Novel avenues to approach non-CPAP therapy and implement comprehensive obstructive sleep apnoea care

Abstract

Recent advances in obstructive sleep apnoea (OSA) pathophysiology and translational research have opened new lines of investigation for OSA treatment and management. Key goals of such investigations are to provide efficacious, alternative treatment and management pathways that are better tailored to individual risk profiles to move beyond the traditional, continuous positive airway pressure (CPAP)-focused, “one size fits all”, trial and error approach which is too frequently inadequate for many patients. Identification of different clinical manifestations of OSA (clinical phenotypes) and underlying pathophysiological phenotypes (endotypes), that contribute to OSA have provided novel insights into underlying mechanisms and have underpinned these efforts. Indeed, this new knowledge has provided the framework for precision medicine for OSA to improve treatment success rates with existing non-CPAP therapies such as mandibular advancement devices and upper airway surgery, and newly developed therapies such as hypoglossal nerve stimulation and emerging therapies such as pharmacotherapies and combination therapy. These concepts have also provided insight into potential physiological barriers to CPAP adherence for certain patients. This review summarises the recent advances in OSA pathogenesis, non-CPAP treatment, clinical management approaches and highlights knowledge gaps for future research. OSA endotyping and clinical phenotyping, risk stratification and personalised treatment allocation approaches are rapidly evolving and will further benefit from the support of recent advances in e-health and artificial intelligence.

Current and novel treatment options for obstructive sleep apnoea

“…This definition has been refined, in which the AHI in the nonsupine posture should be at a nonpathological level (AHI <5 events·h −1 or <10 events·h −1 , described as supine isolated OSA) [ 91 , 92 ]. Recent studies have provided insight into the mechanisms of action [ 93 ]. When OSA patients shift from the supine to lateral position, they experience a significant increase in awake functional residual capacity, passive V′ 0 (ventilation off CPAP when the upper airway dilator muscles are quiescent), and active V′ 0 (ventilation off CPAP when the muscles are activated), and a significant decrease in critical positive end-expiratory pressure ( P crit ).…”

Obstructive sleep apnea endotypes and their postoperative relevance

“…Impaired upper airway/increased collapsibility is the target of most existing OSA therapies, including continuous positive airway pressure (CPAP), mandibular advancement splints, upper airway surgery, supine avoidance devices, and weight loss. 11 In CPAP users, CPAP use postoperatively can be critical to avoid hypoxic events. 45…”

Investigation and management of residual sleepiness in CPAP-treated patients with obstructive sleep apnoea: the European view

“…However, consistent data from large-scale studies are demonstrating that the rate of CPAP termination is up to 45% at 3 years after CPAP initiation [91]. Implementation of alternatives to CPAP remain limited in routine practice [15,92], and the majority of these patients stay untreated. Recent data demonstrate in real-life that CPAP discontinuation is associated with an increase of 39% in mortality rates [93].…”