What are the non-CPAP (Continuous Positive Airway Pressure) interventions for sleep apnea?

Non-CPAP Interventions for Obstructive Sleep Apnea

Mandibular advancement devices (MADs) are the most effective non-CPAP intervention for mild to moderate obstructive sleep apnea (OSA) and should be considered first-line therapy for patients who cannot tolerate CPAP or have mild-moderate disease. 1

Primary Non-CPAP Interventions

Oral Appliance Therapy

• Mandibular Advancement Devices (MADs)
  • Most effective for mild to moderate OSA (AHI 5-30/h) 1, 2
  • Custom, titratable devices show best results 1
  • Can be used in severe OSA when CPAP is not tolerated 1
  • Contraindicated in patients with severe periodontal disease, temporomandibular disorders, or inadequate dentition 1
  • Initial titration should start at 50% of maximum mandibular advancement 2

Weight Management

• Recommended for all overweight/obese OSA patients 1
• Target BMI ≤25 kg/m² 1
• Weight reduction alone is insufficient as single treatment 3

Positional Therapy

• Effective for position-dependent OSA 1
• Best results in younger, less obese patients with lower AHI 1
• Poor long-term compliance limits effectiveness 4

Myofunctional Therapy

• Oropharyngeal exercises may reduce OSA severity in select cases 1
• Limited evidence but promising adjunctive therapy 5

Surgical Interventions

Maxillomandibular Advancement (MMA)

• As effective as CPAP in selected patients 4
• Recommended for young, non-obese patients who refuse conservative treatment 4
• Grade B recommendation (consistent level 2-3 studies) 4

Upper Airway Surgery Options

• Tonsillectomy/Adenotonsillectomy

  • Recommended when tonsillar hypertrophy is present 4
  • Grade C recommendation for adults, Grade C for children 4

• Uvulopalatopharyngoplasty (UPPP)

  • Only effective in selected patients with oropharyngeal obstruction 4
  • Risk of side effects: velopharyngeal insufficiency, dry throat, abnormal swallowing 4
  • Grade C recommendation (limited to carefully selected patients) 4

• Multilevel Surgery (MLS)

  • Only as salvage procedure when CPAP and other therapies fail 4
  • Results often unpredictable and less effective than CPAP 4
  • Grade C recommendation 4

Hypoglossal Nerve Stimulation

• Effective for select patients meeting specific criteria 1
• Emerging option for moderate to severe OSA 5

Interventions NOT Recommended

• Laser-assisted uvulopalatoplasty (negative recommendation B) 4
• Radiofrequency tonsil reduction (negative recommendation D) 4
• Nasal surgery as single intervention (negative recommendation C) 4
• Laser midline glossectomy and tongue suspension (negative recommendation C) 4
• Drugs and nasal dilators (insufficient evidence) 4

Treatment Algorithm Based on OSA Severity

Mild OSA (AHI 5-15/h)

1. Weight loss and lifestyle modifications
2. Mandibular advancement device
3. Positional therapy (if positional OSA)
4. Consider surgery only if specific anatomical abnormalities

Moderate OSA (AHI 15-30/h)

1. CPAP (first-line)
2. If CPAP intolerant:
   • Mandibular advancement device
   • Consider surgical options based on anatomical assessment

Severe OSA (AHI >30/h)

1. CPAP (first-line)
2. If CPAP intolerant:
   • Maxillomandibular advancement in suitable candidates
   • Mandibular advancement device
   • Hypoglossal nerve stimulation in select patients
   • Multilevel surgery as salvage procedure

Clinical Pearls and Pitfalls

• Drug-induced sleep endoscopy can improve patient selection for surgical interventions and oral appliance therapy 5
• Regular follow-up is essential regardless of treatment modality 1
• Early intervention for side effects can improve treatment adherence 1
• Avoidance of alcohol and sedatives before bedtime is crucial for all OSA patients 1
• Combined therapies may be more effective than single interventions in many patients 6

The selection of non-CPAP interventions should be guided by disease severity, anatomical factors, patient preference, and comorbidities, with the understanding that while these alternatives may be less effective than CPAP for reducing AHI, they may achieve better outcomes through improved adherence in CPAP-intolerant patients.