Treatment of obstructive sleep apnea. A review

Treatment of obstructive sleep apnea (OSA) has developed over the last 25 years from tracheostomy to a variety of options, including weight loss, nasal continuous positive airway pressure (N-CPAP), pharyngeal surgery, and medications. None of these options is definitive or curative, except possibly weight loss. The most widely prescribed treatment is N-CPAP, but recently published studies using objective measurement of patient compliance show less than ideal compliance. Attempts have been made to design pharyngeal surgery according to the site of upper airway collapse or narrowing, as identified by various techniques in wakefulness. How representative these studies are of upper airway physiology in sleep is questionable. Recent studies have shown improved surgical success in correcting OSA. However, disturbing data are available in a limited number of patients that demonstrate worsening of the OSA months after a favorable response to surgery. More studies assessing the long-term outcome of pharyngeal surgery are needed. Several pharmacologic agents have been used to treat OSA. Results with any particular agent are not better than with N-CPAP or surgery. However, studies of subgroups of patients with OSA in which a particular pharmacologic agent may be specifically indicated, such as thyroxine in hypothyroidism, have not been conducted (to our knowledge). An algorithm for the approach to treatment recommendations is presented. Basic to this algorithm is an objective presentation of therapeutic options to the patient with OSA and a respect for the patient's preferences.