Treatment Options for Obstructive Sleep Apnea
Continuous positive airway pressure (CPAP) is the first-line treatment for all patients diagnosed with OSA, regardless of severity, and should be strongly recommended as initial therapy. 1, 2
Primary Treatment Algorithm
First-Line: CPAP Therapy
- CPAP or automatic positive airway pressure (APAP) are equally effective and should be prescribed as the primary treatment option for OSA 2
- CPAP has moderate-quality evidence showing it improves symptoms, normalizes traffic accident risk, reduces sympathetic activity, decreases cardiovascular morbidities, and normalizes mortality in severe OSA 1, 2
- Patients should use CPAP for the entirety of their sleep period, though even partial use (less than 4 hours per night) provides benefits and should be encouraged 2
- Nasal or intranasal masks are preferred over oronasal masks to minimize side effects and maintain efficacy 2
- Heated humidification should be used with CPAP devices to reduce dry mouth/throat, nasal congestion, and nosebleeds 2
- Educational interventions at CPAP initiation improve adherence 2
Concurrent Weight Loss (Mandatory for Overweight/Obese Patients)
- All overweight and obese patients with OSA must be encouraged to lose weight as obesity is the primary modifiable risk factor 1, 3
- This is a strong recommendation despite low-quality evidence, as weight reduction shows a trend toward improvement in OSA severity 1, 3
- Weight loss should be considered adjunctive therapy alongside CPAP, not a replacement 2, 3
Second-Line Options for CPAP-Intolerant Patients
Mandibular Advancement Devices (MADs)
- MADs are recommended as an alternative therapy for patients who prefer them or experience CPAP adverse effects (discomfort, skin irritation, noise, claustrophobia) 1, 3
- Evidence supports MAD use in mild to moderate OSA, but they are less effective for severe OSA 1, 2
- This is a weak recommendation with low-quality evidence 1
Hypoglossal Nerve Stimulation
- Consider for patients with AHI 15-65/h and BMI <32 kg/m² who cannot adhere to PAP therapy 2
- This represents a newer option for select CPAP-intolerant patients 2
Maxillomandibular Advancement Surgery
- Maxillomandibular osteotomy appears as efficient as CPAP in patients who refuse conservative treatment 1
- Should be considered for severe OSA patients who cannot tolerate or are not appropriate candidates for other recommended therapies 2
- Distraction osteogenesis is useful in congenital micrognathia or midface hypoplasia 1
Treatments NOT Recommended
Ineffective as Primary Therapy
- Positional therapy is clearly inferior to CPAP with poor long-term compliance 1, 2
- Drugs, nasal dilators, and apnea-triggered muscle stimulation cannot be recommended as effective OSA treatments 1, 2, 3
- Oxygen therapy is not recommended as stand-alone treatment 2
- Pharmacologic agents lack sufficient evidence and should not be prescribed for OSA treatment 3
Surgical Procedures with Limited Evidence
- 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
- Uvulopalatopharyngoplasty, pillar implants, and hyoid suspension should only be considered in selected patients, with potential benefits weighed against long-term side-effects 1
- Multilevel surgery is only a salvage procedure for OSA patients 1
Common Pitfalls to Avoid
- Do not prescribe oronasal masks as first-line despite patient complaints of mouth dryness—nasal masks with oral shields or heated humidification are superior 2, 4
- Do not abandon CPAP therapy if patients use it less than 4 hours per night; encourage continued use as benefits still accrue 2
- Do not offer MADs as first-line therapy for severe OSA, as they are significantly less effective than CPAP in this population 1, 2
- Bilevel positive airway pressure (BPAP) should be reserved for OSA with associated hypoventilation (COPD, severe obesity), not routine OSA treatment 5