Clinical Consequences and Management of Sleep Disordered Breathing

Sleep disordered breathing and obstructive sleep apnea (OSA) in particular are associated with several adverse health consequences including cardiovascular, metabolic, and neurocognitive disease. In the last decade, there has been a gradual increase in the awareness of these interactions. The prevalence of OSA is expected to increase substantially in the coming years, tracking with the rising rates of obesity worldwide. Despite these trends, the majority of patients suffering from OSA remain undiagnosed. In addition, there is a significant shortage of sleep medicine specialists to handle the ever increasing demands. It is in this context that clinicians face the challenge of developing efficient and effective diagnostic and treatment strategies for individual patients as well as populations.

This issue of Seminars in Respiratory and Critical Care Medicine reviews topics ranging from our current understanding of the pathophysiology of OSA, strategies to improve access to care, to technological innovations aimed at improving treatment adherence and efficacy.

The first article provides a comprehensive review of the role of OSA and resultant intermittent hypoxia, oxidative stress, and systemic inflammation in the development and progression of cardiovascular disease, cardiac dysrhythmias, pulmonary hypertension, insulin resistance, stroke, and potentially malignancy.

The following three articles review strategies to address the rising demands for care. Primary care providers will need to be increasingly involved in the diagnosis and management of OSA and will need an evidence-based approach to guide them. In the appropriate patient populations, home sleep apnea testing will play an integral role in helping to cut the cost and improve the efficiency of diagnostic testing. Incorporating tele-medicine into existing care delivery systems carries with it the potential to improve access to care.

We then focus on the growing evidence regarding sleep disruption during acute hospitalization. Sleep disruption potentiated by the complex interactions among acute illness, surgery, medications, and sleep disordered breathing contribute to increased hospital morbidity and cost. The acute care clinician is sure to encounter the undiagnosed sleep apnea patient in practice. The fifth article discusses screening and perioperative management of patients with likely sleep apnea and interventions to mitigate risk. The sixth article explores factors contributing to sleep disruption in the hospitalized patient with an emphasis on opportunities for improvement and timely management of individuals with comorbid sleep apnea.

Although continuous positive airway pressure therapy remains the gold standard for treatment of OSA, adequate patient adherence remains elusive. Auto-adjusting and servo ventilation devices have been developed to improve patient comfort and adherence as well as to address central apnea and complex sleep apnea syndromes. The seventh article reviews the evidence for use of advanced PAP modalities and informs a practical approach to patient management.

Addressing an individual's barriers to PAP adherence is fundamental in formulating an effective care plan. The eighth article considers factors that impede adherence and offers ways to improve patients' acceptance of PAP therapy.

Ongoing efforts to develop alternatives to PAP therapy have yielded promising results. Oral appliances are widely used by individuals who are unable or unwilling to use PAP. Moreover, there exist a range of surgical interventions that may significantly improve disease severity. The ninth article compares oral appliance and surgical treatments for OSA, emphasizing careful patient selection to maximize positive outcomes.

Advances in our understanding of the multiple mechanisms contributing to upper airway collapse offer an opportunity to more precisely individualize treatment. The tenth article introduces novel approaches for the treatments for OSA that have the potential to significantly expand our therapeutic armamentarium.

We sincerely thank the authors for their expertise and thoughtful contribution to this issue of Seminars. We hope the information presented will encourage practitioners to consider the profound impact of sleep and sleep disordered breathing on several disease states across a spectrum of clinical scenarios and serve as a valuable reference.

Thank you.