From the Journals

New sleep apnea guidelines offer evidence-based recommendations

Octavian C. Ioachimescu, MD, FCCP, comments: The last guidelines and practice parameters for the use of positive airway pressure (PAP) as therapy for adult patients with obstructive sleep apnea, were published in 2006 and 2008, respectively. Since then, new technological advances, an ever-growing body of literature, and shifting practice patterns led to an acute need for a thorough reassessment, a comprehensive update of the previous recommendations, and the potential of issuing new ones for emerging areas. As such, the American Academy of Sleep Medicine commissioned a task force of content experts to review the existing evidence, to issue new guidelines and to publish an associated systematic review and a meta-analysis of the literature on this topic.

Dr. Octavian C. Ioachimescu

Dr. Octavian C. Ioachimescu

These guidelines show that we still have so many areas insufficiently explored, with very conflicting or suboptimal level of evidence. A publication like this can help us see what our blind spots are in this area. For example, we do not know yet if patients without daytime sleepiness (most of the time defined bluntly by specific cutoffs of the Epworth Sleepiness Scale) benefit in the long term by instituting PAP therapy. Furthermore, impairments of other domains of quality of life have been insufficiently correlated with long-term, hard adverse outcomes. Another example: the utility of Multiple Sleep Latency testing as an objective methodology to assess residual sleepiness after PAP therapy initiation.

A welcome recommendation is the endorsement by the task force of the use of telemedicine capabilities in monitoring patients’ adherence to PAP therapy. Another interesting aspect is that, while our literature is represented by a mix of both randomized and nonrandomized controlled trials, occasionally there seems to be an interesting dichotomy in the results: Randomized trials tend to point in one direction, while nonrandomized studies pooled in the meta-analysis seem to point to the contrary or to give the impression of more definitive effects. While this is clearly not the place to make an extensive analysis of the strengths and the potential pitfalls of randomized versus nonrandomized studies, this clearly raises some issues. One is that our randomized studies are typically small, underpowered, and hence with nonconvincing risk or hazard reduction assessments. Second, the dichotomy in the results may be driven by publication bias, expense, and difficulty in performing adequately-powered, long-term trials that essentially may be studying small effects.

Guidelines are not intended to be used in an Occam’s razor approach, but in a fashion that would allow individualization of therapy while critically appraising the existing evidence for various interventions in specific conditions and maintaining a very stringent and critical view on generalizability, expected results, and adequate management of reasonable expectations. In addition, the areas that are unclear, with conflicting evidence or in which the guidelines allow “too much” latitude to the treating clinician, may be seen as either an invitation to remain “creative,” or one for abstaining from action in the name of equipoise. I would advise that both extremes are to be avoided.



New guidelines on treating obstructive sleep apnea with positive airway pressure include recommendations for using positive airway pressure (PAP) versus no therapy, using either continuous PAP (CPAP) or automatic PAP (APAP) for ongoing treatment, and providing educational interventions to patients starting PAP. The complete guidelines, issued by the American Academy of Sleep Medicine, were published in the Journal of Clinical Sleep Medicine.

The guidelines were driven by improvements in PAP adherence and device technology, wrote lead author Susheel P. Patil, MD, of Johns Hopkins University, Baltimore, and his colleagues.

The guidelines begin with a pair of Good Practice Statements to ensure effective and appropriate management of obstructive sleep apnea (OSA) in adults. First, “Treatment of OSA with PAP therapy should be based on a diagnosis of OSA established using objective sleep apnea testing.” Second, “Adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data to ensure adequate treatment and adherence, should occur following PAP therapy initiation and during treatment of OSA.”

The nine recommendations, approved by the AASM board of directors, include four strong recommendations that clinicians should follow under most circumstances, and five conditional recommendations that are suggested but lack strong clinical support for their appropriateness for all patients in all circumstances.

The first of the strong recommendations, for using PAP versus no therapy to treat adults with OSA and excessive sleepiness, was based on a high level of evidence from a meta-analysis of 38 randomized, controlled trials and the conclusion that the benefits of PAP outweighed the harms.

The second strong recommendation for using either CPAP or APAP for ongoing treatment was based on data from 26 trials that showed no clinically significant difference between the two. The third strong recommendation that PAP therapy be initiated using either APAP at home or in-laboratory PAP titration in adults with OSA and no significant comorbidities was supported by a meta-analysis of 10 trials that showed no clinically significant difference between at-home and laboratory initiation, and that each option has its benefits. The authors noted that “the majority of well-informed adult patients with OSA and without significant comorbidities would prefer initiation of PAP using the most rapid, convenient, and cost-effective strategy.” This comment supports the fourth strong recommendation for providing educational interventions to patients starting PAP.

The conditional recommendations include using PAP versus no therapy for adults with OSA and impaired quality of life related to poor sleep, such as insomnia, snoring, morning headaches, and daytime fatigue. Other conditional recommendations include using PAP versus no therapy for adults with OSA and comorbid hypertension, choosing CPAP or APAP over bilateral PAP for routine treatment of OSA in adults, providing behavioral interventions or troubleshooting during patients’ initial use of PAP, and using telemonitoring-guided interventions to monitor patients during their initial use of PAP.

“The ultimate judgment regarding any specific care must be made by the treating clinician and the patient, taking into consideration the individual circumstances of the patient, available treatment options, and resources,” the authors noted.

“When implementing the recommendations, providers should consider additional strategies that will maximize the individual patient’s comfort and adherence such as nasal/intranasal over oronasal mask interface and heated humidification,” they added.

The guidelines were developed by a task force commissioned by the AASM that included board-certified sleep specialists and experts in PAP use, and will be reviewed and updated as new information surfaces, the authors wrote.

Dr. Patil reported no financial conflicts; several coauthors reported conflicts that were managed by their not voting on guidelines related to those conflicts.

SOURCE: Patil SP et al. J Clin Sleep Med. 2018 Feb 15;15(2):335-43.

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