What are the non‑surgical internal treatment options for sleep‑disordered breathing, including obstructive and central sleep apnea?

Internal Treatments for Sleep-Disordered Breathing

First-Line Therapy: Positive Airway Pressure

Continuous positive airway pressure (CPAP) is the gold standard first-line treatment for obstructive sleep apnea of all severities, improving symptoms, normalizing mortality in severe OSA, reducing cardiovascular morbidities, and decreasing traffic accident risk. 1, 2

• CPAP or automatic positive airway pressure (APAP) are equally effective and should be prescribed as the primary treatment option 2
• 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, nasal congestion, and nosebleeds 2, 3
• Educational interventions at CPAP initiation improve adherence and should be implemented systematically 2, 3
• Bilevel positive airway pressure (BPAP) may be offered for patients unable to tolerate CPAP due to high pressure requirements, as it allows independent adjustment of inspiratory and expiratory pressures 1, 4

CPAP Optimization Requirements

Before abandoning CPAP therapy, comprehensive optimization must be documented including:

• Mask refitting with multiple mask types attempted 1
• Pressure adjustments and consideration of BPAP trial if high pressures were the primary intolerance issue 1
• Heated humidification implementation 1, 2
• Behavioral interventions and troubleshooting 1

Second-Line Therapy for CPAP-Intolerant Patients

Mandibular Advancement Devices (Mild-to-Moderate OSA)

Custom, titratable mandibular advancement devices are the primary alternative therapy for CPAP-intolerant patients with mild-to-moderate OSA. 1, 2

• Only custom titratable devices should be prescribed; non-titratable appliances are not recommended 1
• MADs reduce AHI, arousal index, and oxygen desaturation index, though CPAP remains superior in these metrics 5, 1
• MADs are less effective for severe OSA and would represent a therapeutic step-down 1
• Contraindications include severe periodontal disease, severe temporomandibular disorders, inadequate dentition, and severe gag reflex 1

Hypoglossal Nerve Stimulation (Moderate-to-Severe OSA)

Hypoglossal nerve stimulation is recommended for moderate-to-severe OSA patients who fail CPAP and MADs, with specific eligibility criteria that must be strictly met. 1, 6

Eligibility Criteria:

• AHI between 15-65 events/hour (some guidelines allow up to 100) 1, 6
• BMI <32 kg/m² (some guidelines allow <40 kg/m²) 1, 6
• Documented CPAP failure or intolerance 1, 6
• Confirmed anatomical candidacy via drug-induced sleep endoscopy (DISE) 1, 6
• Absence of complete concentric collapse at the soft palate level 1, 6
• No central or mixed sleep apnea patterns 6

The American Academy of Sleep Medicine, Veterans Administration/Department of Defense, and European Respiratory Society all support hypoglossal nerve stimulation in appropriately selected CPAP-intolerant patients 1, 6

Maxillomandibular Advancement Surgery

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

Adjunctive Therapies (Not Monotherapy)

Weight Reduction

Weight loss is strongly recommended for all overweight and obese OSA patients as obesity is the primary modifiable risk factor, but should not be used as monotherapy or delay definitive treatment. 1, 2

• Weight reduction improves breathing patterns, quality of sleep, and daytime sleepiness 1
• Lower BMI predicts better anatomical features and surgical efficacy for interventions like hypoglossal nerve stimulation 6
• Definitive therapy should not be delayed by prolonged weight loss attempts in symptomatic moderate-to-severe OSA 6

Positional Therapy

Positional therapy is clearly inferior to CPAP with poor long-term compliance and cannot be recommended except in carefully selected patients with position-dependent OSA 5, 1, 2

Treatments NOT Recommended

The following treatments lack sufficient evidence and should not be prescribed:

• Pharmacologic agents - no drugs are recommended as effective OSA treatments 2
• Oxygen therapy - not recommended as stand-alone treatment 2
• Nasal dilators - cannot be recommended as effective treatment 5, 2
• Apnea-triggered muscle stimulation (older technology, distinct from hypoglossal nerve stimulation) - cannot be recommended 5, 2
• Single-level surgical interventions including uvulopalatopharyngoplasty, pillar implants, nasal surgery, radiofrequency tonsil reduction, tongue base surgery alone - cannot be recommended as single interventions 5
• Multilevel surgery - only a salvage procedure for OSA patients who have failed all other options 5, 6

Treatment Algorithm

1. Diagnose OSA severity via polysomnography or home sleep testing 3, 7
2. Initiate CPAP with heated humidification, educational interventions, and appropriate mask fitting 2, 3
3. Optimize CPAP over several weeks with troubleshooting, mask adjustments, and consideration of BPAP if needed 1, 3
4. If CPAP fails after comprehensive optimization:
   • For mild-to-moderate OSA: Custom titratable mandibular advancement device 1, 2
   • For moderate-to-severe OSA with AHI 15-65/h and BMI <32 kg/m²: Hypoglossal nerve stimulation (after DISE confirmation) 1, 6
   • For severe OSA not meeting hypoglossal nerve stimulation criteria: Consider maxillomandibular advancement surgery 2
5. Concurrent weight loss in all overweight/obese patients 1, 2

Common Pitfalls to Avoid

• Do not abandon CPAP without documenting comprehensive optimization attempts including multiple mask types, pressure adjustments, heated humidification, and behavioral interventions 1
• Do not delay definitive treatment with prolonged weight loss attempts in symptomatic moderate-to-severe OSA 6
• Do not prescribe non-titratable mandibular advancement devices 1
• Do not proceed to hypoglossal nerve stimulation without confirming anatomical candidacy via DISE, as complete concentric collapse at the soft palate predicts failure 6
• Do not use positional therapy, oxygen, or pharmacologic agents as monotherapy for OSA 2
• Do not recommend single-level surgical procedures as they lack evidence for efficacy 5

Follow-Up Requirements

• Initial CPAP follow-up within the first few weeks to establish utilization pattern and provide remediation if needed 3
• Monitor CPAP usage objectively to ensure utilization 3
• Longer-term follow-up yearly or as needed to address mask, machine, or usage problems 3
• For hypoglossal nerve stimulation, long-term follow-up confirms sustained safety and efficacy 6