What is the primary therapy for sleep apnea?

Primary Therapy for Obstructive Sleep Apnea

Continuous Positive Airway Pressure (CPAP) is the recommended initial therapy for patients diagnosed with obstructive sleep apnea (OSA). 1, 2

First-Line Treatment Options

• CPAP therapy is strongly recommended as the primary treatment for OSA based on moderate-quality evidence 1, 2
• CPAP effectively alleviates airway obstruction during sleep by delivering compressed air into the airway to keep it open, creating a pneumatic splint for the nasopharyngeal airway 2, 3
• CPAP has demonstrated significant improvements in:
  • Excessive daytime sleepiness 1, 4
  • Sleep-related quality of life 2
  • Reduction in apnea-hypopnea index (AHI) and arousal index scores 1, 5
  • Increased oxygen saturation during sleep 1, 4

Indications for CPAP Therapy

• CPAP is indicated for diagnosed OSA with an AHI ≥ 15 events/hour, regardless of symptoms 4
• Mild OSA (AHI 5-15 events/hour) with symptoms such as excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia 4
• Patients with OSA and comorbid cardiovascular conditions including hypertension, coronary artery disease, or history of stroke 4
• Patients at high risk for motor vehicle accidents due to OSA-related sleepiness 4

Weight Management as Adjunctive Therapy

• All overweight and obese patients diagnosed with OSA should be strongly encouraged to lose weight as part of their treatment plan 1, 2
• Weight loss can significantly decrease or eliminate apneas, though typically serves as an adjunct to CPAP rather than a replacement 4, 6

Alternative Treatment Options

• Mandibular Advancement Devices (MADs) are recommended as an alternative therapy for patients who:
  • Prefer MADs over CPAP 1
  • Experience adverse effects with CPAP 1, 2
  • Cannot tolerate CPAP therapy 1, 4
• MADs are particularly effective in mild to moderate OSA (AHI between 5-30 events/hour), though this is a weak recommendation based on low-quality evidence 1, 2

CPAP Implementation and Adherence

• CPAP therapy can be initiated using either auto-adjusting PAP (APAP) at home or in-laboratory PAP titration 2
• Both fixed CPAP and auto-CPAP have similar adherence and efficacy 1
• Higher AHI and ESS scores are generally associated with better adherence to CPAP 1, 4
• Average nightly CPAP usage is typically less than 5 hours per night 7
• Patients who experience side effects from CPAP use their machines significantly less than those who do not 7
• Heated humidification can improve CPAP adherence, especially in patients with nasal congestion or dryness 5

Common Pitfalls and Considerations

• Adherence is the major challenge in CPAP therapy - systematic approach including education, objective adherence monitoring, and early intervention for side effects is essential 5
• Minimum effective CPAP usage is generally considered to be at least 4 hours per night on 70% of nights 4
• Regular monitoring of CPAP adherence with early follow-up is recommended to address any issues 4
• Pharmacologic therapy (including mirtazapine, xylometazoline, fluticasone, paroxetine, pantoprazole, acetazolamide, and protriptyline) is not currently supported by evidence and should not be prescribed for OSA treatment 1
• Surgical treatments are associated with risks and serious adverse effects; current evidence is limited and insufficient to show benefits as initial treatment 1