What alternative interventions can be used for a patient with sleep apnea who refuses Continuous Positive Airway Pressure (CPAP) therapy and has respiratory acidosis?

From the Guidelines

For a patient with sleep apnea who refuses CPAP and has respiratory acidosis (pH 7.29), the most effective alternative intervention is the use of mandibular advancement devices, as supported by the latest evidence from 2025 1. This approach is recommended by the Portuguese Society of Pulmonology, the Portuguese Society of Stomatology and Dental Medicine, the Portuguese Dental Association, and the Portuguese Society of Temporomandibular Disorders, Orofacial Pain and Sleep. Key considerations for managing sleep apnea in this context include:

• Weight loss counseling if the patient is overweight, as weight reduction is associated with a trend of improvement in breathing pattern, quality of sleep, and daytime sleepiness 1
• Positional therapy to avoid sleeping supine, which can improve airway patency and reduce apnea events 1
• Avoidance of alcohol and sedatives before bedtime, as these can exacerbate sleep apnea
• Consideration of surgical interventions such as maxillomandibular advancement for selected patients who refuse conservative treatment, as this has been shown to be as efficient as CPAP in patients with OSA 1 The goal of these interventions is to normalize breathing during sleep, thereby resolving the respiratory acidosis and preventing long-term complications such as cardiovascular disease, cognitive impairment, and increased mortality. It is essential to discuss treatment options with a multidisciplinary team, including a qualified dentist, sleep unit, and sleep doctor, to determine the best course of action for each patient 1.

From the Research

Alternative Interventions for Sleep Apnea

If a patient refuses CPAP and has sleep apnea with a pH of 7.29, there are several alternative interventions that can be considered:

• Oral appliance therapy (OAT) is a leading alternative to CPAP for obstructive sleep apnea (OSA) 2
• Combination therapy with CPAP and oral appliance (CPAP + OA) can reduce therapeutic CPAP requirements and minimize epiglottic pressure swings 2
• Sleep positional therapy (SPT) can be an effective alternative for managing positional OSA, particularly for patients intolerant to CPAP 3
• Positional therapy (PT) with the sleep position trainer (SPT) can be as effective as OAT in reducing the median apnea-hypopnea index (AHI) in patients with mild-to-moderate positional obstructive sleep apnea (POSA) 4

Considerations for Alternative Interventions

When considering alternative interventions, the following factors should be taken into account:

• The patient's specific needs and preferences
• The severity of the sleep apnea
• The presence of positional OSA
• The patient's ability to tolerate different therapies
• The potential benefits and risks of each alternative intervention 5, 3, 4, 6

Potential Benefits of Alternative Interventions

The potential benefits of alternative interventions include:

• Improved adherence to therapy
• Reduced symptoms of sleep apnea
• Improved quality of life
• Reduced risk of complications associated with sleep apnea
• Increased patient satisfaction with therapy 2, 5, 3, 4