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DOI: 10.12998/wjcc.v12.i24.5456 ISSN 2307-8960 (online)

EDITORIAL

Recent advances in managing obstructive sleep apnea

Deb Sanjay Nag, Abhishek Chatterjee, Roushan Patel, Biswajit Sen, Bappa Ditya Pal, Gunjan Wadhwa

Specialty type: Anesthesiology Deb Sanjay Nag, Abhishek Chatterjee, Roushan Patel, Bappa Ditya Pal, Gunjan Wadhwa,
Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, Jharkhand, India
Provenance and peer review:
Invited article; Externally peer Abhishek Chatterjee, Roushan Patel, Department of Anaesthesiology, Manipal Tata Medical
reviewed. College, Jamshedpur 831017, India

Peer-review model: Single-blind Biswajit Sen, Department of Anesthesiology, Tata Main Hospital, Jamshedpur 831001, India

Peer-review report’s classification Corresponding author: Deb Sanjay Nag, MD, Doctor, Department of Anaesthesiology, Tata
Main Hospital, C Road West, Northern Town, Bistupur, Jamshedpur 831001, Jharkhand, India.
Scientific Quality: Grade C
[Link]@[Link]
Novelty: Grade C
Creativity or Innovation: Grade C
Scientific Significance: Grade C Abstract
P-Reviewer: Seeman MV, Canada Obstructive sleep apnea (OSA) is a rapidly increasing global concern. If it remains
untreated, it can lead to cardiovascular, metabolic, and psychiatric complications
Received: March 10, 2024 and may result in premature death. The efficient and effective management of
Revised: April 28, 2024 OSA can have a beneficial effect and help reduce the financial burden on the
Accepted: May 16, 2024 health sector. There has been constant development in OSA management, and
Published online: August 26, 2024 numerous options are available. The mainstay of therapy is still the conventional
Processing time: 123 Days and 2.3 measures and behavioral modifications. However, in cases of failure of these
Hours modalities, surgical therapy is the only option. Numerous studies have shown
that proper management of OSA has beneficial effects with good long-term
outcomes.

Key Words: Sleep apnea; Obstructive; Continuous positive airway pressure; Concepts;
Pharmacological

©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.

Core Tip: Obstructive sleep apnea (OSA) is a common sleep disorder that is responsible
for not only its symptoms but is also a causative disorder for many chronic and morbid
diseases like hypertension, diabetes, and metabolic disorders. While patients with OSA
have various treatment options with varied success, conservative modalities, airway
pressure devices, pharmacologic modalities, and surgical options must be customized
based on individual patient needs.

WJCC [Link] 5456 August 26, 2024 Volume 12 Issue 24

 Nag DS et al. Recent advances in the management of OSA

Citation: Nag DS, Chatterjee A, Patel R, Sen B, Pal BD, Wadhwa G. Recent advances in managing obstructive sleep apnea. World J
Clin Cases 2024; 12(24): 5456-5461
URL: [Link]
DOI: [Link]

INTRODUCTION
The term “Apnea” is a Greek word that means “without breath.” Obstructive sleep apnea was described for the first time
in 1837 by Charles Dickens[1], who described it as “Pickwickian syndrome.” However, in 1956, Sydney Burwell described
the signs and symptoms of this condition in detail and distinguished this condition from other diseases[2]. Apnea is a
discontinuance of airflow during sleep, which has to last for at least 10 seconds with oxygen desaturation of more than
3% with or without associated arousal[3]. Intermittent complete or partial upper airway obstruction OSA is defined as the
occurrence of at least five hypo-apneas or apneas in an hour, which decreases oxygen saturation and sleep fragmentation
[3].
OSA presents a global burden and affects almost 10% of the population[4], with 14% prevalence among males and 5%
in females[4]. The prevalence of OSA is 47%-67% after menopause, and an increase in body weight is not the only factor
responsible for this[5].
Several authors have found a strong correlation between OSA and the development of hypertension, stroke, coronary
artery disease, congestive heart failure, diabetes mellitus, and metabolic syndrome[6,7]. OSA is also associated with
daytime somnolence[8], depression[9], cognitive decline[10] and may also lead to motor vehicle accidents[11]. Therefore,
OSA should be diagnosed early and managed efficiently and adequately to avoid significant economic costs to the
healthcare system.

MANAGEMENT OF OSA
The management of OSA can be sub-stratified into conservative measures, including weight loss, exercise, positional
therapy, and alcohol avoidance.

Weight loss
Body mass index has been considered an important predictor of OSA, and studies[11] have shown that a reduction of
10% in body weight can reduce the apnea and hypopnoea index by 26%. Reduction in body weight also decreases the
collapsibility of the airway and results in near-complete resolution of apnea[12]. However, the effect of bariatric surgery
on the management of OSA is controversial. Some studies[13,14] have shown beneficial effects, whereas some studies[15]
have failed to observe any favorable effects. A systematic review and meta-analysis of 136 studies of 22094 patients
showed that effective weight loss resulted in “complete resolution or improvement” in OSA[13].

Exercise
Physical exercise is recommended in patients suffering from OSA because it significantly decreases the cardiovascular
complications associated with OSA. Authors of the AHEAD (Action for Health in Diabetes) study[15] observed the
beneficial effects of lifestyle interventions, including exercise, on OSA. A 10-year follow-up of 134 adults with polysomno-
graphy showed that weight loss through intensive lifestyle intervention improved OSA severity[16].

Positional sleep therapy

The mainstay of positional sleep therapy is to encourage patients with OSA to sleep on their side rather than sleeping in
the supine position. To keep the patients off their backs at night, various devices and garments are used in positional
sleep therapy. Vibratory sleep devices raise a vibratory alarm when placed around the neck at night, and the patient rolls
over to a supine position. The vibration stops when the patient rolls out of the supine position. A Cochrane Database
Systematic Review, which included 8 studies and 323 patients, showed that positional sleep therapy was significantly less
effective as compared to continuous positive airway pressure (CPAP) in reducing apnea-hypopnea index (AHI)[17].
However, it was tolerated longer than CPAP at night[17].

Alcohol avoidance
A meta-analysis[18] has shown that not only do people consuming alcohol have a 25% higher prevalence of obstructive
sleep apnea, but they also have a longer duration of apnea and a lower nadir of oxygen saturation[19]. The authors have
concluded that these effects were due to the selective adverse effect on airway dilator muscles with depression of
genioglossus muscle activity or on the hypoglossal nerve[20,21]. A systematic review and meta-analysis of 21 studies
from 1985 to 2015 concluded that the “risk of OSA to be increased by 25%” in those who consumed alcohol or consumed
it in higher amounts as compared to those who did not consume it in lower amounts[18].

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Nag DS et al. Recent advances in the management of OSA

AIRWAY PRESSURE TREATMENTS

CPAP
This is the most common mode of administration of positive airway pressure in the management of OSA. In this mode, a
positive pressure is maintained throughout the respiratory cycle. CPAP machines deliver a continuous flow of pressu-
rized air to help keep the upper airway patent; thus, they help reduce AHI significantly[21]. In a meta-analysis[21], CPAP
has been considered as the first line of treatment for moderate-to-severe OSA and for mild obstructive sleep apnea with
cardiovascular disease or excessive daytime somnolence. CPAP should be used for at least 4 hours on 70% of nights
recommended for use during the entire sleep period[21]. The common adverse effects of using CPAP in OSA patients are
nasal irritation, dry mouth, and infection of the sinuses[21]. The m but is-analyses commissioned by the American Aca-
demy of Sleep Medicine evaluated 184 studies and concluded that positive airway pressures resulted in significant
clinical improvement in disease severity and “sleep-related quality of life in adults”[21].

Nasal expiratory airway pressure

Devices have been used as an alternative to CPAP devices in mild to moderate OSA[22]. In contrast to CPAP, these
devices only generate resistance to expiratory airflow while providing minimal inspiratory resistance[22]. In a rando-
mized trial involving a “cohort of 34 analyzable subjects” where these devices were compared to placebo treatment, the
median AHI of the subjects reduced from 15.7 events per hour to 4.1 events per hour[23]. Discomfort during exhalation,
nasal irritation, and dry mouth are the common adverse effects of using these nasal devices[22].

Intraoral negative pressure therapy

The United States Food and Drug Administration (FDA) has recently approved this therapy for sleep apnea of any
variety[23]. These devices apply negative pressure through an intraoral device held in place by a flange between teeth
and lips. Studies[23] have shown that compared to retroglossal airway collapse, these devices are more effective when
OSA is due to retropalatal collapse[23]. In a study that enrolled 19 patients, 15 were responders, and 4 were non-
responders to therapy with a negative pressure with an intraoral interface[24].

Mid-frequency anti-snoring devices

This device is usually worn in the lower jaw (submandibular area) when a patient lies supine and sleeps. The device
delivers a mid-frequency electrical stimulus when the patient starts snoring. In a recently concluded study[25] on 50
patients, the mid-frequency anti-snoring device successfully decreased the duration of snoring, AHI episodes, and SpO2
< 90% in moderate-to-severe OSA patients.

Pharmacological agents
Studies[22] have shown that protriptyline and fluoxetine reduced the number of apnea and hypopnea events by reducing
rapid eye movement sleep. Carbonic anhydrase inhibitors like topiramate, acetazolamideor zonisamide, also reduce the
adverse impact on AHI[22]. In a “prospective crossover unblinded trial” on 12 patients, 6 had good responses to either
fluoxetine or protriptyline, and fluoxetine was better tolerated than protriptyline[26].

Surgical
Surgical options to OSA patients should be offered only when conservative measures and airway devices have failed to
provide any benefits to these patients[20]. The surgical procedures offered to these patients are:

Uvulopalatopharyngoplasty
This procedure has been the mainstay of surgical treatment since 1980 when Fujita et al[27] described it for the first time.
A meta-analysis of 15 observational studies showed that the AHI could be reduced by 33%[28]. However, the same meta-
analysis[28] showed that laser-assisted uvulopalatopharyngoplasty could reduce the incidence of AHI by only 17%.
Adverse effects of this surgery include postoperative hemorrhage, difficulty in swallowing or nasal regurgitation, voice
changes, disturbance of taste, and even death in 0.2% of the operated cases[28].

Tongue reduction surgery

Midline glossectomy with removing elliptical tongue tissue from the dorsal surface has been proposed as an adjunct to
uvulopalatopharyngoplasty[22]. Radiofrequency ablation and reduction of tongue size were associated with a decrease in
AHI by 34%[27]. In a study on 45 patients of moderate-to-severe OSA AHI reduction of > 50% was achieved in 75% of
patients undergoing transoral robotic surgery (TORS) and 62.1% in patients undergoing tongue base coblation resection
[29]. Patients undergoing TORS have less incidence of postoperative hemorrhage foreign body sensation of dysfunction
in taste perceptio[29].

Hypoglossal nerve stimulation

The FDA approved hypoglossal nerve stimulation[22] in 2014; since then, it has been gaining popularity. The hypoglossal
nerve stimulator device has an implantable pulse generator, a lead for stimulation, and a lead for sensing respiration. The
pulse generator senses and, if needed, then enhances the neural stimulation of the hypoglossal nerve to the genioglossus
and geniohyoid muscles. Thus it results in protrusion of the tongue forward. In the first such report of a 5-year follow-up
surgical intervention for OSA using “upper airway stimulation via a unilateral hypoglossal nerve implant” on 97 patients

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 Nag DS et al. Recent advances in the management of OSA

Table 1 Treatment modalities of obstructive sleep apnea

Broad modalities Specific modalities Evidence

Conservative measures Weight reduction Moderate

Exercise Moderate

Positional sleep therapy Moderate

Alcohol avoidance Moderate

Airway pressure treatments Continuous positive airway pressure High (Gold standard)

Nasal expiratory airway pressure devices Moderate

Intraoral negative pressure therapy Moderate-low

Pharmacological therapy Antidepressants, carbonic anhydrase inhibitors Very low

Surgical procedures Uvulopalatopharyngoplasty Moderate-low

Tongue size reduction Moderate-low

Hypoglossal nerve stimulation Moderate-low

Maxillomandibular advancement Moderate-low

who completed the protocol, significant improvement in quality of life and Epworth Sleepiness Scale was observed in
15%-67% and 33%-78% respectively), with significant AHI improvements being observed on 75% of 71 participants who
volunteered for polysomnography[30].

Maxillomandibular advancement
A composite procedure consisting of Lefort 1 osteotomy and bilateral sagittal split of mandibular rami increases airway
volume by creating a larger space[22]. A Case series involving 214 such cases has shown that this surgery resulted in an
87% decrease in AHI[28].

CONCLUSION
OSA, although a commonly encountered problem, can be managed efficiently. Various existing and evolving treatment
modalities (Table 1: Treatment modalities of obstructive sleep apnea) include conservative measures, airway pressure
treatments, pharmacological therapy, and surgical procedures. The Grading of Recommendations Assessment,
Development, and Evaluation approach has been used to provide the quality of currently available evidence for each
therapeutic modality[31]. All have demonstrated varied degrees of success, and further search will guide us toward
patient-specific treatment modalities. However, CPAP remains the gold standard of treatment as of date. It is also highly
cost-effective, especially after 1-2 years of continuous therapy, given its impact on quality of life, incidence of cardio-
vascular diseases, and motor vehicle accidents[32,33].

FOOTNOTES
Author contributions: Nag DS, Chatterjee A, Patel R, Sen B, Pal BD, Wadhwa G contributed to this paper; Nag DS and Chatterjee A
designed the overall concept and outline of the manuscript; Chatterjee A, Sen B, Patel R, Pal BD contributed to the discussion and design
of the manuscript; Nag DS, Chatterjee A, Patel R, Sen B, Pal BD, Wadhwa G contributed to the writing, and editing the manuscript and
review of literature.

Conflict-of-interest statement: All authors have no conflicts of interest to disclose.

Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.
It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to
distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the
original work is properly cited and the use is non-commercial. See: [Link]

Country of origin: India

ORCID number: Deb Sanjay Nag 0000-0003-2200-9324.

Corresponding Author's Membership in Professional Societies: Indian Society of Anaesthesiology, No. S2863.

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Nag DS et al. Recent advances in the management of OSA

S-Editor: Liu JH
L-Editor: A
P-Editor: Zhang XD

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