Mount Sinai School of Medicine, New York, NY, USA.
Sleep. 2010 Oct;33(10):1408-13. doi: 10.1093/sleep/33.10.1408.
Practice parameters for the treatment of obstructive sleep apnea syndrome (OSAS) in adults by surgical modification of the upper airway were first published in 1996 by the American Academy of Sleep Medicine (formerly ASDA). The following practice parameters update the previous practice parameters. These recommendations were reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine.
A systematic review of the literature was performed, and the GRADE system was used to assess the quality of evidence. The findings from this evaluation are provided in the accompanying review paper, and the subsequent recommendations have been developed from this review. The following procedures have been included: tracheostomy, maxillo-mandibular advancement (MMA), laser assisted uvulopalatoplasty (LAUP), uvulopalatopharyngoplasty (UPPP), radiofrequency ablation (RFA), and palatal implants.
The presence and severity of obstructive sleep apnea must be determined before initiating surgical therapy (Standard). The patient should be advised about potential surgical success rates and complications, the availability of alternative treatment options such as nasal positive airway pressure and oral appliances, and the levels of effectiveness and success rates of these alternative treatments (Standard). The desired outcomes of treatment include resolution of the clinical signs and symptoms of obstructive sleep apnea and the normalization of sleep quality, the apnea-hypopnea index, and oxyhemoglobin saturation levels (Standard). Tracheostomy has been shown to be an effective single intervention to treat obstructive sleep apnea. This operation should be considered only when other options do not exist, have failed, are refused, or when this operation is deemed necessary by clinical urgency (Option). MMA is indicated for surgical treatment of severe OSA in patients who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances, which are more often appropriate in mild and moderate OSA patients, have been considered and found ineffective or undesirable (Option). UPPP as a sole procedure, with or without tonsillectomy, does not reliably normalize the AHI when treating moderate to severe obstructive sleep apnea syndrome. Therefore, patients with severe OSA should initially be offered positive airway pressure therapy, while those with moderate OSA should initially be offered either PAP therapy or oral appliances (Option). Use of multi-level or stepwise surgery (MLS), as a combined procedure or as stepwise multiple operations, is acceptable in patients with narrowing of multiple sites in the upper airway, particularly if they have failed UPPP as a sole treatment (Option). LAUP is not routinely recommended as a treatment for obstructive sleep apnea syndrome (Standard). RFA can be considered as a treatment in patients with mild to moderate obstructive sleep apnea who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances have been considered and found ineffective or undesirable (Option). Palatal implants may be effective in some patients with mild obstructive sleep apnea who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances have been considered and found ineffective or undesirable (Option). Postoperatively, after an appropriate period of healing, patients should undergo follow-up evaluation including an objective measure of the presence and severity of sleep-disordered breathing and oxygen saturation, as well as clinical assessment for residual symptoms. Additionally, patients should be followed over time to detect the recurrence of disease (Standard).
While there has been significant progress made in surgical techniques for the treatment of OSA, there is a lack of rigorous data evaluating surgical modifications of the upper airway. Systematic and methodical investigations are needed to improve the quality of evidence, assess additional outcome measures, determine which populations are most likely to benefit from a particular procedure or procedures, and optimize perioperative care.
1996 年，美国睡眠医学学会（前身为 ASDA）首次发布了治疗成人阻塞性睡眠呼吸暂停综合征（OSAS）的气道上呼吸道手术治疗的实践参数。以下实践参数更新了以前的实践参数。这些建议经过美国睡眠医学学会董事会的审查和批准。
对文献进行了系统评价，并使用 GRADE 系统评估证据质量。评估结果在随附的综述论文中提供，随后的建议也基于该评估。以下程序已包括在内：气管切开术、下颌前伸（MMA）、激光辅助悬雍垂腭成形术（LAUP）、悬雍垂腭咽成形术（UPPP）、射频消融术（RFA）和腭植入物。
在开始手术治疗之前，必须确定阻塞性睡眠呼吸暂停的存在和严重程度（标准）。应告知患者潜在的手术成功率和并发症、替代治疗选择（如鼻正压通气和口腔器械）的可用性，以及这些替代治疗的有效性和成功率（标准）。治疗的预期结果包括解决阻塞性睡眠呼吸暂停的临床体征和症状，以及改善睡眠质量、呼吸暂停低通气指数和血氧饱和度水平（标准）。气管切开术已被证明是治疗阻塞性睡眠呼吸暂停的有效单一干预措施。只有在其他选择不存在、失败、被拒绝，或者临床紧急情况下需要手术时，才应考虑这种手术（选择）。MMA 适用于不能耐受或不愿意接受气道正压治疗的严重 OSA 患者的手术治疗，或者对于轻度和中度 OSA 患者更常考虑的口腔器械无效或不理想（选择）。UPPP 作为单一手术，联合或不联合扁桃体切除术，在治疗中重度阻塞性睡眠呼吸暂停综合征时不能可靠地使 AHI 正常化。因此，严重 OSA 患者应最初接受气道正压治疗，中度 OSA 患者应最初接受 PAP 治疗或口腔器械治疗（选择）。对于上气道多个部位狭窄的患者，可接受多水平或阶梯式手术（MLS）作为联合手术或阶梯式多次手术，尤其是当 UPPP 作为单一治疗失败时（选择）。LAUP 不常规推荐作为阻塞性睡眠呼吸暂停综合征的治疗方法（标准）。RFA 可考虑用于不能耐受或不愿意接受气道正压治疗的轻度至中度阻塞性睡眠呼吸暂停患者，或已考虑口腔器械但发现无效或不理想的患者（选择）。腭植入物可能对一些不能耐受或不愿意接受气道正压治疗的轻度阻塞性睡眠呼吸暂停患者有效，或已考虑口腔器械但发现无效或不理想的患者（选择）。术后，在适当的愈合期后，患者应接受随访评估，包括睡眠呼吸障碍和氧饱和度存在和严重程度的客观测量，以及对残留症状的临床评估。此外，应随时间跟踪患者，以发现疾病复发（标准）。
尽管治疗 OSA 的手术技术取得了重大进展，但仍缺乏严格评估气道上呼吸道手术修正的研究数据。需要系统和有方法的研究来提高证据质量，评估额外的结果测量，确定哪些人群最有可能从特定的手术或手术中受益，并优化围手术期护理。
