What is the typical treatment for obstructive sleep apnea (OSA)?

Treatment of Obstructive Sleep Apnea

Continuous positive airway pressure (CPAP) or auto-adjusting positive airway pressure (APAP) is the first-line treatment for all adults diagnosed with obstructive sleep apnea, regardless of severity. 1, 2

Primary Treatment: Positive Airway Pressure Therapy

Initial Therapy Selection

• CPAP or APAP are equally effective and should be prescribed as the primary treatment option for OSA, with strong evidence showing improvements in excessive sleepiness, sleep-related quality of life, cardiovascular outcomes including hypertension, and normalization of mortality in severe OSA. 1, 2
• PAP therapy must be based on a diagnosis established using objective sleep apnea testing (polysomnography or home sleep apnea testing). 1
• For patients without significant comorbidities, initiate PAP therapy using either APAP at home or in-laboratory PAP titration—both approaches are equally effective. 1, 3

Device Selection and Settings

• Use CPAP or APAP over bilevel PAP (BPAP) for routine treatment of OSA in adults, as BPAP offers no additional benefit for most patients and increases cost. 1
• Prescribe nasal or intranasal masks rather than oronasal masks to minimize side effects and maintain efficacy. 2
• Add heated humidification to CPAP devices to reduce dry mouth/throat, nasal congestion, and nosebleeds. 2

Contraindications to APAP

APAP should not be used in patients with: 3, 4

• Congestive heart failure
• Significant lung disease (chronic obstructive pulmonary disease)
• Daytime hypoxemia or respiratory failure
• Obesity hypoventilation syndrome
• Central sleep apnea syndromes
• History of uvulopalatopharyngoplasty
• Chronic opiate use
• Neuromuscular disease

Optimizing Adherence

• Provide educational interventions at PAP therapy initiation—this is a strong recommendation that significantly improves adherence. 1
• Implement behavioral and troubleshooting interventions during the initial period of PAP therapy. 1
• Consider telemonitoring-guided interventions during the initial treatment period to improve adherence. 1
• Conduct adequate follow-up with troubleshooting and monitoring of objective efficacy and usage data to ensure adequate treatment and adherence. 1, 2
• Address adherence issues proactively with education, mask adjustments, and humidification before abandoning CPAP. 2

Weight Loss as Essential Adjunctive Therapy

• All overweight and obese patients with OSA must be encouraged to lose weight, as obesity is the primary modifiable risk factor for OSA. 2, 5, 3
• Weight loss should be pursued concurrently with PAP therapy, not as a replacement for it. 2, 5
• Combining CPAP with weight control is beneficial, though this approach requires evaluation in randomized controlled trials. 6

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, particularly in mild to moderate OSA. 2, 3
• MADs are less effective than CPAP in reducing respiratory disturbances (CPAP reduces apnea-hypopnea index by approximately 8 events/hour more than oral appliances). 7
• Responders to both treatments often express a strong preference for oral appliances due to convenience, despite lower efficacy. 7

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
• Maxillomandibular advancement surgery appears as efficient as CPAP and should be considered for severe OSA patients who refuse or cannot tolerate conservative treatment. 2, 3

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, 3
• Drugs, nasal dilators, and apnea-triggered muscle stimulation cannot be recommended as effective OSA treatments. 2
• Oxygen therapy is not recommended as stand-alone treatment. 2
• Pharmacologic agents lack sufficient evidence and should not be prescribed for OSA treatment (with the exception of tirzepatide, which is FDA-approved specifically for moderate to severe OSA with obesity). 2, 5

Common Pitfalls to Avoid

• Do not abandon CPAP prematurely—many adherence issues can be resolved with proper mask fitting, humidification, pressure adjustments, and patient education. 2, 3
• Do not use APAP for split-night studies, as this has not been adequately studied. 4
• Do not prescribe APAP for patients with the contraindications listed above, as efficacy and safety have not been established in these populations. 3, 4
• Do not rely on unattended APAP to initially determine pressures for fixed CPAP in CPAP-naïve patients, as this approach is not currently established. 4
• Ensure re-evaluation and standard attended CPAP titration if symptoms do not resolve or treatment appears to lack efficacy. 4