What should we do with patients who have mild OSA and no daytime consequences?
It looks like the jury is still out on whether mild OSA should be treated with CPAP (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564770/). The latest clinical guidance (http://apneaguy.net/wp-content/uploads/2013/09/OSA_Adults.pdf) suggests that patients with mild OSA be treated only if they experience symptoms. See Figure 1. Hope this helps.
Even if mild asymptomatic OSA "should" be treated, compliance will likely be low.
The treatment in milder cases is controversial and the AASM guidelines recommend weight management, MADs etc rather than PAP.
However, some other literature suggests that treatment decision should not be based solely upon AHI. Rather co-morbid conditions should be taken into account.
In our clinic we usually include following factors while deciding for the treatment: disease severity, comorbidities, patient's preference/acceptance, compliance, affordability, expected benefit with treatment versus risk of not treating it etc.
Both Sleep Heart Health and Wisconsin Cohort suggest an increased risk in CV outcomes whether they be HTN or CVA. Yes, Sleep Heart Study suggests a much greater risk of CV in severe OSA, but all levels of OSA deserve attention with mild to moderate worthy of oral appliance consideration
Yes - because the high cardiovascular, cerebrovascular and metabolic risk
I would refer to the published pro-con debate on this matter.
( I think this was cited in the reply by Brian Gonzalez. )
CON:
Littner MR. J Clin Sleep Med. 2007 Apr 15;3(3):263-4.
PRO:
Brown LK. J Clin Sleep Med. 2007 Apr 15;3(3):259-62.
I think a case-by-case approach is needed in theses situations. With regard to the "asymptomatic" patient - sometimes patients don't realize they were symptomatic until after they have experienced the benefits of CPAP. Other times, CPAP just induces or exacerbates insomnia. I would advocate a trial of CPAP for a few months and re-assess clinically.
I think the question beneath your question is - is mild OSA, regardless of symptoms, harmful from a cardiovascular or neuro-cognitive standpoint? We have yet to learn which aspects of OSA are most detrimental for which outcomes (i.e. sleep fragmentation, hypoxia, hypoventilation, thoracic pressure changes). Until we learn these issues we will not be able to argue strongly for either position on this matter.
The question that we need to ask is OSA progressive. Will mild lead to moderate then to severe. Not sure we could ethically do a controlled study because we know OSA has significant associated health issues. Get a full sleep study by a board certified sleep physician. Oral appliances do work on mild to moderate OSA and many but not all CPAP intolerant patients. My personal experience with a split night documented sleep study RDI 25 first 1/2 of night and RDI of 5 with a custom titratable oral appliance. I am CPAP intolerant. We are presently doing studies on orthodontic age patients with 3D facial surface capture (non-radiographic) for biomarkers on the face to evaluate clues for allergy and airway, asymmetry, etc. This helps us determine the need for more definitive diagnosis with 3D Conebeam CT imaging.
Yes I think mild sleep apnea patients without daytime sleepiness should be treated. Daytime sleepiness is not the only symptom of sleep apnea. Those patients may be experiencing other symptoms. Their treatment will depend on the severity of the symptoms they are having.
Even with "mild SA" there is a drop in O2 level and a cessation of breathing of 10 sec or more per episode. need to evaluate the other parameters in the Sleep study. better to be safe may progress with time.
You are right, EDS is only one symptom of OSA/OSAS and other Sleep Breathing Disorders. Without treatment it is a progressive disease and the patients can develop a lot of different comorbidities.
You ask about treatment. be sure the patient has been diagnosed by a Sleep physician and if the Sleep apnea is obstructive (OSA) vs central (CSA). dentists cannot help with central SA that is treated by the sleep Doc. usually mild SA can be controlled by an oral appliance (OA) . we take a CBCT prior to and after placement of the OA to evaluate the physical size changes of the airway, even though it is upright and awake. also have the Sleep Doc do a followup Sleep study or home Sleep test to evaluate the effectiveness and help in titration is also important .
Another way to look at the question , Should someone who had a "mild Heart attack" be treated. Of course they should. Mild OSA does not mean insignificant only a designation of the severity of the disease.
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