Severe Obstructive Sleep Apnoea

Most patients with severe OSA (AHI > 30/hr) who are seeking an oral device are often looking for an alternative to CPAP, Continuous Positive Airway Pressure.

CPAP is the “gold standard” of treatment for OSA. It involves the use of a machine to pump air into the airway via a mask worn over the nose. The air pressure “pneumatically splints” the airway open and prevents soft tissue collapsing into the upper airway. However, despite its high therapeutic efficacy, CPAP is often not well tolerated by patients, resulting in low compliance rate and limited clinical effectiveness. Fewer than 50% of patients adequately tolerate this first line therapy, CPAP (McEvoy, Weaver)

Today, oral appliances, particularly mandibular advancement splints (MAS), are considered to be a valuable, non-invasive treatment option for patients with sleep apnoea and for patients who do not comply with or refuse CPAP therapy. They are worn intraorally at night in order to advance the lower jaw, thus reducing the collapsibility of the upper airway. Studies have shown that patients using an oral device have been more compliant with therapy than CPAP patients.

Australia is very much at the forefront of sleep research; CPAP was invented by an Australian, Professor Colin Sullivan. A highly referenced paper, based on research done at The University of Sydney and the Woolcock Institute, illustrated in a randomised controlled clinical trial that the treatment of moderate – severe OSA with either CPAP or MAS has similar effects on health outcomes. The results are most likely explained by greater efficacy with CPAP being offset by a greater compliance with MAS; patient preference favoured MAS.

Often, patients who are non-compliant with CPAP have encountered issues with nasal obstruction and require assistance with an ENT (Ear, Nose, Throat) Specialist to provide medical or surgical management of the airway in order to improve compliance. Note that surgery is not curative of sleep disordered breathing but will often improve quality of life and enable the patient to use their treatment more effectively. This does not appeal to all patients and oral appliances, in many ways, are a suitable alternative to CPAP and /or surgery.

Patients who fail medical management often seek surgical treatment. There is a large amount of variability in outcomes for sleep surgeries, however, in order to maximise success and cure rates, multiple procedures are most often necessary. (Camacho)

If you are experiencing difficulties with CPAP and seek an alternative, please contact us.

Phillips CL, Grunstein RR, Darendeliler MA, et al.Health outcomes of continuous of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnoea; a randomized controlled trial. Am J Respir Crit Care Med. 2013;187(8):879-887

McEvoy RD, Antic NA, Heeley E, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnoea. N Engl J Med. 2016;375(10):919-931.

Weaver, TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thor Soc, 2008;5(2):173-178.

Camacho M, Certal V, Capasso R, Comprehensive review of surgeries for obstructive sleep apnoea syndrome.  Braz J Otorhinolaryngol. 2013;79(6):780-788.