Clinical Objectives of Surgical Treatment in OSA

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Clinical Objectives of Surgical Treatment in OSA

• Ho-Sheng Lin, MD
• Associate Professor
• Department of Otolaryngology/
• Head and Neck Surgery
• SCS Educational Day
• 11/27/07

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J Clin Sleep Med. 2005 Jul 151(3)241-5
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Surgical Success gt 50 reduction in RDI and
with RDI lt 20
J Clin Sleep Med. 2005 Jul 151(3)241-5
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Clinical Objectives

• Positive Airway Pressure, not surgery, is the
  first line of treatment for OSA
• Safe and effective
• Compliance rate for CPAP is about 50 (40-80)
• Kribbs et al. (based on objective measures)
• 25 use CPAP on a full time basis
• 46 use CPAP gt 4 hrs/night on 70 of nights
  monitored
• Sanders et al. CPAP via nasal
  mask. Chest 198383144-5.
• Waldhorn
  et al. Long-term compliance with nasal CPAP.
  Chest 19909733-7.
• Kribbs
  et al. Objective monitoring of nasal CPAP usage.
  Sleep Res 199120270-1.

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Arch Otolaryngol Head Neck Surg. 200713369-72

• 35 of pts failed to show up following PSG (Lost
  to followup)
• 15 of pts never received machine
• May not be a problem in Canada/European
  countries, but a major problem here due to
  insurance hassles
• 15 are compliant w/ PAP Tx
• Compliance defined as
• Use gt 4 hrs/night
• Use gt 5 nights/wk (70)
• 35 of pts who are prescribed PAP Tx are
  compliant and adequately treated

n 68
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Otolaryngolgoy-Head Neck Surg. 2007136(2)236-40

• 35 of pts failed to show up following study
• 28 are compliant w/ PAP Tx 10
• 45 (35 10) of pts who are prescribed PAP Tx
  are compliant and adequately treated

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Clinical Objectives

• 50 of OSA pts who are noncompliant
• Improve PAP compliance
• Offer surgical treatments to alleviate physical
  discomfort such as nasal obstruction
• Offer surgical treatments, such as tonsillectomy
  for pts w/ obstructing tonsils, to decreased
  positive pressure required increase comfort
• Provide surgical alternatives by offer
  multi-level surgical procedures based on the
  level of airway obstruction
• Surgical Response (? AHI gt50 and AHIlt20)
• Improved tolerance and compliance with PAP
• ? Improved daytime symptoms and nighttime sleep

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Intention to Tx
AHI pre 45.0 AHI post21.9
BMI pre 32.1 BMI post 32.1
26/48 54
12/22 55
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Sleep 2007 30461-7
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Other Measures of Surgical Success in OSA

• Quality of life
• Function / Performance
• Motor vehicle accident risk
• Cardiovascular disease risk
• Mortality risk

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Quality of life
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Quality of lifeMinor Symptoms Evaluation Profile
J Sleep Res 20009303-8
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Cardiovascular Dz
CPAP gt 50 use UPPP AI lt 5
(n14) (n22)
Am. J. Respir. Crit. Care Med. 2002 166 159-165.
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Marti et al., Eur Resp J 2002201511-18
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OSA Survival
Treated
Untreated
Marti et al., Eur Resp J 2002201511-18
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Overall Mortality
P 0.05
Adjusted Hazard Ratio of Death
(N124)
(N88)
(N98)
85 gt 6 hr use 33 AHI lt 10
Adjusted for age, sex, smoking, BMI, AHI, AHT,
CHD, COPD.
Marti et al., Eur Resp J 2002201511-18
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UPPP
CPAP
No Tx
UPPP 3,977
CPAP 28,612
No Tx 116,678
Weaver et al. Otolaryngol Head Neck Surg. 2004
Jun130(6)659-65
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Overall Mortality
P lt 0.001
P lt 0.001
(n116,678)
(n32,589)
(n28,612)
(n3,977)
Adjusted Hazard Ratio of Death Adjusted for age,
sex, race, comorbidity, inception year
Weaver et al. Otolaryngol Head Neck Surg. 2004
Jun130(6)659-65
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CPAP v UPPP
CPAP
UPPP
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Conclusion

• Positive Airway Pressure, not surgery, is the
  first line of treatment for OSA
• However, in patients noncompliant with PAP,
  surgery is better than no surgery
• Goal of Surgery
• Improve PAP compliance
• Offer surgical treatments to alleviate physical
  discomfort such as nasal obstruction
• Offer surgical treatments, such as tonsillectomy
  for pts w/ obstructing tonsils, to decreased
  positive pressure required increase comfort
• Provide surgical alternatives by offer
  multi-level surgical procedures based on the
  level of airway obstruction
• Surgical Response (? AHI gt50 and AHIlt20)
• Improved tolerance and compliance with PAP
• ? Improved daytime symptoms and nighttime

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Final Thought

• Hypothetical pt
• AHI of 40
• Sleep 8 hrs/night
• Total AH 320/night w/out Tx
• 2 scenarios considered treatment success
• 1)Patient underwent UPPP and his AHI went down to
  20
• His total number of AH per night is now 160
• 2)Patient started on CPAP treatment, w/ average
  use of 4 hrs/night every night.
• Assuming that while on CPAP, his AHI went down to
  0.
• His total number of AH per night would also be
  160.
• 0 AH/hr x 4 hrs 40 AH/hr x 4 hrs 160.
• Both of the above success scenarios result in
  equal number of apnea and hypopnea per night
• Is one scenario better than the other?
• Is it better to have mediocre sleep all night
  (UPPP) or have good sleep half night and poor
  sleep the other half of the night (CPAP)?
• Both scenarios are clearly not ideal

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Redefining Improvement for Patients Who Fail CPAP