Evaluation and Management of Adults with Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) is a common and underdiagnosed medical condition characterized by recurrent sleep-dependent pauses and reductions in airflow. While a narrow, collapsible oropharynx plays a central role in the pathophysiology of OSAS, there are other equally important nonanatomic factors including sleep-stage dependent muscle tone, arousal threshold, and loop gain that drive obstructive apneas and hypopneas. Through mechanisms of intermittent hypoxemia, arousal-related sleep fragmentation, and intrathoracic pressure changes, OSAS impacts multiple organ systems. Risk factors for OSAS include obesity, male sex, age, specific craniofacial features, and ethnicity. The prevalence of OSAS is rising due to increasing obesity rates and improved sensitivity in the tools used for diagnosis. Validated questionnaires have an important but limited role in the identification of patients that would benefit from formal testing for OSA. While an in-laboratory polysomnography remains the gold standard for diagnosis, the widespread availability and accuracy of home sleep apnea testing modalities increase access and ease of OSAS diagnosis for many patients. In adults, the most common treatment involves the application of positive airway pressure (PAP), but compliance continues to be a challenge. Alternative treatments including mandibular advancement device, hypoglossal nerve stimulator, positional therapies, and surgical options coupled with weight loss and exercise offer possibilities of an individualized personal approach to OSAS. Treatment of symptomatic patients with OSAS has been found to be beneficial with regard to sleep-related quality of life, sleepiness, and motor vehicle accidents. The benefit of treating asymptomatic OSA patients, particularly with regard to cardiovascular outcomes, is controversial and more data are needed.