Treatment of Very Severe Obstructive Sleep Apnea

First-Line Treatment: PAP Therapy

The American Academy of Sleep Medicine strongly recommends positive airway pressure (PAP) therapy as the first-line treatment for very severe obstructive sleep apnea (OSA) and should be used for the entirety of a patient's sleep period 1, 2
Continuous positive airway pressure (CPAP) or automatic positive airway pressure (APAP) are equally effective and recommended as the primary treatment options for severe OSA 2
PAP therapy has been shown to improve symptoms, normalize risk of traffic accidents, reduce sympathetic activity, and decrease cardiovascular morbidities 3
Recent evidence demonstrates that PAP therapy normalizes mortality in patients with severe OSA 3
Educational interventions should be provided at the initiation of PAP therapy to improve adherence 2
Nasal or intranasal mask interfaces are generally preferred over oronasal or oral interfaces to minimize side effects 4
Heated humidification should be used with PAP devices to reduce side effects such as dry mouth/throat, nasal congestion, and nose bleeds 4

Patients should be encouraged to use PAP for the entirety of their sleep period 1
Even if patients use PAP for less than 4 hours per night, they should be encouraged to continue treatment as there are still benefits 1, 5
Studies show that greater PAP use is associated with improved outcomes, though benefits can be seen even with partial nightly use 5

Mandibular advancement devices (MADs) can be considered for patients with mild to moderate OSA who cannot tolerate PAP, but are less effective for severe OSA 3, 6
Hypoglossal nerve stimulation therapy can be considered for patients with an AHI of 15-65/h and BMI <32 kg/m² who cannot adhere to PAP 1
Maxillomandibular advancement surgery may be considered for patients with severe OSA who cannot tolerate or are not appropriate candidates for other recommended therapies 1, 3
Weight reduction may provide improvement in OSA severity and should be encouraged as an adjunctive therapy 3, 6

Oxygen therapy is not recommended as a stand-alone treatment for patients with OSA who cannot tolerate other recommended therapies 1
Positional therapy is clearly inferior to CPAP and has poor long-term compliance 6
Drugs, nasal dilators, and apnea-triggered muscle stimulation cannot be recommended as effective treatments of OSA 6

Adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data, is essential following PAP therapy initiation 2