Obstructive Sleep Apnoea

Management of Risk Factors

Management of risk factors of patients with OSA includes behaviour modification.

Behaviour modification relevant to OSA includes limitation of the use of alcohol and sedatives, weight reduction, and change in sleep position.

Table. Behaviour modification relevant to OSA

Limit the use of alcohol (<2 standard drinks, consumed at least 4 hours before bedtime) and certain common sedatives and anti-anxiety/ anti-depressant medications (e.g. benzodiazepines)

5-15% weight reduction for overweight or (morbidly) obese patients by behavioural modification, diet, exercise (of note, exercise may slightly improve apnoea hypopnoea index (AHI) even in the absence of weight loss)¹, and bariatric surgery – referral to a dietitian/multi-disciplinary team and/or bariatric surgeon may be beneficial ^{2, 3}

Change in sleep position (i.e. sleeping in a non-supine position ^{4, 5} for patients with positional OSA). These patients tend to have less severe OSA, to be less obese, and to be younger than non-positional patients. ⁶

For patients with co-morbid insomnia, cognitive behavioural therapy for insomnia should be used to improve insomnia symptoms and potentially increase acceptance and use of CPAP therapy ⁷

Acute alcohol consumption often worsens the duration and frequency of obstructive respiratory events during sleep as well as the degree of oxyhemoglobin desaturation, snoring , and sleepiness, increasing the risk of accidents or injury.⁸ All patients with untreated OSA should avoid alcohol, even during the daytime, because it can depress the central nervous system, exacerbate OSA, worsen sleepiness, and promote weight gain.

OSA is more prevalent in people with higher BMI; OSA (defined as apnoea-hypopnoea index (AHI) ≥ 15) was present in 63%/22% obese, 21%/9% overweight and 11%/3% of lean men/women.⁹ It has been reported in longitudinal cohort studies^{10, 11} that AHI changes over time in relation to weight gain/loss; a 10% weight gain predicted ~32% increase in the AHI while a 10% weight loss predicted a ~26% decrease in AHI.¹¹

Abbreviations

AHI - Apnoea-Hypopnoea Index
BBTi - Brief Behavioural Therapy for Insomnia
BMI - Body Mass Index (kg/m2)
BQ - Berlin Questionnaire
CBTi - Cognitive Behavioural Therapy for Insomnia
CELL - Coblation Endoscopic Lingual Lightening
COPD - Chronic Obstructive Pulmonary Disease
CVA - Cerebrovascular Accident
CPAP - Continuous Positive Airway Pressure
CSA - Central Sleep Apnoea
DASS - Depression Anxiety Stress Scale
DBAS - Dysfunctional Beliefs and Attitudes about Sleep
DBP - Diastolic Blood Pressure
DIMS - Difficulties Initiating and/or Maintaining Sleep
DISE - Drug-Induced Sleep Endoscopy
DISS - Daytime Insomnia Symptom Scale
ENT - Ear Nose and Throat
ESS - Epworth Sleepiness Scale
FOSQ - Functional Outcomes of Sleep Questionnaire
FSH - Follicle-Stimulating Hormone
FTP - Friedman Tong Position
GP - General Practitioner
HANDI - RACGP Handbook of Non-Drug Interventions
HGNS - Hypoglossal Herve Htimulation
ISI - Insomnia Severity Index
K10 - Kessler Psychological Distress Scale
MAD - Mandibular Advancement Device
MAS - Mandibular Advancement Rplint
MBS - Medicare Benefits Schedule
MMA - Maxillomandibular Advancement Surgery
MRA - Mandibular Repositioning Appliance
ODI - Oxygenation Desaturation Index
OSA - Obstructive Sleep Apnoea
PLMD - Periodic Limb Movement Disorder
PT - Positional Therapy
PTSD - Post-Traumatic Stress Disorder
PSG - Polysomnography
QSQ - Quebec Sleep Questionnaire
REM - Rapid Eye Movement
RFTB - Radiofrequency Thermotherapy of the Tongue Base
SBP - Systolic Blood Pressure
SCI - Sleep Condition Indicator
SE - Sleep Efficiency
SF36 - Short-Form (36) Health Survey
SMILE - Submucosal Minimally Invasive Lingual Excision
SNRIs - Serotonin-Norepinephrine Reuptake Inhibitors
SOL - Sleep Onset Latency
SSRI - Selective Serotonin Reuptake Inhibitors
TFTs - Thyroid Function Tests
TIB - Time In Bed
TORS - Transoral Robotic Surgery
TST - Total Sleep Time
UPPP - Uvulopalatopharyngoplasty
WASO - Wake After Sleep Onset

Quick links

Obstructive Sleep Apnoea

Overview

OSA

Steps in Assessment & Management

OSA

Questionnaires

Insomnia

Overview

Insomnia

Steps in Assessment & Management

Insomnia

Questionnaires

References

Iftikhar IH, et al. Effects of exercise training on sleep apnea: a meta-analysis. Lung 2014;192:175
Qaseem A, et al. Management of obstructive sleep apnea in adults: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2013;159:471
Randerath WJ, et al. Non-CPAP therapies in obstructive sleep apnoea. Eur Respir J 2011;37:1000
Benoist L, et al. A randomized, controlled trial of positional therapy versus oral appliance therapy for position-dependent sleep apnea. Sleep Med 2017;34:109
de Vries GE, et al. Usage of positional therapy in adults with obstructive sleep apnea. J Clin Sleep Med 2015;11:131
Morgenthaler TI, et al. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep 2006;29:1031
Sweetman A, et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with co-morbid insomnia: A randomized clinical trial. Sleep 2019;42(12)
Issa FG, Sullivan CE. Alcohol, snoring and sleep apnea. J Neurol Neurosurg Psychiatry 1982;45:353
Tufik S, et al. Obstructive sleep apnea syndrome in the Sao Paulo Epidemiologic Sleep Study. Sleep Med. 2010;11(5):441-6
Newman et al. Progression and Regression of Sleep-Disordered Breathing With Changes in Weight: The Sleep Heart Health Study. Arch Intern Med 2005;165:2408-13
Peppard PE, et al. Longitudinal study of moderate weight change and sleep-disordered breathing. Journal of the American Medical Association JAMA 2000;284:3015-21