This section provides a schematic overview of select OSA treatment modalities but does not advocate one over another. Consult a sleep specialist to determine the best approach for your individual needs.

OSA Treatment Modalities

PAP Therapy

Positive Airway Pressure (PAP) devices are a first line treatment option recommended by the American Academy of Sleep Medicine (AASM) for OSA. Through the medium of a mask over the nasal, oral, or oronasal interface (nose, mouth or both), PAP devices create a pneumatic splint (air support) to open the upper airway that is prone to collapse during apneic events. PAP may be delivered in continuous (CPAP), bilevel (BiPAP), autotitrating (APAP) or adaptive servo ventilation (ASV) modes. PAP is the standard treatment recommended for moderate to severe OSA, and is a primary option for mild OSA.

Although AASM Practice Parameters and Clinical Guidelines consider PAP the standard recommended clinical treatment modality for OSA (but not the only one), it requires proper introduction and education on the part of the Durable Medical Equipment (DME) provider, and an open mindset and willingness on the part of the patient. This is an extremely important dialogue since PAP compliance statistics are generally poor, hovering at or just above 50%; mostly because of pre-therapy biases, poor experiences during the introduction of PAP and inadequate attempts to accommodate.
Be sure to investigate a reputable DME source for introduction to PAP should your physician prescribe it. It is a well-established fact in sleep medicine that PAP compliance can rise significantly with a proper introduction to a suitable interface that fits well. Still, however, the dialogue remains two-sided. If the patient's attitude has been skewed by a reflexive bias against "sleeping with a mask", then PAP compliance will be an up-hill challenge from the start. Consider instead the entire vicious cycle of health that you have learned about, and how that snowball effect can work in the other direction to form a cascade of positive effects that feed off each other and assist other domains of your life. Based on the track record of PAP along with other forms of therapy for moderate to severe cases of OSA, PAP therapy should be a serious consideration. Full accommodation may take about a week after you receive the device. Remember, 76% of AASM survey respondents reported the quality of their sleep to be good to very good post-treatment versus only 7% before (n=506). The same survey also disclosed that 41% of respondents were finally diagnosed with severe OSA and 43% were moderate even though the initial physician's assessment guessed that 62% were mild, 30% moderate and only 8% severe. Get screened!

BP Improvement

After PAP Treatment, 41% of AASM survey hypertensives had improvements in BP


HbA1c Improvement

After PAP, 31% of AASM survey diabetic patients had improved HbA1c numbers


Heart Disease Risk

After PAP Treatment, 56% of survey heart disease candidates had decreased risk


Pulmonary Function

After PAP, 54% of survey asthmatics had improvements in pulmonary function

Other Treatments

Oral (Dental) Appliances: Oral appliances are an established treatment option for snoring and mild-to-moderate OSA. Oral appliances work by increasing the upper airway space. Appliances are designed to stabilize the anterior position of the mandible and/or to advance the tongue (or soft palate). Oral appliance therapy is generally well-tolerated, with short term side effects or minor discomfort.

Recently, the field of sleep medicine and sleep diagnostics have begun to recognize (through clinical studies) that oral appliances are an additional viable first-line treatment to consider for mild to moderate sleep apnea in addition to CPAP.

AASM considers oral appliance therapy, in tandem with PAP, a first-line treatment option for patients with mild to moderate OSA, or patients that have tried and failed PAP therapy. Dental appliances are thus an important option for patients that have proved intolerant or non-compliant of CPAP therapy. Appliances are custom fit to the anatomical idiosyncrasies of the individual. Appliances and adjustments should be overseen by an experienced dentist so that chronic discomfort or long term damage are not introduced by the process. Commercial "boil-and-bite" appliances are thus more risky and less effective.
Surgical Management of OSA: OSA is potentially amenable to surgical intervention when specific anatomic features are present in the candidate. Three principle anatomic regions of potential collapse during sleep in patients with OSA include the nose, the palate, and the base of the tongue. Each region can be surgically restructured on its own or in combination when warranted. Soft tissue can be removed and the maxilla and mandible may be repositioned forward to expand the posterior airway space.

Weight-Loss: Weight-loss is considered an important adjunct (additional) treatment option for OSA. Weight-loss is not often emphasized (as a primary option) by physicians. Studies have demonstrated that loss of 20 lbs to 40 lbs in obese men with severe OSA resulted in a reduced apnea hypopnea index (AHI) of about 50%. Reductions in apnea events appears to be dose-dependent with regard to weight-loss— the more weight lost, the greater reduction in AHI. Interestingly, reductions in AHI are sustained over 1 to 4 years despite a weight regain of 30% to 50%. Some individuals will not experience the same rate of reduction in AHI. The dose-dependent effect of weight-loss does not always resolve OSA, even through (bariatric) surgical means. (See additional section on weight-loss approaches below)
Expiratory Nasal Resistors: An ENR is a device that is designed with a one-way valve that is placed on the outside of the nares (nostril) with an adhesive. The ENR allows inspiration to flow unimpeded but it partially closes during expiration. This creates a nasal resistance pressure, or expiratory positive airway pressure (EPAP) within the pharynx in an attempt to 'stent' and stabilize the airway during collapse. Studies have demonstrated that ENR's appear to bring as much as a 50% - 60% reduction in apnea events along with a reduction in reported sleepiness. However, ENR data is not yet iron clad with regard to its effectiveness for all OSA patients. Individuals that previously accommodated to PAP therapy did not show as robust a response during a transition to ENR. Side effects include a headache and nasal irritation. Currently, ENR devices are considered an alternative therapy for patients that are intolerant to PAP or oral appliances. Patients with mild to moderate OSA and positional OSA (pathological levels of events during supine "on the back" sleep versus other positions) may be good candidates for ENR devices. Patients with nasal obstruction are less likely to respond.

Hypoglossal Nerve Stimulation: HGNS stimulates the hypoglossal nerve that stimulates the genioglossus upper airway dilator musculature. The systems use implanted pulse generators similar to a pacemaker. The pulses are synchronized with inspiration through a cuff that is implanted around the hypoglossal nerve to increase airflow. Studies have shown the devices to be very effect for some (50% - 70% reduction in AHI) but ineffectual for others, sometimes nearly 1/3 of patients undergoing the procedure. Due to the need for additional studies, existing HGNS devices are considered an alternative therapy for patients that are intolerant to PAP and oral therapy.
Oral Pressure Therapy: OPT therapy consists of a device to create a vacuum in the oral cavity through a customized mouth piece. Negative pressure is limited to the oral cavity, thus "pulling" the upper airway space behind into an arrangement that allows for more air and less collapse. Initial studies demonstrate an estimated 50% reduction in AHI with OPT therapy. Nonetheless, until further review, they are considered a potential adjunct source when PAP and oral devices are intolerant to the patient.

Positional Therapies: Because the repeated collapse (or partial collapse) of the upper airway that characterizes OSA is worse during supine sleep (lying on the back), positional therapies have long been around to deter supine sleep. Basic 'technologies' such as tennis balls sewn to the back of a night shirt to modern 'smart' watches and wearables all deploy the same logic of positional therapy. Positional therapies can be very effective, even as effective as PAP for some mild to moderate OSA patients that demonstrate nearly exclusive vulnerability during supine sleep. However, as OSA progresses in severity, other sleep positions will be vulnerable to events, particularly during REM sleep. We learn in the Sleep Architecture section of this platform that the brain actively "turns on" paralysis of the skeletal muscles (except the ocular muscles of the eyes) during REM so that we do not act out our dreams. This means that the musculature around the upper-airway becomes more vulnerable to apnea and hypopneas during REM. As the severity of OSA increases over time, REM vulnerability progresses to effect other positions while OSA airway collapse becomes more pronounced even in other positions. In short, positional therapy works for early OSA stages.
Pharmacological Approaches: A number of agents have been investigated or are being investigated to address the OSA airway potency and REM vulnerability of OSA through pharmacology. Serotonergic agents known to regulate upper airway motor output and (through complex interactions) also take part in respiratory control have been investigated, but these agents have modest effects on apnea severity and frequency while impacting or slightly retard REM as a byproduct (like some SRI's). Remember, REM has basic sleep-dependent functions, so the goal is to reduce the severity to OSA without reducing REM itself. Acetylcholine, a cholinergic neurotransmitter that is active during REM is involved with modulation of the upper airway 'tone'. Cholinergic medications increase REM. Ongoing studies (including that referenced below) are investigating the potential of cholinergic agents in tandem with other medications. Cannabinoid agonists have recently been proposed as a target for OSA therapy (based on their quality to increase phasic genioglossal activity) but additional studies need to be performed. Early indicators suggest that they may reduce a severe AHI measure of OSA (48.8 AHI ) by 29%.
Potential Drug Combo: A recent drug combination consisting of oxybutinin, which blocks receptors for acetlycholine on hypoglossal motor neurons (making it more responsive during REM-invoked muscle paralysis) in combination with atomoxetine, which prevents norepinephrine from being reabsorbed by releasing neurons, appears to in concert, boost the responsiveness of the genioglossus in NREM. Thus both NREM (atomoxetine and oxybutinin) and REM (oxybutinin) receive an airway potency (tone) boost to prevent airway collapse. The initial studies of the combination show great promise for significant effects from the tandem, but there have been pharmacological approaches that showed promise in the past yet did not pan out. In addition, the sustained effect of norepinephrine (the brain's 'adrenalin') may not be welcome for PTSD patients that suffer from the intrusion of norepinephrine during nightmares and flashbacks, as well as the proportion of the general population that suffers from insomnia due to hyper-arousal and anxiety. It is unclear how the neurotransmitter environment will effect these conditions, along with those with anxiety disorders and hypertension. Given these constraints, this combination at first appears to show the most promise relative to other pharmacological approaches in the past.

More On Weight Loss

Dieting Strategies: To some degree, very low calorie diets (VLCD) have been studied in a clinical setting both in terms of obesity research and sleep medicine. There is much debate about the efficacy of VLCDs versus combinations of macronutrient ratio alterations in the context of slower calorie restriction methodologies designed for long-term management. Many still argue that there is a place or phase for both styles in select circumstances, but we should also recognize that long-term weight-management problems from unsupervised "yo-yo" severe caloric restriction dieting strategies have been shown to be problematic and not very effective over the mid to long term (even resulting in the recovery of additional weight above the baseline level prior to severe calorie restriction). Moreover, advocates of 'diet-only' weight-loss (without increasing physical activity) attempt to utilize studies that appear to demonstrate that weight-loss is less effective than physical activity alone. Physical activity does more for overall health and weight management than simply burn calories. For example, insulin and blood-sugar dynamics are skewed decidedly toward metabolic disorders such as diabetes when large skeletal muscle groups are brought "off-line" through a mostly sedentary lifestyle. These large muscle groups, when utilized in a normally active and functional pattern of work and locomotion, combine to form a major reservoir for insulin and blood sugar dynamics. Blood flow and cardiovascular efficiency is increased in general with exercise and activity. Even the brain's "feel good" chemistry is heightened once adaptation to exercise has occurred and efficiency has increased. In short, exercise invokes numerous processes that are not alien to normal physiological functioning. An analysis has recently disclosed a sedentary non-exercising lifestyle to have a higher association with morbid medical outcomes than even smoking or hypertension alone (2018; Mandsager, et al). To see how physical activity alters the basic nutrient use priorities of the body, check out the Fuel Use Sequential Steps (F.U.S.S.) learning modules that are available through the Tri-Nourish link.

Sleep & Weight-Loss: Given the above emphasis regarding the dual-sided tandem of nutrition-and-exercise for long term health strategies, it is clear that in the arena of weight management we advocate an integrated approach. Nonetheless, it is up to you and your physician whether to include weight loss as a primary or additional OSA treatment option. More generally, we recognize that many modern facilities, dietitians, and clinicians advocate diet-and-exercise as an integrated tandem for weight management, but what has been glaringly missing is communication about the fundamental role that sleep-dependent processes play with regard to that very tandem itself. We discuss elsewhere on this platform the fact that poor sleep quality from common sleep disorders or common behavioral patterns leads to a hormonal cocktail that increases stress and hunger hormones and skews insulin and blood-sugar balance while decreasing satiation, energy and motivation. These poor sleep behaviors include shortened planned sleep periods and delayed circadian rhythms that are out of alignment with the body's peripheral "clocks".

Sleep Is Not Rest.

Although Nourish Sleep is a non-clinical entity, we do not operate outside of a responsible care pathway. Nourish Sleep screening does not constitute confirmation of a sleep disorder or lack thereof. Only a face-to-face clinical evaluation with a clinician or board certified sleep physician can affirm the necessity for further diagnostics or treatment. Our role is to educate you and provide you a rigorous, but highly tailored and comprehensive understanding of your specific sleep quality. Although we work collaboratively with a diverse array of clinical and educational resources to fulfill that mission, Tri-Nourish Inc and Nourish Sleep constitute non-clinical entities offering non-clinical services. Our goal is to assist your sleep quality in a pre-pathological (preventative) approach that takes into consideration domains that impact health and wellbeing before they transition into common sleep, mental or physiological disorders. Poor sleep quality radically impacts productivity, performance, health, emotional resilience, and safety— well before the sleep disorder threshold has been breached.