Non-surgical alternatives to continuous positive airway pressure

There are many alternatives to the use of CPAP or surgery in the treatment of OSA. Weight loss can be curative in obese patients, the largest group of OSA patients, but is difficult to achieve and even more difficult to maintain. Positional therapy is effective for those patients with position- dependent OSA; however, position dependency should be demonstrated before initiating this form of treatment. Long-term outcome studies are not available for this form of treatment. All patients should be counseled to avoid factors that promote upper airway collapse such as alcohol, sedatives, narcotics, sleep deprivation, and cigarette smoking. Protriptyline and fluoxetine reduce the number of apneas in patients with mild OSA, but individual response is variable and should be validated. There is no role for any other agent as primary treatment for OSA, except to treat an underlying contributing condition such as hypothyroidism. Supplemental oxygen may ameliorate hypoxemia but does not relieve upper airway obstruction or improve symptoms and should be used only as an adjunct therapy. Oral appliances are an effective treatment for mild-to-moderate OSA and may have better patient acceptance than CPAP, but appropriate response to treatment should be documented. Electrical stimulation of pharyngeal muscles may prove to be an effective therapy but still requires further investigation. Patients with mild-to-moderate OSA are the best candidates for the nonsurgical alternatives, whereas patients with severe OSA should have a trial of CPAP. Behavioral therapies can be initiated as primary therapy but should also be used in conjunction with other forms of treatment. OAs can be utilized as first-line treatment for mild-to-moderate OSA patients and may be useful in patients intolerant of other forms of therapy.