Experts Describe Advances in OSA Management

Kathleen Yaremchuk, MD, chair emeritus of otolaryngology-head and neck surgery at Henry Ford Health in Detroit, discussed changes coming to OSA management in the next five years, noting that the apnea–hypopnea index (AHI) will likely no longer be central in assessing the disorder.

“We’ve all grown up with AHI, we live and die by AHI, but in the future, I don’t think that’s going to be the case,” she said. “Every study that’s been done has shown that disease burden doesn’t correlate with AHI—it just doesn’t.”

Alternatives to the AHI include ventilatory burden—how much respiratory disruption people have when they sleep—and the Baveno classification, which does not consider AHI but takes into account the severity of symptoms and comorbidities. In the Baveno, for instance, someone asymptomatic with no comorbidities would receive no intervention, regardless of their AHI, while someone with higher levels of either one might be considered for intervention.

“If you imagine that—the number of people that are on CPAP [continuous positive airway pressure machine] that don’t need to be on CPAP — it’s going to be very interesting,” she said.

Hypoxic burden—how much time people spend below the threshold for being hypoxic—also could rise in prominence, she said.

Studies of atomoxetine, a selective noradrenergic reuptake inhibitor, with the selective antimuscarinic aroxybutynin, which increase the muscle tone of the upper airway, are in stage 3 clinical trials. The same is true for a potassium channel-blocker nasal spray for OSA, intended to increase the muscle tone of the upper airway, which has shown promise, she said (Am J Physiol Heart Circ Physiol. 2024;326:H715-H723. doi: 10.1152/ajpheart.00541.2023).

“I think these pharmaceutical agents,” she said, “are going to be game changers in terms of how you counsel a patient.”

Michael J. Hutz, MD, assistant professor and section head of sleep surgery at Rush University in Chicago, discussed a new approach to drug-induced sleep endoscopy (DISE) that involves a practical, inexpensive way to incorporate the measurement of upper airway collapsibility with CPAP during DISE.

The approach stems from an effort to assess CPAP intolerance by conducting a DISE while the patient is hooked up to CPAP. This evolved to the next-generation “DISE–PAP,” with a pneumotachometer hooked to a nasal CPAP to measure nasal airflow and pressure catheters in the nose and at different points in the airway. Doing it this way, Dr. Hutz said, allows clinicians to identify not only anatomic points of collapse and upper airway collapsibility, but also the drivers of collapse, which, if it makes the difference in treating an upstream or downstream cause, can be very important in the patient’s management, he said.

Now, he has helped design what he calls the “poor man’s DISE–PAP,” at a cost of about $20 per procedure, which can be bundled into billing—the expense of CPAP tubing, viral filters, a bronchi adapter, and CPAP masks.

He said the system has been shown to be quite accurate in measuring upper airway collapsibility and could help predict which patients might do well with an upper airway stimulation system for OSA.

“When you include the palatal opening pressure of a patient in addition to the age, sex, and body mass index,” he said, “it significantly increases the area under the curve and allows you to more accurately select people who would do well.”    

Thomas R. Collins is a freelance medical writer based in Florida.