Indications for treatment of obstructive sleep apnea in adults Patrick J. Strollo, Jr, MD, FCCP Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Montefiore Hospital, Suite 628 West, 3459 Fifth Avenue, Pittsburgh, PA 15213-2582, USA Why treat obstructive sleep apnea (OSA)? OSA is associated with significant daytime sleepiness, reduced quality of life, insulin resistance, motor vehicle crashes, and vascular morbidity and mortality [1 – 3]. Current evidence supports the belief that all these parameters can be impacted favorably by treat- ment. Medical therapy with positive pressure elimi- nates snoring and favorably affects daytime sleepiness, driving risk, vascular function, vascular risk, and quality of life [4 – 8]. The conundrum for the clinician is that patients are variably affected by OSA of similar severity (Fig. 1). Treatment may be difficult to accept or adhere to, and some treatment options are not uniformly effective. The long-term impact of treatment is uncertain. The current convention is to grade the severity of OSA by the apnea-hypopnea index (AHI). The Amer- ican Academy of Sleep Medicine recommends grad- ing sleep apnea as mild (AHI 5 – 15), moderate (AHI 15 – 30), and severe (AHI > 30) [9]. This metric sta- tistically correlates the presence of sleepiness, neuro- cognitive impairment, and vascular risk [10 – 12]. It is relatively easy to treat patients with severe, symp- tomatic OSA. The difficulty with regard to treatment frequently occurs when patients with severe OSA are not symptomatic or when patients are profoundly symptomatic with a low AHI. Treatment of the minimally symptomatic patient with severe OSA can be challenging. The medical therapy of choice—positive pressure via a mask—is unique and not discrete [13]. The treatment is administered in one of the most intimate settings, the bedroom. In the absence of definitive long-term outcome data, there is uncertainty regarding how hard to push therapy in patients with mild to moderate OSA with minimal symptoms [14]. Patients who are profoundly symptomatic with relatively mild OSA may not accept positive pressure therapy. The long-term effect of alternative treatments to positive pressure is un- known but may be of value in select circumstances. Patient assessment Successful treatment cannot be accomplished with- out proper patient assessment. It is helpful to under- stand what a patient hopes to gain from the evaluation. This expectation is best handled by seeing the patient before polysomnography. The clinician can under- stand what is driving the evaluation: the complaint of snoring, the complaint of fatigue or daytime sleepi- ness, or the concern of vascular risk. It is also helpful to understand up front whether the patient, spouse, or referring physician is most concerned about OSA. If the patient is most concerned with the pos- sibility of OSA and he or she is subjectively sleepy, there is a good chance that medical therapy with positive pressure will be accepted. These patients are good candidates for split-night polysomnography [15 – 17]. If the patient does not complain of daytime fatigue or sleepiness or does not regard snoring as a significant problem, acceptance and adherence to positive pressure therapy may be difficult to estab- lish, and split-night polysomnography may not be the best approach [18,19]. In this circumstance, it is generally best to obtain a full night of diagnostic polysomnography data and review the findings before a trial of positive pressure. 0272-5231/03/$ – see front matter D 2003, Elsevier Inc. All rights reserved. doi:10.1016/S0272-5231(03)00025-X E-mail address: strollopj@msx.upmc.edu Clin Chest Med 24 (2003) 307 – 313