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What matters: CPAP vs. appliances for sleep apnea.

Most likely I am not alone with the feeling that we spend a lot of resources diagnosing sleep apnea, meticulously titrating CPAP devices, and listening to some of our patients as they list the reasons for not using it.

Many times, the patients have been back to the sleep specialists, who try in earnest to make it work because we all know the potential adverse downstream effects of untreated apnea.

We all also know that frightening our patients ("untreated sleep apnea can increase the risk for sudden cardiac death and heart failure") into CPAP compliance is ineffective. So, for the lucky patients whose insurance coverage facilitates the fitting of oral appliances, such as the mandibular advancement device (MAD), we can try these.

Although the reduction in overall apneic episodes is less with MAD than with CPAP devices, the adherence to the MAD may be higher.

Australian investigators conducted a randomized controlled clinical trial evaluating the health outcomes of patients using the MAD or CPAP for obstructive sleep apnea (Am. J. Respir. Crit. Care Med. Feb. 14, 2013 [doi:10.1164/rccm.201212-22230C]).

In this study, 126 patients with moderate to severe OSA were randomly assigned to use of MAD or CPAP for 1 month.

The primary outcome was a difference in 24-hour mean arterial blood pressure. Secondary outcomes included cardiovascular events and arterial stiffness.

CPAP was significantly more effective for reducing the apnea-hypopnea index (AHI), but compliance was significantly greater with MAD (6.5 hours per night vs. 5.2 hours per night). No differences in the 24-hour mean arterial pressure were observed, though neither treatment improved blood pressure. Sleepiness, driving stimulator performance, and disease-specific quality of life improved with both treatments by similar amounts. MAD was superior to CPAP on several quality of life domains.

This study is extremely informative for our practices in which we cannot consistently provide either motivational enhancement or interventions to improve adherence with CPAP. For CPAP-nonadherent patients for whom an appliance seems like an appropriate next step, this should be pursued.

In the case of sleep apnea, we should not let perfect be the enemy of good.


Dr. Ebbert is professor of medicine and primary care clinician at the Mayo Clinic in Rochester, Minn. He reports having no conflicts of interest. The opinions expressed are those of the author. Scan the QR code to read more What Matters columns at
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Title Annotation:OPINION
Author:Ebbert, Jon O.
Publication:Internal Medicine News
Date:Apr 15, 2013
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