The Indian Association of Surgeons for Sleep Apnoea (IASSA) has released the first ever surgical guidelines for Indian ENT surgeons treating obstructive sleep apnoea (OSA) across the country.

The new OSA clinical guidelines have included standards for diagnostic techniques, treatment options and follow-ups for Indian surgeons and clinics performing evaluation and management including surgery for OSA.

The OSA clinical guidelines were unveiled by IASSA president Dr Vikas Agrawal, secretary Dr Vijaya Krishnan and patron Prof. Moan Kameswaran during three-day 4th National Conference of Indian Association of Surgeons for Sleep Apnoea 2016 in Mumbai recently. The conference witnessed congregation of over 400 ENT specialists from around the globe looking to gain insight in the field of OSA research, treatment and diagnosis.

OSA is a breathing disorder in which a person stops breathing during the night, perhaps hundreds of times. These gaps in breathing are called apnoeas. The disorder occurs when tissues in the upper throat collapse at different times during sleep, thereby blocking the passage of air. The airway obstruction may also cause episodic sleep-associated oxygen desaturation, episodic hypercarbia, and cardiovascular dysfunction.

In India, the prevalence of OSA is 2.4 per cent to 5 per cent in males and 1 to 2 per cent in females. Sleep-disordered breathing (SDB) has frequently been associated with various forms of cardiovascular disease. Individuals with severe SDB are two- to four-times more likely to develop complex arrhythmias than those without SDB.  Individuals with diagnosed OSA are between two and three times more likely to develop hypertension. The prevalence of OSA in patients with heart failure is estimated at 40 to 70 percent. Individuals with diagnosed OSA are more likely to suffer a stroke than those without OSA.

Speaking on the occasion, Dr Vikas Agrawal, president, IASSA said “Incorrect diagnosis is one of the biggest concern areas when it comes to OSA treatment in India. Over 90 per cent of sleep apnoea cases are misdiagnosed in India, because sleep apnoea is a relatively new subject. IJMR already has physician guidelines. IASSA has focussed on surgical guidelines, while also sharing detailed methods to diagnose sleep apnoea correctly.”

Dr Agrawal said “There is consensus among AISSA surgeons that patients, depending on where they are located, may visit their nearest family doctor, chest physician, MD physician or ENT physician as a primary step. Here, it is critical that they get diagnosed properly. Misdiagnosis includes thyroid, depression, anxiety, hypertension or even the common thought that snoring is not such a problem. Sleep apnoea is a new subject. Post diagnosis, complete surgery and recovery mechanism is also very critical. Sometimes, when surgeries go wrong or are incomplete, there is no reference point to decide whether the doctor has done full justice to the case. These surgical guidelines will offer a reference framework.”

The aim of the clinical practice guidelines is to increase the recognition of the disease by primary care clinicians to minimise delay in diagnosis and avoid serious sequelae of OSAS, evaluate diagnostic techniques, describe treatment options, provide guidelines for follow-up, and discuss areas requiring further research, he said.

He added that sleep apnoea is basically life style disease. The demographic characteristics that predispose to development of OSA include older age, male gender, pregnancy and post-menopausal state. Risk factors that are linked by strong published evidence include obesity, central body fat distribution, increased neck circumference and several anatomical abnormalities of the craniofacial region and upper airway.

He concluded that surgical treatment is recommended in patients who have failed or intolerant to Positive Airways Pressure (PAP) therapy or patients who refuse Continuous Positive Airway Pressure (CPAP) therapy. The adaptation of a logical and systematic approach to clinical evaluation, treatment planning and surgical execution is necessary in order to maximise safety and improve surgical results.

While talking about the newer treatment options for OSA, Dr P Vijaya Krishnan, secretary, IASSA said, “Sleep related disorders are high in Indian population and the accessibility for diagnosis and treatment is still not enough. However this scenario is slowly changing with the advent of cost effective diagnostic and surgical options for treating OSA. Dynamic Sleep MRI and Drug Induced Sleep Endoscopy (DISE) is one such example of diagnostic tool which helps in identifying the obstruction in the airway and improve patient management and treatment success.”