Sleep Disordered Breathing: Alternatives to CPAP Therapy

Continuous positive airway pressure (CPAP) is the first line treatment for obstructive sleep apnea (OSA), and resolves the majority of complications associated with untreated OSA. However, many patients are unable to tolerate CPAP and may be offered alternate treatments. Positional therapy is most helpful in some OSA patients with a low body mass index (BMI). Both dietary and surgical weight loss are effective in improving OSA; a 10% weight reduction can decrease AHI by 26%, Oral appliances (OA) are effective in 57-81% of patients with mild-moderate OSA. Though oral appliances have a lower success rate (14-61%) in patients with severe OSA, they may be helpful in patients who have failed CPAP or upper airway surgery. A follow up polysomnography and close follow up for dental occlusion changes is recommended in all patients. Uvulopalatopharyngoplasty (UPPP) is effective in half (52.3%) of patients with retro-palatal narrowing, and is effective in a very small proportion of patients (5.3%) with retro-lingual or both retro-palatal and retro-lingual narrowing. Maxillomandibular osteotomy and advancement (MMO) enlarges both the retro-lingual and retro-palatal airway. Patients with normal BMI's and skeletal abnormalities are most likely to benefit from it. A follow up polysomnography is recommended after upper airway surgery. Palatal implants need to be studied further before they can be considered a mainstream treatment. Improvement in nasal patency with intranasal corticosteroids and treatment of residual daytime sleepiness with modafinil may be beneficial in some patients.