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

Treatment of Obstructive Sleep Apnea

Positive airway pressure (PAP) therapy—specifically CPAP or APAP—is the first-line treatment for all adults diagnosed with OSA, and should be initiated immediately upon diagnosis in patients with excessive sleepiness, impaired quality of life, or comorbid hypertension. 1, 2

Primary Treatment: PAP Therapy

Strong Indications for PAP

• Use PAP therapy (versus no treatment) in all adults with OSA who have excessive daytime sleepiness (STRONG recommendation) 1
• Consider PAP therapy in adults with OSA who have impaired sleep-related quality of life (CONDITIONAL recommendation) 1
• Consider PAP therapy in adults with OSA and comorbid hypertension (CONDITIONAL recommendation) 1

Choosing Between CPAP and APAP

• Either CPAP or APAP should be used for ongoing treatment—both are equally effective with no clinically significant differences in adherence, sleepiness, or quality of life (STRONG recommendation) 1, 2
• CPAP or APAP are preferred over bilevel PAP (BPAP) for routine OSA treatment (CONDITIONAL recommendation) 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, nasal congestion, and nosebleeds 2

Initiation Strategy

• PAP therapy should be initiated using either APAP at home OR in-laboratory PAP titration in adults with OSA and no significant comorbidities (STRONG recommendation) 1
• Home APAP initiation is more rapid, convenient, and cost-effective compared to in-laboratory titration, with no clinically significant differences in adherence, sleepiness, or quality of life 1
• In-laboratory titration may be preferred for patients with significant comorbidities including congestive heart failure, chronic obstructive pulmonary disease, obesity hypoventilation syndrome, or central sleep apnea syndromes 1, 3

Essential Adjunctive Interventions

Patient Education and Support

• Educational interventions must be provided at PAP therapy initiation (STRONG recommendation) 1, 2
• Behavioral and/or troubleshooting interventions should be given during the initial period of PAP therapy (CONDITIONAL recommendation) 1
• Telemonitoring-guided interventions should be considered during the initial PAP therapy period (CONDITIONAL recommendation) 1

Weight Loss

• Weight loss is strongly recommended as first-line therapy for all overweight and obese patients with OSA, as obesity is the primary modifiable risk factor 4, 2
• Weight reduction improves breathing patterns, quality of sleep, and daytime sleepiness 5
• Tirzepatide (Zepbound) is 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), achieving 15-20.9% weight loss at 72 weeks 4
• Tirzepatide should be initiated alongside CPAP therapy rather than as monotherapy, addressing the underlying pathophysiology through weight loss while CPAP provides immediate symptom relief 4

Second-Line Options for PAP-Intolerant Patients

Before Abandoning PAP

• Address adherence issues proactively with education, mask adjustments, and heated humidification before considering PAP failure 2, 5
• Consider intranasal corticosteroids as concomitant therapy if there is any component of rhinitis or upper airway inflammation 5

Alternative Treatments

• Mandibular advancement devices (MADs) are recommended as first-line alternatives for patients who prefer them or experience CPAP adverse effects, particularly in mild-to-moderate OSA 4, 2
• MADs are less effective for severe OSA and should not be the primary recommendation in this population 2, 5
• Hypoglossal nerve stimulation should be considered for CPAP-intolerant patients with moderate-to-severe OSA (AHI 15-65 events/hour) and BMI <32 kg/m² 2, 5
• Maxillomandibular advancement surgery should be considered for severe OSA patients who cannot tolerate or are not appropriate candidates for other recommended therapies 2

Treatments NOT Recommended

• Pharmacologic agents (other than tirzepatide for weight loss) lack sufficient evidence and should not be prescribed as primary OSA treatment 4, 2
• Positional therapy is clearly inferior to CPAP with poor long-term compliance and cannot be recommended except in carefully selected patients 2, 5
• Oxygen therapy is not recommended as stand-alone treatment 2
• Nasal dilators and apnea-triggered muscle stimulation cannot be recommended as effective OSA treatments 2

Critical Follow-Up Requirements

• Adequate follow-up with troubleshooting and monitoring of objective efficacy and usage data is essential following PAP therapy initiation and during ongoing treatment 1, 2, 5
• Monitor CPAP adherence, as it is critical for effective OSA treatment and cardiovascular risk reduction 4
• Perform re-evaluation and, if necessary, standard attended CPAP titration if symptoms do not resolve or treatment appears to lack efficacy 3

Common Pitfalls to Avoid

• Do not prescribe PAP therapy without establishing an OSA diagnosis using objective sleep apnea testing 1
• Do not use APAP devices that rely on vibration or sound algorithms in patients who do not snore (due to palate surgery or naturally) 3
• Do not abandon PAP therapy prematurely without attempting comprehensive optimization including heated humidification, mask adjustments, and patient education 2, 5
• Do not use tirzepatide as monotherapy for OSA—it must be combined with CPAP therapy 4
• Recognize that only approximately 10% of screened patients typically meet all criteria for hypoglossal nerve stimulation 5