Personalized Treatment for Obstructive Sleep Apnea: Beyond CPAP

Obstructive sleep apnea (OSA) is a sleep disorder characterized by repetitive episodes of partial or complete obstruction of the upper airway during sleep, leading to reduced or completely stopped airflow despite ongoing respiratory efforts. This results in disrupted sleep and intermittent hypoxia. This disorder is estimated to affect 17% of middle-aged women and 34% of middle-aged men [1]. Loud snoring, a precursor of OSA, is even more prevalent and is estimated to affect 40-60% of adult people [2]. OSA does not only cause symptoms such as excessive daytime sleepiness, loud snoring, and interrupted breathing during sleep. OSA can have significant health implications, including increased risk of hypertension, cardiovascular disease, and impaired cognitive function in the long term, as shown in several scientific studies [3,4,5]. Although 80% of patients remain undiagnosed, increasing awareness is seen over the last years [6].

OSA is diagnosed with an overnight polysomnography in a hospital setting or at home, in patients who are clinically and anamnestically suspected of OSA. Symptoms are habitual snoring, choking or gasping during sleep, excessive daytime sleepiness, inattention, and poor recall. Severity of OSA is measured using the apnea-hypopnea index (AHI), the number of apneas and hypopneas per hour of sleep. The diagnosis is confirmed if the AHI is at least five events per hour of sleep. Severity based on AHI is defined as follows: mild OSA (5 < AHI ≤ 15/h), moderate OSA (15 < AHI < 30/h) and severe OSA (AHI ≥ 30/h) [7].

Continuous positive airway pressure (CPAP) is a method used as first-line treatment for OSA. CPAP therapy significantly reduces disease severity, sleepiness, blood pressure, and sleepiness-related traffic accident occurrence, as well as improves the sleep-related quality of life in adults with sleep apnea [8].

However, intolerance and resistance to CPAP can limit its long-term effectiveness. Various factors contribute to CPAP intolerance, including mask discomfort, claustrophobia, nasal congestion, air leaks, pressure intolerance, and difficulty adjusting to the therapy [9]. Compliance failure is reported to be different in various countries. A recent nation-wide French database study showed that almost half of patients on CPAP therapy terminate the CPAP treatment after three years [10]. Therefore, alternative treatment options in CPAP-intolerant or non-compliant patients have gain increased interest and importance in daily practice, leading us towards a more personalized way of treatment.

Alternative treatments for OSA include Mandibular Advancement Devices (MADs), positional therapy, upper airway surgery, and maxillomandibular osteotomy [11,12,13,14]. MAD therapy has emerged as a second-line conservative non-invasive treatment method for the management of mild to moderate OSA, and lately even for severe OSA patients. MAD therapy consists of a titratable duo-block with separate upper and lower parts that are dynamically interconnected. This allows for a gradual protrusion of the lower jaw until the optimal position is reached. As such, patients can optimize the ideal position that allows symptoms (such as snoring and tiredness) to disappear and to tolerate protrusion as well. MAD therapy functions on increasing the upper airway volume, mainly the widening of the lateral walls of the velopharynx [15].