What are the best treatments for moderate Obstructive Sleep Apnea (OSA) other than Continuous Positive Airway Pressure (CPAP)?

From the Guidelines

For moderate obstructive sleep apnea when CPAP isn't an option, mandibular advancement devices are the most effective alternative, as they have been shown to reduce sleep apneas and improve quality of life 1. The use of mandibular advancement devices is supported by recent guidelines, which recommend their use in patients with mild to moderate obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternative therapy 1. Some key points to consider when treating moderate obstructive sleep apnea without CPAP include:

• Weight loss, which can significantly improve sleep apnea severity in overweight patients, with even a 10% reduction in body weight showing benefits 1
• Positional therapy, which can help patients whose apnea worsens in the supine position, although it is generally considered inferior to CPAP and mandibular advancement devices 1
• Surgical options, such as uvulopalatopharyngoplasty (UPPP), maxillomandibular advancement, or hypoglossal nerve stimulation (Inspire therapy), which may be considered in selected patients who have failed other treatments 1
• Lifestyle modifications, including avoiding alcohol and sedatives before bedtime, establishing regular sleep schedules, and treating nasal congestion with saline sprays or antihistamines if allergies contribute to breathing difficulties 1 It's worth noting that the most recent and highest quality study 1 suggests that CPAP and mandibular advancement devices are equal in patients with mild to moderate OSA, but CPAP should be considered in patients with increasing severity of OSA, comorbidities, or odontological concerns. Overall, the choice of treatment for moderate obstructive sleep apnea without CPAP should be individualized and based on the patient's specific needs and preferences, with a focus on improving quality of life and reducing morbidity and mortality.

From the Research

Alternative Treatments for Moderate Obstructive Sleep Apnea

• Oral appliance therapy is a viable alternative to CPAP, with custom-made titratable mandibular advancement devices (MAD) being the recommended type 2, 3, 4.
• MAD therapy has been shown to be efficacious in reducing the severity of obstructive sleep apnea, although to a lesser extent than CPAP 3, 4.
• The health outcome of MAD therapy is similar to that of CPAP, possibly due to the inferior compliance of CPAP compared to MAD therapy 3.
• Combination therapy with CPAP and oral appliance (CPAP + OA) may be a beneficial alternative for incomplete responders to OA therapy alone and those who cannot tolerate high CPAP levels 5.
• Sleep positional therapy (SPT) is a safe alternative for managing positional OSA, particularly for patients intolerant to CPAP, although it remains less effective than CPAP in reducing overall AHI and improving oxygenation 6.
• Weight loss should always be recommended for patients with OSA who are overweight or obese, as weight loss may result in improvement in OSA 2.
• Upper airway surgical intervention remains a second- or third-line treatment class for moderate to severe OSA, though multiple case series of maxillomandibular advancement (MMA) have shown considerable, statistically significant improvements in AHI 2.
• Pharmacotherapy has not been shown to be significantly effective in the treatment of OSA and should be considered as an adjunctive treatment class, though some emerging evidence may support pharmacotherapy for specific purposes 2.