European Respiratory Society guideline on obstructive sleep apnoea

Key points

• This ERS guideline updates the 2011 statement on non-CPAP therapies for obstructive sleep apnoea (OSA) using GRADE; all its recommendations are conditional and based on low or very low quality evidence.
• CPAP is suggested over a custom-made dual-block mandibular advancement device (MAD), as CPAP lowered the AHI by 7.8 events per hour more; in mild to moderate OSA, both can be considered equally because effects on sleepiness and quality of life were similar.
• Hypoglossal nerve stimulation is not suggested as first-line treatment, but may be considered as salvage therapy in symptomatic OSA that cannot be treated with positive airway pressure or MAD, with an AHI below 50 and BMI below 32 kg/m2.
• In obese adults with OSA whose weight has not improved despite a comprehensive weight reduction programme, bariatric surgery evaluation is suggested over a weight-reducing diet.
• In mild to moderate position-dependent OSA, either vibratory positional therapy or CPAP is suggested, and in mild positional OSA either vibratory positional therapy or MAD.

Overview

CPAP remains the standard treatment for OSA, but limited adherence, heterogeneous pathophysiology and a growing focus on patient-reported outcomes encourage alternatives. A multidisciplinary task force including patient representatives addressed 8 clinical questions; the literature was searched up to 15 June 2020, and 41 studies were included. Weight loss in overweight patients and soft-tissue surgery were not re-evaluated.

Myofunctional therapy and maxillo-mandibular osteotomy

Myofunctional therapy is not suggested as standard treatment, but only for specific patients seeking alternatives who are reluctant to accept surgical or mechanical strategies; CPAP is suggested over myofunctional therapy. Either maxillo-mandibular osteotomy or CPAP is suggested: in one trial, AHI fell from 56.8 to 8.1 events per hour after osteotomy and from 50.3 to 6.3 with auto-adjusting CPAP at 1 year, without a significant difference.

Carbonic anhydrase inhibitors

Carbonic anhydrase inhibitors (acetazolamide, zonisamide, topiramate) reduced AHI by up to 45% in unselected patients but had no documented effect on sleepiness. Because no drug in this class has an approved label for OSA, they are suggested only in the context of a randomised controlled trial.

FAQ

Is a mandibular advancement device as good as CPAP?

CPAP lowers the AHI more, so it is suggested overall, but in mild to moderate OSA both can be considered equally because sleepiness and quality of life improve similarly and adherence often favours MAD.

Who may be considered for hypoglossal nerve stimulation?

Symptomatic patients who cannot be treated sufficiently with positive airway pressure or MAD, with an AHI below 50 and a BMI below 32 kg/m2, as salvage treatment.

Can positional therapy replace CPAP?

In mild to moderate position-dependent OSA, vibratory positional therapy is an alternative to CPAP: it is slightly less effective on AHI but adherence is better.

Source

Randerath W, Verbraecken J, de Raaff CAL, et al. European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea. Eur Respir Rev 2021;30:210200. DOI: 10.1183/16000617.0200-2021. Open access under CC BY-NC 4.0. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.