Last updated January 25, 2022

Referral of Adults with Obstructive Sleep Apnea for Surgical Consultation

Surgical treatment of patients who are intolerant or unaccepting of PAP

Recommendation 1: We recommend that clinicians discuss referral to a sleep surgeon with adults with OSA and BMI < 40 kg/m2 who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options. ( S )
Remarks: The recommendation to discuss referral is not required to result in referral and does not preclude patient consideration of other viable alternative treatment options (eg, mandibular advancement device, positional therapy, lifestyle changes). The strong recommendation to discuss surgical referral with patients with a BMI < 40 kg/m2 is not a recommendation against (and does not preclude) discussion of surgical referral with patients with a BMI ≥ 40 kg/m2 if the health care provider deems it an appropriate management discussion point. For patients within the BMI range of 35–40 kg/m2, discussion regarding a referral to both sleep and bariatric surgeons (as per Recommendation 2) to discuss management options is appropriate.
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Surgical treatment of patients with obesity with bariatric surgery

Recommendation 2: We recommend that clinicians discuss referral to a bariatric surgeon with adults with OSA and obesity (class II/III, BMI ≥ 35) who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options. ( S )
Remarks: The recommendation to discuss referral is not required to result in referral and does not preclude patient consideration of medical weight loss strategies or other viable alternative treatment options for OSA. For patients within the BMI range of 35–40 kg/m2, discussion regarding a referral to both sleep and bariatric surgeons (as per Recommendations 1 and 3) to discuss management options is appropriate. The strong recommendation to discuss surgical referral with patients with OSA, obesity, and PAP intolerance or unacceptance is not a recommendation against (and does not preclude) discussion of surgical referral with patients with OSA, obesity, and adequate PAP use if the health care provider deems it an appropriate management discussion point. Other organizations, such as the National Heart, Lung, and Blood Institute, recommend consideration of bariatric surgery for individuals suffering from obesity (class II/III, BMI ≥ 35 kg/m2) and OSA, regardless of PAP adherence status.
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Surgical treatment of patients to facilitate PAP use

Recommendation 3: We suggest that clinicians discuss referral to a sleep surgeon with adults with OSA, BMI < 40 kg/m2, and persistent inadequate PAP adherence due to pressure-related side effects as part of a patient-oriented discussion of adjunctive or alternative treatment options.
  ( C )
Remarks: Available data suggest that upper airway surgery has a moderate effect in reducing minimum therapeutic PAP level and increasing PAP adherence. The decision to offer referral should be based on the clinician’s judgment of a patient’s current PAP adherence and tolerance as well as the patient’s treatment preferences. Low degrees of nonadherence or minimal side effects may preclude consideration of a referral. Referral may be informed by the presence of other surgically treatable conditions that contribute to upper airway obstruction (eg, persistent nasal obstruction, chronic tonsillitis, malocclusion). For patients within the BMI range of 35–40 kg/m2, discussion regarding a referral to both sleep and bariatric surgeons (as per Recommendation 2) to discuss management options may be appropriate. The conditional recommendation to discuss surgical referral with patients with a BMI < 40 kg/m2 is not a recommendation against (and does not preclude) discussion of surgical referral with patients with a BMI ≥ 40 kg/m2 if the health care provider deems it an appropriate management discussion point, especially as some surgical therapies that reduce minimum therapeutic PAP level (eg, nasal surgery) are not anticipated to be impacted by BMI.
 
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Surgical treatment as initial therapy in patients with a major upper airway anatomical abnormality

Recommendation 4: We suggest that clinicians recommend PAP as initial therapy for adults with OSA and a major upper airway anatomic abnormality prior to consideration of referral for upper airway surgery. ( C )
Remarks: Major upper airway anatomic abnormalities considered by the task force included tonsillar hypertrophy and maxillomandibular abnormalities. While data suggest a clinically significant benefit from surgical intervention in these populations, PAP should be recommended as initial treatment as it carries minimal risk relative to surgery. The decision to discuss referral for initial surgical therapy should be based on the clinician’s judgment of the patient’s medical history as consideration of initial surgical intervention may be justified in the setting of other surgical indications affecting upper airway patency (eg, chronic tonsillitis, malocclusion, abnormal lesion, or growth). The conditional recommendation does not preclude discussion of surgical referral prior to the initial PAP trial if the health care provider deems it an appropriate management discussion point. Furthermore, this recommendation is for the initial treatment of OSA and does not address management of patients who have previously trialed PAP, as detailed in Recommendations 1–3.
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Recommendation Grading

Overview

Title

Referral of Adults with Obstructive Sleep Apnea for Surgical Consultation

Authoring Organization

Publication Month/Year

December 1, 2021

Document Type

Guideline

Country of Publication

US

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory

Scope

Counseling, Management

Diseases/Conditions (MeSH)

D020181 - Sleep Apnea, Obstructive, D012017 - Referral and Consultation

Keywords

CPAP, sleep apnea, OSA, sleep apnea surgery, PAP

Source Citation

Kent D, Stanley J, Aurora RN, Levine C, Gottlieb DJ, Spann MD, Torre CA, Green K, Harrod CG. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021 Dec 1;17(12):2499-2505. doi: 10.5664/jcsm.9592. PMID: 34351848.