What are the treatment options for sleep apnea?

Treatment Options for Sleep Apnea

Continuous positive airway pressure (CPAP) or automatic positive airway pressure (APAP) is the first-line treatment for all patients with obstructive sleep apnea, regardless of severity, and should be prescribed as the primary treatment option. 1, 2

Primary Treatment: Positive Airway Pressure Therapy

Initial Treatment Selection

• CPAP and APAP are equally effective and interchangeable as first-line therapy, with strong evidence showing improvements in daytime sleepiness, sleep-related quality of life, normalization of traffic accident risk, reduction in sympathetic activity, decreased cardiovascular morbidities, and normalized mortality in severe OSA. 1, 2, 3
• PAP therapy should be initiated using either APAP at home or in-laboratory PAP titration in adults with OSA who have no significant comorbidities. 1
• Bilevel PAP (BPAP) should be reserved for patients with therapeutic pressure requirements greater than can be provided with CPAP or APAP, not used routinely. 1

Optimizing PAP Delivery

• Use nasal or intranasal masks rather than oronasal masks to minimize side effects and maintain efficacy. 1, 2
• Add heated humidification to all PAP devices to reduce dry mouth/throat, nasal congestion, and nosebleeds. 1, 2
• Patients should use PAP for the entirety of their sleep period, though even partial use (less than 4 hours per night) provides benefits and should be encouraged. 2, 4

Enhancing Adherence

• Provide educational interventions at PAP initiation (strong recommendation), covering what OSA is, consequences of untreated disease, how to use PAP, and potential benefits. 1, 2
• Implement behavioral and/or troubleshooting interventions during the initial treatment period to address PAP-related problems and identify solutions. 1
• Consider telemonitoring-guided interventions during the initial PAP therapy period to remotely monitor device data and proactively address issues. 1
• Ensure adequate follow-up with troubleshooting and monitoring of objective efficacy and usage data following PAP initiation and throughout treatment. 1, 2

Second-Line Options for PAP-Intolerant Patients

Mandibular Advancement Devices

• Mandibular advancement devices (MADs) are recommended as an alternative therapy for patients who prefer them or experience adverse effects with CPAP, particularly for mild to moderate OSA. 1, 2
• MADs are less effective than CPAP in reducing respiratory disturbances (CPAP reduces apnea-hypopnea index by approximately 8 events/hour more than oral appliances) but some patients strongly prefer them despite lower efficacy. 2, 3
• MADs are less effective for severe OSA and should not be considered first-line in this population. 2, 4

Surgical Options

• Hypoglossal nerve stimulation should be considered for patients with AHI 15-65/hour and BMI <32 kg/m² who cannot adhere to PAP therapy. 2, 4
• Maxillomandibular advancement surgery appears as efficient as CPAP and should be considered for severe OSA patients who refuse or cannot tolerate conservative treatment and are not appropriate candidates for other recommended therapies. 2, 4

Adjunctive Therapy

Weight Loss

• All overweight and obese patients with OSA must be encouraged to lose weight, as obesity is the primary modifiable risk factor for OSA, though evidence quality for weight loss efficacy is low. 2
• Weight reduction may provide improvement in OSA severity and should be encouraged as adjunctive therapy alongside primary treatment. 4, 5

Treatments NOT Recommended

Ineffective Therapies

• Positional therapy is clearly inferior to CPAP with poor long-term compliance and should not be used as primary treatment. 2, 4
• Oxygen therapy is not recommended as stand-alone treatment for OSA. 2, 4
• Pharmacologic agents lack sufficient evidence and should not be prescribed for OSA treatment, including mirtazapine, xylometazoline, fluticasone, paroxetine, pantoprazole, acetazolamide, protriptyline, antidepressants, and respiratory stimulants. 1, 2, 5
• Drugs, nasal dilators, and apnea-triggered muscle stimulation cannot be recommended as effective OSA treatments. 2, 4

Common Pitfalls to Avoid

• Do not abandon CPAP prematurely—address adherence issues proactively with education, mask adjustments, and humidification before considering alternatives. 2
• Do not use surgical treatments as initial therapy, as current evidence is limited and insufficient to show benefits, and surgery carries risks and serious adverse effects. 1
• Do not prescribe BPAP routinely when CPAP or APAP would suffice, as this increases costs without additional benefit in most patients. 1
• Do not neglect follow-up—inadequate monitoring is a major cause of treatment failure and poor adherence. 1, 2