What are the typical treatment options for sleep apnea?

Treatment Options for Sleep Apnea

Continuous Positive Airway Pressure (CPAP) is strongly recommended as the first-line treatment for obstructive sleep apnea (OSA), with weight loss as an important adjunctive therapy for overweight and obese patients. 1

Primary Treatment Approaches

First-Line Treatment: Positive Airway Pressure (PAP) Therapy

• CPAP is the most extensively studied and recommended initial therapy for patients diagnosed with OSA, delivering compressed air into the airway to keep it open during sleep 1
• PAP therapy has been shown to improve excessive daytime sleepiness, reduce apnea-hypopnea index (AHI), and increase oxygen saturation 1
• Both fixed CPAP and auto-adjusting PAP (APAP) have similar efficacy and can be used as primary treatment options 1, 2
• PAP therapy should be used for the entirety of a patient's sleep period for optimal benefit 3
• Nasal interfaces are generally preferred over oronasal interfaces to minimize side effects 3
• Heated humidification should be used with PAP devices to reduce side effects such as dry mouth/throat and nasal congestion 3, 4

Weight Management

• All overweight and obese patients diagnosed with OSA should be encouraged to lose weight as part of their treatment plan 1, 2
• Weight loss may reduce OSA symptoms and has many other health benefits 1
• Weight reduction can serve as an important adjunctive therapy to PAP treatment 3

Alternative Treatment Options

Mandibular Advancement Devices (MADs)

• MADs are recommended as an alternative therapy for patients who:
  • Prefer these devices over CPAP
  • Experience adverse effects with CPAP
  • Cannot tolerate or adhere to CPAP therapy 1
• MADs are particularly effective in mild to moderate OSA (AHI between 18 and 40 events per hour) 1
• This is considered a weak recommendation based on low-quality evidence 1

Advanced Interventions for PAP-Intolerant Patients

• 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 3
• Maxillomandibular advancement surgery may be considered for patients with severe OSA who cannot tolerate other recommended therapies 3
• Positional therapy (avoiding the supine position during sleep) may help patients who primarily have apneas while lying on their back, though it's clearly inferior to CPAP and has poor long-term compliance 3, 5

Treatments Not Recommended

• Pharmacologic therapy is not currently supported by evidence and should not be prescribed for OSA treatment 1
• Surgical treatments (except in specific cases mentioned above) are associated with risks and serious adverse effects and should not be used as initial treatment 1
• Oxygen therapy alone is not recommended as a stand-alone treatment 3
• Nasal dilators and apnea-triggered muscle stimulation cannot be recommended as effective treatments 3

Optimizing PAP Adherence

• Educational interventions should be provided at the initiation of PAP therapy 1, 3
• Close follow-up, including troubleshooting and monitoring of objective efficacy and usage data, is essential 1, 3
• Telemonitoring-guided interventions can help improve initial therapy adherence 2
• Addressing side effects promptly (mask leaks, nasal congestion, skin irritation) is crucial for maintaining adherence 4, 6
• Even partial nightly use of PAP (less than 4 hours) provides benefits and patients should be encouraged to continue treatment 3, 7

Clinical Considerations

• OSA severity is measured by the apnea-hypopnea index (AHI): mild (5-14/h), moderate (15-30/h), and severe (>30/h) 7
• Untreated OSA increases risk of cardiovascular disease, hypertension, cerebrovascular events, and cardiac dysrhythmias 7
• The prevalence of sleep apnea increases with age, though severity may decrease in the elderly 5
• Cognitive impairment from OSA in older adults may resemble dementia 5