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Treatment Indications Reduction in apnea-hypopnea index Caveats Possible predictors of success Weight loss7 BMI ≥ 26 kg/m2 26% per 10% weight loss Weight loss and lifestyle changes difficult to maintain Higher BMI, larger neck circumference Positional therapy13,14 Positional sleep apnea 7.4 fewer events per hour 10% have sleep disturbance, back or chest discomfort Positional obstructive sleep apnea, no obesity, lower AHI Drug therapy15,16 No current labeling of specific drugs Noradrenergic with antimuscarinic: 76% Anticholinergic effects Lower AHI and decreased collapsibility Carbonic anhydrase inhibitors: 45% Paresthesia, dyspepsia High loop gain Oxygen therapy17,18,21 Inability to tolerate positive airway pressure, failure of upper airway surgery 72.5% in responders (25% of patients) Prolongs apnea, increases risk of hypercarbia, no effect on blood pressure or excessive daytime sleepiness High loop gain, decreased collapsibility, and increased pharyngeal compensation Oral appliances19,22 Can be first-line, especially in mild to moderate obstructive sleep apnea 56%; effective in 68% of patients after 2 years of treatment Temporomandibular joint dysfunction, occlusion changes; requires manual dexterity Retracted maxilla and mandible, narrow airway, short soft palate, positional obstructive sleep apnea, lower BMI, female, smaller neck circumference, lower AHI Myofunctional tongue stimulation20 Alternative to CPAP, or adjunct to CPAP to improve adherence 50% Not recommended as standard treatment Ineffective upper-airway dilator muscles AHI = apnea-hypopnea index; BMI = body mass index; CPAP = continuous positive airway pressure therapy
Treatment Indications Reduction in apnea-hypopnea index Caveats Possible predictors of success Positive airway pressure73 First-line treatment for mild obstructive sleep apnea with cardiovascular disease or excessive daytime sleepiness, and moderate to severe obstructive sleep apnea 73% Nasal irritation, dry mouth, sinus infection; weight loss should not be expected Positional obstructive sleep apnea Nasal expiratory pressure70,74,75 Mild to moderate obstructive sleep apnea 70% Difficulty exhaling, nasal discomfort, dry mouth, different effects between devices Positional obstructive sleep apnea Intraoral negative pressure71 Moderate to severe obstructive sleep apnea 25% have at least a 50% reduction from baseline Dental or oral tissue discomfort Retropalatal airway collapse Negative external pressure72 Moderate to severe obstructive sleep apnea 75% Skin irritation Anteroposterior airway collapse Treatment Indications Reduction in apnea-hypopnea index Caveats Possible predictors of success Hypoglossal nerve stimulation100–102 Moderate to severe obstructive sleep apnea not tolerating CPAP; BMI < 40 kg/m2; AHI 15–100 68% Tongue weakness, infection, hematoma, pneumothorax Anteroposterior collapse, female, lower BMI and AHI, higher arousal threshold Uvulopalatopharyngoplasty99 Excessive daytime sleepiness, AHI > 15 33%; with laser-assisted uvuloplasty, 18% Velopharyngeal insufficiency, nasal regurgitation, foreign body sensation Velopharyngeal/retropharyngeal airway collapse Tongue reduction99 Macroglossia 34% (radiofrequency ablation) Bleeding, tongue edema causing airway obstruction, wound infection Large base of tongue, macroglossia Maxillomandibular advancement99 Failure of other options, especially CPAP; can be a primary option with jaw deformities 87% Change in appearance, dental or facial numbness Craniofacial deformities with retruded mandible AHI = apnea-hypopnea index; BMI = body mass index; CPAP = continuous positive airway pressure therapy
