What are the treatments for Obstructive Sleep Apnea (OSA)?

Treatment Options for Obstructive Sleep Apnea

Continuous positive airway pressure (CPAP) or automatic positive airway pressure (APAP) should be initiated as first-line therapy for all adults diagnosed with OSA, regardless of severity. 1, 2, 3

First-Line Treatment: PAP Therapy

Primary Recommendations

• CPAP or APAP are equally effective and should be prescribed as the primary treatment for OSA, with strong evidence showing improvements in excessive daytime sleepiness, normalization of traffic accident risk, reduction in sympathetic activity, decreased cardiovascular morbidities, and normalized mortality in severe OSA. 1, 2, 3
• PAP therapy should be used for the entirety of the patient's sleep period, though even partial use (less than 4 hours per night) provides benefits and patients should be encouraged to continue treatment. 2, 3
• Fixed CPAP and auto-CPAP have similar adherence and efficacy profiles. 1

Optimizing PAP Therapy

• Educational interventions must be provided at PAP initiation to improve adherence and treatment success. 1, 2, 3
• Nasal or intranasal mask interfaces are preferred over oronasal or oral interfaces to minimize side effects and maintain efficacy. 2, 3
• Heated humidification should be used with PAP devices to reduce dry mouth/throat, nasal congestion, and nosebleeds. 2, 3
• Behavioral and troubleshooting interventions should be given during the initial period of PAP therapy. 1
• Telemonitoring-guided interventions during the initial PAP period can improve adherence. 1
• Adequate follow-up with monitoring of objective efficacy and usage data is essential following PAP therapy initiation. 1, 2, 3

Weight Management

• All overweight and obese patients with OSA must be encouraged to lose weight, as obesity is the primary modifiable risk factor for OSA and weight reduction may improve OSA severity. 1, 3

Second-Line Treatments for PAP-Intolerant Patients

Mandibular Advancement Devices (MADs)

• MADs are recommended as an alternative therapy for patients who prefer them or experience CPAP adverse effects, with evidence supporting their use primarily in mild to moderate OSA. 1, 2, 3
• MADs are less effective than CPAP for severe OSA and should be considered only after documented CPAP failure or intolerance. 2, 3
• MADs are contraindicated in patients with severe periodontal disease, severe temporomandibular disorders, inadequate dentition, or severe gag reflex. 4

Hypoglossal Nerve Stimulation

• Hypoglossal nerve stimulation should be considered for patients with AHI 15-65/h and BMI <32 kg/m² who cannot adhere to PAP therapy. 2, 3, 4
• Patients must undergo drug-induced sleep endoscopy (DISE) to confirm absence of complete concentric collapse at the soft palate level, as this anatomical pattern predicts treatment failure. 4
• This therapy requires documented CPAP failure or intolerance before consideration. 4

Surgical Options

• Maxillomandibular advancement surgery may be considered for patients with severe OSA who cannot tolerate or are not appropriate candidates for other recommended therapies. 2, 3
• Surgery should not be used as initial treatment and is reserved for patients who have failed conservative therapies. 1
• Multilevel surgery is considered a salvage procedure with unpredictable results and higher morbidity. 4

Treatments NOT Recommended

Ineffective or Insufficient Evidence

• Positional therapy is clearly inferior to CPAP with poor long-term compliance and should not be relied upon as primary treatment. 2, 3
• Pharmacologic agents lack sufficient evidence and should not be prescribed for OSA treatment, including mirtazapine, xylometazoline, fluticasone, paroxetine, pantoprazole, acetazolamide, and protriptyline. 1, 3
• Oxygen therapy is not recommended as stand-alone treatment for patients with OSA who cannot tolerate other recommended therapies. 2, 3
• Drugs, nasal dilators, and apnea-triggered muscle stimulation cannot be recommended as effective OSA treatments. 2, 3

Treatment Algorithm Summary

1. Initiate CPAP or APAP with educational interventions, nasal/intranasal masks, and heated humidification 1, 2, 3
2. Optimize adherence through troubleshooting, behavioral interventions, and telemonitoring 1, 3
3. Encourage weight loss in all overweight/obese patients 1, 3
4. If CPAP fails or is not tolerated:
   • For mild-moderate OSA: Consider MADs 1, 2, 3
   • For moderate-severe OSA with AHI 15-65/h and BMI <32 kg/m²: Consider hypoglossal nerve stimulation after DISE confirmation 2, 3, 4
   • For severe OSA with failed conservative therapies: Consider maxillomandibular advancement surgery 2, 3

Common Pitfalls to Avoid

• Do not abandon CPAP prematurely without addressing adherence issues through mask adjustments, humidification, and education. 3
• Do not prescribe pharmacologic therapy as primary treatment for OSA. 1, 3
• Do not use surgery as initial treatment before attempting conservative therapies. 1
• Do not consider hypoglossal nerve stimulation without confirming appropriate anatomical features via DISE. 4
• Greater baseline AHI and Epworth Sleepiness Scale scores are generally associated with better CPAP adherence. 1