Advances in the treatment of obstructive sleep apnea.

OPINION STATEMENT: This article focuses on the treatment of obstructive sleep apnea (OSA), using the most recent available data. The first choice of treatment for patients with moderate or severe obstructive sleep apnea is continuous positive airway pressure (CPAP), which was first described in 1981 (Sullivan et al. Lancet 1(8225):862-5, 1981) and works by splinting the airway open to facilitate proper airflow. For patients with mild OSA, other treatments may be considered including positional therapy, weight loss, or oral appliances. Oral appliances are continuing to become more mainstream, and may be a reasonable first-line treatment even for some patients with moderate OSA, such as those who cannot tolerate or do not want to use CPAP. Some evidence suggests that adherence to mandibular advancement devices (MADs), a type of oral appliance, may be superior to that of CPAP. Recent evidence has suggested that the MAD may be similar to CPAP in preventing cardiovascular mortality in OSA, though objective measurement of MAD adherence was not available in the study. Objective adherence monitors are now available for oral appliances and should prove valuable for clinicians. Pharmacotherapy has not been shown to be significantly effective in the treatment of OSA and should be considered as an adjunctive treatment class, though some emerging evidence may support pharmacotherapy for specific purposes, such as acetazolamide for high-altitude travelers and zonisamide for weight loss. Upper airway surgical intervention remains a second- or third-line treatment class for moderate to severe OSA, though multiple case series of maxillomandibular advancement (MMA) have shown considerable, statistically significant improvements in AHI. Weight loss should always be recommended for patients with OSA who are overweight or obese, as weight loss may result in improvement in OSA. Bariatric operations are effective for obesity and are reasonable considerations for obese patients, although a recent randomized controlled trial found that bariatric intervention failed to achieve superiority over conventional weight loss therapy in terms of apnea-hypopnea index (AHI) reduction.