Cleveland Clinic Journal of MedicineTreatments for Obstructive Sleep Apnea: CPAP and Beyond

Exploring diverse therapeutic approaches for obstructive sleep apnea, highlighting individual preferences and phenotypic characteristics that influence treatment outcomes and broader implications for related conditions.

Obstructive sleep apnea (OSA) affects a significant portion of the adult population, with various treatment modalities available to address this condition. Although continuous positive airway pressure (CPAP) remains the gold standard, many patients struggle with adherence, necessitating alternative treatments. This article reviews the range of therapeutic options, including conservative measures, pressure-based treatments, oral appliances, and surgical interventions, providing insights into their effectiveness, indications, and practical implications for clinical practice.

Key Points:

• Prevalence and Diagnosis:
  • Up to 25% of individuals aged 30-70 may have OSA, with increasing prevalence.
  • Diagnosis is based on the apnea-hypopnea index (AHI), with thresholds for diagnosis including 15+ events per hour or 5+ events with symptoms/comorbidities.
• Conservative Treatments:
  • Weight Loss: Significant predictor of OSA severity; 10% weight loss can reduce AHI by 26%.
  • Lifestyle Modifications: Intensive interventions show higher remission rates for OSA compared to standard education.
  • Bariatric Surgery: Improves OSA but may not cure it; 20% of patients may still have moderate/severe OSA post-surgery.
  • Exercise: Benefits OSA patients by reducing associated cardiovascular risks, even without significant weight change.
  • Positional Therapy: Effective for patients whose OSA worsens when supine; adherence is higher compared to CPAP.
  • Alcohol Avoidance: Reduces the severity of OSA; alcohol adversely affects airway muscle tone.
• Pharmacologic Interventions:
  • Unapproved Drugs: Protriptyline, fluoxetine, and carbonic anhydrase inhibitors show potential but lack FDA approval.
  • Combination Therapy: Noradrenergic and antimuscarinic combinations (e.g., atomoxetine with oxybutynin) demonstrate promising AHI reductions.
• Pressure-Based Treatments:
  • CPAP: Standard care for moderate/severe OSA; improves blood pressure control, sleep quality, and daytime sleepiness.
  • APAP: Automatically adjusts pressure, offering convenience and cost-effectiveness.
  • BiPAP: Suitable for patients with mixed apnea events, hypercapnia, or those intolerant to high CPAP pressures.
  • Nasal EPAP: Effective for moderate/mild OSA; works by generating expiratory resistance.
• Oral Appliances:
  • Custom-fitted devices advance the mandible to open the airway.
  • Effective for mild/moderate OSA and in severe cases when CPAP is intolerable.
  • Requires evaluation by a qualified dentist and regular follow-up to monitor efficacy and side effects.
• Surgical Options:
  • Uvulopalatopharyngoplasty (UPPP): Reduces AHI but may lose effectiveness over time.
  • Tongue Reduction: Radiofrequency or midline glossectomy to reduce tongue size, improving airway patency.
  • Hypoglossal Nerve Stimulation: FDA-approved for select patients; shows high adherence and durable benefits.
  • Maxillomandibular Advancement: Effective but less commonly performed; increases airway volume significantly.
• Innovative Therapies:
  • Myofunctional Therapy: Includes tongue stimulation, speech therapy, and singing; shows improvement in AHI and associated symptoms.
  • Oral Negative Pressure Therapy: Uses negative pressure to displace tongue and soft palate anteriorly.
  • Negative External Pressure: Silicone collar applies external pressure to keep the airway open.

A diagnosis of OSA was associated with a 17% increased risk of motor vehicle accidents (MVAs). (Sleep Medicine)

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