Clinical Objectives of Surgical Treatment in OSA

Clinical Objectives of Surgical Treatment in OSA
By:Ho-Sheng Lin, MD
Associate Professor
Department of Otolaryngology/
Head and Neck Surgery

SCS Educational Day
Clinical Objectives
* Positive Airway Pressure, not surgery, is the first line of treatment for OSA
o Safe and effective
* Compliance rate for CPAP is about 50% (40-80%)
o Kribbs et al. (based on objective measures)
+ 25% use CPAP on a full time basis
+ 46% use CPAP > 4 hrs/night on 70% of nights monitored
* 35% of pts failed to show up following PSG (Lost to followup)
* 15% of pts never received machine
o May not be a problem in Canada/European countries, but a major problem here due to insurance hassles
* 15% are compliant w/ PAP Tx
o Compliance defined as
+ Use > 4 hrs/night
+ Use > 5 nights/wk (70%)
* 35% of pts who are prescribed PAP Tx are compliant and “adequately” treated
Clinical Objectives
Preop & Postop PSG
Other Measures of Surgical Success in OSA
* Quality of life
* Function / Performance
* Motor vehicle accident risk
* Cardiovascular disease risk
* Mortality risk
Quality of life
Minor Symptoms Evaluation Profile
Cardiovascular Dz
Overall Mortality
UPPP
CPAP
Adjusted Hazard Ratio of Death
CPAP v UPPP
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
o 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
o Provide surgical alternatives by offer multi-level surgical procedures based on the level of airway obstruction
+ Surgical Response (AHI >50% and AHI<20)
+ Improved tolerance and compliance with PAP
+ ? Improved daytime symptoms and nighttime
* Hypothetical pt
o AHI of 40
o Sleep 8 hrs/night
o Total AH = 320/night w/out Tx
* 2 scenarios considered “treatment success”:
o 1)Patient underwent UPPP and his AHI went down to 20
+ His total number of AH per night is now 160
o 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”

Final Thought
Redefining Improvement for Patients Who Fail CPAP
CPAP
Success
Treatment

Clinical Objectives of Surgical Treatment in OSA.ppt