Treatment Options for Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common sleep disorder characterized by repeated collapse of the upper airway during sleep, resulting in reduced or complete cessation of breathing. Left untreated, OSA increases the risk of serious health conditions like heart disease, stroke, diabetes, and high blood pressure.

The preferred first-line treatment is continuous positive airway pressure (CPAP) therapy, which uses a machine to deliver air pressure through a mask worn during sleep to keep the airway open. However, not all patients can tolerate CPAP therapy long-term. New guidelines from the National Institute for Health and Care Excellence (NICE) in the UK now recommend expanded treatment options for OSA beyond CPAP.

Background on Obstructive Sleep Apnea

OSA occurs when the muscles in the throat relax during sleep, causing the airway to narrow or collapse. This blocks oxygen from reaching the lungs and brain, resulting in loud snoring, frequent arousals from sleep, and daytime sleepiness. OSA is quite common, affecting at least 4% of men and 2% of women.

Risk factors include obesity, large tonsils, receding chin, small jaw, large neck, nasal obstruction, and family history. If left untreated, OSA increases the risk of high blood pressure, heart disease, stroke, diabetes, depression, and other health problems. OSA has also been linked to traffic and workplace accidents due to daytime sleepiness and inattention.

CPAP Therapy for OSA

The first-line treatment for moderate to severe OSA is CPAP therapy. CPAP involves wearing a mask over the nose and/or mouth during sleep connected to a machine that delivers constant air pressure to keep the airway open. Studies show that CPAP is highly effective at reducing apneas, improving oxygen levels, reducing daytime sleepiness, lowering blood pressure, and improving quality of life.

However, CPAP requires nightly use and some patients have difficulty tolerating the mask and pressurized air. Estimates suggest up to 50% of patients prescribed CPAP are non-adherent or stop using the device.

Prior UK Guidelines Focused on CPAP

Until recently in the UK, clinical guidelines from NICE focused heavily on CPAP as the primary treatment for OSA in adults. Patients who could not tolerate CPAP had limited alternative options covered by the National Health Service (NHS).

Sleep centers run mainly by respiratory physicians emphasized CPAP therapy. Patients who could not adhere to CPAP were often left with untreated OSA and associated health risks.

New NICE Guidelines Recommend Expanded Treatment Options

At the end of 2021, NICE updated its clinical guidelines on OSA treatment. For the first time, the guidelines acknowledge a role for surgery in managing OSA after failed conservative measures like CPAP.

The new guidelines encourage a more individualized approach, taking into account patient factors like tonsil size, nasal obstruction, and jaw structure that may impact treatment success. Recommended steps include:

Assess Tonsil Size

Patients with enlarged tonsils that obstruct the airway should be offered tonsillectomy as a first-line treatment over CPAP. This is already standard practice for treating OSA in children. There is no reason adults with obstructive tonsils should not also benefit from tonsil removal before trying CPAP.

Evaluate Nasal Obstruction

A blocked or congested nose can increase CPAP pressure needs and cause treatment failure. All OSA patients should be examined for nasal obstruction from septal deviation, polyps, allergies, or other causes. Treating nasal obstruction may allow successful CPAP use. Nasal congestion often worsens with CPAP use, so nasal sprays or other medications may be needed.

Consider Oral Appliances

Custom-fit oral appliances that advance the lower jaw can effectively treat mild to moderate OSA in some patients. The guidelines recommend oral appliances be prescribed by qualified dental professionals for best fit and comfort.

Refer for Surgery If Needed

For patients who cannot tolerate CPAP despite addressing obstructive factors like tonsils and nasal blockage, or who are not candidates for oral appliances, referral to an ENT surgeon or sleep surgeon for evaluation is now recommended. A variety of OSA surgeries are available to modify the anatomy and improve airway patency during sleep.

OSA Surgery Options

Surgical procedures for OSA aim to increase the size of the airway and prevent collapse during sleep. Potential surgeries include:

• Tonsillectomy – Removing enlarged tonsils and adenoids is curative for some OSA patients. This should be considered as a first step.
• UPPP – Uvulopalatopharyngoplasty trims excess soft tissue in the throat including the uvula and soft palate.
• MMA – Maxillomandibular advancement surgically moves the upper and/or lower jaws forward to open the airway. Highly effective but invasive.
• Hypoglossal nerve stimulation – An implant activates tongue muscles to prevent collapse during sleep.
• Tracheostomy – Opening a surgical airway in the neck bypasses the obstructed throat. Used as a last resort.

Not all patients are candidates for every surgery. Evaluation by an experienced surgeon is important to select the optimal procedure based on each individual’s anatomy and factors contributing to OSA.

Benefits of OSA Surgery

While CPAP is still considered first-line, surgery can be an excellent option for select patients with anatomical obstruction. Benefits of surgery include:

• Curative treatment for some patients
• Improved compliance compared to CPAP
• Reduced daytime sleepiness
• Lower blood pressure
• Decreased risk of heart disease, stroke, diabetes
• Improved quality of life

With more treatment choices now available, patients struggling with untreated OSA have new hope for finding an effective solution.