality of life measures
• Patient and spousal satisfaction
• Adherence to therapy
• Avoidance of factors worsening disease
• Obtaining an adequate amount of sleep
• Practicing proper sleep hygiene
• Weight loss for overweight/obese patients
THANK YOU FOR LISTENING