What is the treatment for sleep apnea disorder?

Treatment of Sleep Apnea Disorder

Positive airway pressure (PAP) therapy is the first-line treatment for obstructive sleep apnea (OSA) and should be used for the entirety of a patient's sleep period, even if used for less than 4 hours per night. 1

Primary Treatment Options

Continuous Positive Airway Pressure (CPAP)

• First-line therapy for OSA, particularly for moderate to severe cases (AHI ≥15/h)
• Consistently demonstrates significant improvements in:
  • Apnea-hypopnea index (AHI)
  • Arousal index
  • Minimum oxygen saturation
  • Quality of life measures
  • Daytime sleepiness 1
• PAP use for ≥4 hours per night is associated with reduced risk for new-onset hypertension and cardiovascular events (7.90 vs. 11.02 events per 100 person-years) 1
• Common side effects include nasal congestion, oronasal dryness, mask discomfort, and nocturnal awakenings 1

Mandibular Advancement Devices (MADs)

• Recommended for patients with mild to moderate OSA who cannot tolerate CPAP 1
• Most effective in younger, less obese patients with lower AHI 2
• While CPAP is superior in reducing AHI, MADs show similar improvements in:
  • Daytime sleepiness
  • Cognitive function
  • Quality of life measures
  • Blood pressure control 1
• Require adequate healthy teeth, no significant TMJ disorder, and adequate jaw range of motion 1
• Higher patient preference and adherence compared to CPAP in some studies 1

Weight Management

• Weight loss is strongly recommended for overweight/obese patients with OSA 1, 2
• Low-energy diet interventions have shown:
  • Statistically significant reductions in AHI (range -4 to -23 events/h)
  • Improvements in oxygen saturation
  • Very low-calorie diet was associated with a 4-fold increase in OSA cure rate (AHI <5/h) 1

Positional Therapy

• Recommended for patients with position-dependent OSA (symptoms primarily when supine)
• Most effective in younger, less obese patients with lower AHI 1, 2
• Long-term compliance is generally poor 1

Surgical Options

• Consider surgical treatment when:
  1. CPAP and other therapies fail
  2. Patient has specific anatomical abnormalities

Surgical procedures by indication:

• Tonsillectomy/Adenotonsillectomy: Recommended when tonsillar hypertrophy is present (Grade C recommendation) 1
• Uvulopalatopharyngoplasty (UPPP): Only effective in selected patients with oropharyngeal obstruction; risk of side effects including velopharyngeal insufficiency, dry throat, and abnormal swallowing 1
• Maxillomandibular advancement: Among the most effective surgical options, comparable to CPAP in selected cases 3
• Nasal surgery: Not recommended as a single intervention for OSA treatment 1

Adjunctive Measures

• Avoid alcohol and sedative medications, particularly before bedtime 1, 3
• Avoid opioids and sedative hypnotics as they can worsen OSA 1
• Intranasal corticosteroids may improve mild to moderate OSA in patients with co-existing rhinitis 1

Treatment Algorithm Based on OSA Severity

1. Mild OSA (AHI 5-14/h):

   • Weight loss if overweight/obese
   • Positional therapy if position-dependent
   • MAD if anatomically suitable
   • CPAP if symptomatic or with comorbidities

2. Moderate OSA (AHI 15-30/h):

   • CPAP as first-line therapy
   • MAD if CPAP intolerant
   • Weight loss as adjunctive therapy

3. Severe OSA (AHI >30/h):

   • CPAP as first-line therapy
   • Consider BiPAP if CPAP intolerant
   • Surgical options if CPAP/BiPAP failed and anatomically suitable

Monitoring and Follow-up

• All patients should undergo sleep study with oral appliance in place after final adjustments 1
• Regular monitoring of CPAP adherence and efficacy is essential
• Early intervention for side effects improves treatment adherence 2
• Provide supportive, educational, and behavioral interventions to improve adherence early in treatment 1

Common Pitfalls

• Up to 50% of patients struggle with long-term CPAP compliance 2
• Self-reported CPAP use is often inaccurate; objective monitoring is crucial 2
• Surgical success rates vary widely and patient selection is critical
• Drug therapy (including mirtazapine, fluticasone, paroxetine, and protriptyline) has insufficient evidence and is not recommended 1
• Nasal dilators are not recommended for treating OSA 1