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PHILIPPINE CLINICAL PRACTICE GUIDELINES ON THE DIAGNOSIS AND MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA IN ADULTS

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  • Objectives of the Clinical Practice Guidelines
  •  To develop clinical practice guidelines on the screening, diagnosis and management of Obstructive Sleep Apnea (OSA) among adults which reflect the current best evidence and which incorporate local data into the recommendations, in view of aiding clinical decision making for the benefit of the Filipino patient.  

Organizations in the Consensus Panel

  • Philippine Society of Sleep Medicine                       Philippine Heart Association (PHA)
  • Philippine College of Chest Physicians                    Philippine Academy of Family Physicians (PAFP)
  • PCCP Council on Sleep Medicine                                               Philippine Dental Association
  • Philippine Academy of Sleep Surgeons                  Philippine College of Occupational Medicine
  • Philippine Society of Otorhinology-HNS                 Philippine College of Physicians
  • Philippine Society of Endocrinology,                        PhilHealth

Diabetes and Metabolism (PSEDM)

 

This CPG used two main methods for guideline development:

(1) Guideline adaptation using the ADAPTE process (ADAPTE, 2007); and

(2) de novo development of guideline statements whenever there are no guidelines on certain issues from published literature or for issues that are unique to local practice.

Scope of the Guidelines

  • The main focus of these guidelines is the diagnosis and management of adult patients with OSA
  • The guideline statements will cover three general areas:

1. Screening

2. Diagnosis

3. Treatment (Pharmacologic and Non-pharmacologic, Surgical)

Section I.Questions on Screening

Question 1: When should you suspect OSA?

  • Obstructive sleep apnea should be suspected in patients with witnessed apneas, chronic snoring and excessive daytime sleepiness not explained by other factors. The presence of risk factors such as obesity, diabetes, dyslipidemia and hypertension along with the triad strengthens the suspicion of OSA.   Recommend
  • Physical findings suspicious for OSA include obesity, increased neck circumference, and narrowed pharyngeal airway.     Recommend

Question 2:  When should we screen for OSA?

  • OSA should be screened:
    • During routine health maintenance evaluation
    • Routinely, among patients for pre-operative evaluation
    • In populations where OSA poses a public health hazard (e.g. public utility drivers, long haul drivers, pilots)
    • Recommend

 

Question 3:  What is the utility of questionnaires and clinical prediction rules for the diagnosis of OSA?

  •  Questionnaires may be used to screen patients for further testing for OSA.  Recommend (Consensus)

 

Section II. QUESTIONS ON DIAGNOSIS

Question 4: What is the gold standard for the diagnosis of OSA?

  • Attended, in-laboratory polysomnogram is the gold standard to diagnose OSA.
  • Strongly Recommended

 

Question 5:  Can portable monitors or other diagnostic tests be used as an alternative to PSG in the diagnosis of OSA?

  • 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 are met:
    • High risk  for moderate to severe OSA
    • Do not have serious co-morbidities
    • Other sleep disorders are not a consideration, and
    • With a prior comprehensive sleep evaluation by a sleep specialist.

 

Question 6: What is the criteria for the diagnosis of OSA?

  • The diagnosis of OSA is confirmed if any of the following criteria is met:
  • Using the gold standard of polysomnography:
    • Greater than 5 obstructive events per hour (apneas, hypopneas, & respiratory event related arousals)
    • in a patient who reports any of the following symptoms:
      • sleepiness, non-restorative sleep, fatigue, or insomnia, wakes up with breath holding, gasping, or choking, habitual loud snoring, breathing interruptions, or both during the patient’s sleep; 
      • or is diagnosed with one or more of these conditions - HPN, T2DM, CHF or CAD, has AF, stroke, mood disorder, or cognitive dysfunction
    • Strongly recommended

 

  • Using portable monitoring:
    • Greater than 5 obstructive events per hour (apneas, and hypopneas) is in a patient who reports any of the above symptoms, or
    • Greater than 15 events/hour even in the absence of sleep related symptoms 
    • Strongly recommended

 

Question 7:  What is the severity classification for OSA?

  • OSA severity is classified as mild for RDI/AHI 5-14/hour, moderate for RDI/AHI 15-30/hour and severe for RDI/AHI > 30/hour.1
  •   Strongly recommended

 

Question 8: What are the indications for follow-up PSG?

  • Follow up PSG is not routinely indicated in patients treated with CPAP whose symptoms continue to be resolved with CPAP treatment.
  • Follow-up PSG is STRONGLY RECOMMENDED to be done routinely in the following situations:
    • For assessment of treatment results after surgical treatment for moderate to severe OSA; (routine)
    • 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. (routine)

 

Section 3:  Questions on the Management of OSA

Question 9:  When should OSA be managed?   

  • Management should commence once the diagnosis and severity classification has been established using a multidisciplinary approach.             
  • Strongly Recommend (Consensus)

 

Question 10:  What are the goals of therapy for OSA?

  • The goals of therapy for OSA are:
    • To improve symptoms (excessive sleepiness, concentration, snoring), quality of life and sexual intimacy.
    • To decrease AHI to <5, events/hour with no desaturations nor arousals
    • Improvement of associated comorbidities such as hypertension, arrhythmia, heart failure, stroke, and hyperglycemia.
    • To decrease fatal cardiovascular events and traffic accidents.
    • Strongly recommend

 

Question 11:  What is the primary treatment for Obstructive Sleep Apnea in Adults?

  • CPAP at a fixed pressure is the standard treatment of choice for moderate-severe OSA in adults.  CPAP should be used for at least 4 hours during sleep daily.
  • Strongly Recommend

 

Question 12:  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 poorly tolerant of fixed CPAP, and those with position related & REM related OSA  Recommend
  • Caution in 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 population. Recommend-Consensus

Question 13:  Can auto-titrating CPAP (APAP) be used in determining fixed CPAP pressure in lieu of formal CPAP titration?

  • APAP use during an ambulatory titration procedure to determine a fixed CPAP treatment pressure for patients with OSA in lieu of formal CPAP titration, is currently NOT RECOMMENDED since studies are few & have not consistently shown that APAP is equivalent to the standard titration.

Question 14: What is the role of the following interventions for the management of OSA?

  • Weight Loss

All overweight and obese patients diagnosed with OSA should be encouraged to lose weight as medically supervised weight loss may improve the AHI. However it should be combined with primary treatment because of the low success rates for weight loss alone.  Strongly recommend

 

  • Alcohol Intake

Alcohol intake and routine use of sedatives among patients with OSA is discouraged.  Recommend

 

  • Positional Therapy

Strategies that keep the patient in a non-supine position can be used as treatment for positional OSA.  Recommend

 

  • Oxygen therapy

Oxygen supplementation is NOT RECOMMENDED as a sole treatment for OSA

 

  • Pharmacologic treatment

There is NO accepted pharmacological treatment for OSA.  Strongly recommend 

Question 15:  What is the role of oral appliance therapy in OSA?

  • The use of Prefabricated Non-custom, non-titratable OA is NOT RECOMMENDED for OSA. 
  • The decision to use custom fitted titratable OA must be made by a sleep specialist in conjunction with a dentist trained in sleep medicine.  Recommend.

 

Question 16: When is surgery indicated for Obstructive Sleep Apnea? 

  • Generally, surgery is not recommended for OSA  (Consensus)
  • Among patients with OSA and significant obstructing anatomy, the recommendation to perform surgery must be made by a multidisciplinary team which includes the referring physician, sleep specialist and a qualified surgeon (Recommend-consensus).

 

Question 17:  Which patients require urgent treatment for OSA?

  • Any patient with known or suspected OSA with severe/unstable co-morbid conditions may benefit from a referral to a sleep specialist for evaluation and/or possible initiation of CPAP or non-invasive ventilation
  • Among patients with suspected OSA, a definitive pSG is recommended after stabilization of co-morbid condition to confirm diagnosis of OSA.
  • (Recommend-consensus)