Non-CPAP therapy for obstructive sleep apnoea.

Treatment of obstructive sleep apnoea in adults is evolving, from a "one treatment fits all" to a more individualised approach. The spectrum of treatment options is broad and heterogeneous, including conservative, technological and pharmaceutical modalities. This raises the questions of which patients these modalities might be useful for, and if there are specific criteria for single or combined treatment. The most commonly used non-CPAP treatment is a mandibular advancement device. Furthermore, it appears from the available evidence that upper airway surgery, bariatric surgery, and maxillomandibular advancement can be effective in particular patient groups and should be indicated more readily in clinical practice. Technically, a tracheotomy is the most effective surgical treatment, but is not socially acceptable and is associated with major side-effects. Other treatment options are emerging, like positional therapy, hypoglossal nerve stimulation, and myofunctional exercises. Drug therapy is also promising when pathophysiological traits are considered. The range of currently available treatment options will be discussed in this review, with emphasis on the selection of appropriate patients, therapeutic efficacy and compliance, and reference to recent guidelines. In the selection process, routine application of drug-induced sleep endoscopy to assess the site(s) of collapse during sleep can increase the success rate of both surgical interventions and oral appliance therapy. To outline recommendations concerning the proper management of obstructive sleep apnoea (OSA) patients that cannot be treated adequately with continuous positive airway pressure (CPAP) due to intolerance, poor adherence or compliance, or CPAP refusal.To provide information about the selection of appropriate patients for alternative non-CPAP treatment options.To better understand the different aspects of OSA treatment with noninvasive approaches, such as oral appliances, positional therapy, drug treatment and myofunctional therapy, including indications, contraindications, and expected short- and long-term results.To discuss the different surgical options for the treatment of OSA and to provide information on the important issue of proper patient selection for surgery, as most OSA surgical outcomes are associated with the pre-operative assessment of the level(s) of upper airway collapse.

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Copyright ©ERS 2022.

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Conflict of interest: All authors have seen and approved this manuscript. J. Verbraecken reports institutional fees and educational grants from AirLiquide, AstraZeneca, Bekaert Deslee Academy, Bioprojet, Desitin, Ectosense, Epilog, Fisher & Paykel, Heinen & Löwenstein, Idorsia, Inspire, Jazz Pharmaceutics, Medidis, Mediq Tefa, OSG, Philips, ResMed, Sefam, SomnoMed, Total Care, UCB Pharma, Vivisol, and Westfalen Medical. M. Dieltjens holds a Postdoctoral Fellowship at the Research Foundation Flanders (FWO: 12H4520N). S. Op de Beeck holds a Postdoctoral Fellowship at the Research Foundation Flanders (FWO). A. Vroegop has nothing to disclose. M. Braem reports a research grant from SomnoMed at the Antwerp University Hospital and sits on the advisory board of ResMed and SomnoMed. O. Vanderveken reports research support outside the submitted work from Philips, SomnoMed, Inspire Medical Systems and Nyxoah at the Antwerp University Hospital, consultancy for Galvani and Liva Nova, and is an advisory board member for Zephyr and SomnoMed; he holds a Senior Clinical Investigator Fellowship from the Research Foundation Flanders (FWO: 1833517 N). W. Randerath reports personal fees and travel grants from Weinmann, Heinen & Löwenstein, Resmed, Philips, Inspire and Bioprojet.