Reena Mehra, MD, MS: The State of Sleep Apnea


Why are diagnoses still significantly underwhelming for a chronic condition on the rise?

Obstructive sleep apnea (OSA) care is a far more assured practice than OSA diagnosis. Though it’s been known for nearly 2 decades the latter has been notably under-addressed, frontline efforts to spot chronic sleep conditions are still lacking.

In an interview with MD Magazine® while at the American Thoracic Society (ATS) 2019 International Meeting in Dallas, TX, Reena Mehra, MD, MS, director of the Sleep Disorders Center at the Cleveland Clinic, gave a rundown of preferred OSA therapies before tackling the burden of condition underdiagnosis.

MD Mag: What is the current state of therapeutic care for obstructive sleep apnea?

Mehra: The best and the go-to standard therapy is positive airway pressure, and it has been, because we know it's effective. The level of collapse of the airway can vary from person to person—so it can be retropalatal, retroglossal, hypopharyngeal. And positive airway pressure is effective because it serves to splint all aspects of the airway irrespective of where the collapse is occurring.

Upper airway surgery, primarily to remove the soft palate in the uvula—the outcomes with it are just not very good. It's a 50/50 chance as to whether that type of surgery will be effective. Oral appliances are another option for mild obstructive sleep apnea and positional sleep apnea. The effect of oral appliance is not as great as CPAP, but some data suggests that the compliance the oral appliances is greater than what you see with positive airway pressure.

So the actual treatment effect may be somewhat similar between the 2, but for moderate to severe obstructive sleep apnea, the oral appliances really are not going to be effective. It's really reserved for mild sleep apnea. So upper airway neurostimulation really does provide a new way, an alternative to the treatment of obstructive sleep apnea, particularly in those who are unable to tolerate or are recalcitrant to positive airway pressure.

Is sleep apnea a currently under-addressed or underestimated field?

There are data going back to 2002, from an epidemiologic study—the Sleep Heart Health study, involving about 6000 participants. In that study, they identified that—and sleep studies were performed on all of these participants—approximately 85% of those individuals had not been diagnosed with obstructive sleep apnea, and of course therefore not treated. You know, the thought is that perhaps we're doing better and that was in 2002.

However, there's recent results published in 2015, from the multi-ethnic study of atherosclerosis which is a cohort involving fairly equal amounts of Caucasians, African-Americans, Latinos, and Asians, and again, it appeared that about 85 to 90% of the individuals participating in that cohort had not had their obstructive sleep apnea diagnosed and therefore not treated.

And interestingly in that study, it was the underrepresented minorities that appeared to be most vulnerable to that under-diagnosis. I mean, on the front line, the primary care physician—it's hard to address all issues. But sleep should be considered as significant as weight and physical activity, because there are data to show that if you don't get enough sleep, this can contribute to weight gain and to an increase in cardiovascular risk, and even increase mortality. In many longitudinal studies, this has been shown.

So even sleep deprivation alone—which you can argue occurs in obstructive sleep apnea

because your sleep is so interrupted you're getting less sleep, most likely—may be one of the pathways that's causing increased cardiovascular risk. But that's a very easy question that can be asked on the front lines, in terms of the quantity of sleep, and also the standard symptoms for obstructive sleep apnea, such as snoring, daytime sleepiness, or witnessed episodes of stopping breathing by the bed partner.

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