Dr Susheel PatilSusheel Patil, MD, PhD
The American Academy of Sleep Medicine released a new clinical practice guideline providing guidance on the use of positive airway pressure (PAP) therapy to treat obstructive sleep apnea (OSA).

The guideline provides 9 recommendations and is intended for use in conjunction with other American Academy of Sleep Medicine guidelines when evaluating and treating sleep-disordered breathing.

“The new guidelines updates guidelines on PAP that were last published in 2006 and 2008 and implemented the more rigorous GRADE methodology that has been advocated by the Institute of Medicine and to have more of a patient-centered perspective,” lead author Susheel Patil, MD, PhD, assistant professor of medicine and clinical director of the Johns Hopkins Sleep Medicine Program, told NeurologyLive.  “Treating clinicians should recognize that the new guidelines are focused on patients with obstructive sleep apnea only and not patients that have central sleep apnea, both obstructive and central sleep apnea, or sleep-related hypoventilation syndromes.”

The updated practice parameters were based on a systematic literature review, meta-analyses, and assessment of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The task force developed recommendations and assigned strengths based on the quality of evidence, balance of clinically significant benefits and harms, patient values and preferences, and resource use. Additionally, recommendations were adapted from prior guidelines as a good practice statement which established the basis for appropriate and effective treatment of OSA.

There were 4 recommendations deemed by the task force as strong recommendations, which clinicians should follow under most circumstances:
  • We recommend that clinicians use PAP, compared to no therapy, to treat OSA in adults with excessive sleepiness.
  • We recommend that PAP therapy be initiated using either auto-adjusting PAP (APAP) at home or in-laboratory PAP titration in adults with OSA and no significant comorbidities.
  • We recommend that clinicians use either continuous PAP (CPAP) or APAP for ongoing treatment of OSA in adults.
  • We recommend that educational interventions be given with initiation of PAP therapy in adults with OSA.
The guideline includes 2 practice statements that are considered necessary to implement for appropriate and effective care:
  • Treatment of OSA with PAP therapy should be based on a diagnosis of OSA established using objective sleep apnea testing.
  • Adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data to ensure adequate treatment and adherence, should occur following PAP therapy initiation and during treatment of OSA.
The guideline also provides 5 conditional recommendations that reflect a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy:
  • We suggest that clinicians use PAP, compared to no therapy, to treat OSA in adults with impaired sleep-related quality of life.
  • We suggest that clinicians use PAP, compared to no therapy, to treat OSA in adults with comorbid hypertension.
  • We suggest that clinicians use CPAP or APAP over bilevel PAP (BPAP) in the routine treatment of OSA in adults.
  • We suggest that behavioral and/or troubleshooting interventions be given during the initial period of PAP therapy in adults with OSA.
  • We suggest that clinicians use telemonitoring-guided interventions during the initial period of PAP therapy in adults with OSA.

“While the busy clinician may have time to only read the recommendations, we strongly recommend taking the time to read the full clinical practice guidelines to understand the task force’s interpretation and perspective of the available data,” Patil explained. “In addition, a section of the guideline reviews the available evidence regarding mask interfaces, humidified PAP, and modified pressure profile PAP which are important factors in optimizing adherence. In particular, the task force’s review of the literature on mask selection suggested that nasal interfaces, whether nasal masks or nasal pillows, should be considered as preferable to full face masks when initiating PAP therapy for OSA, due to data indicating higher pressure requirements, higher residual sleep apnea severity, and lower patient preference with the use of full-face masks.
 
Patil explained that additional research is needed to evaluate the impact of PAP therapy on cardiovascular risk, neurocognition and mortality, “Almost as important as what is included in the clinical practice guideline is what is not included or recommended. The task force reviewed impact of PAP in OSA on cardiovascular outcomes and concluded that there was insufficient and inconclusive evidence to recommend or withhold PAP in non-sleepy adults with OSA to reduce cardiovascular risk or mortality. In addition, there was inconclusive evidence of the benefits of PAP for adults with OSA in improving neurocognitive outcomes.”

The guideline provides recommendation for the use of PAP, approaches to the initiation of PAP treatment and interventions promoting PAP adherence in this patient population.

When asked about the difference between the current guideline and the previous guideline, Patil told NeurologyLive that the current guideline recognizes that in OSA with adults that APAP in the home is non-inferior to in-lab PAP titration strategies when initiating therapy, and also that there is recognition that continued treatment of adults with OSA with either APAP or CPAP results in similar outcomes. “In addition, the new guidelines attempt to focus clinicians on implementing strategies to optimize adherence to PAP, which many patients struggle with. Educational interventions, behavioral and/or troubleshooting interventions are either recommended or suggested to be given prior to and during the initiation of PAP therapy. Furthermore, telemonitoring-guided interventions may have a role in optimizing PAP adherence.”
REFERENCE
Patil, S, Ayappa I, Caples S, et al. Treatment of Adult Obstructive Sleep Apnea with Positive Airway Pressure: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine. 2019;15(2).
doi: 10.5664/jcsm.764.