American Academy of Sleep Medicine Publishes Updated Recommendations on Referring OSA Candidates for Surgery

The newly adopted AASM guidelines are designed to help health care providers treating obstructive sleep apnea know when to discuss referral for upper airway or bariatric surgery evaluation with their patients.

Using a task force of experts in sleep medicine, otolaryngology, and bariatric surgery, the American Academy of Sleep Medicine (AASM) has developed and released recommendations that update previously published 2010 guidelines on the use of surgery to treat adults with obstructive sleep apnea (OSA).

Lead author David Kent, MD, director, Sleep Surgery, Vanderbilt University, and colleagues assigned recommendations with a strength of either “Strong” or “Conditional.” A strong recommendation inferred that clinicians should follow it under most circumstances, whereas a conditional recommendation required the clinicians to use clinical knowledge and experience while considering the patient’s values and preferences to determine the right course of action.

The new recommendations supported patients who are intolerant or unaccepting of positive airway pressure (PAP) therapy, those who have persistent inadequate PAP adherence due to pressure-related adverse effects, and those with obvious airway anatomic abnormalities potentially amenable to surgery as initial OSA treatment. Approved by the AASM Board of Directors, these new guidelines follow a systematic review of the literature and an assessment of the evidence using the GRADE process. In total, the group of experts made 4 major recommendations, 2 of which were considered strong and 2 deemed conditional (FIGURE).

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The first strong recommendation states that clinicians should discuss referral to a sleep surgeon for adults with OSA and body mass index (BMI) of less than 40 kg/m2 who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options. Notably, this is not a recommendation against those with BMI greater than 40 kg/m2 and may be still an option for those based on discussions with a health care provider.

Evidence for this recommendation was based on 4 randomized clinical trials and 239 observational studies that demonstrated clinically meaningful and beneficial differences in nearly all critical outcomes. Additionally, for those with BMI between 35-40 kg/m2, the updated guideline stated it may appropriate to discuss referral to both sleep and bariatric surgeons.

The second new guideline, also strong, stressed clinicians to discuss referral to a bariatric surgeon for adults with OSA and obesity, defined as BMI greater than 35 kg/m2, who are intolerant or unaccepting of PAP. Similarly, those in the range of 35-40 kg/m2 may also be referred to both sleep and bariatric surgeons to discuss appropriate management options.

"The strong recommendation to discuss surgical referral with patients with OSA, obesity, and PAP intolerance or unacceptance is not a recommendation against (and does not preclude) discussion of surgical referral with patients with OSA, obesity, and adequate PAP use if the health care provider deems it an appropriate management discussion point,” the study authors wrote. “Other organizations, such as the National Heart, Lung, and Blood Institute, recommend consideration of bariatric surgery for individuals suffering from obesity (class II/III, BMI ≥35 kg/m2) and OSA, regardless of PAP adherence status."

Recommendation 3 suggested that patients with OSA, BMI less than 40 kg/m2, and persistent inadequate PAP adherence due to pressure-related side effects, should discuss referral to a sleep surgeon to better facilitate PAP use. "Available data suggest that upper airway surgery has a moderate effect in reducing minimum therapeutic PAP level and increasing PAP adherence. The decision to offer referral should be based on the clinician’s judgment of a patient’s current PAP adherence and tolerance as well as the patient’s treatment preferences. Low degrees of nonadherence or minimal side effects may preclude consideration of a referral," Kent et al wrote.

This conditional recommendation was based on what the authors considered "low-quality evidence" from 7 observational studies that showed clinically meaningful improvements in multiple critical outcomes. Additionally, the benefits of discussing referral in this instance may be dependent on the patient’s degree of PAP use.

The fourth and final recommendation, although conditional, suggested PAP as the initial therapy for patients with OSA and major upper airway anatomical abnormality before seeking a referral for upper airway surgery. Patients with tonsillar, hypertrophy, and maxillomandibular abnormalities, all considered by the task force, should refer to PAP because it carries minimal risk relative to surgery, according to study authors.

Based on 2 randomized controlled trials and 15 observational studies, the conditional recommendation does not preclude discussion of surgical referral prior to the initial PAP trial if deemed necessary; however, it does point out there are benefits to harms that benefit PAP as over surgery as the first option.

REFERENCE
Kent D, Stanley J, Aurora NR, 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. Published online December 1, 2021. doi:10.5664/jcsm.9592.