What are the treatment options for sleep apnea symptoms?

Treatment Options for Sleep Apnea

Continuous positive airway pressure (CPAP) is the gold standard treatment for moderate to severe symptomatic obstructive sleep apnea (OSA), while mandibular advancement devices are recommended for mild to moderate OSA or as an alternative when CPAP is not tolerated. 1

First-Line Treatment: Positive Airway Pressure Therapy

CPAP Indications and Efficacy

• CPAP is strongly recommended for adults with OSA and excessive daytime sleepiness, demonstrating clinically significant improvements in sleepiness with high-quality evidence 1
• CPAP should be used for patients with moderate to severe symptomatic OSA (AHI ≥15/h with symptoms or AHI ≥30/h) 1
• Treatment improves sleep quality, reduces AHI, augments cardiac output, reduces resistant hypertension, decreases cardiac dysrhythmias, and reduces daytime sleepiness 2
• CPAP is conditionally recommended for adults with impaired sleep-related quality of life, including symptoms such as snoring, nocturnal choking, insomnia, bed partner sleep disruption, morning headaches, nocturia, and daytime fatigue 1

CPAP Implementation Strategies

• Use nasal interfaces preferentially over oral or oronasal interfaces 1
• Employ heated humidification to minimize side effects like nasal dryness, irritation, dry mouth, and sore throat 1
• Adequate follow-up is essential to ensure treatment efficacy and adherence 1
• Chronic use for ≥4 hours/night for >70% of nights is necessary for clinical benefit 2

Alternative PAP Modalities

• Bilevel positive airway pressure (BPAP) may be needed for patients requiring therapeutic pressures greater than CPAP can provide, based on clinical judgment 1
• Auto-adjusting positive airway pressure (APAP) is another option for selected patients 1

Oral Appliance Therapy

Mandibular Advancement Devices (MADs)

• MADs are recommended (Grade A) for patients with mild to moderate OSA without comorbidities 1
• MADs are an accepted alternative for severe OSA patients who are intolerant to, unable to use, or unwilling to use CPAP 1
• These devices stabilize the lower jaw in a forward and downward position, maintaining airway patency during sleep 1
• MADs reduce AHI, arousal index, daytime sleepiness, improve quality of life, and improve nocturnal oxygenation 1
• Adherence with MADs is superior to CPAP, though CPAP is more effective at normalizing respiratory parameters 1, 3

MAD Contraindications

• Severe periodontal disease 1
• Severe pre-existing temporomandibular disorders 1
• Inadequate dentition or implants for retention 1
• Severe gag reflex 1
• Poor dexterity or hand function compromising device handling 1

Follow-up Requirements

• Patients using MADs should be followed by a qualified dentist every 6 months for the first year and at least annually thereafter 3
• Treatment efficacy should be evaluated by a sleep physician through appropriate sleep testing 3

Behavioral and Lifestyle Interventions

Weight Management

• Weight reduction to BMI ≤25 kg/m² is recommended and associated with improvement in breathing pattern, sleep quality, and daytime sleepiness 1
• Weight reduction surgery should be considered in selected cases of severe obesity 1
• Weight loss is beneficial for all overweight patients with OSA 4, 5

Positional Therapy

• Positional therapy can yield moderate reductions in AHI, particularly in younger patients with lower AHI and less obesity 1
• Devices include alarms, pillows, backpacks, or tennis balls to maintain non-supine positioning 1
• Positional therapy is clearly inferior to CPAP and cannot be recommended except in carefully selected patients, with poor long-term compliance 1

Other Behavioral Modifications

• Avoidance of alcohol and sedatives before bedtime 1, 4
• Regular physical exercise 1

Surgical Options

Tonsillectomy and Adenotonsillectomy

• Tonsillectomy can be recommended for OSA treatment in adults with tonsillar hypertrophy 1
• Adenotonsillectomy is recommended for pediatric OSA with adenotonsillar hypertrophy 1

Uvulopalatopharyngoplasty (UPPP)

• UPPP is effective only in selected patients with obstruction limited to the oropharyngeal area 1
• Cannot be recommended except in carefully selected patients due to frequent long-term side effects including velopharyngeal insufficiency, dry throat, and abnormal swallowing 1
• Laser-assisted uvulopalatoplasty is not recommended (negative recommendation Grade B) 1

Advanced Surgical Procedures

• Maxillomandibular advancement surgery for specific cases, particularly with craniofacial malformation 1, 5
• Hypoglossal nerve stimulation is a conditional recommendation for selected adult patients seeking alternative treatments 1

Therapies NOT Recommended

Pharmacological Treatment

• Drug therapy is not recommended for OSA treatment (most drugs Grade C, mirtazapine and protriptyline Grade B) 1
• Antidepressants and respiratory stimulants have been found ineffective or cause tolerance and serious adverse effects 6

Other Non-Effective Interventions

• Nasal dilators are not recommended (Grade D) 1
• Nasal surgery as a single intervention cannot be recommended (negative recommendation Grade C) 1
• Radiofrequency tonsil reduction is not recommended as a single procedure (negative recommendation Grade D) 1
• Tongue-retaining devices cannot be recommended (Grade C) 1
• Apnea-triggered muscle stimulation cannot be recommended (negative recommendation Grade C) 1

Special Considerations

Myofunctional Therapy

• Myofunctional therapy is a conditional recommendation for selected adult patients seeking alternatives 1
• Tongue muscle training improves snoring but is not efficacious for sleep apnea in general (negative recommendation Grade B) 1

Intranasal Corticosteroids

• Recommended for mild to moderate OSA in children with co-existing rhinitis and/or upper airway obstruction due to adenotonsillar hypertrophy (Grade B) 1
• Can be recommended as concomitant therapy in appropriate situations 1

Treatment Selection Algorithm

• Moderate to severe symptomatic OSA → CPAP first-line 1
• Mild to moderate OSA without comorbidities → MADs 1
• Severe OSA with CPAP intolerance → MADs as alternative 1
• All patients → behavioral interventions (weight loss, avoid alcohol/sedatives) 1, 4
• Selected patients with specific anatomical issues → surgical evaluation 1

Common Pitfalls

• Sleep apnea tends to worsen and does not cure spontaneously, requiring ongoing treatment 1
• Approximately 80% of patients remain undiagnosed, representing a massive public health burden 1
• Treatment decisions should involve a multidisciplinary team including sleep physicians, qualified dentists, and specialists as appropriate 1