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, as it effectively reduces airway obstruction during sleep and improves clinical outcomes. 1

First-Line Treatment Options

CPAP Therapy

• CPAP delivers compressed air into the airway to keep it open during sleep and is the standard first-line OSA treatment 1
• CPAP therapy has been shown to improve symptoms, normalize risk of traffic accidents, reduce sympathetic activity, and decrease cardiovascular morbidities 1
• Recent evidence demonstrates that CPAP therapy normalizes mortality in patients with severe OSA 2
• Variants of PAP therapy include:
  • Automatic positive airway pressure (APAP) 3
  • Bilevel positive airway pressure (BPAP) - useful for patients who require higher pressures or have associated hypoventilation 4

Weight Management

• All overweight and obese patients diagnosed with OSA should be strongly encouraged to lose weight 1
• Weight reduction may provide significant improvement in OSA severity and should be encouraged as an adjunctive therapy 2
• Evidence shows that increasing OSA rates are likely due to escalating obesity rates 1

Alternative Treatment Options for CPAP-Intolerant Patients

Mandibular Advancement Devices (MADs)

• Recommended as an alternative therapy for patients who:
  • Prefer MADs over CPAP 1
  • Experience adverse effects with CPAP treatment 1
  • Have mild to moderate OSA 1
• Custom-made dual-block MADs have shown better evidence of effectiveness 1
• MADs are less effective than CPAP for severe OSA 2

Positional Therapy

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

Surgical Options

• Maxillomandibular osteotomy (MMO) can be as efficient as CPAP in patients who refuse conservative treatment 1, 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 2
• Uvulopalatopharyngoplasty, pillar implants, and hyoid suspension should only be considered in selected patients with careful consideration of potential long-term side effects 1
• Multilevel surgery is only a salvage procedure for OSA patients 1

Treatments Not Recommended for OSA

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

Adherence Considerations

• Many patients do not tolerate CPAP due to discomfort, skin irritation, noise, and claustrophobia 1
• Educational interventions should be provided at the initiation of PAP therapy to improve adherence 2
• Heated humidification can help reduce side effects such as dry mouth/throat, nasal congestion, and nose bleeds 2, 5
• Nasal or intranasal mask interfaces are generally preferred over oronasal or oral interfaces to minimize side effects 2
• A systematic approach to PAP treatment including education, objective adherence monitoring, early intervention for side effects, and telephone and clinic support is essential to optimize adherence 5

Treatment Algorithm Based on OSA Severity

1. Mild to Moderate OSA:

   • First-line: CPAP therapy 1
   • Alternative: MADs if CPAP is not tolerated 1
   • Adjunctive: Weight loss for overweight/obese patients 1
   • Consider: Positional therapy if position-dependent OSA 1

2. Severe OSA:

   • First-line: CPAP therapy 1, 2
   • Alternative if CPAP fails: Consider HNS (with appropriate patient selection) or maxillomandibular advancement surgery 2
   • Adjunctive: Weight loss for overweight/obese patients 1, 2