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

Treatment of Obstructive Sleep Apnea

Continuous positive airway pressure (CPAP) or auto-adjusting PAP (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 should be prescribed as the primary treatment option for OSA, with both modalities demonstrating equal effectiveness in reducing symptoms, improving quality of life, and normalizing mortality risk in severe OSA. 1, 2, 3
• PAP therapy effectively alleviates airway obstruction by delivering compressed air to keep the upper airway open during sleep, preventing apneas, hypoxias, and sleep disturbances. 3, 4
• The American Academy of Sleep Medicine strongly recommends PAP therapy for adults with excessive sleepiness and conditionally recommends it for those with impaired sleep-related quality of life or comorbid hypertension. 1

Initiation Strategy

• PAP therapy can be initiated using either APAP at home or in-laboratory PAP titration, with no clinically significant differences in adherence, sleepiness reduction, or quality of life improvement between these approaches. 1, 3
• Home APAP initiation offers advantages of lower cost, faster treatment start, and greater access to care, making it preferable for most patients without significant comorbidities. 1
• In-laboratory titration should be reserved for patients with congestive heart failure, chronic obstructive pulmonary disease, neuromuscular disease, chronic opiate use, central sleep apnea syndromes, or anticipated nocturnal oxygen desaturation from conditions other than OSA. 1, 3, 5

Device Selection and Settings

• Either CPAP or APAP should be used for ongoing treatment, as meta-analyses of 26 randomized controlled trials demonstrated no clinically significant differences between these modalities in adherence, sleepiness, or quality of life. 1
• CPAP or APAP is preferred over bilevel PAP (BPAP) for routine OSA treatment, with BPAP reserved for specific clinical scenarios. 1
• Nasal or intranasal masks are preferred over oronasal masks to minimize side effects while maintaining efficacy. 2
• Heated humidification should be used with CPAP devices to reduce dry mouth, throat irritation, nasal congestion, and nosebleeds. 2

Optimizing Adherence

• Educational interventions must be provided at PAP therapy initiation to improve adherence, representing a strong recommendation from the American Academy of Sleep Medicine. 1, 2
• Behavioral and troubleshooting interventions should be implemented during the initial treatment period to address mask fit, air leak, and comfort issues. 1
• Telemonitoring-guided interventions during the first weeks of therapy can improve initial adherence rates. 1, 3
• Adequate follow-up with monitoring of objective efficacy and usage data is essential to ensure treatment effectiveness and identify adherence problems early. 1, 2

Adjunctive Treatment: Weight Loss

All overweight and obese patients with OSA must be encouraged to lose weight, as obesity is the primary modifiable risk factor for this condition. 6, 2, 3

Weight Loss Strategies

• Weight loss is strongly recommended as first-line therapy alongside PAP treatment for overweight and obese patients, with evidence showing trends toward OSA improvement after weight reduction. 6
• Tirzepatide (Zepbound) represents the first FDA-approved pharmacologic agent specifically indicated for moderate to severe OSA with obesity (BMI ≥30) or overweight (BMI ≥27 with weight-related comorbidities). 6
• Tirzepatide produces mean weight loss of 15-20.9% at 72 weeks depending on dose (5-15 mg), substantially greater than other GLP-1 receptor agonists, and should be initiated alongside CPAP therapy. 6
• Long-term use of weight loss medications is necessary, as discontinuation leads to weight regain. 6

Second-Line Options for CPAP-Intolerant Patients

Mandibular Advancement Devices

• Mandibular advancement devices (MADs) are recommended as alternative therapy for patients who prefer them, experience CPAP adverse effects, or cannot tolerate CPAP, particularly in mild to moderate OSA. 2, 3
• MADs are less effective than CPAP in reducing respiratory disturbances, with CPAP showing 7.97 events/hour greater reduction in apnea-hypopnea index compared to oral appliances. 4
• Despite lower efficacy, patients who respond to both treatments often express strong preference for oral appliances due to greater convenience. 4

Surgical Options

• Hypoglossal nerve stimulation should be considered for patients with apnea-hypopnea index 15-65 events/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 treatments. 2

Treatments NOT Recommended

Ineffective Therapies

• Pharmacologic agents (other than tirzepatide for weight loss) lack sufficient evidence and should not be prescribed for OSA treatment. 6, 2
• Positional therapy is clearly inferior to CPAP with poor long-term compliance and cannot be recommended as primary treatment. 2, 3
• Oxygen therapy is not recommended as stand-alone treatment for OSA. 2
• Nasal dilators and apnea-triggered muscle stimulation cannot be recommended as effective OSA treatments. 2

Common Pitfalls and How to Avoid Them

Adherence Issues

• Address CPAP adherence problems proactively with education, mask adjustments, and humidification before abandoning therapy, as even partial CPAP use provides clinical benefits. 2
• Monitor for treatment effectiveness within the first few weeks and make necessary PAP adjustments when indicated. 1
• Patients should be encouraged to use CPAP for the entirety of their sleep period for optimal results. 2

Patient Selection Errors

• Do not use APAP for patients with significant comorbidities including heart failure, significant lung disease, neuromuscular disease, history of uvulopalatopharyngoplasty, or central sleep apnea syndromes. 3, 5
• Ensure objective sleep apnea testing establishes the diagnosis before initiating PAP therapy. 1, 2
• Perform reevaluation and standard attended CPAP titration if symptoms do not resolve or treatment appears ineffective. 5