Comparative effectiveness of CPAP and isolated or combined non-invasive therapies for obstructive sleep apnea: A network meta-analysis

Abstract

Introduction

Obstructive sleep apnea (OSA) is a prevalent condition associated with an increased risk of multiple adverse health outcomes. CPAP is the standard treatment. However, poor adherence has increased interest in alternative and combined non-invasive therapies.

Objective

This network meta-analysis compares the effectiveness of CPAP alone, isolated non-invasive therapies, and their combinations in key clinical outcomes for OSA.

Methods

Fifty-five randomized controlled trials were analyzed, comparing interventions such as CPAP, mandibular advancement devices (MAD), oropharyngeal myofunctional therapy (OMT), inspiratory muscle training (IMT), and combined approaches. Outcomes assessed included apnea-hypopnea index (AHI), minimum oxygen saturation (SpO₂), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), and oxygen desaturation index (ODI). The certainty of evidence was evaluated using the GRADE framework.

Results

CPAP was the most effective for reducing AHI and improving minimum SpO₂. OMT outperformed CPAP in reducing daytime sleepiness, while the combination of CPAP and IMT was more effective than CPAP alone in improving sleep quality. CPAP showed no significant differences compared to other interventions regarding mean SpO₂, time spent with SpO₂ < 90%, and ODI. Compared to the control group, MADs and OMT reduced AHI, while IMT and OMT decreased daytime sleepiness and improved sleep quality.

Conclusion

Although CPAP remains the gold standard for treating OSA, combining CPAP with IMT and using OMT alone provide additional benefits for sleep quality and daytime sleepiness, respectively. MADs and OMT are viable alternatives for patients who are intolerant to CPAP. However, the effectiveness of combination therapies requires further high-quality evidence.