Monitoring

Patients with OSA receiving continuous positive airway pressure (CPAP) therapy should undergo periodic assessment of symptoms and CPAP adherence after regular use has been established. In the US, Medicare requires an assessment of adherence within 12 weeks to demonstrate minimal use of 4 hours a night in at least 5 of 7 nights a week, and clinical benefit.[67]​ This represents about 41% to 44% usage, assuming 6.5 to 7 hours of sleep a night. The time interval between subsequent clinical assessments has not been established, but 1 or 2 times a year is common practice.

Adherence and Apnea-Hypopnea Index (AHI) improvement may be assessed using sensors integrated into CPAP devices. Sleep testing should be repeated for persistent or recurrent symptoms such as sleepiness or in the setting of significant weight change (≥10%) associated with change in symptoms.[235] Some home testing devices, such as those using peripheral arterial tonometry, may allow for assessment while using PAP in sleep.

Monitoring for oral appliance and surgical treatment effectiveness may follow similar guidelines, except that initial response to treatment of moderate to severe OSA is assessed using polysomnography or unattended (at-home) sleep study.[235]​[236]​​

Patients not adherent to CPAP or oral appliance regimen are questioned about the reason for nonadherence. Interventions should be administered to address the specific problems when possible:[131][134][137][138][139][140][237][238]

  • Patient education and support via bespoke programs

  • Cognitive behavioral therapy

  • Intranasal corticosteroid application may improve adherence in patients with rhinitis or turbinate hypertrophy

  • Trying a different interface

  • A chin strap may be considered to reduce air leak as a consequence of oral breathing

  • Use of a nonbenzodiazepine soporific, such as eszopiclone, may improve CPAP titration and adherence.

  • Nasal surgery may reduce nasal resistance in patients with anatomic nasal obstruction, and so improve CPAP adherence and reduce CPAP pressure

  • Bilevel positive airway pressure may be used to attempt to reduce pressure intolerance, although evidence is lacking for improved tolerance.

  • Auto-titrating positive airway pressure devices may be better tolerated in some patients: possibly those with positionally or rapid eye movement-dependent variable AHI.

  • Oral appliances, upper airway surgery, or implantable hypoglossal neurostimulation therapy are considered if CPAP is not accepted or tolerated

Options when adherence to oral appliance devices is low include:

  • Reducing jaw protrusion for discomfort problems

  • Troubleshooting appliance fit, ensuring symmetry (even intercuspation [proper fitting cusp-fossa of opposing teeth]), addressing temporomandibular joint problems, and/or applying posterior stops

  • Using or reattempting CPAP treatment: CPAP is more effective for AHI reduction, and reuse for those with moderate to severe condition is recommended

  • Using a different type of appliance: decision made based on dental anchoring mechanism/location and discomfort

  • Undergoing upper airway surgery: for patients who cannot tolerate oral appliances or CPAP

  • Undergoing implantation of a hypoglossal neurostimulation system: for patients with moderate to severe OSA

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