What are the alternative treatments for patients who refuse to wear Continuous Positive Airway Pressure (CPAP) devices?

Alternative Treatments for CPAP-Refusing OSA Patients

For patients refusing CPAP therapy, custom-made dual-block mandibular advancement devices (MADs) represent the first-line alternative for mild to moderate OSA, while hypoglossal nerve stimulation should be considered for moderate to severe OSA in appropriately selected patients who meet strict criteria. 1

Critical First Step: Document Refusal and Risks

Before pursuing alternatives, you must document the patient's understanding of:

• Increased cardiovascular morbidity and mortality risk with untreated OSA compared to CPAP therapy 1
• CPAP's superior efficacy in reducing apnea-hypopnea index (AHI) and blood pressure compared to all alternative treatments 2
• The specific risks of their chosen alternative, including potentially inferior outcomes for severe disease 1

Treatment Algorithm Based on OSA Severity

Mild to Moderate OSA (AHI <30 events/hour)

First-line alternative: Custom-made dual-block mandibular advancement devices 1

• MADs showed the highest level of evidence among alternatives, with 13 randomized controlled trials 2
• While CPAP is superior for AHI reduction, patient-related outcomes (sleepiness, quality of life) are equivalent between CPAP and MADs 2
• This equivalence in patient-centered outcomes justifies MADs as a reasonable first alternative 2

Second-line: Positional therapy (if positional OSA confirmed) 1

• Only appropriate for patients with documented lower AHI in non-supine positions 1
• Requires polysomnography verification before initiating as primary therapy 1
• Vibratory positional therapy has very low certainty evidence but can be considered 2

Moderate to Severe OSA (AHI ≥30 events/hour)

The treatment hierarchy becomes more restrictive:

Hypoglossal nerve stimulation (HNS) 1, 3

• Strict eligibility criteria must be met: 3
  • AHI 15-65 events/hour (some guidelines specify 15-100) 1, 3
  • BMI <32 kg/m² (some sources allow <40 kg/m²) 1, 3
  • No complete concentric collapse at soft palate level on drug-induced sleep endoscopy (DISE) 3
  • Documented CPAP failure or intolerance 3
• HNS received a conditional recommendation against first-line use but can be used after CPAP failure following STAR trial criteria 2

Maxillomandibular advancement (MMO) 1

• Reserved for young patients without excessive BMI who refuse all other treatments 1
• Can be considered as salvage therapy after CPAP failure 2
• Requires surgical expertise and has significant perioperative considerations 2

Universal Adjunctive Interventions

Weight loss for all overweight/obese patients 1

• Rarely curative as monotherapy but improves all treatment outcomes 1
• Repeat sleep study indicated after ≥10% body weight loss to reassess treatment needs 1

Behavioral modifications 1

• Avoid alcohol and sedatives before bedtime 1
• Sleep hygiene optimization 1

Emerging and Investigational Options

The following have insufficient evidence for routine recommendation but may be considered in specialized centers:

• Myofunctional therapy: Limited evidence, cannot be recommended as standard treatment 2, 3
• Carbonic anhydrase inhibitors: Addressed in guidelines but with very limited data 2
• Combination therapies: Promising pathophysiological rationale but evidence remains preliminary 2
• Gastric bypass surgery: No randomized trials comparing to CPAP available 2

Common Pitfalls to Avoid

Do not offer soft palate surgery alone - lacks substantial evidence for efficacy and was excluded from recent guidelines 2

Do not use tongue-retaining devices routinely - only for selected mild-to-moderate OSA patients when other treatments have failed 3

Do not skip DISE before HNS - complete concentric collapse at the soft palate predicts failure 3

Do not assume MADs work for severe OSA - they are significantly less effective than CPAP for AHI reduction in severe disease, though the clinical significance depends on patient-centered outcomes 2

Beware of health inequity - high costs of HNS and limited availability of specialized surgical expertise create access barriers 2

Follow-Up Requirements

All alternative treatments require objective follow-up assessment 1:

• Repeat sleep study to document treatment efficacy 1
• Ongoing monitoring of symptoms and cardiovascular risk factors 1
• Reassessment if clinical status changes (weight gain, symptom worsening) 1

When No Alternative Is Appropriate

For patients with severe OSA who refuse CPAP and don't meet criteria for alternatives, you must clearly document that untreated OSA carries significant mortality risk and that the patient accepts this risk against medical advice 1. Consider multidisciplinary consultation including sleep medicine, ENT, and dental sleep specialists to explore all possible options 4.