European Respiratory Review Published online November 30, 2021 | https://err.ersjournals.com/content/30/162/210200.long
Digest author(s): Johan Verbraecken | 19 January, 2022
Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have been refined or reconsidered. In this European Respiratory Society (ERS) guideline on non-CPAP therapies for OSA, recommendations are presented determined by a systematic review of the literature. It is as an update of the 2011 ERS Statement on non-CPAP therapies, advanced into a clinical guideline. A multidisciplinary group of experts, including pulmonary, surgical, dentistry and ear-nose-throat specialists, methodologists and patient representatives considered the most relevant clinical questions (for both clinicians and patients) relating to the management of OSA. Eight key clinical questions were generated, and a systematic review was conducted to identify published randomised clinical trials that answered these questions. PICO 4 was split in two separate PICOs. The GRADE approach was used to assess the quality of the evidence and the strength of recommendations. The resulting guideline addressed gastric bypass surgery, custom-made dual-block mandibular advancement device, hypoglossal nerve stimulation, myofunctional therapy, maxillo-mandibular osteotomy, carbonic anhydrase inhibitors, and positional therapy.
The final recommendations were as follows:
| In adult patients with OSA … |
Recommendation (all conditional) |
Certainty of evidence |
| PICO 1 (laparoscopic R-en-Y Gastric bypass surgery or diet) |
FOR |
Very low |
| PICO 2 (MAD or CPAP) |
AGAINST |
Low |
| PICO 3 (NXII stimulation or no treatment) |
AGAINST |
Very low |
| PICO 4a (MYOFUNCTIONAL therapy or no treatment) |
FOR |
Low |
| PICO 4b (MYOFUNCTIONAL therapy or CPAP) |
AGAINST |
Very low |
| PICO 5 (MAXILLO-MANDIBULAR OSTEOTOMY or CPAP) |
FOR |
Very low |
| PICO 6 (carbonic anhydrase inhibitor or placebo) |
FOR |
Low |
| PICO 7 (sleep position therapy or CPAP) |
FOR |
Very low |
| PICO 8 (sleep position therapy or MAD) |
FOR |
Very low |
All recommendations were conditional for the intervention or the comparison (6 for, 3 against). The overall certainty of evidence was low to very low.
These recommendations can be used to benchmark quality of care for people with OSA across Europe and to improve outcomes.