What are the treatment options for very severe sleep apnea?

Treatment Options for Very Severe Sleep Apnea

Positive airway pressure (PAP) therapy is strongly recommended as the first-line treatment for very severe obstructive sleep apnea (OSA) and should be used for the entirety of a patient's sleep period. 1

First-Line Treatment: PAP Therapy

Types of PAP Therapy

• Continuous positive airway pressure (CPAP) or automatic positive airway pressure (APAP) are equally effective and recommended as the primary treatment options for severe OSA 1
• Bilevel positive airway pressure (BPAP) should be considered only when patients cannot tolerate CPAP or APAP due to pressure intolerance 2
• PAP therapy has been shown to improve symptoms, normalize risk of traffic accidents, reduce sympathetic activity, and decrease cardiovascular morbidities 1
• Recent evidence demonstrates that PAP therapy normalizes mortality in patients with severe OSA 1

Optimizing PAP Therapy

• Educational interventions should be provided at the initiation of PAP therapy to improve adherence 1
• Behavioral and troubleshooting interventions are recommended during the initial period of PAP therapy 1
• Telemonitoring-guided interventions can help improve adherence during the initial treatment period 1
• Nasal or intranasal mask interfaces are generally preferred over oronasal or oral interfaces to minimize side effects 1
• Heated humidification should be used with PAP devices to reduce side effects such as dry mouth/throat, nasal congestion, and nose bleeds 1

PAP Usage Considerations

• Patients should be encouraged to use PAP for the entirety of their sleep period 1
• Even if patients use PAP for less than 4 hours per night, they should be encouraged to continue treatment as there are still benefits 1
• Studies show that greater PAP use is associated with improved outcomes, though benefits can be seen even with partial nightly use 1

Alternative Treatments for PAP-Intolerant Patients

Mandibular Advancement Devices (MADs)

• MADs can be considered for patients with mild to moderate OSA who cannot tolerate PAP, but are less effective for severe OSA 1
• MADs are fabricated by qualified dental providers and work by advancing the mandible to increase upper airway space 1
• While MADs may not be as efficacious as PAP therapy in reducing the apnea-hypopnea index (AHI), increased patient adherence may result in similar overall treatment benefits 1

Surgical Options

• Hypoglossal nerve stimulation therapy can be considered for patients with an AHI of 15-65/h and BMI <32 kg/m² who cannot adhere to PAP 1
• Maxillomandibular advancement surgery may be considered for patients with severe OSA who cannot tolerate or are not appropriate candidates for other recommended therapies 1
• Maxillomandibular osteotomy has been shown to be as efficient as CPAP in selected patients who refuse conservative treatment 1
• Multilevel surgery should only be considered as a salvage procedure for OSA patients in whom PAP and other conservative therapies have failed 1

Other Interventions

• Weight reduction may provide improvement in OSA severity and should be encouraged as an adjunctive therapy 1
• Nasal surgery may be considered for patients with anatomical nasal obstruction as a barrier to PAP use 1
• Alternative/salvage therapies may be offered to patients who cannot tolerate or have declined all other recommended treatments 1

Treatments Not Recommended for Severe OSA

• Oxygen therapy is not recommended as a stand-alone treatment for patients with OSA who cannot tolerate other recommended therapies 1
• Positional therapy is clearly inferior to CPAP and has poor long-term compliance 1
• Drugs, nasal dilators, and apnea-triggered muscle stimulation cannot be recommended as effective treatments of OSA 1
• Single-intervention procedures such as uvulopalatopharyngoplasty, pillar implants, and hyoid suspension should only be considered in carefully selected patients 1

Follow-up and Monitoring

• Adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data, is essential following PAP therapy initiation 1
• Early intervention for side effects and regular telephone and clinic support are essential to optimize adherence 3
• A systematic approach to PAP treatment including education, objective adherence monitoring, and support is crucial for treatment success 3

Remember that despite the availability of alternative treatments, PAP therapy remains the gold standard for very severe OSA due to its proven efficacy in reducing the apnea-hypopnea index and improving both subjective and objective sleepiness, as well as reducing cardiovascular risk 3, 4.