Kent D, Stanley J, Aurora RN, Levine C, Gottlieb DJ, Spann MD, Torre CA, Green K, Harrod CG. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021 Dec 1;17(12):2499-2505. doi: 10.5664/jcsm.9592. PMID: 34351848.
The American Academy of Sleep Medicine (AASM) recently published two papers that were a result of taskforce of sleep surgeons and physicians led by A/Prof. David Kent. Dr. David Kent, director of sleep surgery within the department of otolaryngology-head and neck surgery at Vanderbilt University in Nashville, Tennessee.
The first was a systematic review and meta-analysis of sleep surgery literature1 and subsequent clinical practical guidelines2. The guidelines focus on whether or not surgical referral should be discussed in adult patients in varying scenarios. This differs from previous AASM guidelines, and deliberately avoids recommendation on specific procedure but looks at the body of evidence in regards to surgery as a whole. The guidelines acknowledge that the scenario where surgery may option for treatment is common and that the assessment and discussion around surgery can only be provided by the surgeon offering the treatment. Evidence for bariatric surgery was also included. Clinic-based procedures were excluded, as they are primarily aimed at patients with snoring without OSA. Strict inclusion criteria were defined a priori: of the 3230 articles identified through literature searches, 247 papers were included for analysis, including 6 RCTs. RCT data was analysed separately from observational data but were combined to form four recommendations, that were assigned either “strong” or “conditional”.
These recommendations were:
1. Clinicians discuss referral to a sleep surgeon with adults with OSA and BMI<40 kg/m2 who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options. (STRONG). Quality of evidence: LOW.
2. Clinicians discuss referral to a bariatric surgeon with adults with OSA and obesity (class II/III, BMI ≥35 kg/m2) who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options. (STRONG). Quality of evidence: MODERATE.
3. Clinicians discuss referral to a sleep surgeon with adults with OSA, BMI<40, and persistent inadequate PAP adherence due to pressure-related side effects as part of a patient-oriented discussion of adjunctive or alternative treatment options. (CONDITIONAL). Quality of evidence: VERY LOW
4. Clinicians recommend PAP as initial therapy for adults with OSA and a major upper airway anatomic abnormality prior to consideration of referral for upper airway surgery. (CONDITIONAL). Quality of evidence: LOW.
It should be noted that these recommendations generally came with caveats, i.e. for recommendation 1, patients with a BMI >40 kg/m2 can still be considered for referral if deemed appropriate by the treating clinician. Although the evidence for non-bariatric surgery was low or very low, the quality of evidence was higher when looking at RCT data. It is also important to understand that the results were a mixture of papers published over a long timeline, involved the spectrum of sleep surgery procedures and most were observational in nature. This was required by nature of the guideline’s aims. However, the paper formalises the evidence of something that we as surgeons have long suspected. That surgery is an important arm in the treatment of patient with OSA and clinicians treating OSA should consider surgical referral in the appropriate patient, especially if they have failed conservative treatment measures.