An update to the American Academy of Sleep Medicine clinical practice guideline acknowledges the expanding evidence for surgical interventions for sleep apnea. But some physicians think the guideline doesn’t go far enough.
By Jane Kollmer
CPAP is the gold standard treatment for obstructive sleep apnea (OSA), but when patients struggle with CPAP adherence, surgery may be an effective alternative.
“Recent years have seen significant innovations in sleep surgery with improved outcomes,” says Cristina Baldasarri, MD, associate professor of pediatric otolaryngology at Children’s Hospital of The King’s Daughters in Norfolk, Va. “Unfortunately, many patients who are unable to tolerate CPAP are not aware that there are surgical options.”
A new clinical practice guideline issued by the American Academy of Sleep Medicine (AASM) outlines appropriate situations for when adults with OSA should be referred to a surgeon for consultation.1
The guideline, which was published in the Journal of Clinical Sleep Medicine in December 2021, updates a guideline published in 2010. Instead of making recommendations for or against specific surgical procedures, the new guideline answers the critical question of when a discussion about surgery should be brought into the conversation between clinicians and sleep apnea patients.
A task force of experts in sleep medicine, otolaryngology, and bariatric surgery developed four recommendations and assigned strengths based on a systematic review of the literature and an assessment of the evidence using the GRADE process.2
The guideline contains “strong” recommendations, meaning they are applicable in most cases, and two that are “conditional,” meaning there are situations that require a clinician’s judgment and patient preferences.
“The evidence base for sleep surgeries has grown quite dramatically since 2010; we have whole new lines of intervention and we’ve seen real growth in the way we assess patients anatomically for potential interventions,” says David Kent, MD, chair of the AASM task force that developed the new guideline, and assistant professor and director of sleep surgery within the department of otolaryngology-head and neck surgery at Vanderbilt University in Nashville, Tenn.
Referral Recommendations for Sleep Apnea Surgery
The guideline’s first statement was written to address adults with OSA and a body mass index (BMI) under 40 who are either unaccepting or intolerant of CPAP therapy. Under most circumstances, the task force strongly recommends that sleep specialists discuss referral to a sleep surgeon with these patients.
As patients exceed a BMI of 40, there are limited ways that upper airway surgery can be helpful, according to Kent; however, this is not a recommendation against (and does not preclude) discussion of surgical referral.
The second statement recommends discussing referral to a bariatric surgeon for adults with OSA and obesity (BMI over 35) who are intolerant or unaccepting of CPAP. Patients with a BMI that falls between 35 and 40 may be referred to both a sleep surgeon and bariatric surgeon.
Bariatric surgery is overall an effective intervention for patients with obesity. Data shows that the dramatic weight loss that results from bariatric surgery can have profound effects on sleep apnea and sleep-related quality of life.3
“Having a whole additional treatment pathway that can be quite effective for patients who have struggled with weight gain throughout their lives is pretty helpful,” Kent says.
In Kent’s view, including bariatric surgery “in the armamentarium of all surgical interventions is actually forward-thinking on the part of the AASM.”
The third statement in the guideline makes a conditional recommendation, which requires more clinical judgment, for discussion of referral to a sleep surgeon for adults with sleep apnea, a BMI under 40, and persistent inadequate CPAP adherence due to pressure-related side effects.
“There are patients who can’t wear the mask comfortably for the whole night,” Kent says. “They complain the pressure feels too high or too intense, and it makes them feel as though they are swallowing air or being smothered.”
The fourth statement conditionally recommends that CPAP be provided as an initial treatment for sleep apnea in patients with a major upper airway anatomic abnormality, such as large tonsils, prior to consideration of referral for upper airway surgery. But in the remarks that provide more context, the authors state there may be other indications for surgery that justify surgical intervention prior to a CPAP trial.
Disagreement Over Guideline
A clinical practice guideline for sleep surgery referral presents an opportunity to keep CPAP-intolerant patients from leaving their OSA untreated unnecessarily. In a study by the Cleveland Clinic, three years after obstructive sleep apnea diagnosis, only 42% of patients were using positive airway pressure, but only 35% of the CPAP-intolerant patients were offered an alternative.4
“There is clearly a need to educate the medical community and advocate referrals to sleep surgeons,” says Ofer Jacobowitz, MD, PhD, co-director of sleep at ENT and Allergy Associates and an associate professor of otolaryngology at the Zucker School of Medicine at Hofstra/Northwell University in New York, who was an external reviewer of the guideline and provided feedback prior to its publication. “I do wish to thank the expert task force for performing the review and promoting the option of sleep surgery for better patient care.”
Overall, the sleep surgery community has responded positively to the guideline, but some—including Jacobowitz—felt that the recommendations could have been stronger.
“Sleep surgery is safe and effective with the benefits well outweighing the long-term risks of sleep apnea, which include increasing risk for stroke and heart attack,” says Baldasarri, who was not involved in developing the new guidelines. “While the guidelines are a good step toward acknowledging the benefit of sleep surgery, they could be taken a step further to strongly recommend discussion of potential surgical options for patients with sleep apnea that are unable to tolerate CPAP.”
One aspect that was particularly troublesome for Jacobowitz was the choice of words used. Rather than recommending “a discussion of a referral for surgery,” he says the guideline should say “refer for surgery.” A referral does not mean the patient will definitely undergo surgery, he notes. The purpose of a referral is to discuss the benefits, risks, and alternatives to sleep surgery, which are often not well understood by patients nor by non-ENT sleep specialists.
“Often, after a discussion of surgery, the patient is encouraged to return to PAP or oral appliance therapy,” he says. “For other patients, sleep surgery may actually be appropriate and attractive. Without a referral, the patient cannot make an informed decision about surgery.”
In addition, it is important for people to understand that the reason the overall quality of data supporting sleep surgeries was low is because randomized clinical trials of surgery could be unethical and are extremely difficult to perform, Jacobowitz says. He suggested that when the task force evaluated the evidence for sleep surgery, they did not adequately consider large population observational studies that demonstrate the benefits of surgery for survival, major cardiovascular disease, depression, and dementia. He said these “hard” clinical outcomes are more meaningful and relevant than improvements in apnea-hypopnea index and reduction of blood pressure.
In terms of the individual statements, Jacobowitz provided his rationale for why he felt a referral to a surgeon was more appropriate than a discussion about a referral. For example, in the third statement, since the nasal route of breathing is critical for success with CPAP therapy, a sleep surgeon can evaluate the nasal and pharyngeal airway for any possible reason for pressure intolerance such as a deviated septum, nasal polyps, and even tumors. Addressing upper airway anatomic barriers through surgery may help decrease CPAP pressure requirements and improve patient adherence to CPAP.
With regard to the fourth statement about major upper airway abnormalities, he strongly disagrees with craniofacial abnormalities being included in the same statement as tonsillar hypertrophy because of the wide range of outcomes and risks for these surgeries.
“If an adult has a good probability of not needing to use CPAP after tonsillectomy, shouldn’t consultation for surgery be first-line?” he asks. “If there is a high probability of success, many patients may opt for a single surgical procedure, especially tonsillectomy, rather than the prospect of life-long PAP therapy.”
Kathleen L. Yaremchuk, MD, chair of the Department of Otolaryngology at Henry Ford Hospital in Detroit, calls the recommendation tone-deaf to the fact that tonsillectomy in adults with major anatomical obstruction has shown clinically significant reduction in apnea hypopnea index/respiratory disturbance index, Epworth Sleepiness Scale scores, snoring, blood pressure, and oxygen desaturation index.
“To continue to recommend lifelong PAP therapy when it is known that adherence is poor and a surgical procedure can eliminate obstructive sleep apnea does not seem reasonable in this patient population,” says Yaremchuk, who was not involved in developing the recommendations.
Framework for Patient-Centered Care
In the guideline, the authors state that the recommendations are intended to provide a framework for explicitly addressing the role of patient-specific values and preferences in the creation of a customized treatment plan evaluating the risks, benefits, costs, and side effects associated with various medical and surgical therapies. The authors also state that as part of comprehensive management of patients, it is important for sleep physicians to establish relationships with surgeons.
“None of these recommendations supersede clinician judgment, and nowhere do we recommend against a patient having a discussion about surgery if that is what they want,” Kent says. “It’s always a possibility.”
Future iterations of the guideline are likely to include advancements in surgical techniques, such as in the emerging area of neurostimulation devices. According to Kent, as the current diagnostic techniques become more sophisticated and existing surgical treatments are refined or new ones are created, the field will only see interventions for CPAP-intolerant patients improve and be more effective and less invasive.
He says, “As this field continues to evolve, down the road perhaps surgery will elevate to a position ultimately where it has similar efficacy to positive airway pressure.”
Jane Kollmer is co-owner of Ch/At Communications, which provides writing and editing services to clients in the healthcare and travel industries.
References
1. Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(12):2499–2505.
2. Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(12):2507–31.
3. Priyadarshini P, Singh VP, Aggarwal S, et al. Impact of bariatric surgery on obstructive sleep apnoea-hypopnea syndrome in morbidly obese patients. J Minim Access Surg. 2017 Oct-Dec;13(4):291-5.
4. Russell JO, Gales J, Bae C, Kominsky A. Referral patterns and positive airway pressure adherence upon diagnosis of obstructive sleep apnea. Otolaryngol Head Neck Surg. 2015 Nov;153(5):881-7.
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