European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea

Abstract

Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have been refined or reconsidered. In this European Respiratory Society (ERS) guideline on non-continuous positive airway pressure (CPAP) therapies for OSA, we present recommendations determined by a systematic review of the literature. It is an update of the 2011 ERS statement on non-CPAP therapies, advanced into a clinical guideline. A multidisciplinary group of experts, including pulmonary, surgical, dentistry and ear–nose–throat specialists, methodologists and patient representatives considered the most relevant clinical questions (for both clinicians and patients) relating to the management of OSA. Eight key clinical questions were generated and a systematic review was conducted to identify published randomised clinical trials that answered these questions. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the quality of the evidence and the strength of recommendations. The resulting guideline addresses gastric bypass surgery, custom-made dual-block mandibular advancement devices, hypoglossal nerve stimulation, myofunctional therapy, maxillo-mandibular osteotomy, carbonic anhydrase inhibitors and positional therapy. These recommendations can be used to benchmark quality of care for people with OSA across Europe and to improve outcomes.

Current and novel treatment options for obstructive sleep apnoea

“…Therefore, regular follow-up is required. Recently, international scientific societies (European Respiratory Society (ERS), American Thoracic Society) have recommended gastric bypass surgery in obese OSA patients [ 31 , 47 ]. Compliance to active lifestyle and healthy food intake in this context is paramount.…”

“…The 2021 ERS guideline compared custom-made, adjustable, dual-block MAD ( figure 4 ) with CPAP in patients with mild to severe OSA, with a dominance of patients within the milder range of severity [ 47 ]. It was recommended that CPAP should generally be used, mainly based on the higher decrease of AHI with CPAP over MAD.…”

“…It increases both the dimension of the upper airway and the stability of the pharyngeal dilator muscles [ 111 – 113 ]. In the latest ERS guideline on non-PAP therapies, it was recommended that (although acceptability can vary between patients) both MMA and CPAP are good options in adult patients with OSA [ 47 ]. Initially, MMA was primarily indicated for overweight, skeletal and dental class II patients with an AHI ≥30 events·h −1 and often after unsuccessful uvulopalatopharyngoplasty and/or mandibular osteotomy/genioglossus advancement with hyoid suspension [ 114 , 115 ].…”

“…The current recommendation by the ERS guidelines found a very low level of evidence of data from RCTs. Myofunctional therapy should not be considered when CPAP therapy is available; however, it may be considered if there is no other treatment that can be offered [ 47 ].…”

Beyond Usual Care: A Multidisciplinary Approach Towards the Treatment of Obstructive Sleep Apnoea

“…However, long-term adherence to CPAP therapy is limited, with studies using “big data” reporting about 75% at 3-months ( 15 , 16 ) It is therefore time to re-think a widely practised “one-size-fits-all” approach. The recently published NICE guidelines on OSA ( 17 ) have shifted the focus on the use of Mandibular Advancement Devices (MAD), while the recent European Respiratory Society (ERS) guidelines on non-CPAP therapy ( 18 ) mention further therapeutic choices and promote future research to develop the existing evidence base. The wider involvement of different specialties would favour “patient's choice.”…”