Obstructive sleep apnea (OSA) is characterized by repetitive airway closure, which can lead to hypoxemia and sympathetic nervous system activation. This can result in significant cardiovascular and neurologic morbidity. Therefore, early recognition and treatment are extremely important. The gold standard treatment of OSA is positive airway pressure, which has been shown to decrease the risk of these sequelae. Alternatives to positive airway pressure therapy are not commonly discussed but are available to those who are not able to tolerate positive airway pressure. The goal of this review is to discuss the pathophysiology, epidemiology, screening and testing, and treatment considerations for OSA.
SenaratnaCVPerretJLLodgeCJ, et al.Prevalence of obstructive sleep apnea in the general population: a systematic review. Sleep Med Rev. 2017;34:70-81.
2.
YeghiazariansYJneidHTietjensJR, et al.Obstructive sleep apnea and cardiovascular disease: a scientific statement from the American heart association. Circulation. 2021;144(3):e56-e67.
3.
EpsteinLJKristoDStrolloPJ, et al.Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med : JCSM : official publication of the American Academy of Sleep Medicine. 2009;5(3):263-276.
4.
AbbasiAGuptaSSSabharwalN, et al.A comprehensive review of obstructive sleep apnea. Sleep science (Sao Paulo, Brazil). 2021;14(2):142-154.
5.
DempseyJAVeaseySCMorganBJO'DonnellCP. Pathophysiology of sleep apnea. Physiol Rev. 2010;90(1):47-112.
6.
FietzeILaharnarNObstA, et al.Prevalence and association analysis of obstructive sleep apnea with gender and age differences - results of SHIP-Trend. Journal of sleep research. 2019;28(5):e12770.
7.
DragerLFTogeiroSMPolotskyVYLorenzi-FilhoG. Obstructive sleep apnea: a cardiometabolic risk in obesity and the metabolic syndrome. J Am Coll Cardiol. 2013;62(7):569-576.
8.
IsonoS. Obesity and obstructive sleep apnoea: mechanisms for increased collapsibility of the passive pharyngeal airway. Respirology. 2012;17(1):32-42.
9.
MarinJMAgustiAVillarI, et al.Association between treated and untreated obstructive sleep apnea and risk of hypertension. JAMA. 2012;307(20):2169-2176.
10.
ShahNAYaggiHKConcatoJMohseninV. Obstructive sleep apnea as a risk factor for coronary events or cardiovascular death. Sleep Breath. 2010;14(2):131-136.
11.
JohnsMW. Daytime sleepiness, snoring, and obstructive sleep apnea. Chest. 1993;103(1):30-36.
12.
JohnsMW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540-545.
13.
GodoyPHNuceraAPCDSColcherAPde AndradeJEAlvesDDSB. Screening for obstructive sleep apnea in elderly: performance of the Berlin and STOP-Bang questionnaires and the Epworth sleepiness scale using polysomnography as gold standard. Sleep science (Sao Paulo, Brazil). 2022;15(2):136-142.
14.
BoyntonGVahabzadehAHammoudSRuzickaDLChervinRD. Validation of the STOPBANG questionnaire among patients referred for suspected obstructive sleep apnea. Journal of Sleep Disorders: Treatment & Care. 2013;02(4):1000121. doi:10.4172/2325-9639.1000121
15.
ChiuHYChenP-YChuangL-P, et al.Diagnostic accuracy of the Berlin questionnaire, STOP-BANG, STOP, and Epworth sleepiness scale in detecting obstructive sleep apnea: a bivariate meta-analysis. Sleep Med Rev. 2017;36:57-70.
16.
NetzerNCStoohsRANetzerCMClarkKStrohlKP. Using the Berlin questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999;131(7):485.
17.
KapurVKAuckleyDHChowdhuriS, et al.Clinical Practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of sleep medicine clinical Practice guideline. J Clin Sleep Med : JCSM : official publication of the American Academy of Sleep Medicine. 2017;13(3):479-504.
18.
GottliebDJPunjabiNM. Diagnosis and management of obstructive sleep apnea. JAMA. 2020;323(14):1389-1400.
19.
WittineLMOlsonEJMorgenthalerTI. Effect of recording duration on the diagnostic accuracy of out-of-center sleep testing for obstructive sleep apnea. Sleep. 2014;37(5):969-975.
20.
IftikharIHValentineCWBittencourtLRA, et al.Effects of continuous positive airway pressure on blood pressure in patients with resistant hypertension and obstructive sleep apnea. J Hypertens. 2014;32(12):2341-2350.
21.
KanekoYFlorasJSUsuiK, et al.Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea. N Engl J Med. 2003;348(13):1233-1241.
22.
MarinJMCarrizoSJVicenteEAgustiAG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365(9464):1046-1053.
23.
PépinJLBaillySRinderP, et al.Relationship between CPAP termination and all-cause mortality: a French nationwide database analysis. Chest. 2022;161(6):1657-1665.
24.
WeaverTEMaislinGDingesDF, et al.Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep. 2007;30(6):711-719.
25.
BrattonDJStradlingJRBarbéFKohlerM. Effect of CPAP on blood pressure in patients with minimally symptomatic obstructive sleep apnoea: a meta-analysis using individual patient data from four randomised controlled trials. Thorax. 2014;69(12):1128-1135.
26.
WeaverTE. Novel aspects of CPAP treatment and interventions to improve CPAP adherence. J Clin Med. 2019;8(12).
27.
CistulliPAArmitsteadJPepinJ-L, et al.Short-term CPAP adherence in obstructive sleep apnea: a big data analysis using real world data. Sleep Med. 2019;59:114-116.
28.
GagnadouxFLe VaillantMParisA, et al.Relationship between OSA clinical phenotypes and CPAP treatment outcomes. Chest. 2016;149(1):288-290.
29.
MehrtashMBakkerJPAyasN. Predictors of continuous positive airway pressure adherence in patients with obstructive sleep apnea. Lung. 2019;197(2):115-121.
30.
WildMREnglemanHMDouglasNJEspieCA. Can psychological factors help us to determine adherence to CPAP? A prospective study. Eur Respir J. 2004;24(3):461-465.
31.
StepnowskyCJJr.MarlerMRAncoli-IsraelS. Determinants of nasal CPAP compliance. Sleep Med. 2002;3(3):239-247.
32.
BakkerJPWeaverTEParthasarathySAloiaMS. Adherence to CPAP. Chest. 2019;155(6):1272-1287.
33.
Villa AlvarezJDalesRKendzerskaT. Demographics, sleep apnea and positive airway pressure (PAP) treatment-related characteristics associated with PAP adherence: a large retrospective community-based longitudinal observational study. Sleep Med. 2022;98:139-143.
34.
LewisKESealeLBartleIEWatkinsAJEbdenP. Early predictors of CPAP use for the treatment of obstructive sleep apnea. Sleep. 2004;27(1):134-138.
35.
DrakeCLDayRHudgelD, et al.Sleep during titration predicts continuous positive airway pressure compliance. Sleep. 2003;26(3):308-311.
36.
PatilSPAyappaIACaplesSM, et al.Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of sleep medicine clinical Practice guideline. J Clin Sleep Med : JCSM: Official Publication of the American Academy of Sleep Medicine. 2019;15(2):335-343.
37.
WozniakDRLassersonTJSmithI. Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev. 2014;1:CD007736.
38.
HuYSuYHuS, et al.Effects of telemedicine interventions in improving continuous positive airway pressure adherence in patients with obstructive sleep apnoea: a meta-analysis of randomised controlled trials. Sleep Breath. 2021;25(4):1761-1771.
39.
HwangDChangJWBenjafieldAV, et al.Effect of telemedicine education and telemonitoring on continuous positive airway pressure adherence. The tele-OSA randomized trial. Am J Respir Crit Care Med. 2018;197(1):117-126.
40.
GentinaTBaillySJounieauxF, et al.Marital quality, partner's engagement and continuous positive airway pressure adherence in obstructive sleep apnea. Sleep Med. 2019;55:56-61.
41.
MalhotraACrockerMEWillesL, et al.Patient engagement using new technology to improve adherence to positive airway pressure therapy. Chest. 2018;153(4):843-850.
42.
RowlandSAiyappanVHennessyC, et al.Comparing the efficacy, mask leak, patient adherence, and patient preference of three different CPAP interfaces to treat moderate-severe obstructive sleep apnea. J Clin Sleep Med : JCSM : official publication of the American Academy of Sleep Medicine. 2018;14(1):101-108.
43.
AndradeRGMadeiroFPiccinVS, et al.Impact of acute changes in CPAP flow route in sleep apnea treatment. Chest. 2016;150(6):1194-1201.
44.
BakkerJPMarshallNS. Flexible pressure delivery modification of continuous positive airway pressure for obstructive sleep apnea does not improve compliance with therapy. Chest. 2011;139(6):1322-1330.
45.
LettieriCJShahAAHolleyABKellyWFChangASRoopSA. Effects of a short course of eszopiclone on continuous positive airway pressure adherence. Ann Intern Med. 2009;151(10):696-702.
46.
WangDTangYChenY, et al.The effect of non-benzodiazepine sedative hypnotics on CPAP adherence in patients with OSA: a systematic review and meta-analysis. Sleep. 2021;44(8):zsab077.
47.
WallaceDMSawyerAMShafazandS. Comorbid insomnia symptoms predict lower 6-month adherence to CPAP in US veterans with obstructive sleep apnea. Sleep Breath. 2018;22(1):5-15.
48.
Suarez-GironMGarmendiaOLugoV, et al.Mobile health application to support CPAP therapy in obstructive sleep apnoea: design, feasibility and perspectives. ERJ open research. 2020;6(1):00220-2019.
49.
PillarGShehadehN. Abdominal fat and sleep apnea. Diabetes Care. 2008;31(Supplement_2):S303-S309.
50.
HudgelDWPatelSRAhasicAM, et al.The role of weight management in the treatment of adult obstructive sleep apnea. An official American thoracic society clinical Practice guideline. Am J Respir Crit Care Med. 2018;198(6):e70-e87.
51.
TuomilehtoHPISeppäJMPartinenMM, et al.Lifestyle intervention with weight reduction. Am J Respir Crit Care Med. 2009;179(4):320-327.
52.
ChirinosJAGurubhagavatulaITeffK, et al.CPAP, weight loss, or both for obstructive sleep apnea. N Engl J Med. 2014;370(24):2265-2275.
53.
DixonJBSchachterLMO'BrienPE. Polysomnography before and after weight loss in obese patients with severe sleep apnea. Int J Obes. 2005;29(9):1048-1054.
54.
CaplesSMAndersonWMCaleroKHowellMHashmiSD. Use of polysomnography and home sleep apnea tests for the longitudinal management of obstructive sleep apnea in adults: an American Academy of Sleep Medicine clinical guidance statement. J Clin Sleep Med. 2021;17(6):1287-1293.
55.
PapandreouCSchizaSEBouloukakiI, et al.Effect of Mediterranean dietversusprudent diet combined with physical activity on OSAS: a randomised trial. Eur Respir J. 2012;39(6):1398-1404.
56.
OmobomiOQuanSF. Positional therapy in the management of positional obstructive sleep apnea-a review of the current literature. Sleep Breath. 2017;22(2):297-304.
57.
BlackmanAaufnmFosterGD, et al.Effect of liraglutide 3.0 mg in individuals with obesity and moderate or severe obstructive sleep apnea: the SCALE Sleep Apnea randomized clinical trial. Int J Obes. 2016;40(8):1310-1319.
58.
OksenbergAGadothNTöyräsJLeppänenT. Prevalence and characteristics of positional obstructive sleep apnea (POSA) in patients with severe OSA. Sleep Breath. 2019;24(2):551-559.
59.
BamagoosAACistulliPASutherlandK, et al.Dose-dependent effects of mandibular advancement on upper airway collapsibility and muscle function in obstructive sleep apnea. Sleep. 2019;42(6).
60.
MohammadiehASutherlandKCistulliPA. Sleep disordered breathing: management update. Intern Med J. 2017;47(11):1241-1247.
61.
MarklundMBraemMJAVerbraeckenJ. Update on oral appliance therapy. Eur Respir Rev. 2019;28(153):190083.
62.
BenderB. Hypoglossusstimulation bei OSAS. Laryngo-Rhino-Otol. 2016;95(11):795-807.
63.
ManchandaSNeupanePSiguaNL. Upper airway stimulation/hypoglossal nerve stimulator. Am J Respir Crit Care Med. 2020;202(8):P23-P24.
64.
YuMSIbrahimBRileyRWLiuSY-C. Maxillomandibular advancement and upper airway stimulation: extrapharyngeal surgery for obstructive sleep apnea. Clinical and experimental otorhinolaryngology. 2020;13(3):225-233.
65.
MahadeviaAKOnalELopataM. Effects of expiratory positive airway pressure on sleep-induced respiratory abnormalities in patients with hypersomnia-sleep apnea syndrome. The American review of respiratory disease. 1983;128(4):708-711.
66.
SleeperGRashidiMStrohlKP, et al.Comparison of expiratory pressures generated by four different EPAP devices in a laboratory bench setting. Sleep Med. 2022;96:87-92.
67.
BerryRBKrygerMHMassieCA. A novel nasal expiratory positive airway pressure (EPAP) device for the treatment of obstructive sleep apnea: a randomized controlled trial. Sleep. 2011;34(4):479-485.
68.
ZaghiSHoltyJ-ECCertalV, et al.Maxillomandibular advancement for treatment of obstructive sleep apnea. JAMA Otolaryngology-Head & Neck Surgery. 2016;142(1):58.
69.
MyersKAMrkobradaMSimelDL. Does this patient have obstructive sleep apnea?JAMA. 2013;310(7):731.
70.
SheltonKEWoodsonHGaySSurattPM. Pharyngeal fat in obstructive sleep apnea. Am Rev Respir Dis. 1993;148(2):462-466.
71.
YoungTPeppardPETaheriS. Excess weight and sleep-disordered breathing. J Appl Physiol. 2005;99(4):1592-1599.
72.
LecubeASampolGLloberesP, et al.Asymptomatic sleep-disordered breathing in premenopausal women awaiting bariatric surgery. Obes Surg. 2009;20(4):454-461.
73.
EckertDJWhiteDPJordanASMalhotraAWellmanA. Defining phenotypic causes of obstructive sleep apnea. Identification of novel therapeutic targets. Am J Respir Crit Care Med. 2013;188(8):996-1004.
74.
KumarPRaiDKKanwarMS. Comparison of clinical and polysomnographic parameters between obese and nonobese obstructive sleep apnea. J Fam Med Prim Care. 2020;9(8):4170-4173.
75.
GrayELMcKenzieDKEckertDJ. Obstructive sleep apnea without obesity is common and difficult to treat: evidence for a distinct pathophysiological phenotype. J Clin Sleep Med : JCSM : official publication of the American Academy of Sleep Medicine. 2017;13(1):81-88.
76.
Terán-SantosJJimenez-GomezACordero-GuevaraJ. The association between sleep apnea and the risk of traffic accidents. N Engl J Med. 1999;340(11):847-851.
77.
PatelSR. Obstructive sleep apnea. Ann Intern Med. 2019;171(11):ITC81.
78.
ChowdhuriSQuanSFAlmeidaF, et al.An official American thoracic society research statement: impact of mild obstructive sleep apnea in adults. Am J Respir Crit Care Med. 2016;193(9):e37-e54.
79.
PekerYGlantzHEulenburgCWegscheiderKHerlitzJThunströmE. Effect of positive airway pressure on cardiovascular outcomes in coronary artery disease patients with nonsleepy obstructive sleep apnea. The RICCADSA randomized controlled trial. Am J Respir Crit Care Med. 2016;194(5):613-620.
80.
McEvoyRDAnticNAHeeleyE, et al.CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med. 2016;375(10):919-931.
81.
MazzottiDRKeenanBTLimDCGottliebDJKimJPackAI. Symptom subtypes of obstructive sleep apnea predict incidence of cardiovascular outcomes. Am J Respir Crit Care Med. 2019;200(4):493-506.
82.
KrygerMHRothTDementWC, Principles and Practice of Sleep Medicine. 6th ed.2017, Philadelphia, PA: Elsevier. xlv:1730.
83.
FranklinKASahlinCStenlundHLindbergE. Sleep apnoea is a common occurrence in females. Eur Respir J. 2012;41(3):610-615.
84.
YoungT. The gender bias in sleep apnea diagnosis. Are women missed because they have different symptoms?Arch Intern Med. 1996;156(21):2445-2451.
