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Impact of Mild Obstructive Sleep Apnea in Adults Susmita Chowdhuri, Stuart F

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Impact of Mild Obstructive Sleep Apnea in Adults Susmita Chowdhuri, Stuart F AMERICAN THORACIC SOCIETY DOCUMENTS An Official American Thoracic Society Research Statement: Impact of Mild Obstructive Sleep Apnea in Adults Susmita Chowdhuri, Stuart F. Quan, Fernanda Almeida, Indu Ayappa, Salma Batool-Anwar, Rohit Budhiraja, Peggy E. Cruse, Luciano F. Drager, Barbara Griss, Nathaniel Marshall, Sanjay R. Patel, Susheel Patil, Shandra L. Knight, James A. Rowley, and Alison Slyman; on behalf of the ATS Ad Hoc Committee on Mild Obstructive Sleep Apnea THIS OFFICIAL RESEARCH STATEMENT OF THE AMERICAN THORACIC SOCIETY (ATS) WAS APPROVED BY THE ATS BOARD of DIRECTORS,FEBRUARY 2016 Background: Mild obstructive sleep apnea (OSA) is a highly prevalent Results: Studies were incongruent in their definitions of “mild” disorder in adults; however, whether mild OSA has significant OSA. Data were inconsistent regarding the relationship between neurocognitive and cardiovascular complications is uncertain. mild OSA and daytime sleepiness. However, treatment of mild OSA fi may improve sleepiness in patients who are sleepy at baseline and Objectives: The speci c goals of this Research Statement are to improve quality of life. There is limited or inconsistent evidence appraise the evidence regarding whether long-term adverse pertaining to the impact of therapy of mild OSA on neurocognition, neurocognitive and cardiovascular outcomes are attributable to mild mood, vehicle accidents, cardiovascular events, stroke, and OSA in adults, evaluate whether or not treatment of mild OSA is arrhythmias. effective at preventing or reducing these adverse neurocognitive and cardiovascular outcomes, delineate the key research gaps, and provide direction for future research agendas. Conclusions: There is evidence that treatment of mild OSA in individuals who demonstrate subjective sleepiness may be beneficial. Methods: Literature searches from multiple reference databases Treatment may also improve quality of life. Future research agendas were performed using medical subject headings and text words for should focus on clarifying the effect of mild OSA and impact of OSA in adults as well as by hand searches. Pragmatic systematic effective treatment on other neurocognitive and cardiovascular reviews of the relevant body of evidence were performed. endpoints as detailed in the document. Contents Loss, MVAs, and Poor Quality Question 4: Does Treatment Overview of Life? of Mild OSA in Comparison Introduction Question 2: Does Treatment of to No Treatment Prevent Purpose Mild OSA in Comparison to No or Reduce Adverse Methods Treatment Prevent or Reduce Cardiovascular Outcomes, Questions Adverse Neurocognitive Including Hypertension, Definition of Mild OSA Consequences and MVAs and CAD, Cerebrovascular Literature Search Methodology Improve Quality of Life? Events, Arrhythmias, and Literature Review Methodology Question 3: Does Mild OSA in Cardiovascular and Evidence Syntheses Comparison to the Absence of All-Cause Mortality? Question 1: Does Mild OSA in OSA Contribute to Adverse Limitations Comparison to Absence of Long-Term Cardiovascular Knowledge Gaps OSA Contribute to Adverse Outcomes, Such as Neurocognitive Outcomes Long-Term Neurocognitive Hypertension, CAD, Cardiovascular Outcomes Outcomes, Such as Cerebrovascular Events, Other Daytime Sleepiness, Arrhythmias, and Cardiovascular Research Recommendations Poor Attention/Memory and All-Cause Mortality? Conclusions An Executive Summary of this document is available at http://www.atsjournals.org/doi/suppl/10.1164/rccm.201602-0361ST ORCID IDs: 0000-0002-5927-1169 (S.C.); 0000-0002-9474-7679 (S.F.Q.); 0000-0002-8704-9506 (F.A.); 0000-0002-9014-1397 (N.M.); 0000-0002-9142- 5172 (S.R.P.); 0000-0002-4404-3833 (S.L.K.). This article has an online supplement, which is accessible from this issue’s table of contents at www.atsjournals.org Am J Respir Crit Care Med Vol 193, Iss 9, pp e37–e54, May 1, 2016 Copyright © 2016 by the American Thoracic Society DOI: 10.1164/rccm.201602-0361ST Internet address: www.atsjournals.org American Thoracic Society Documents e37 AMERICAN THORACIC SOCIETY DOCUMENTS Overview function, if any, improve as a result of accompanied by cardiovascular, treatment for mild OSA. neurocognitive, or metabolic Mild obstructive sleep apnea (OSA) is a highly d There are discordant data examining the consequences. General population-based prevalent disorder in adults. However, association between mild OSA and studies indicate that the prevalence of fi whethermildOSAhassignificant mood, as well as limited data regarding OSA syndrome de ned as AHI greater the effect of treatment of mild OSA on neurocognitive and cardiovascular than or equal to 5/h with daytime mood. sleepiness ranges from 3 to 7.5% in adult complications is uncertain. This Research d It is unclear whether there is an menandfrom2to3%inadultwomen Statement appraises the evidence regarding association between mild OSA and (2–8); if using a criterion of AHI greater whether or not long-term adverse increased incidence of cardiovascular than or equal to 5/h alone, the prevalence neurocognitive and cardiovascular outcomes events. It is unclear whether there is a is much higher, ranging from 8 to 28% in are attributable to mild OSA in adults, differential impact of mild OSA on adult men and 3 to 26% in adult women determines whether or not treatment of mild hypertension and cardiovascular (2–4, 6, 8–12), respectively. Most of these OSA is effective at preventing or reducing complications in high-risk populations population-based studies have estimated a (e.g., individuals with underlying these adverse neurocognitive and two- to threefold greater risk for men than cardiovascular disease or multiple cardiovascular outcomes, delineates the key women. comorbid conditions) as well as those Over the years, there have been a research gaps, and provides direction for who are sleepy. number of attempts to standardize the future research agendas. d Mild OSA is likely not associated with an definitions and diagnostic criteria for OSA d In this research statement, mild OSA was increase in stroke in subjects from the to provide a uniform framework for identified when the metric of OSA general population or patients referred comparing results of research investigations for sleep studies. However, limited data severity (apnea–hypopnea index, as well as to assist in clinical management. In suggest that mild OSA may increase 1997, a group of experts reached a consensus respiratory disturbance index, or oxygen stroke risk in persons with underlying desaturation index) in the sleep study to categorize OSA into three severity groups coronary artery disease. on the basis of AHI (13): was at least 5/h and less than 15/h. d It is not clear whether an association d Most randomized controlled trials with exists between mild OSA and the risk for 1. Mild OSA: 5 to ,15 events/h continuous positive airway pressure developing atrial fibrillation and other 2. Moderate OSA: 15 to ,30 events/h (CPAP) demonstrate that treatment arrhythmias. 3. Severe OSA: >30 events/h of mild OSA improves subjective d Available evidence from population- The group acknowledged the lack of assessments of daytime sleepiness by a based longitudinal studies indicates prospective studies to validate the definitions small amount and that this effect may only that mild OSA is not associated with and considered the thresholds, also known as be present in patients with an elevated level increased cardiovascular or all-cause the “Chicago criteria” (13), as operational of sleepiness at baseline. However, limited mortality. There are no studies of the definitions. This consensus statement hoped existing data show no impact of treatment impact of treatment on cardiovascular to stimulate further research to identify the on objective measures of sleepiness. The mortality. There was no evidence from a impact of non–positive airway pressure single study that treatment of mild OSA optimal approach to quantifying OSA. The (PAP) therapies on daytime sleepiness reduces all-cause mortality. data to justify a severity index on the basis of remains unclear. d The task force members identified event frequency and the AHI of 5/h as a d A limited number of population-based specific research gaps and made minimal threshold value were derived from and clinic-based studies provide recommendations to address these gaps the Wisconsin Sleep Cohort (7, 14) showing conflicting data regarding the risk of in knowledge. an increasing dose-dependent risk of “ ” motor vehicle accidents as a consequence hypertension that was substantial at AHI 30/h. The recommended cutoff of 15/h of mild OSA. There are no studies on the Introduction for moderate OSA was based on both expert impact of treatment of mild OSA on the consensus opinion and clinical research, risk for motor vehicle accidents. fi OSA is a major public health problem that where mild OSA has frequently been de ned d Although the few studies that have is characterized by repetitive obstruction as AHI 5/h to less than 15/h. Consequently, evaluated the impact of mild OSA on of the upper airway resulting in oxygen the same AHI severity definition was used quality of life have yielded conflicting desaturation and/or arousals from sleep. in this Research Statement. results, most studies seem to show a The International Classification of Sleep Notwithstanding the lack of clarity small improvement in quality of life after Disorders (1) defines OSA as the regarding definitions for OSA severity, treatment of OSA. occurrence of predominantly obstructive observational and interventional data d In
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