成人阻塞性睡眠呼吸暂停评价，管理和长期护理治疗指南【美国2009】

Journal of Clinical Sleep Medicine, Vol.5, No. 3, 2009 263 Obstructive sleep apnea (OSA) is a common disorder affect-ing at least 2% to 4% of the adult population and is increas- ingly recognized by the public. The signs, symptoms and conse- quences of OSA are a direct result of the derangements that occur due to repetitive collapse of the upper airway: sleep fragmenta- tion, hypoxemia, hypercapnia, marked swings in intrathoracic pressure, and increased sympathetic activity. Clinically, OSA is defined by the occurrence of daytime sleepiness, loud snoring, witnessed breathing interruptions, or awakenings due to gasping or choking in the presence of at least 5 obstructive respiratory events (apneas, hypopneas or respiratory effort related arousals) per hour of sleep. The presence of 15 or more obstructive respi- ratory events per hour of sleep in the absence of sleep related symptoms is also sufficient for the diagnosis of OSA due to the greater association of this severity of obstruction with important consequences such as increased cardiovascular disease risk.1 The Practice Parameters of the American Academy of Sleep Medicine (AASM) present evidence-based recommendations for several aspects of the diagnosis and management of OSA. However, they do not present a comprehensive approach to OSA patients. The Board of Directors of the AASM assembled the Adult Obstructive Sleep Apnea Task Force in January 2007 to review available literature and produce a clinical guideline for the evaluation, management and long-term care of adult pa- tients with OSA. This guideline is meant to assist primary care Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine Task Force Members: Lawrence J. Epstein, M.D.1(Chair); David Kristo, M.D.2; Patrick J. Strollo, Jr., M.D.2; Norman Friedman, M.D.3; Atul Malhotra, M.D.4; Susheel P. Patil, M.D., Ph.D.5; Kannan Ramar, M.D.6; Robert Rogers, D.M.D.7; Richard J. Schwab, M.D.8; Edward M. Weaver, M.D., M.P.H.9; Michael D. Weinstein, M.D.10 1Sleep HealthCenters, Brighton, MA and Harvard Medical School, Boston, MA; 2University of Pittsburgh, Pittsburgh, PA; 3University of Colorado Health Sciences Center, Aurora, CO; 4Brigham and Women’s Hospital, Boston, MA; 5Johns Hopkins University, Baltimore, MD; 6Mayo Clinic, Rochester, MN; 7Pittsburgh Dental Sleep Medicine, Pittsburgh, PA; 8University of Pennsylvania, Philadelphia, PA; 9University of Washington School of Medicine, Seattle, WA; 10Winthrop-University Hospital, Mineola, NY Submitted for publication March, 2009 Accepted for publication March, 2009 Address correspondence to: Lawrence J. Epstein, M.D., Sleep Health- Centers, 1505 Commonwealth Ave., Brighton, MA 02135 SpeciAl Article Background: Obstructive sleep apnea (OSA) is a common chronic disorder that often requires lifelong care. Available practice param- eters provide evidence-based recommendations for addressing as- pects of care. Objective: This guideline is designed to assist primary care provid- ers as well as sleep medicine specialists, surgeons, and dentists who care for patients with OSA by providing a comprehensive strategy for the evaluation, management and long-term care of adult patients with OSA. Methods: The Adult OSA Task Force of the American Academy of Sleep Medicine (AASM) was assembled to produce a clinical guideline from a review of existing practice parameters and available literature. All existing evidence-based AASM practice parameters relevant to the evaluation and management of OSA in adults were incorporated into this guideline. For areas not covered by the practice parameters, the task force performed a literature review and made consensus recom- mendations using a modified nominal group technique. recommendations: Questions regarding OSA should be incorpo- rated into routine health evaluations. Suspicion of OSA should trigger a comprehensive sleep evaluation. The diagnostic strategy includes a sleep-oriented history and physical examination, objective testing, and education of the patient. The presence or absence and severity of OSA must be determined before initiating treatment in order to identify those patients at risk of developing the complications of sleep apnea, guide selection of appropriate treatment, and to provide a baseline to establish the effectiveness of subsequent treatment. Once the diag- nosis is established, the patient should be included in deciding an ap- propriate treatment strategy that may include positive airway pressure devices, oral appliances, behavioral treatments, surgery, and/or ad- junctive treatments. OSA should be approached as a chronic disease requiring long-term, multidisciplinary management. For each treat- ment option, appropriate outcome measures and long-term follow-up are described. Keywords: Obstructive sleep apnea; sleep evaluation; positive airway pressure treatment; oral appliance treatment; behavioral treatment; surgical treatment. citation: Epstein LJ; Kristo D; Strollo PJ; Friedman N; Malhotra A; Patil SP; Ramar K; Rogers R; Schwab RJ; Weaver EM; Weinstein MD. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5(3):263- 276. Journal of Clinical Sleep Medicine, Vol.5, No. 3, 2009 264 LJ Epstein, D Kristo, PJ Strollo et al providers as well as sleep medicine specialists, surgeons, and dentists who care for patients with OSA. Guideline Development All existing AASM practice parameters relevant to the evalu- ation and management of OSA in adults were incorporated into the development of this guideline. These parameters were pre- viously developed via a computerized, systematic search of the scientific literature (for specific search terms and further details, see referenced practice parameters) and subsequent critical re- view, evaluation, and evidence grading. On the basis of these reviews the AASM Standards of Practice Committee developed practice parameters. Practice parameters were designated as “Standard,” “Guideline,” or “Option” based on the level and amount of scientific evidence available (Table 1). The Adult OSA Task Force constructed the clinical guide- lines from the current practice parameters. The practice param- eters, which are updated every 5 years, were not revised by the task force. Consensus-based recommendations were developed to address important areas of clinical practice that had not been the subject of a previous AASM practice parameter, or where the available empirical data were limited or inconclusive. The Task Force held face-to-face meetings where members of the panel presented reviews of the current literature on consensus topics. Recommendations were generated by panel members and discussed by all. To minimize individual expert bias, the group voted anonymously and rated consensus recommenda- tions using a modified nominal group technique.2 All task force members voted on all questions. If a first round vote was in- conclusive, a second anonymous vote was conducted. Consen- sus-based recommendations reflect the shared judgment of the committee members and reviewers, based on the literature and common clinical practice of topic experts. The consensus state- ments regarding the use of portable monitors were developed, employing similar methods, by the Portable Monitoring Task Force of the AASM for use in a previous guideline document.3 Use of practice parameters and clinical Guidelines Practice parameters and clinical guidelines define principles of practice that should meet the needs of most patients in most situations. They should not, however, be considered exhaustive, inclusive of all available methods of care, or exclusive of other methods of care reasonably expected to obtain the same results. The ultimate judgment regarding appropriateness of any spe- cific therapy must be made by the physician and patient in light of the individual circumstances presented by the patient, avail- able diagnostic tools, accessible treatment options, resources available, and other relevant factors. The AASM expects this clinical guideline to have an impact on professional behavior and patient outcomes. It reflects the state of knowledge at the time of publication and will be reviewed, updated, and revised as new information becomes available. Diagnosis The presence or absence and severity of OSA must be de- termined before initiating treatment in order to identify those patients at risk of developing the complications of sleep apnea, guide selection of appropriate treatment and to provide a baseline to establish the effectiveness of subsequent treatment. Diagnostic criteria for OSA are based on clinical signs and symptoms deter- mined during a comprehensive sleep evaluation, which includes a sleep oriented history and physical examination, and findings identified by sleep testing (Standard).4 The overall evaluation of patients suspected of having OSA is summarized in Figure 1. History and PHysical Examination The diagnosis of OSA starts with a sleep history that is typi- cally obtained in one of three settings: first, as part of routine health maintenance evaluation, second, as part of an evaluation of symptoms of obstructive sleep apnea, and third, as part of the comprehensive evaluation of patients at high risk for OSA. High-risk patients include those who are obese, those with congestive heart failure, atrial fibrillation, treatment refractory hypertension, type 2 diabetes, stroke, nocturnal dysrhythmias, pulmonary hypertension, high-risk driving populations (such as commercial truck drivers), and those being evaluated for bariat- ric surgery (Consensus). (Table 2) Questions to be asked during a routine health maintenance evaluation should include a history of snoring and daytime sleepiness and an evaluation for the presence of obesity, retrog- nathia, or hypertension (Consensus). (Table 3) Positive findings on this OSA screen should lead to a more comprehensive sleep history and physical examination. A comprehensive sleep history in a patient suspected of OSA should include an evaluation for snoring, witnessed apneas, gasping/choking episodes, excessive sleepiness not explained by other factors, including assessment of sleepiness severity by the Epworth Sleepiness Scale,5 total sleep amount, nocturia, morning headaches, sleep fragmentation/sleep maintenance in- somnia, and decreased concentration and memory (Consensus). Table 1—AASM Levels of Recommendation Term Definition Standard This is a generally accepted patient-care strategy that reflects a high degree of clinical certainty. The term standard generally implies the use of Level 1 Evidence, which directly addresses the clinical issue, or overwhelming Level 2 Evidence. Guideline This is a patient-care strategy that reflects a moderate degree of clinical certainty. The term guideline implies the use of Level 2 Evidence or a consensus of Level 3 Evidence. Option This is a patient-care strategy that reflects uncertain clinical use. The term option implies insufficient, inconclusive, or con flicting evidence or conflicting expert opinion. Journal of Clinical Sleep Medicine, Vol.5, No. 3, 2009 265 Clinical Guidelines (Table 4) An evaluation of secondary conditions that may occur as a result of OSA, including hypertension, stroke, myocardial infarction, cor pulmonale, decreased daytime alertness, and motor vehicle accidents, should also be obtained (Consensus). The physical examination can suggest increased risk and should include the respiratory, cardiovascular, and neurologic systems.6 Particular attention should be paid to the presence of obesity, signs of upper airway narrowing, or the presence of oth- er disorders that can contribute to the development of OSA or to the consequences of OSA. Features to be evaluated that may suggest the presence of OSA include increased neck circumfer- ence ( > 17 inches in men, > 16 inches in women), body mass Figure 1—Evaluation. Flow chart for evaluation of patients suspected of having OSA. PCP = primary care physician, SS = sleep specialist. Sleep Disorder Symptoms? Sleep Evaluation (PCP/SS) Routine Health Maintenance Exam (PCP) Patient Complains of Symptoms (PCP/SS) High Risk Screenings (PCP) History and Physical See Table 3 Risk Factor Assessment See Table 2 OSA Symptoms? Evaluate for other sleep disorders and co-morbidities Sleep Study Polysomnography: Full night Split-night Portable Monitor Other Sleep Procedures Results Reviewed with Sleep Specialist OSA? AHI ≥ 15 AHI ≥ 5 + Sxs Patient Education: See Table 4 Evaluate for other disorders or co- morbidities Discuss Treatment Options CPAP Offered?CPAPFigure 2 Alternative Therapies Behavioral Oral Appliance Surgical Adjunctive Figure 3 Figure 4 Figure 5 Figure 6 Yes YesNo No Yes Accept Decline See Table 1 Journal of Clinical Sleep Medicine, Vol.5, No. 3, 2009 266 Patients with hypertension should undergo evaluation and test- ing if they have nocturnal symptoms (disturbed sleep, nocturnal dyspnea, or snoring) suggestive of obstructive sleep apnea or if they remain hypertensive despite optimal medical management (Consensus). A preoperative clinical evaluation that includes PSG or PM is routinely indicated to evaluate for the presence of OSA in patients before they undergo upper airway surgery for snoring or OSA (Standard).6 A preoperative clinical sleep evaluation that includes PSG is recommended to evaluate for the presence of OSA in patients before they undergo bariatric surgery (Consensus). PM testing may also be indicated for the diagnosis of OSA in patients for whom in-laboratory PSG is not possible by virtue of immobility, safety or critical illness and to monitor response to non-CPAP therapies (Consensus).3 Follow-up PSG or attended cardiorespiratory (type 3 PM) sleep study is routinely indicated for the assessment of treat- ment results after surgical treatment for moderate to severe OSA (Standard).6 To ensure satisfactory therapeutic benefit from oral appliances (OA), patients with OSA should undergo PSG or an attended cardiorespiratory (type 3 PM) sleep study with the OA in place after final adjustments of fit have been per- formed (Guideline).4 Also, unattended PM may be indicated to monitor the response to non-CPAP treatments for OSA, includ- ing OAs, upper airway surgery, and weight loss (Consensus).3 Follow-up PSG or attended cardiorespiratory (type 3 PM) sleep study is routinely indicated to assess treatment results after sur- gical or dental treatment for sleep related breathing disorders when symptoms return, despite a good initial response to treat- ment (Standard).6 Follow-up PSG is routinely indicated in OSA patients for the assessment of treatment results on CPAP after substantial weight loss (e.g., 10% of body weight), substantial weight gain with return of symptoms, when clinical response is insufficient, or symptoms return despite a good initial response to CPAP (Standard).6 Follow-up PSG or PM is not routinely index (BMI) > 30 kg/m2, a Modified Mallampati score of 3 or 4,7 the presence of retrognathia, lateral peritonsillar narrowing, macroglossia, tonsillar hypertrophy, elongated/enlarged uvula, high arched/narrow hard palate, nasal abnormalities (polyps, deviation, valve abnormalities, turbinate hypertrophy) and/or overjet (Consensus). Following the history and physical examination, patients can be stratified according to their OSA disease risk. Those patients deemed high risk should have the diagnosis confirmed and se- verity determined with objective testing in an expedited manner in order to initiate treatment. For other patients, the timing of further testing is determined by the risk of OSA and the pres- ence of daytime impairment or associated morbidity. As part of the initial sleep evaluation, and prior to objective testing, patients should receive education regarding possible diagno- ses, diagnostic steps, and the procedure involved in any testing (Consensus). objEctivE tEsting The severity of OSA must be established in order to make an appropriate treatment decision.4 No clinical model is recom- mended to predict severity of obstructive sleep apnea (Option),6 therefore objective testing is required. A diagnosis of OSA must be established by an acceptable method (Standard).8 The two ac- cepted methods of objective testing are in-laboratory polysom- nography (PSG) and home testing with portable monitors (PM). For specifics on the parameters to be measured with PSG and PM, see the sections below. PSG is routinely indicated for the diagnosis of sleep related breathing disorders (Standard).6 PMs may be used to diagnose OSA when utilized as part of a com- prehensive sleep evaluation in patients with a high pretest likeli- hood of moderate to severe OSA (Consensus).3 PM testing is not indicated in patients with major comorbid conditions including, but not limited to, moderate to severe pulmonary disease, neuro- muscular disease, or congestive heart failure, or those suspected of having a comorbid sleep disorder (Consensus).3 High-risk patients with nocturnal symptoms of OSA should undergo sleep testing, including those who are obese, those with systolic or diastolic heart failure (Standard), coronary ar- tery disease (Guideline),6 history of stroke or transient ischemic attacks (Option),6 or significant tachyarrhythmias or bradyar- rhythmias (Guideline).6 Patients with congestive heart failure who continue to have nocturnal symptoms of sleep related breathing disorders despite optimal medical management are also at risk for OSA and should undergo testing (Standard).6 Table 2—Patients at High Risk for OSA Who Should Be Evalu- ated for OSA Symptoms Obesity (BMI > 35) Congestive heart failure Atrial fibrillation Treatment refractory hypertension Type 2 diabetes Nocturnal dysrhythmias Stroke Pulmonary hypertension High-risk driving populations Preoperative for bariatric surgery Table 3—Questions about OSA that Should Be Included in Rou- tine Health Maintenance Evaluations Is the patient obese? Is the patient retrognathic? Does the patient complain of daytime sleepiness? Does the patient snore? Does the patient have hypertension? Table 4—OSA Symptoms that Should Be Evaluated during a Comprehensive Sleep Evaluation Witnessed apneas Snoring Gasping/choking at night Excessive sleepiness not explained by other factors Nonrefreshing sleep Total sleep amount Sleep fragmentation/maintenance insomnia Nocturia Morning headaches Decreased concentration Memory loss Decreased libido Irritability LJ Epstein, D Kristo, PJ Strollo et al Journal of Clinical Sleep Medicine, Vol.5, No. 3, 2009 267 arousals) on PSG is greater than 15 events/hr or greater than 5/ hour in a patient who reports any of the following: unintention- al sleep episodes during wakefulness; daytime sleepiness; un- refreshing sleep; fatigue; insomnia; waking up breath holding, gasping, or choking; or the bed partner describing loud snoring, breathing interruptions, or both during the patient’s sleep.1 OSA severity is defined as mild for RDI ≥ 5 and < 15, moderate for RDI ≥ 15 and ≤ 30, and severe for RDI > 30/hr (Consensus). Testing with Portable Monitors PM for the diagnosis of OSA should be performed only in conjunction with a comprehensive sleep evaluation. Clinical sleep evaluations using PM must be supervised by a practitio- ner with board certification in sleep medicine or an individual who fulfills the eligibility criteria for the sleep medicine certifi- cation examination (Consensus).3 A PM shoul