What are the treatment options for Obstructive Sleep Apnea (OSA)?

Treatment Options for Obstructive Sleep Apnea (OSA)

Continuous positive airway pressure (CPAP) is strongly recommended as the initial therapy for patients diagnosed with OSA due to its proven effectiveness in improving symptoms, reducing cardiovascular risks, and normalizing mortality in severe cases. 1, 2

First-Line Treatment Options

CPAP Therapy

• CPAP delivers compressed air into the airway to keep it open during sleep and is considered the gold standard treatment for OSA 1
• CPAP therapy has been shown to improve symptoms, normalize risk of traffic accidents, reduce sympathetic activity, and decrease cardiovascular morbidities 1, 2
• Recent evidence demonstrates that CPAP therapy normalizes mortality in patients with severe OSA 2
• Automatic positive airway pressure (APAP) is equally effective as CPAP for OSA treatment 2
• Many technological modifications have been made to CPAP devices to improve adherence, though their utility is not fully established 1
• Bilevel positive airway pressure (BPAP) can be used for patients who need lower mean pressure or require ventilatory support 3

Weight Management

• All overweight and obese patients diagnosed with OSA should be encouraged to lose weight (strong recommendation) 1
• Weight reduction may provide significant improvement in OSA severity and should be implemented as an adjunctive therapy 2
• There is a trend toward improvement in OSA symptoms after weight reduction 1

Alternative Treatments for CPAP-Intolerant Patients

Mandibular Advancement Devices (MADs)

• MADs are recommended as an alternative therapy for patients who prefer them or experience adverse effects with CPAP (weak recommendation) 1
• Evidence supports the use of MADs particularly in mild to moderate OSA 1
• Custom-made dual-block MADs have shown effectiveness in treating OSA 1
• MADs are less effective than CPAP for severe OSA but may be better tolerated by some patients 2, 4

Surgical Options

• Maxillomandibular osteotomy (MMO) appears to be as efficient as CPAP in patients who refuse conservative treatment 1
• MMO may be considered for patients with severe OSA who cannot tolerate other recommended therapies 2
• Hypoglossal nerve stimulation (HNS) can be considered for patients with an AHI of 15-65/h and BMI <32 kg/m² who cannot adhere to PAP therapy 2
• Multilevel surgery is only a salvage procedure for OSA patients 1
• Uvulopalatopharyngoplasty, pillar implants, and hyoid suspension should only be considered in selected patients, weighing potential benefits against long-term side effects 1

Positional Therapy

• Vibratory positional therapy can be used in patients with mild to moderate position-dependent OSA 1
• However, positional therapy is clearly inferior to CPAP and has poor long-term compliance 1, 2

Treatments Not Recommended for OSA

• Drugs, nasal dilators, and apnea-triggered muscle stimulation cannot be recommended as effective treatments 1
• Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension, and genioglossus advancement are not recommended as single interventions 1
• Oxygen therapy alone is not recommended for patients with OSA 2

Improving CPAP Adherence

• Educational interventions should be provided at initiation of CPAP therapy 2
• Nasal or intranasal mask interfaces are generally preferred over oronasal interfaces to minimize side effects 2
• Heated humidification should be used with CPAP devices to reduce side effects such as dry mouth/throat and nasal congestion 2
• Adequate follow-up, troubleshooting, and monitoring of objective efficacy and usage data are essential following CPAP initiation 2
• Common barriers to CPAP adherence include discomfort, skin irritation, noise, and claustrophobia 1, 5

Treatment Algorithm Based on OSA Severity

1. For all OSA patients: Encourage weight loss if overweight/obese 1
2. For mild to moderate OSA:
   • First-line: CPAP therapy 1
   • Alternative: MADs if patient prefers or cannot tolerate CPAP 1
   • For position-dependent OSA: Consider positional therapy 1
3. For severe OSA:
   • First-line: CPAP/APAP therapy 2
   • For CPAP-intolerant patients: Consider MADs (less effective) or surgical options like MMO or HNS in appropriate candidates 2
4. For OSA with hypoventilation (e.g., COPD or severe obesity):
   • Consider BPAP to augment ventilation via pressure support 3