For many patients, sleep apnea is worse when lying on the back.For example, Oksenberg and colleagues found in their study of 100 consecutive adult patients with OSA that the supine position was associated with increased frequency of apneas and hypopneas during the rapid eye movement (REM) stage of sleep, although duration of these episodes did not increase.12
Gravity, airway anatomy, airway critical closing pressures, and effects on upper-airway dilator muscle function all come into play when a person is in the supine position and can aggravate OSA. In normal sleep, parasympathetic activity is enhanced and the muscle tone of the upper airway is decreased. A healthy person can maintain a patent airway and adequate airflow during sleep. A patient with OSA has a smaller, more collapsible upper airway during sleep, resulting in apneic or hypopneic events and often causing snoring from upper-airway tissue vibration.13
Positional therapy involves the use of assistive devices to help a patient avoid the supine position during sleep. Studies noting the efficacy of positional therapy are lacking or have not been consistent. Sleeping on one’s side is often advised to assist in decreasing the risk of OSA.6 Other simple sleeping strategies include the following:
- Have the person sew a small pocket to the back of the pajamas and place a tennis ball or other small ball into it, to keep the person off of his or her back during sleep.
- Have the person use a special pillow that helps to stretch the neck; this may reduce snoring and improve sleep for people with mild sleep apnea.
- Have the person sleep in an upright position; this may improve oxygen levels in overweight people with sleep apnea. Elevating the head of the bed may help.6
Weight loss can significantly reduce OSA symptoms and should be recommended for all overweight persons with OSA, as illustrated by results reported by Foster and fellow members of the Sleep AHEAD Research Group, part of the Look AHEAD Research Group for the study of intensive lifestyle interventions for overweight persons with diabetes.14 In the randomized trial conducted by Foster’s team, 264 adults (mean age 61.2 years) with type 2 diabetes, mean BMI 36.7 kg/m2, and mean AHI 23.2 events per hour were assigned to a behavioral weight-loss program or to 3 group sessions related to effective diabetes management. At 1 year, after losing significantly more weight than the diabetes-management group (10.8 kg vs. 0.6 kg), the weight-loss group demonstrated an adjusted decrease in AHI of 9.7 events per hour relative to the diabetes-management group. In addition, 3 times as many weight-loss participants experienced total remission of OSA, and severe OSA was only half as prevalent in the weight-loss group as in the diabetes-management group. The investigators noted that persons who lost 10 kg or more had the greatest reductions in AHI.
Weight loss should occur in conjunction with primary treatment of OSA. Once substantial weight loss is achieved, a follow-up polysomnogram is indicated to assess for residual OSA, especially in patients who had low oxygen saturation levels and high supine AHI before weight loss.15
Clinicians should be aware that within the global epidemic of childhood and adolescent obesity, up to 60% of obese children have OSA.16 Early recognition and treatment of OSA in obese youths are likely to lead to a reduction in the cardiometabolic burden of these patients.16 In addition to following healthy eating habits, children and adolescents generally should engage in at least 60 minutes of moderately intense physical exercise per day to prevent obesity or maintain weight.16 Almost half of all obese children with OSA have adenotonsillar hypertrophy; as a result, the American Board of Pediatrics recommends adenotonsillectomy as the first step in OSA management.16 This surgery leads to improvement of obstructive symptoms in 80% of cases in otherwise normal children with OSA, but is less likely to be successful in morbidly obese children.16
Bariatric surgery was described as “a definitive treatment for obstructive sleep apnea” by the authors of a systematic review involving 69 studies and 13,900 patients.17 Undertaken by Sarkhosh and associates to determine which of the available bariatric procedures were the most effective in the treatment of OSA, the review indicated that more than 75% of patients had at least some improvement in OSA, with biliopancreatic diversion being the most successful bariatric procedure in improving or resolving OSA and laparoscopic adjustable gastric banding being the least successful.
Clinical practice guidelines for bariatric surgery cosponsored by the American Association of Clinical Endocrinologists, The Obesity Society, and the American Society for Metabolic and Bariatric Surgery list OSA as a severe obesity-related comorbidity, with the recommendation being that a patient with OSA and with a BMI ≥35 kg/m2 be offered bariatric surgery.18 The guideline authors caution, however, that OSA is associated with increased risk for all-cause mortality and in bariatric surgery patients, with adverse outcomes. Bariatric surgery is rarely recommended for children unless the child is morbidly obese (BMI >40 kg/m2, or has a BMI of 35-40 kg/m2 with coexisting diseases.16 Other nonsurgical approaches should be exhausted before bariatric surgery is considered for the treatment of OSA in children.