What is the best initial treatment for a patient with mild obstructive sleep apnea (apnea‑hypopnea index 5–14 events per hour)?

Treatment of Mild Obstructive Sleep Apnea

For patients with mild OSA (AHI 5-14 events/hour), begin with weight loss if overweight/obese (targeting BMI ≤25 kg/m²) combined with behavioral modifications, and reserve CPAP or mandibular advancement devices for those with persistent excessive daytime sleepiness despite these interventions. 1

Initial Behavioral Interventions

Weight Loss (First-Line for Overweight/Obese Patients)

• All overweight and obese patients with mild OSA should be encouraged to lose weight, targeting BMI ≤25 kg/m² 1
• Intensive weight-loss interventions can reduce AHI scores by 4-23 events/hour and improve symptoms 1
• Weight reduction of ≥10% body weight warrants repeat polysomnography to reassess disease severity and determine if additional therapy remains necessary 1

Additional Behavioral Modifications

• Avoid alcohol and sedatives before bedtime to prevent upper airway muscle relaxation 1
• Implement positional therapy using positioning devices for position-dependent OSA where AHI normalizes in non-supine positions 1
• Document efficacy of positional therapy with polysomnography before relying on it as primary treatment 1

When to Escalate to Device Therapy

CPAP Therapy

• Initiate CPAP for patients with mild OSA who have persistent excessive daytime sleepiness despite behavioral interventions 1
• CPAP can improve Epworth Sleepiness Scale scores, reduce AHI and arousal index, and increase oxygen saturation 1
• Add heated humidification and systematic education programs to improve CPAP utilization 1
• Fixed CPAP and auto-CPAP demonstrate similar adherence and efficacy 1

Mandibular Advancement Devices (MADs)

• MADs are recommended for patients with mild OSA, particularly those who prefer them over CPAP or experience CPAP adverse effects 2, 1
• Custom-made titratable MADs achieve treatment success (AHI <5) in 19-75% of patients and AHI <10 in 30-94% of patients 2
• MADs reduce sleep apneas and subjective daytime sleepiness compared to placebo 2
• Milder sleep apnea, supine-dependent sleep apneas, female sex, and less obesity predict better treatment success with MADs 2

Key Implementation Details for MADs

Device Selection and Titration

• The device should be custom-made and titratable, as prefabricated devices are less effective 2
• Advance the mandible at least 50% of maximum protrusion 2
• A titration procedure is essential to achieve optimal results, as non-advanced devices are ineffective and may even increase apnea frequency 2
• Re-evaluation with a new sleep apnea recording is necessary after MAD fitting, since improvement of OSA symptoms is an imprecise indicator of treatment success 2

Expected Outcomes and Adherence

• Although CPAP reduces sleep apneas more efficiently than MADs, the effect on sleepiness is usually similar between the two treatments 2
• MADs show better patient preference and compliance compared to CPAP 2
• After 1 year, 76% of patients continue MAD treatment, and 65% are still using devices after 4 years 2
• Initial side effects (jaw discomfort, tooth tenderness, excessive salivation, temporary occlusal changes) occur in slightly more than half of patients but are generally tolerable 2

Therapies to Avoid in Mild OSA

• Pharmacologic agents should not be prescribed as primary OSA treatment due to lack of sufficient evidence 1
• Surgical interventions and pillar implants have insufficient evidence and cannot be recommended except in carefully selected patients after conservative therapy failure 1

Monitoring and Follow-Up

• Reassess symptoms, daytime sleepiness (using Epworth Sleepiness Scale), and quality of life after initiating any therapy 1
• Repeat polysomnography after substantial weight loss (≥10% body weight) to determine ongoing treatment needs 1
• If behavioral interventions fail to resolve symptoms within 2-3 months, escalate to CPAP or MAD 1
• For MAD users, follow-up should be performed regularly over the long term to monitor efficacy and side effects 2

Clinical Pitfalls to Avoid

• Do not assume symptom improvement with MAD therapy indicates adequate AHI reduction—objective sleep testing is required 2
• Persistent snoring during MAD treatment may indicate poor apnea control 2
• Non-advanced or inadequately titrated MADs are ineffective and may worsen apnea 2
• Do not delay definitive treatment with prolonged weight loss attempts in patients with persistent excessive daytime sleepiness 1