From the Guidelines
The most effective treatment for Obstructive Sleep Apnea (OSA) is continuous positive airway pressure (CPAP) therapy, which should be used as the initial therapy for patients diagnosed with OSA, as recommended by the American College of Physicians 1.
Diagnosis and Treatment
OSA is a common sleep disorder characterized by repeated episodes of complete or partial upper airway obstruction during sleep, leading to disrupted breathing and sleep fragmentation. The goal of OSA treatment is to alleviate airway obstruction during sleep.
Lifestyle Modifications
Treatment depends on severity but typically begins with lifestyle modifications such as:
- Weight loss, ideally to a BMI of 25 kg/m2 or less
- Avoiding alcohol before bedtime
- Sleeping on one's side
- Positional therapy when indicated
- Avoidance of sedatives before bedtime
CPAP Therapy
For moderate to severe OSA, CPAP therapy is the gold standard treatment, involving wearing a mask during sleep that delivers pressurized air to keep the airway open. The pressure setting is individually determined during a titration study, typically ranging from 5-20 cmH2O. CPAP should be used whenever sleeping, including naps.
Alternative Treatments
Alternative treatments include:
- Oral appliances that reposition the jaw forward
- Positional therapy devices
- Surgical interventions like uvulopalatopharyngoplasty or hypoglossal nerve stimulation for selected patients
- Mandibular advancement devices (MADs) as an alternative therapy to CPAP treatment for patients who prefer MADs or have adverse effects associated with CPAP treatment 1
Complications of Untreated OSA
Untreated OSA increases risks of:
- Cardiovascular problems, including hypertension, heart failure, stroke, and arrhythmias
- Daytime sleepiness
- Cognitive impairment
- Reduced quality of life These complications occur because repeated oxygen desaturations and sleep fragmentation trigger sympathetic activation, oxidative stress, and systemic inflammation, affecting multiple organ systems over time.
Recent Guidelines
The European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea 1 and the Portuguese Society of Pulmonology statement on treatment of OSA with mandibular advancement devices 1 provide updated recommendations on the management of OSA. However, CPAP therapy remains the most effective treatment for OSA, and its use should be prioritized as the initial therapy for patients diagnosed with OSA.
From the Research
Diagnosis of Obstructive Sleep Apnea (OSA)
- OSA is characterized by repeated apnoeas and hypopnoeas while asleep due to collapse of the upper airway 2
- The main symptom is daytime sleepiness, although it has been linked to premature death, hypertension, ischaemic heart disease, stroke, and road traffic accidents 3, 4
- Diagnosis is typically made based on an apnoea and hypopnoea index (AHI) greater than five per hour 3, 4
Treatment of OSA
- Continuous Positive Airway Pressure (CPAP) therapy is the evidence-based treatment to maintain upper airway patency in patients with moderate to severe OSA 5, 3, 2, 6, 4
- CPAP has been shown to improve objective and subjective sleepiness, quality of life, cognitive function, and depression measures 5, 3, 4
- Alternative treatments include:
- Oral appliances, such as mandibular advancement devices (MADs) 5, 3, 2, 4
- Positional therapy 5
- Weight loss 5, 6
- Surgical options, such as uvulopalatopharyngoplasty, tonsillectomy, or maxillomandibular advancement 2, 6
- Hypoglossal Nerve Stimulation (HNS) and transcutaneous electrical stimulation of the upper airway dilator muscles (TESLA) 2
- A multidisciplinary team approach may be helpful in managing "difficult-to-treat" patients with OSA 2
- Symptom control, patient-related outcome measures, and long-term cardiovascular health should be prioritized when choosing long-term therapies to treat OSA 2