Behavioral measures, such as weight loss, altered sleeping position, and avoidance of alcohol and sedatives, can benefit some patients with mild obstructive sleep apnea (OSA) (SOR: A).
 The mainstay of therapy for OSA is administration of continuous positive airway pressure (CPAP) (SOR: A).
 Oral appliances may benefit patients who are unable or unwilling to use CPAP or other forms of PAP therapy (SOR: A).
 The wakefulness-promoting agent modafinil is recommended for patients who experience residual sleepiness despite optimal CPAP therapy, provided CPAP compliance is closely monitored (SOR: A).
Several approaches can be used to manage obstructive sleep apnea (OSA), depending on the severity of the condition. Behavioral measures include weight loss, sleeping in a nonsupine position, and avoidance of alcohol and sedatives. However, the vast majority of OSA patients will require more effective therapy. Continuous positive airway pressure (CPAP) is a reliable and effective treatment for most patients with significant OSA. Other options include upper airway surgery and oral appliances.
Management of OSA focuses on treatment of the sleep-associated breathing abnormality itself, but if excessive sleepiness (ES) arising from OSA persists despite such treatment, wakefulness-promoting medications may also be considered.
Behavioral measures that patients with OSA should be advised to take include losing weight (if applicable), eliminating evening alcohol and sedatives, and sleeping in a lateral or prone position. Such positional therapy is best reserved for patients with mild OSA (Apnea Hypopnea Index [AHI] of 5 to 15 events per hour) with polysomnographic evidence that their AHI score normalizes in the nonsupine position. (1,2) Treatment of nasal inflammation and congestion with nasal topical corticosteroids and anti-inflammatory agents has been found helpful in the pediatric population (3) and may be helpful in some adults, (4) but it is unlikely that this therapy alone will treat OSA sufficiently. Nasal dilating strips have been reported to decrease the frequency of obstructive breathing events in some patients with OSA, (5,6) but convincing data supporting their efficacy are lacking, and their use is therefore not recommended as primary therapy for OSA.
Positive airway pressure therapy
Positive airway pressure (PAP) is currently the mainstay of therapy for OSA. Air is delivered at positive pressure from a compressor via a snug-fitting nasal or oronasal mask and acts as a pneumatic splint, preventing pharyngeal soft tissue collapse and thereby stabilizing the upper airway (FIGURE 1 ). The most commonly used form of this therapy is continuous PAP, or CPAP, which was introduced as OSA therapy in 1981 by Sullivan. (7) CPAP delivers continuous fixed pressure, set at the lowest level necessary to maintain upper airway patency and eliminate snoring throughout the respiratory cycle. Auto-adjusting PAP (APAP) is a variation of CPAP that incorporates various algorithms to automatically adjust air pressure based on persistence of apneas/hypopneas, snoring, and airflow limitation. Such devices can be useful in patients with variable pressure requirements dictated by changes in sleep posture or alcohol consumption,a but they have not been found clinically superior to standard CPAP in the treatment of...