What are the typical management strategies for obstructive sleep apnea besides Continuous Positive Airway Pressure (CPAP)?

Management of Obstructive Sleep Apnea Beyond CPAP

For patients who cannot tolerate or refuse CPAP, mandibular advancement devices (MADs) are the recommended first alternative therapy, particularly for mild-to-moderate OSA, followed by hypoglossal nerve stimulation for carefully selected patients with moderate-to-severe disease who meet strict criteria. 1, 2

Weight Loss: Universal First-Line Intervention

• All overweight and obese patients with OSA must be counseled to lose weight regardless of other treatments pursued, as obesity is the primary modifiable risk factor and weight loss improves apnea-hypopnea indices and provides multiple health benefits beyond OSA treatment. 1, 2, 3
• Intensive weight-loss interventions help reduce AHI scores and improve OSA symptoms, though the evidence quality is low. 1

Mandibular Advancement Devices (MADs)

• MADs are recommended as the primary alternative to CPAP for patients who prefer them or experience CPAP adverse effects, with evidence supporting their use particularly in mild-to-moderate OSA. 1, 2
• Custom-made, titratable dual-block MADs fabricated by qualified dental providers are the recommended type of oral appliances, not over-the-counter devices. 2, 4
• MADs are less effective than CPAP in eliminating OSA (approximately 50% of patients experience resolution), but patient satisfaction and adherence may be superior to CPAP, resulting in similar overall clinical effectiveness. 4, 5, 6
• MADs are clearly less effective for severe OSA and should not be considered first-line in this population. 2, 3
• Contraindications include severe periodontal disease, severe temporomandibular disorders, inadequate dentition, and severe gag reflex. 7
• Close follow-up after device prescription is mandatory, as a small proportion of patients will experience worsening of their sleep apnea with an oral appliance. 5

Hypoglossal Nerve Stimulation (HNS)

• HNS should be considered for patients with AHI 15-65/h and BMI <32 kg/m² who cannot adhere to PAP therapy, representing a newer option for select CPAP-intolerant patients. 2, 7
• Strict patient selection criteria are crucial: documented CPAP failure or intolerance, appropriate anatomical features confirmed by drug-induced sleep endoscopy (DISE), and absence of complete concentric collapse at the soft palate level. 7
• HNS is not first-line therapy and should only be considered after failed conservative treatments including CPAP optimization (mask refitting, pressure adjustments, heated humidification) and attempted oral appliance therapy. 7
• Adherence to HNS is superior to CPAP, with significant improvements in AHI, quality of life measures, and Epworth Sleepiness Scale scores demonstrated in randomized controlled trials. 7

Surgical Options

• Maxillomandibular advancement surgery appears as efficient as CPAP in patients who refuse conservative treatment and should be considered for severe OSA patients who cannot tolerate or are not appropriate candidates for other recommended therapies. 2
• Multilevel surgery should be considered a salvage procedure with unpredictable results, not as first-line treatment, and only after failure of CPAP and other conservative therapies. 7, 8
• Tracheotomy is technically the most effective surgical treatment but is not socially acceptable, associated with major side-effects, and reserved only for extreme cases. 7, 8

Treatments NOT Recommended

• Positional therapy is clearly inferior to CPAP with poor long-term compliance and cannot be recommended as primary treatment. 2
• Pharmacologic agents lack sufficient evidence and should not be prescribed for OSA treatment, including mirtazapine, xylometazoline, fluticasone, paroxetine, pantoprazole, acetazolamide, and protriptyline. 1, 2
• Oxygen therapy is not recommended as stand-alone treatment. 2
• Drugs, nasal dilators, and apnea-triggered muscle stimulation cannot be recommended as effective OSA treatments. 2
• Oropharyngeal exercises have shown limited effects and cannot be recommended as standard treatment. 7
• Palatal implants are not recommended in current evidence-based guidelines. 7

Combination Therapy

• Combined CPAP and oral appliance therapy reduces therapeutic CPAP requirements by 35-45% and may be beneficial for incomplete responders to oral appliance therapy alone and those who cannot tolerate high CPAP levels. 9

Critical Follow-Up Requirements

• Adequate follow-up with troubleshooting and monitoring of objective efficacy and usage data is essential following any alternative therapy initiation. 2
• Address adherence issues proactively with education, device adjustments, and optimization strategies before abandoning any treatment modality. 2
• Drug-induced sleep endoscopy to assess the site(s) of collapse during sleep can increase the success rate of both surgical interventions and oral appliance therapy. 8