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CC BY-NC-ND 4.0 · Sleep Sci 2021; 14(03): 257-265
DOI: 10.5935/1984-0063.20200111
REVIEWS

The public health burden of obstructive sleep apnea

Andre Faria
1   Universidade Federal de Minas Gerais, Faculdade de Medicina - Pampulha - Belo Horizonte - Brazil.
,
AJ Hirsch Allen
2   University of British Columbia, Department of Medicine, Faculty of Medicine - Vancouver - British - Columbia - Canada.
,
Nurit Fox
2   University of British Columbia, Department of Medicine, Faculty of Medicine - Vancouver - British - Columbia - Canada.
,
Najib Ayas
2   University of British Columbia, Department of Medicine, Faculty of Medicine - Vancouver - British - Columbia - Canada.
,
Ismail Laher
3   University of British Columbia, Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine - Vancouver - British - 'Columbia - Canada.
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ABSTRACT

Obstructive sleep apnea (OSA) is the most common respiratory disorder of sleep. The vast majority (>80%) of adults with moderate to severe OSA remain undiagnosed. The economic costs associated with OSA are substantial for both the individual and society as a whole; expenses are likely to be underestimated given that the disease remains undiagnosed in such a large percentage of individuals. The economic burden of motor vehicle collisions related to OSA alone is significant; it is estimated that 810,000 collisions and 1400 fatalities from car crashes in the United States were attributable to sleep apnea in 2000. The many health consequences of OSA include daytime sleepiness, reduced quality of life, decreased learning skills, and importantly, neurocognitive impairments that include impaired episodic memory, executive function, attention and visuospatial cognitive functions. Untreated OSA leads to numerous medical problems such as cardiovascular diseases that can potentially increase healthcare utilization. Untreated patients with sleep apnea consume a disproportionate amount of healthcare resources, expenditures that decrease after treatment. The gold-standard management of OSA remains treatment with CPAP (Continuous Positive Airway Pressure), which is effective in eliminating sleep fragmentation and preserving nocturnal oxygenation, thereby improving daytime sleepiness and quality of life. However, its impacts in reversing neurocognitive function are still uncertain. A significant impediment to CPAP effectiveness is low adherence rates (ranges from 50% to 75%). It is commonly accepted that CPAP improves excessive drowsiness; hence meliorates attention, and accumulating data suggest that CPAP improves a variety of other outcomes such as the risk of motor vehicle crashes.

Keywords:

Sleep Apnea - Motor Vehicle Accidents - Cognitive Dysfunction - Treatment - Health Burden - Economic Burden


Publication History

Received: 19 October 2020

Accepted: 06 February 2021

Article published online:
30 November 2023

© 2021. Brazilian Sleep Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • REFERENCES

  • 1 Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993 Apr;328(17):1230-5.
  • 2 American Academy of Sleep Medicine (AASM). The International Classification of Sleep Disorders: diagnostic and coding manual. 2nd ed. Westchester, IL: AASM; 2005.
  • 3 White DP. Sleep-related breathing disorder. 2. Pathophysiology of obstructive sleep apnoea. Thorax. 1995 Jul;50(7):797-804.
  • 4 Mulgrew AT, Fox N, Ayas NT, Ryan CF. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. Ann Intern Med. 2007 Feb;146(3):157-66.
  • 5 Lugaresi E, Cirignotta F, Gerardi R, Montagna P. Snoring and sleep apnea: natural history of heavy snorers disease: In: Guilleminault C, Partinen M, eds. Obstructive sleep apnea syndrome: clinical research and treatment. New York, NY: Raven Press; 1990. p. 25-36.
  • 6 Swanson LM, Arnedt JT, Rosekind MR, Belenky G, Balkin TJ, Drake C. Sleep disorders and work performance: findings from the 2008 National Sleep Foundation Sleep in America poll. J Sleep Res. 2011 Sep;20(3):487-94.
  • 7 Viswanath A, Ramamurthy J, Dinesh SPS, Srinivas A. Obstructive sleep apnea: awakening the hidden truth. Niger J Clin Pract. 2015 Jan/Feb;18(1):1-7.
  • 8 White LH, Bradley TD. Role of nocturnal rostral fluid shift in the pathogenesis of obstructive and central sleep apnoea. J Physiol. 2013 Mar;591(5):1179-93.
  • 9 Young T, Peppard PE, Taheri S. Excess weight and sleep-disordered breathing. J Appl Physiol. 2005 Nov;99(4):1592-9.
  • 10 Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013 May;177(9):1006-14.
  • 11 Hendricks JC, Kline LR, Kovalski RJ, O'Brien JA, Morrison AR, Pack AI. The English bulldog: a natural model of sleep-disordered breathing. J Appl Physiol. 1987;63(4):1344-50.
  • 12 Hendricks JC, Kovalski RJ, Kline LR. Phasic respiratory muscle patterns and sleep-disordered breathing during rapid eye movement sleep in the English bulldog. Am Rev Respir Dis. 1991 Nov;144(5):1112-20.
  • 13 Badran M, Abuyassin B, Golbidi S, Ayas N, Laher I. Uncoupling of vascular nitric oxide synthase caused by intermittent hypoxia. Oxid Med Cell Longev. 2016;2016:2354870.
  • 14 Badran M, Golbidi S, Devlin A, Ayas N, Laher I. Chronic intermittent hypoxia causes endothelial dysfunction in a mouse model of diet-induced obesity. Sleep Med. 2014 Feb;15(5):596-602.
  • 15 AlGhanim N, Comondore VR, Fleetham J, Marra CA, Ayas NT. The economic impact of obstructive sleep apnea. Lung. 2008 Jan/Feb;186(1):7-12.
  • 16 Sassani A, Findley LJ, Kryger M, Goldlust E, George C, Davidson TM. Reducing motor-vehicle collisions, costs, and fatalities by treating obstructive sleep apnea syndrome. Sleep. 2004 May;27(3):453-8.
  • 17 Hillman DR, Murphy AS, Antic R, Pezzullo L. The economic cost of sleep disorders. Sleep. 2006 Mar;29(3):299-305.
  • 18 American Diabetes Association (ADA). Economic costs of diabetes in the U.S. in 2002. Diabetes Care. 2003 Mar;26(3):917-32.
  • 19 Engleman H, Joffe D. Neuropsychological function in obstructive sleep apnoea. Sleep Med Rev. 1999 Mar;3(1):59-78.
  • 20 Guglielmi O, Jurado-Gámez B, Gude F, Buela-Casal G. Occupational health of patients with obstructive sleep apnea syndrome: a systematic review. Sleep Breath. 2015 Mar;19(1):35-44.
  • 21 Sanna A. Obstructive sleep apnoea, motor vehicle accidents, and work performance. Chron Respir Dis. 2013 Feb;10(1):29-33.
  • 22 Gagnon K, Baril AA, Montplaisir J, Carrier J, Chami S, Gauthier S, et al. Detection of mild cognitive impairment in middle-aged and older adults with obstructive sleep apnoea. Eur Respir J. 2018 Nov;52(5):1801137.
  • 23 Sforza E, Roche F. Sleep apnea syndrome and cognition. Front Neurol. 2012 May;3:87.
  • 24 Yaffe K, Laffan AM, Harrison SL, Redline S, Spira AP, Ensrud KE, et al. Sleep-disordered breathing, hypoxia, and risk of mild cognitive impairment and dementia in older women. JAMA. 2011 Aug;306(6):613-9.
  • 25 Albert MS, DeKosky ST, Dickson D, Dubois B, Feldman HH, Fox NC, et al. The diagnosis of mild cognitive impairment due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimers Dement. 2011 May;7(3):270-9.
  • 26 Chang WP, Liu ME, Chang WC, Yang AC, Ku YC, Pai JT, et al. Sleep apnea and the risk of dementia: a population-based 5-year follow-up study in Taiwan. PLoS One. 2013;8(10):e78655.
  • 27 Leng Y, McEvoy CT, Allen IE, Yaffe K. Association of sleep-disordered breathing with cognitive function and risk of cognitive impairment: a systematic review and meta-analysis. JAMA Neurol. 2017;74(10):1237-45.
  • 28 Sharma RA, Varga AW, Bubu OM, Pirraglia E, Kam K, Parekh A, et al. Obstructive sleep apnea severity affects amyloid burden in cognitively normal elderly. A longitudinal study. Am J Respir Crit Care Med. 2018 Apr;197(7):933-43.
  • 29 Allen RP, Picchietti D, Hening WA, Trenkwalder C, Walters AS, Montplaisi J. Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. Sleep Med. 2003;4(2):101-19.
  • 30 Bastien CH, Vallières A, Morin CM. Validation of the insomnia severity index as an outcome measure for insomnia research. Sleep Med. 2001 Jul;2(4):297-307.
  • 31 Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991 Dec;14(6):540-5.
  • 32 Wen X, Wang N, Liu J, Yan Z, Xin Z. Detection of cognitive impairment in patients with obstructive sleep apnea hypopnea syndrome using mismatch negativity. Neural Regen Res. 2012 Jul;7(20):1591-8.
  • 33 Wallace A, Bucks RS. Memory and obstructive sleep apnea: a meta-analysis. Sleep. 2013 Feb;36(2):203-20.
  • 34 Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989 May;28(2):193-213.
  • 35 Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005 Apr;53(4):695-9.
  • 36 Kerner NA, Roose SP. Obstructive sleep apnea is linked to depression and cognitive impairment: evidence and potential mechanisms. Am J Geriatr Psychiatry. 2016 Jun;24(6):496-508.
  • 37 Nasr N, Traon APL, Czosnyka M, Tiberge M, Schmidt E, Larrue V. Cerebral autoregulation in patients with obstructive sleep apnea syndrome during wakefulness. Eur J Neurol. 2009 Mar;16(3):386-91.
  • 38 Winklewski PJ, Frydrychowski AF. Cerebral blood flow, sympathetic nerve activity and stroke risk in obstructive sleep apnoea. Is there a direct link?. Blood Press. 2013 Feb;22(1):27-33.
  • 39 Xu LH, Xie H, Shi ZH, Du LD, Wing YK, Li AM, et al. Critical role of endoplasmic reticulum stress in chronic intermittent hypoxia-induced deficits in synaptic plasticity and long-term memory. Antioxid Redox Signal. 2015 Sep;23(9):695-710.
  • 40 Xie H, Yung WH. Chronic intermittent hypoxia-induced deficits in synaptic plasticity and neurocognitive functions: a role for brain-derived neurotrophic factor. Acta Pharmacol Sin. 2012 Jan;33(1):5-10.
  • 41 Howard ME, Desai AV, Grunstein RR, Hukins C, Armstrong JG, Joffe D, et al. Sleepiness, sleep-disordered breathing, and accident risk factors in commercial vehicle drivers. Am J Respir Crit Care Med. 2004 Nov;170(9):1014-21.
  • 42 Tregear S, Reston J, Schoelles K, Phillips B. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med. 2009 Dec;5(6):573-81.
  • 43 Lindberg E, Carter N, Gislason T, Janson C. Role of snoring and daytime sleepiness in occupational accidents. Am J Respir Crit Care Med. 2001 Dec;164(11):2031-5.
  • 44 Uehli K, Mehta AJ, Miedinger D, Hug K, Schindler C, Holsboer-Trachsler E, et al. Sleep problems and work injuries: a systematic review and meta-analysis. Sleep Med Rev. 2014 Feb;18(1):61-73.
  • 45 Ulfberg J, Carter N, Edling C. Sleep-disordered breathing and occupational accidents. Scand J Work Environ Health. 2000 Jul;26(3):237-42.
  • 46 Chen YH, Keller JK, Kang JH, Hsieh HJ, Lin HC. Obstructive sleep apnea and the subsequent risk of depressive disorder: a population-based follow-up study. J Clin Sleep Med. 2013 May;9(5):417-23.
  • 47 Peppard PE, Szklo-Coxe M, Hla KM, Young T. Longitudinal association of sleep-related breathing disorder and depression. Arch Intern Med. 2006 Sep;166(16):1709-15.
  • 48 Jennum P, Kjellberg J. Health, social and economical consequences of sleep-disordered breathing: a controlled national study. Thorax. 2011 Jul;66(7):560-6.
  • 49 Deloitte Access Economics (AU). Re-awakening Australia: the economic cost of sleep disorders in Australia, 2010 [Internet]. Sydney: Deloitte Access Economics Pty Ltd.; 2011 Oct; [access in 2014 Dec 21]. Available from: http://www.sleephealthfoundation.org.au/pdfs/news/Reawakening%20Australia.pdf
  • 50 Dean B, Aguilar D, Shapiro C, Orr WC, Isserman JA, Calimlim B, et al. Impaired health status, daily functioning, and work productivity in adults with excessive sleepiness. J Occup Environ Med. 2010 Feb;52(2):144-9.
  • 51 Burton WN, Pransky G, Conti DJ, Chen CY, Edington DW. The association of medical conditions and presenteeism. J Occup Environ Med. 2004 Jun;46(6 Suppl 1):S38-S45.
  • 52 Schultz AB, Edington DW. Employee health and presenteeism: a systematic review. J Occup Rehabil. 2007 Sep;17(3):547-79.
  • 53 Jelic S, Lederer DJ, Adams T, Padeletti M, Colombo PC, Factor P, et al. Endothelial repair capacity and apoptosis are inversely related in obstructive sleep apnea. Vasc Health Risk Manag. 2009;5:909-20.
  • 54 Kapur V, Blough DK, Sandblom RE, Hert R, Maine JB, Sullivan SD, et al. The medical cost of undiagnosed sleep apnea. Sleep. 1999 Sep;22(6):749-55.
  • 55 Young T, Peppard P, Palta M, Hla KM, Finn L, Morgan B, et al. Population-based study of sleep-disordered breathing as a risk factor for hypertension. Arch of Intern Med. 1997 Aug;157(15):1746-52.
  • 56 Punjabi NM, Shahar E, Redline S, Gottlieb DJ, Givelber R, Resnick HE, et al. Sleep-disordered breathing, glucose intolerance, and insulin resistance: the Sleep Heart Health Study. Am J Epidemiol. 2004 Sep;160(6):521-30.
  • 57 Mehra R, Benjamin EJ, Shahar E, Gottlieb DJ, Nawabit R, Kirchner HL, et al. Association of nocturnal arrhythmias with sleep disordered breathing: the sleep heart health study. Am J Respir Crit Care Med. 2006 Apr;173(8):910-6.
  • 58 Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Nieto FJ, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001 Jan;163(1):19-25.
  • 59 Mo L, Gupta V, Modi R, Munnur K, Cameron JD, Seneviratne S, et al. Severe obstructive sleep apnea is associated with significant coronary artery plaque burden independent of traditional cardiovascular risk factors. Int J Cardiovasc Imaging. 2019 Feb;36(2):347-55.
  • 60 Wu Z, Chen F, Yu F, Wang Y, Guo Z. A meta-analysis of obstructive sleep apnea in patients with cerebrovascular disease. Sleep Breath. 2018 Sep;22(3):729-42.
  • 61 Senaratna CV, Perret JL, Lodge CJ, Lowe AJ, Campbell BE, Matheson MC, et al. Prevalence of obstructive sleep apnea in the general population: a systematic review. Sleep Med Rev. 2017 Aug;34:70-81.
  • 62 Young T, Peppard PE, Taheri S. Excess weight and sleep-disordered breathing. J Appl Physiol. 2005;99:1592-9.
  • 63 Epstein LJ, Kristo D, Strollo Junior PJ, Friedman N, Malhotra A, Patil SP, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009 Jun;5(3):263-76.
  • 64 Morgenthaler TI, Kapen S, Lee-Chiong T, Alessi C, Boehlecke B, Brown T, et al. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep. 2006 Aug;29(8):1031-5.
  • 65 Aiello KD, Caughey WG, Nelluri B, Sharma A, Mookadam F, Mookadam M. Effect of exercise training on sleep apnea: a systematic review and meta-analysis. Respir Med. 2016 Jul;116:85-92.
  • 66 Araghi MH, Chen YF, Jagielski A, Choudhury S, Banerjee D, Hussain S, et al. Effectiveness of lifestyle interventions on obstructive sleep apnea (OSA): systematic review and meta-analysis. Sleep. 2013 Oct;36(10):1553-62.
  • 67 Iftikhar IH, Bittencourt L, Youngstedt SD, Ayas N, Cistulli P, Schwab R, et al. Comparative efficacy of CPAP, MADs, exercise-training, and dietary weight loss for sleep apnea: a network meta-analysis. Sleep Med. 2017 Feb;30:7-14.
  • 68 Mitchell LJ, Davidson ZE, Bonham M, O'Driscoll DM, Hamilton GS, Truby H. Weight loss from lifestyle interventions and severity of sleep apnoea: a systematic review and meta-analysis. Sleep Med. 2014 Oct;15(10):1173-83.
  • 69 Ng WL, Stevenson CE, Wong E, Tanamas S, Boelsen-Robinson T, Shaw JE, et al. Does intentional weight loss improve daytime sleepiness? A systematic review and meta-analysis. Obes Rev. 2017 Apr;18(4):460-75.
  • 70 Thomasouli MA, Brady EM, Davies MJ, Hall AP, Khunti K, Morris DH, et al. The impact of diet and lifestyle management strategies for obstructive sleep apnoea in adults: a systematic review and meta-analysis of randomised controlled trials. Sleep Breath. 2013 Sep;17(3):925-35.
  • 71 Carneiro-Barrera A, Díaz-Román A, Guillén-Riquelme A, Buela-Casal G. Weight loss and lifestyle interventions for obstructive sleep apnoea in adults: systematic review and meta-analysis. Obes Rev. 2019 May;20(5):750-62.
  • 72 Malhotra A, Ayas NT, Epstein LJ. The art and science of continuous positive airway pressure therapy in obstructive sleep apnea. Curr Opin Pulm Med. 2000 Nov;6(6):490-5.
  • 73 Kribbs NB, Pack AI, Kline LR, Getsy JE, Schuett JS, Henry JN, et al. Effects of one night without nasal CPAP treatment on sleep and sleepiness in patients with obstructive sleep apnea. Am Rev Respir Dis. 1993 May;147(5):1162-8.
  • 74 Mulgrew AT, Nasvadi G, Butt A, Cheema R, Fox N, Fleetham JA, et al. Risk and severity of motor vehicle crashes in patients with obstructive sleep apnoea/hypopnoea. Thorax. 2008;63(6):536-41.
  • 75 Findley L, Smith C, Hooper J, Dineen M, Suratt PM. Treatment with nasal CPAP decreases automobile accidents in patients with sleep apnea. Am J Respir Crit Care Med. 2000 Mar;161(3 Pt 1):857-9.
  • 76 Turkington PM, Sircar M, Saralaya D, Elliott MW. Time course of changes in driving simulator performance with and without treatment in patients with sleep apnoea hypopnoea syndrome. Thorax. 2004 Jan;59(1):56-9.
  • 77 Gieteling EW, Bakker MS, Hoekema A, Maurits NM, Brouwer WH, Van Der Hoeven JH. Impaired driving simulation in patients with periodic limb movement disorder and patients with obstructive sleep apnea syndrome. Sleep Med. 2012 May;13(5):517-23.
  • 78 Antonopoulos CN, Sergentanis TN, Daskalopoulou SS, Petridou ET. Nasal continuous positive airway pressure (nCPAP) treatment for obstructive sleep apnea, road traffic accidents and driving simulator performance: a meta-analysis. Sleep Med Rev. 2011 Oct;15(5):301-10.
  • 79 Vakulin A, Baulk SD, Catcheside PG, Antic NA, Van Den Heuvel CJ, Dorrian J, et al. Driving simulator performance remains impaired in patients with severe OSA after CPAP treatment. J Clin Sleep Med. 2011 Jun;7(3):246-53.
  • 80 Engleman HM, Martin SE, Kingshott RN, Mackay TW, Deary IJ, Douglas NJ. Randomised placebo controlled trial of daytime function after continuous positive airway pressure (CPAP) therapy for the sleep apnoea/hypopnoea syndrome. Thorax. 1998 May;53(5):341-5.
  • 81 Henke KG, Grady JJ, Kuna ST. Effect of nasal continuous positive airway pressure on neuropsychological function in sleep apnea-hypopnea syndrome. A randomized, placebo controlled trial. Am J Respir Crit Care Med. 2011;163(4):911-7.
  • 82 Jenkinson C, Davies RJ, Mullins R, Stradling JR. Comparison of therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomised prospective parallel trial. Lancet. 1999 Jun;353(9170):2100-5.
  • 83 Jackson ML, McEvoy RD, Banks S, Barnes M. Neurobehavioral impairment and CPAP treatment response in mild-moderate obstructive sleep Apneas. J Clin Sleep Med. 2018 Jan;14(1):47-56.
  • 84 Phillips CL, Grunstein RR, Darendeliler MA, Mihailidou AS, Srinivasan VK, Yee BJ, et al. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea. Am J Respir Crit Care Med. 2013 Apr;187(8):879-87.
  • 85 Canessa N, Castronovo V, Cappa SF, Aloia MS, Marelli S, Falini A, et al. Obstructive sleep apnea: brain structural changes and neurocognitive function before and after treatment. Am J Respir Crit Care Med. 2011 May;183(10):1419-26.
  • 86 Kylstra WA, Aaronson JA, Hofman WF, Schmand BA. Neuropsychological functioning after CPAP treatment in obstructive sleep apnea: a meta-analysis. Sleep Med Rev. 2013 Oct;17(5):341-7.
  • 87 Kushida CA, Nichols DA, Holmes TH, Quan SF, Walsh JK, Gottlieb DJ, et al. Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: the apnea positive pressure long-term efficacy study (APPLES). Sleep. 2012 Dec;35(12):1593-602.
  • 88 Harris M, Glozier N, Ratnavadivel R, Grunstein RR. Obstructive sleep apnea and depression. Sleep Med Rev. 2009 Dec;13(6):437-44.
  • 89 Kyung SH, Park YC, Pae EK. Obstructive sleep apnea patients with the oral appliance experience pharyngeal size and shape changes in three dimensions. Angle Orthod. 2005 Jan;75(1):15-22.
  • 90 Liu Y, Zeng X, Fu M, Huang X, Lowe AA. Effects of a mandibular repositioner on obstructive sleep apnea. Am J Orthod Dentofacial Orthop. 2000 Sep;118(3):248-56.
  • 91 Ryan CF, Love LL, Peat D, Fleetham JA, Lowe AA. Mandibular advancement oral appliance therapy for ob- structive sleep apnoea: effect on awake calibre of the velopharynx. Thorax. 1999 Nov;54(11):972-7.
  • 92 Barnes M, McEvoy RD, Banks S, Tarquinio N, Murray CG, Vowles N, et al. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med. 2004 Sep;170(6):656-64.
  • 93 Naismith SL, Winter VR, Hickie IB, Cistulli PA. Effect of oral appliance therapy on neurobehavioral functioning in obstructive sleep apnea: a randomized controlled trial. J Clin Sleep Med. 2005 Oct;1(4):374-80.
  • 94 Lim J, Lasserson TJ, Fleetham J, Wright J. Oral appliances for obstructive sleep apnoea. Cochrane Database Syst Rev. 2003 Jan;(1):CD004435.
  • 95 Cistulli PA, Gotsopoulos H, Marklund M, Lowe AA. Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliances. Sleep Med Rev. 2004 Dec;8(6):443-57.
  • 96 Hiestand D, Phillips B. Obstructive sleep apnea syndrome: assessing and managing risk in the motor vehicle operator. Curr Opin Pulm Med. 2011 Nov;17(6):412-8.
  • 97 Won CH, Li KK, Guilleminault C. Surgical treatment of obstructive sleep apnea: upper airway and maxillomandibular surgery. Proc Am Thorac Soc. 2008;5:193-9.
  • 98 Sher A. Upper airway surgery for obstructive sleep apnea. Sleep Med Rev. 2002 Jun;6(3):195-212.
  • 99 Stradling JR, Thomas G, Warley AR, Williams P, Freeland A. Effect of adenotonsillectomy on nocturnal hypoxaemia, sleep disturbance, and symptoms in snoring children. Lancet. 1990 Feb;335(8684):249-53.
  • 100 Yalamanchali S, Cipta S, Waxman J, Pott T, Joseph N, Friedman M. Effects of endoscopic sinus surgery and nasal surgery in patients with obstructive sleep apnea. Otolaryngol Head Neck Surg. 2014 Jul;151(1):171-5.
  • 101 Senchak AJ, McKinlay AJ, Acevedo J, Swain B, Tiu MC, Chen BS, et al. The effect of tonsillectomy alone in adult obstructive sleep apnea. Otolaryngol Head Neck Surg. 2015 May;152(5):969-73.
  • 102 Browaldh N, Nerfeldt P, Lysdahl M, Bring J, Friberg D. SKUP3 randomized controlled trial: polysomnographic results after uvulopalatopharyngoplasty in selected patients with obstructive sleep apnea. Thorax. 2013 Sep;68(9):846-53.
  • 103 Schwartz AR, Bennett ML, Smith PL, Backer W, Hedner J, Boudewyns A, et al. Therapeutic electrical stimulation of the hypoglossal nerve in obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2001 Oct;127(10):1216-23.
  • 104 Dedhia RC, Strollo PJ, Soose RJ. Upper airway stimulation for obstructive sleep apnea: past, present, and future. Sleep. 2015 Jun;38(6):899-906.
  • 105 Strollo Junior PJ, Soose RJ, Maurer JT, Vries N, Cornelius J, Froymovich O, et al. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med. 2014 Jan;370(2):139-49.
  • 106 Woodson BT, Soose RJ, Gillespie MB, Strohl KP, Maurer JT, Vries N, et al. Three-year outcomes of cranial nerve stimulation for obstructive sleep apnea: The STAR trial. Otolaryngol Head Neck Surg. 2016 Jan;154(1):181-8.
  • 107 Gillespie MB, Soose RJ, Woodson BT, Strohl KP, Maurer JT, Vries N, et al. Upper airway stimulation for obstructive sleep apnea: Patient-reported outcomes after 48 months of follow-up. Otolaryngol Head Neck Surg. 2017 Apr;156(4):765-71.
  • 108 Fox N, Hirsch-Allen AJ, Goodfellow E, Wenner J, Fleetham J, Ryan CF, et al. The impact of a telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial. Sleep. 2012 Apr;35(4):477-81.