Obstructive sleep apnea: 
an overview of treatments

Pretreatment patient education


Before any form of OSA therapy is initiated, the clinician should review with the patient the results of the polysomnogram and any other objective testing for OSA and sleepiness that has been performed. The educational program should include discussion of the pathophysiology of OSA, risk factors, and possible health consequences of untreated OSA (Table 2). Treatment options should be discussed in the context of the severity of OSA in that particular patient, possible complications associated with a given treatment, and the importance of treatment compliance in improving health and quality of life. The patient should be given general information on weight loss, smoking cessation, reduction of alcohol intake, medication effects, and sleep position. Videos, including those accessible through online sites such as YouTube.com, as well as handouts and brochures can help the patient learn more about OSA and become less apprehensive about treatment.


Table 2: Checklist of key components of OSA patient-education discussion

– Review with the patient his or her polysomnogram results and other objective findings related to OSA. – Explain the pathophysiology of OSA. – Discuss the possible correlation between the person’s individual risk factors and his/her clinical symptoms. – Point out the possible consequences of untreated OSA. – Describe the treatment options. – Clarify the anticipated outcomes of various treatments. – Outline the possible complications of treatment. – Ask the patient to share any concerns and questions.

Adapted from Epstein LJ, Kristo D, Strollo PJ, et al.; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-276. Available at aasmnet.org/Resources/clinicalguidelines/OSA_Adults.pdf

Positive airway pressure


According to the Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine, positive airway pressure (PAP) is the treatment of choice for mild, moderate, or severe OSA and should be offered to all patients.⁷ Introduced by Sullivan and colleagues in 1981,^6,8 PAP provides pneumatic splinting of the upper airway during sleep by delivering pressurized air through a device—usually a face mask or a nasal mask—worn by the patient.⁸ The device is connected by flexible tubing to a portable PAP machine at the person’s bedside. 


Apnea, a breathing cessation of at least 10 seconds, is associated with a decrease in blood oxygenation. Hypopnea is a disruption of air flow of at least 30% during sleep or an arousal during sleep. The combination of apnea and hypopnea causes the blood level of carbon dioxide to increase and the blood level of oxygen to decrease, leading to a disruptive pattern of breathing during that period of sleep. AHI and oxygen desaturation levels are used to indicate the severity of obstructive sleep apnea; PAP therapy reduces AHI.⁷

Mr. W has a severely high AHI with oxygen desaturation. This makes him an ideal candidate for PAP therapy. 


PAP can be delivered in different modes: continuous (CPAP), bilevel (BPAP), or autotitrating (APAP).⁹ CPAP delivers a fixed mild positive pressure during inspiration and expiration to maintain airway openness. In patients who cannot tolerate a fixed positive pressure during exhalation, BPAP delivers a higher pressure during inspiration and a lower pressure during exhalation. APAP has variable inspiratory and expiratory pressures as it continuously monitors the patient’s breathing pattern and delivers pressures accordingly. CPAP is the standard treatment option for moderate to severe cases of OSA and also represents a good treatment option for mild sleep apnea.⁶ 


A polysomnogram can be administered as a split-night study to allow for initial diagnosis of OSA followed by CPAP titration the same night. CPAP can be delivered through a mask or through nasal pillows, which are plastic inserts placed directly under the nose and held in place by straps that cover less of the face than does the CPAP face mask. Nasal pillows might be the better choice for patients who find the CPAP mask too uncomfortable or unattractive, or who find that their mask leaks air.


Patient complaints of congestion, rhinorrhea, sneezing, or other nasal symptoms due to CPAP therapy are common.¹⁰ Humidification of the CPAP air has been shown to reduce the frequency of nasal symptoms in some persons with OSA.¹⁰ The patient can also be prescribed nasal saline or nasal decongestants including nasal steroids. Persons with persistent nasal symptoms during PAP therapy should be referred to a sleep specialist or to a specialized respiratory therapist for reevaluation of the PAP setting and mask fittings.


Other side effects of PAP therapy include skin irritation as well as mask allergies, particularly for persons with a latex allergy. In addition, portability of the CPAP machine may be a concern. For example, a patient such as Mr. W, who drives a truck for a living, might find it difficult to transport and operate a CPAP machine while on the road.


Because compliance with this effective form of primary therapy is essential, and the therapy is long-term, providers should make it a priority to address any patient concerns regarding CPAP during an office visit shortly after the treatment is prescribed and take measures to prevent or minimize any side effects (Table 3). 


Nasal expiratory positive airway pressure (EPAP) is an OSA treatment that utilizes the patient’s own breathing to create positive airway pressure and prevent obstructed breathing. This treatment employs a device consisting of a small valve attached externally to each nostril with hypoallergenic adhesive. Nasal EPAP has been shown to provide significant reductions in AHI and improve subjective daytime sleepiness compared with sham treatment in persons who have mild to severe OSA, with high patient acceptance and compliance.¹¹ Users of EPAP may have difficulty breathing since they need to sleep with an adhesive to the nose and experience increased resistance during expiration. Patients with any nasal problems are not candidates for EPAP therapy. Further research is needed before EPAP therapy can be recommended for use in the pediatric population. 


Table 3: Troubleshooting side effects of CPAP and oral-appliance treatments for OSA

Treatment	Side Effects	Solution
Continuous positive airway pressure (CPAP)	Mask allergies	Ask patient about latex allergy.
	Skin irritation	Have patient try nasal pillows. Discuss with sleep specialist.
	Dry mouth	Blend heated humidifier into CPAP. machine Have patient use chin strap to keep mouth closed. Have patient use a different type of mask. Discuss with sleep specialist.
	Nasal congestion Sinusitis Epistaxis (nosebleed)	Blend heated humidifier into CPAP machine. Ensure patient’s CPAP mask is well-fitted. Have patient use nasal saline at bedtime. Discuss possible use of steroid nasal spray with sleep specialist.
	Aerophagia (air swallowing)	Decrease CPAP pressure (discuss with sleep specialist). Have patient lower head of bed or flatten sleeping position. Have patient try taking a proton pump inhibitor.
	No improvement in symptoms	Have patient keep sleep diary to document: – tolerance – side effects (e.g., nasal symptoms) – daytime symptoms (e.g., sleepiness) – nocturnal awakening Encourage CPAP compliance and discuss with sleep specialist.
Oral appliances	Excessive salivation Dry mouth Tooth and jaw discomfort Temporomandibular joint (TMJ) problems Temporary bite changes Tongue pain Gagging	Adjust oral appliances Discuss with dental sleep specialist Monitor children for dental-skeletal changes Investigate other treatment options, such as CPAP, if side effect continues

Compiled by Susan Collazo, RN, MSN, APN-CNP

From the December 01, 2014 Issue of Clinical Advisor