What to Consider for Sleep Apnea Treatment

Apnea is simply an absence of inspiration and there are several kinds. Often obstructive sleep apnea (OSA) is found in obese patients or patients with abnormal throat (oropharyngeal) anatomy. These patients have frequent obstructive apneas or reduced inspiration (hypopneas) during sleep. OSA leads to multiple sleep-time arousals and excessive sleepiness (hypersomnia) during the day. Central sleep apnea occurs when a patient’s brain fails to send the signals to the breathing muscles. It’s treated with medication, medroxyprogesterone, a respiratory stimulant. Positional sleep apnea is treated by making back-sleeping uncomfortable for the patient.

Medically, apnea is a lack of inspiration for at least ten seconds. Accurate measurement of apnea hypopnea index (AHI) requires about six hours of sleep. Hypopnea means the patient has at least a 30 percent decrease in inspiration with at least a four percent decrease in oxygen saturation. Patients with OSC or central sleep apnea have little difficulty falling asleep, but a routine sleep study can help diagnose these and related sleep disorders.

Doctors measure OSA severity by the AHI and the minimum oxygen saturation. The AHI measures the number of apneas and hypopneas each hour and the minimum oxygen saturation which measures the effect of the disordered breathing on oxygen saturation. Normal AHI is five or less and daytime hypersomnia estimated using the Epworth Sleepiness Score (0-24 where normal is 10 or under).

The medically necessary and accepted treatment for clinically significant OSA is continuous positive airway pressure (CPAP). CPAP is the only treatment for OSA in adults. Unless the patient is intolerant of CPAP which means the patient went through at least a three-month CPAP trial supervised by a sleep medicine specialist.

CPAP is medically necessary when the patient has an AHI of at least 15 unless there is documentation of severe hypersomnia and complications attributed to OSA, such as pulmonary hypertension, hypertension or congestive heart failure.

Bi-level positive airway pressure (BiPAP) is another type of CPAP. The positive pressures for inspiration and expiration can be set independently with this method. Sometimes BiPAP improves the patient’s treatment tolerance.

Patients with positional sleep apnea show a marked difference in the AHI when sleeping on their backs. The usual treatment for this is a backpack vest with a soft ball inside that makes the patient’s sleeping back uncomfortable so that it’s avoided. With positional OSA, CPAP is often medically unnecessary.

Surgical treatment of OSA, commonly called palatopharyngoplasty or UPPP, is controversial. Often, the end point in surgical clinical trials is not normalization of the AHI as in CPAP trials, but rather improvement in the AHI (see first reference).

Case managers should realize there is an economic reason involved in sleep specialist referrals. Many referrals to sleep centers come from ENT physicians. The recommendation section of a sleep medicine report often mentions a surgical treatment. However, CPAP in conjunction with weight loss is always an alternative. Unfortunately, patients often desire the surgical quick-fix. The surgery is usually combined with nasal cosmetic surgery. Such combined surgeries have a usual success rate of less than 50 percent and do not normalize of the AHI. Because weight loss is curative in most adult patients with OSA, routine surgery for this condition is not accepted medical practice.

About AllMed Healthcare Management

Founded in 1995, AllMed is a URAC-accredited Independent Review Organization (IRO) serving insurance payers, providers, TPAs and claims managers nationwide. Reviews are conducted by board-certified physicians in active practice. AllMed’s growing customer base for its allmedmd.com independent medical review and hospital peer review services includes premier organizations, such as Educator’s Mutual Life, IMS Managed Care, Tenet Healthcare Corporation, HealthGuard, several Blue Cross Blue Shield organizations, TriWest Healthcare Alliance, Allianz and many other leading healthcare payers. Read the AllMed allmedmd.com/blog/index.htm Medical News Blog and the allmedmd.com/skipblog/ Independent Review Organization Blog.

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