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A New Direction for Sleep: New OSA guidelines fuel another evidence-based medicine debate

by Mary Beth Nierengarten •

The AASM parameters raised the question of whether otolaryngologists should develop their own guidelines on the surgical management of sleep apnea in adults.

According to Dr. Harwick, the sleep committee discussed this matter at the AAO-HNS meeting held in Boston in September and resolved to develop a realistic way to determine effective, successful outcomes and then create studies to measure that. The result is a suggested blueprint for reporting results of obstructive sleep apnea surgery trials, said Dr. Wardrop. The committee is currently reviewing the document before finalizing it.

Current Sleep Guidelines

  • Clinical practice guideline: indications for polysomnography for sleep-disordered breathing prior to tonsillectomy in children (in development).
  • Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults, October 2010 (SLEEP. 33(10):1408-1413).
  • Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults, June 2009 (J Clin Sleep Med. 5(3):263-276).
  • Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients With Obstructive Sleep Apnea, May 2006 (Anesthesiology. 104(5):1081-1093).
  • Practice parameters for the treatment of obstructive sleep apnea in adults: the efficacy of surgical modifications of the upper airway. Report of the American Sleep Disorders Association, February 1996 (Sleep. 19(2):152-155).

Sleep-Disordered Breathing Guidelines

Norman Friedman, MD, director of the Children’s Sleep Medicine Laboratory at the University of Colorado Children’s Hospital in Aurora, said it is always difficult generating surgical guidelines. Dr. Friedman is currently part of an AAO-HNS-led multidisciplinary panel formed in January 2010 to create pediatric sleep-disordered breathing guidelines to be published in Otolaryngology-Head and Neck Surgery in 2011. Panel members consisting of sleep medicine physicians, pediatricians, anesthesiologists and pulmonary physicians, along with otolaryngologists, are developing the guidelines, which target children ages two to 18 years who have been given a clinical diagnosis of sleep-disordered breathing, are candidates for tonsillectomy and may benefit from a pre-operative polysonogram (PSG). External and internal review of the guidelines will be done by multiple invited representatives from a number of specialties both within and outside of AAO-HNS.

“When it comes to surgical guidelines, the difficulty is that everything is being compared to noninvasive ventilation, and all of us agree that if a person is compliant with noninvasive ventilation, noninvasive treatment will be more successful,” Dr. Friedman said. “The issue is compliance, as well as whether outcomes measured by the apnea-hypopnea index also effectively measure quality of life.”