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SLEEP
MEDICINE

performance of a PSG is recommended. The severity of OSA is based References:
upon the Apnea-Hypopnea Index (AHI). Mild OSA is defined by an 1. Sleepeducation.org
AHI of 5-14, moderate OSA by an AHI 15-29, and severe OSA by an 2. Mannarino MR, De Filippo F, Pirro M. Obstructive sleep apnea
AHI equal/greater than 30. However, the AHI may not be the most syndrome. Eur JF Intern Med 2021; 23: 586-593
important measure of OSA and outcomes. For example, it was found 3. Lloyd R, Morgenthaler TI, Donald R, et al. Quality measures for
that the amount of total sleep time with SpO2 less than 90 percent the care of adult patients with obstructive sleep apnea: 2022 update
(TST90) to be a better predictor of all-cause mortality in an OSA pa- after measure maintenance. J Clin Sleep Med. 2022;18(11):2673–
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tient with heart failure. In the future, we will see improved diagnostic 2680
metrics that improve diagnostic accuracy and treatment outcomes. 4. Rosenthal LD, Dolan DC. The Epworth sleepiness scale in the
The treatment of OSA involves patient education and treatment identification of obstructive sleep apnea. J Nerv Ment Dis. 2008
modalities that result in optimal patient adherence and symptomatic May;196(5):429-31
improvement. Patients should be educated about the goals of OSA 5. Pivetta B, Chen L, Nagappa M, et al. Use and Performance of the
treatment and should have close clinical follow-up to assess treatment STOP-Bang Questionnaire for Obstructive Sleep Apnea Screening
adherence. Kuna et al highlighted the importance of weight manage- Across Geographic Regions: A Systematic Review and Meta-Analy-
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ment for treatment of OSA. Treatment of OSA with CPAP is cur- sis. JAMA Netw Open. 2021;4(3):e211009
rently the recommended treatment and has the greatest evidence of 6. Kapur VK, Auckley DH, Chowdhuri S, Kuhlmann DC, Mehra R,
efficacy on AHI, symptoms and comorbidities. Symptomatic patients Ramar K, Harrod CG. Clinical practice guideline for diagnostic
with moderate-severe OSA generally have good adherence to CPAP testing for adult obstructive sleep apnea: an American Academy of
therapy, while those with mild OSA, female, young and generally pau- Sleep Medicine clinical practice guideline. J Clin Sleep
cisymptomatic, have lower CPAP adherence, especially in the medium Med. 2017;13(3):479–504
and long term. The use of CPAP treatment offers that advantage of 7. Won CHJ. When will we ditch the AHI? J Clin Sleep Med.
non-invasive, adjusted therapy with the ability for the provider to mon- 2020;16(7):1001–1003
itor treatment adherence and therapeutic response. Common patient 8. St-Onge MP, Tasali E. Weight Loss Is Integral to Obstructive Sleep
complaints include challenges with mask comfort and leak, excessive Apnea Management. Ten-Year Follow-up in Sleep AHEAD. Am J
dry mouth and equipment upkeep. Other treatment options include Respir Crit Care Med. 2021 Jan 15;203(2):161-162
Mandibular advancement devices (MAD), positional therapy (PT) and 9. Manetta IP, Ettlin D, Sanz PM, Rocha I, Meira E Cruz M.
hypoglossal nerve stimulation (HSN). The MAD is an attractive treat- Mandibular advancement devices in obstructive sleep apnea: an up-
ment option for most patients with mild to moderate OSA. The MAD dated review. Sleep Sci. 2022 Apr-Jun;15(Spec 2):398-405
developed for treatment of sleep-disordered breathing are devices used 10. Mashaqi S, Patel SI, Combs D, Estep L, Helmick S, Machamer J,
in the oral cavity during sleep with the purpose of preventing the col- Parthasarathy S. The Hypoglossal Nerve Stimulation as a Novel
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lapse between oropharyngeal tissues and the base of the tongue. Com- Therapy for Treating Obstructive Sleep Apnea-A Literature Review.
mon short term side effects include discomfort in the temporo- Int J Environ Res Public Health. 2021 Feb 9;18(4):1642
mandibular joint and in the masticatory muscles. Finally, the hypoglos-
sal nerve stimulator is a novel therapeutic device for patients with mod- David A. Marks, MD, is Board Certified in Pulmonary, Crit-
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erate to severe OSA who are intolerant to traditional treatment. A ical Care and Sleep Medicine with 18 years of experience. Dr.
hypoglossal nerve stimulator is a device that generates electrical im- Marks’ professional interests include COPD, pulmonary hyper-
pulses through a generator that is implanted in the upper right chest. tension, sleep disorders and critical care medicine. He graduated from the
The impulse is transmitted via a tunneled lead that ends up with a cuff University Of Texas Health Sciences Center At San Antonio Long School
that surrounds the hypoglossal nerve, which allows stimulation of the Of Medicine in 1997 and completed a residency at University Of Texas
upper airway muscles. Health Sciences Center/U Hospital. Dr. Marks is a Wellness provider for
OSA is a common medical condition that requires a high index of the San Antonio Fire Department and Senior Aviation Medical Exam-
suspicion. Untreated, it is associated with significant cardiovascular dis- iner for the FAA, and a member of the Bexar County Medical Society.
ease states. Having a strong baseline understanding the evaluation and
pre-identification of an OSA patient is critical. After obtaining an ap-
propriate confirmatory diagnostic test, there are several treatment op-
tions for OSA.

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