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Corina E. Budin
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Anca Maierean, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca,
Romania; Email: firstname.lastname@example.org
J Mind Med Sci. 2019; 6(2): 181-189
Received for publication: June 11, 2019
Accepted: July 21, 2019
Therapeutic alternatives with CPAP in
obstructive sleep apnea
Corina Eugenia Budin1, Lorena Ciumarnean2, Anca Maierean1, Ruxandra Rajnovean3,
Bianca Domokos Gergely3, Milena Man3, Maria Aluas4, Angela Cozma2, Roxana Ioana
1Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
2Iuliu Hatieganu University of Medicine and Pharmacy, Department of Internal Medicine, Cluj Napoca
3Iuliu Hatieganu University of Medicine and Pharmacy, Department of Pneumology, Cluj Napoca
4Iuliu Hatieganu University of Medicine and Pharmacy, Department of Medical Education, Cluj Napoca
5Iuliu Hatieganu University of Medicine and Pharmacy, Dentistry Faculty, Cluj Napoca, Romania
Obstructive Sleep Apnea (OSA), characterized by airflow cessation (apnea) or
reduction (hypopnea) due to repeated pharyngeal obstructions during sleep, causes
frequent disruption of sleep and hypoxic events. The condition is linked to many adverse
health related consequences, such as neurocognitive and cardiovascular disorders, and
metabolic syndrome. OSA is a chronic condition requiring long-term treatment, so
treatment using continuous positive airway pressure (CPAP) has become the gold standard
in cases of moderate or severe OSA. However, its effectiveness is influenced by patients’
adherence. Surgery for OSA or treatment with oral appliances can be successful in selected
patients, but for the majority, lifestyle changes such as exercise and dietary control may
prove useful. However, exercise training remains under-utilized by many clinicians as an
alternative treatment for OSA. Other interventions such as oral appliance (OA), upper way
stimulation, and oropharyngeal exercises are used in OSA. Because the benefit of all these
techniques is heterogeneous, the major challenge is to associate specific OSA therapies
with the maximum efficacy and the best patient compliance.
OSA, oral appliance, upper way stimulation, oropharyngeal exercises, pulmonary
✓ Even though the role of OA is similar to that of CPAP in clinical practice, clinicians may
not achieve the abolition of all obstructive events during sleep by means of OA.
✓ There is currently an alternative therapy to CPAP or OA for subjects with mild to moderate
OSA, consisting in the use of upper airway stimulation devices.
To cite this article: Budin CE, Ciumarnean L, Maierean A, Rajnovean R, Gergely BD, Man M,
Aluas M, Cozma A, Bordea RI. Therapeutic alternatives with CPAP in obstructive sleep apnea. J
Mind Med Sci. 2019; 6(2): 181-189. DOI: 10.22543/7674.62.P181189
Corina Eugenia Budin et al.
Obstructive sleep apnea is characterized by airflow
cessation (apnea) or reduction (hypopnea) due to repeated
pharyngeal obstructions during sleep, causing frequent
disruption of sleep and hypoxic events. The
pathophysiology of OSA varies and includes different
underlying mechanisms, such as the effectiveness of the
upper airway dilator muscles (genioglossus), the upper
airway anatomy, the arousal threshold of the individual,
and the inherent stability of the respiratory control system
(1). It is well-know that obesity is the most significant risk
factor, with other factors such as smoking, alcohol abuse,
chronic nasal congestion, male gender, age, and the use of
sedative medications playing a significant role in OSA
development (2, 3). In addition, OSA is linked to many
adverse health-related consequences, such as
neurocognitive and cardiovascular disorders, and
metabolic syndrome (4, 5, 6). OSA has become a chronic
condition which requires long-term treatment, so treatment
using continuous positive airway pressure (CPAP) has
become the gold standard in cases of moderate or severe
OSA, but its effectiveness is influenced by patients’
adherence. Surgery for OSA or treatment with oral
appliances can be successful in selected patients (4), but for
the majority, lifestyle changes such as exercise and dietary
control may also prove useful. However, exercise training
remains under-utilized by many clinicians as the
alternative treatment for OSA (7). Other interventions such
as oral appliance (OA), upper way stimulation, and
oropharyngeal exercises are used in OSA.
OSA has been recognized as a very common pathology
in recent years, but it still remains undiagnosed and
untreated in many cases. Apnea-hypopnea index (AHI)
quantifies both sleep apnea severity and the number of
apneal or hypopneal obstructive events per hour of sleep.
The prevalence of OSA was found to be 24% in men and
9% in women aged 30-60 years, thus defining OSA as an
AHI greater than 5 events/hour in the Wisconsin Sleep
Cohort in the United States of America. The values of
prevalence worldwide do not vary significantly, thus
confirming that OSA is as common in the developing
world as in the occidental society (8). In Europe, the
prevalence may be even greater, taking into account that
modern diagnostic techniques are used. For example, in a
Swiss study including over 2,000 subjects with the
diagnosis of moderate-severe OSA, the prevalence was
23.4% in females and 49% in males (9).
The highest risk factor for OSA is obesity, especially
central adiposity. According to the worsening pandemic
obesity worldwide, the prevalence of OSA is yet
increasing. Moreover, obesity may contribute to the
development of OSA by affecting the upper airway
mechanisms (2). The deposition of fat in the
parapharyngeal region can reduce the caliber and promote
collapsibility by modifying the shape of the upper airway.
Obesity is also responsible for reducing the lung volumes
and increasing airflow resistance (10). In the pathogenesis
of obesity, a key role is represented by the interaction
between OSA and obesity, in part because excessive
daytime sleepiness and other symptoms of OSA may
accelerate weight gain due to reduced physical activity and
energy expenditure. Weight loss is a key measure of
therapy for overweight or obese patients with OSA, as it
may confer a positive impact on other diseases such as
cardiovascular disorders and type 2 diabetes and it may
reduce the severity of OSA (8, 11).
There is an age-related increase in the prevalence of
OSA. Some mechanisms include changes in the anatomic
parapharyngeal structures, parapharyngeal fat deposition,
and lengthening of the soft palate (12). It is also well
acknowledged that there is a 2 to 3-fold higher prevalence
of OSA in men compared to women (8). Men present
themselves more often for the clinical assessment for OSA
because they have typical symptoms of OSA (loud snoring,
witnessed apneas, and excessive daytime sleepiness). This
fact is responsible for the underdiagnosed OSA in women,
with women more likely presenting with atypical
symptoms such as poor energy levels and fatigue (13).
In addition, multiple craniofacial features related to
pharyngeal soft tissue or skeletal morphology may
predispose to upper airway collapse. Hyoid position,
mandibular size, and maxillary height have been associated
with an increased risk for OSA. Decreased velopharyngeal
area and tonsillar hypertrophy are soft tissue features that
have been associated with increased upper airway
Smoking is another factor implicated in the
development of OSA. The data are controversial, as the
effect of nicotine decreases the upper airway resistance
with a consequent reduction in the risk of OSA, whereas in
case of withdrawal, this resistance would become more
important and would cause a greater risk of OSA. Smoking
is a well-acknowledged risk factor for respiratory diseases,
various neoplasia, and metabolic disorders. Various
compounds in cigarette smoke, such as volatile organic
compounds, heavy metals, and nicotine are responsible for
Therapeutic alternatives with CPAP in obstructive sleep apnea
the increased oxidative stress and systemic inflammation,
with an important role in the occurrence of lipid and
glucose metabolic dysfunction and endothelial injury,
resulting in the development of cardiovascular, cognitive,
and metabolic disorders (14, 15).
Recognizing and treating OSA is very important in
clinical practice. The first step in the diagnosis is a clinical
evaluation, which involves a sleep history and a physical
examination of the respiratory, cardiovascular, and
neurologic systems. The examiner should note symptoms
such as snoring, witnessed apneas, nocturnal choking or
gasping, and restlessness and excessive sleepiness. The
differential diagnosis is made through the general
evaluation in order to select the appropriate test(s) and to
recognize the associated medical conditions such as
obesity, hypertension, stroke, and congestive heart failure.
In the diagnosis of OSA, nocturnal polysomnography is the
gold standard, but in cases of high suspicion of OSA,
nocturnal cardiorespiratory polygraphy is edifying. In the
third edition of the International Classification of Sleep
Disorders (ICSD-3), OSA is defined as a respiratory
disturbance index (RDI) ≥ 5 events/hour of sleep in
patients who associate typical symptoms of OSA (daytime
sleepiness, fatigue or insomnia, unrefreshing sleep, loud
snoring, witnessed apneas, awakening with a gasping or
choking sensation), or an RDI ≥ 15 events/hour of sleep
(even in the absence of symptoms) (16).
A high prevalence of comorbidities in seen in OSA
patients (17). There are specific patterns, with men more
often affected by diabetes and ischemic hearts disease and
women by hypertension and depression (18, 19). Also,
OSA is responsible for the development of cardiovascular
and cerebrovascular diseases through high sympathetic
nervous activity, oxidative stress, systemic inflammation,
intermittent hypoxia, systemic hypertension, endothelial
cell dysfunction, and accelerated atherosclerosis. Systemic
hypertension is the most studied cardiovascular
comorbidity in OSA. Respiratory events such as apneas or
hypopneas during sleep are followed by hypertensive
peaks, so that a variability of blood pressure may occur.
Another aspect in these patients is resistant hypertension or
incomplete blood pressure control on maximum drug
therapy (20). In patients with OSA, atrial fibrillation is very
frequent, with CPAP therapy having a protective role (21).
Another pathology with a high prevalence in OSA patients
with central obesity is metabolic syndrome (MetS),
responsible for increasing cardiovascular risk. Recent
studies have also shown that OSA is part of the MetS. The
intermittent hypoxia and the sleep loss or fragmentation are
involved in the pathogenesis of insulin resistance (17). In
these conditions, OSA treatment with sufficient adherence
(at least 4 hours/night) is required besides the
implementation of lifestyle interventions and weight loss
The association between OSA and chronic obstructive
pulmonary disease (COPD), known as “overlap syndrome”
from the early studies (23), has a prevalence of 1.0 to 3.6%
in the general population, 8-56% in OSA patients, and 3-
66% in COPD patients (24). In COPD patients who have
consulted clinicians for pulmonary rehabilitation, a severe
form of OSA has been diagnosed in 45% of the cases, with
these patients having poor sleep quality and
hypoventilation episodes during sleep (17, 25). Moreover,
overlapping patients have higher rates of mortality
compared to OSA patients, and in this direction there is a
protective effect of CPAP treatment (26). These data
suggest that a low body mass index (BMI) in patients with
COPD protects against OSA, but the upper airway and the
systemic inflammation are responsible for increasing the
prevalence of OSA in COPD patients (27).
Asthma and OSA are often associated, so asthmatic
patients often report symptoms such as daytime sleepiness,
poor asthma control, and poor quality of life. In patients
with difficult-to-treat asthma, the prevalence of OSA is
about 49%. Patients with severe asthma show poor sleep
quality and excessive daytime sleepiness. Often, asthmatic
patients present hypopneas. It appears that both asthma and
OSA play a synergistic role in the upper airway
inflammation, in part because the upper airways seem to be
smaller in patients with asthma and OSA (17).
Therapeutic Attitudes in OSA
In the last two decades, advances in sleep medicine and
the availability of improved diagnostic tools have led to a
better recognition and treatment of the disease. The
management of patients with OSA requires a
multidisciplinary approach, and many treatment options
are currently available in order to eliminate the nocturnal
apnea events and the intermittent hypoxia. Positive airway
pressure (PAP), available since the beginning of the 1980s,
provides the most effective and commonly used treatment.
PAP devices function as a pneumatic support that
maintains upper airway patency by increasing the upper
airway pressure above a ‘critical’ value (the pressure value
under which the airways collapse). The device is applied to
the patient through a nasal or oronasal mask, overnight or
during sleep hours at a set positive pressure. This pressure
can vary according to the severity of OSA, so higher
Corina Eugenia Budin et al.
pressures are needed in order to make nocturnal apneas
disappear. PAP therapy is indicated in patients with an AHI
greater than 15 events/hour of sleep, independently from
the presence of comorbidities and severity of symptoms. If
the AHI is above 5 and below 15, PAP is indicated in the
presence of comorbidities such as hypertension, coronary
artery disease, or previous cerebrovascular accidents, or in
the presence of other symptoms (i.e., sleepiness, impaired
cognition, mood disorders) (28, 29). Alternative options
include weight control, mandibular advancement devices,
oral appliance, upper airway stimulation, oropharyngeal
exercises, and a number of upper airway surgical
As previously shown, obesity is an important risk factor
for OSA, and over 70% of patients with OSA suffer from
obesity. A strict correlation has recently been established
between the body mass index (BMI) and AHI. Weight loss
is therefore a main goal in the management of OSA and all
patients should be encouraged to control their weight (30).
The term “Mediterranean diet” refers to many common
features including the abundant use of olive oil as the main
culinary source of fat, plentiful consumption of plant-based
foods (e.g. nuts, vegetables, fruits, cereals, grains and
vegetables), consumption of fresh and varied fruits,
frequent consumption of fish and other seafood, moderate
wine consumption with meals, limited meat (mainly
poultry) or processed meat intake, and low-to-moderate
consumption of processed products (31). Besides this, the
Mediterranean diet is characterized by abundant plant
foods with antioxidant molecules which have an anti-
inflammatory effect. Longer beneficial effects of a
moderate-carbohydrate (40%), high-fat (40%) calorie-
restricted Mediterranean diet on weight and waist
circumference have been demonstrated among individuals
with metabolic syndrome or more cardiovascular risk
factors. Therefore, a Mediterranean diet seems a promising
approach to reduce mechanical loads and thus improve
OSA severity, compared to a low-fat, calorie-restricted diet
In a study comparing the Mediterranean diet with a
low-carb diet, patients in the Mediterranean diet group had
a greater improvement in AHI after 6 months, mainly due
to an important reduction of the waist circumference,
improved upper airway neuromuscular control, and upper
airway muscular capacity (34).
While dietary-induced weight loss is effective in the
treatment of OSA, OSA influences weight loss through
sleep fragmentation and poor sleep quality, so these
mechanisms could have implications for therapeutic
approaches. Borel et al. studied this assumption in a group
of males with visceral adiposity who underwent a weight
loss intervention that included nutritional counselling and
moderate physical activity promotion. At one-year follow-
up, males with OSA had smaller reductions in waist
circumference, in total fat mass and triglycerides, and
attenuated improvement in high-density lipoprotein
cholesterol compared to males without OSA (35). In a
study by Spiegel et al. (36), the variation of leptin and
ghrelin levels were correlated with increased sympathetic
nervous system activity or cardiac sympathovagal balance
due to sleep loss. In addition, the subjects with sleep
deprivation self-reported increased hunger, probably due to
increased signaling towards reward and pleasure centers of
the brain that enhance the hedonic perception of food,
which would drive motivation for food seeking and
consumption. The obvious implication of these findings is
that inadequate sleep resulting from OSA could promote
excessive eating, especially with high carbohydrate
content, and impair weight loss, but there was no
information related to diet prior to undergoing these sleep
protocols (36, 37).
Physical activity (PA) has been recognized as a key
determinant for good health. PA is defined as any training
program resulting in energy expenditure. A PA plan is
scheduled, repetitive, structured, and purposive in the sense
that it maintains or improves one or more objectives (38).
Moreover, several studies have demonstrated that low
levels of PA are associated with higher incidence of OSA,
obesity, and metabolic syndrome (39, 40). It is possible that
patients with OSA are unable to do physical exercises due
to excessive daytime sleepiness and fatigue (39). The
exercises have multiple effects on OSA, such as improving
the severity of OSA, decreasing the severity of central
sleep apnea in patients with chronic heart failure and
reducing the occurrence of cardiovascular diseases,
impaired glucose tolerance, and fatigue (41). The AASM
recommends training programs as a treatment option for
patients with OSA, given that regular PA reduces the
prevalence of OSA (42, 43).
A meta-analysis by Iftikar et al. showed that exercise
training has a signiﬁcant effect on AHI that seems to be
independent of the BMI changes. The exercises improve
upper airway dilator functions during sleep and another one
refers to the possibilities of including PA in the daily
routine that seems a reorganization of parapharyngeal fat
distribution and diminishes the arousals. Moreover, the
improvement in sleep efﬁciency with exercise is similar to
what is typically achieved with CPAP. Likewise, the
Therapeutic alternatives with CPAP in obstructive sleep apnea
effects on daytime sleepiness (as measured by the Epworth
Sleepiness Scale) with exercise training is similar to those
seen with CPAP (44).
Oral appliances (OA) are the second most-used therapy
in treating snoring and mild to moderate OSA as a primary
therapy or as an alternative in patients who do not tolerate
CPAP devices. It involves the application of dental splints
in order to maintain the mandible in an advanced position
and/or the tongue in a protruded position, in order to
prevent upper airway obstruction during sleep. Imaging
studies show that the lateral dimension of the
velopharyngeal region is increased due to mandibular
advancement resulting in an enlarged upper airway space.
The lateral tissue movement via connections between the
lateral walls and the ramus of the mandible leads to the
lateral expansion of the airway space. Also, the mandibular
advancement determines an anterior tongue movement.
While CPAP and OA therapies are responsible for reducing
the upper airway collapse during sleep, they differ in
efﬁcacy, cost and side effects. The type of OA device is
very important in order to quantify the amount of
mandibular advancement responsible for the decrease of
AHI (45). The role of adjustable OA devices is to obtain
the optimum symptom relief and achieve a signiﬁcant
reduction in the AHI for subjects with a baseline AHI >10
events/hour of sleep (46, 47).
Generally, the treatment effect is determined by the
level of advancement, but clinicians must take into
consideration the potential side effects. One study by Kato
et al. compared 3 levels of advancement (2, 4, and 6 mm),
concluding that improvement in overnight oximetry (25%,
48% and 65% of patients showing improvement in
desaturation) and in the upper airway closing pressures
varies with the degree of advancement (48). In mild to
moderate OSA patients, there is no significant difference
between the levels of advancement (50% or 75%) in
reducing AHI or the proportion of patients successfully
treated (49). However, in patients with severe OSA,
maximizing the level of advancement by 75% compared to
the 50% maximum advancement is important in order to
achieve a successful treatment (50).
OA therapy has often been indicated in mild cases of
OSA, and the severity of OSA decreases even more with
OA in patients with higher baseline AHI, but there is a
smaller probability of achieving an AHI < 5 events/hour of
sleep. Despite the inferiority of efﬁcacy when compared
with CPAP, OA is preferable in patients who do not
tolerate CPAP, being very useful in such cases. Lorenzi-
Filho demonstrated that when compared to CPAP, OA has
the same effectiveness on symptomatology such as
excessive daytime sleepiness, quality of life, and the
improvement of cardiovascular biomarkers such as
endothelial function, blood pressure, and microvascular
reactivity (51). In obese patients, while the BMI increases,
OA is not so efficient. OA should be considered a
potentially complementary therapy in addition to CPAP in
order to improve treatment outcomes. Almeida et al.
demonstrated that patients who were compliant with CPAP
(>4 hours/night) showed improvements in
symptomatology (especially excessive daytime
sleepiness), even in the nights they were not wearing it by
using OA. Patients using OA have an option for a day off
CPAP, resulting in less pressure on the teeth by wearing
OA. Combination therapies are preferred in order to
improve adherence, with a decrease of a speciﬁc treatment
side effect or burden. In conclusion, the oral appliance is
used specifically to decrease snoring in mild, moderate, or
severe OSA, preferably intermittently or with CPAP as it
is a simple and cost-effective therapy (52).
Upper Airway Stimulation
Unilateral and phasic upper airway stimulation (UAS)
stimulates the hypoglossal nerve, resulting in the
augmentation of the neural drive, through a device that acts
via a cuff electrode connected to an implanted impulse
generator that incorporates an effort sensor placed between
the intercostal muscles. Only one device is currently
approved by the Food and Drug Administration (FDA) in
the USA. In this way, the tongue protrudes through a
stimulation sequence that can be programmed. The UAS
can be turned on by the patient with a programmer and it is
used only during the sleep period and can be activated via
a patient programmer. By combining the forward
movement of the tongue with the mechanical coupling of
the soft palate, clinicians can obtain an enlargement of the
retro lingual and retro palatal airways (53). The
Stimulation Therapy for Apnea Reduction (STAR)
improved the oxygen desaturation index by 70% (25.4 to
7.4 events/h), reduced AHI by 68% (29 to 9 events/h), and
also had a beneficial effect on decreasing the arousal index.
This device can also be used as an additional tool in
subjects with moderate to severe OSA because it improves
the excessive daytime sleepiness as quantified by the
Epworth Sleepiness Scale (ESS) and increases the quality
of life as measured by the Functional Outcomes of Sleep
Questionnaire (FOSQ). Before proceeding to UAS, OA
should be the first recommended procedure. These
procedures will improve the hypoglossal nerve mapping
and how clinicians might quantify the impact of UAS in
anatomy. Studies have shown that UAS is not an option for
Corina Eugenia Budin et al.
morbidly obese patients, but more sophisticated analyses
(imaging and/or polysomnography) need to be done.
Examining the role of complementary treatments in
incomplete responders with targeted surgery, OA, weight
loss, or medications needs to be explored (54).
Considering the role of the dilator muscles of the upper
airway in OSA, several studies have investigated the
effects of oropharyngeal exercises on OSA severity.
Oropharyngeal exercises (Oropharyngeal myotherapy -
OMT) are a treatment modality used for patients with
orofacial myofunctional disorders, with benefits on the
orofacial structures and on the cervical muscles. OMT
implies exercises and other strategies capable of increasing
sensitivity, proprioception, mobility, coordination, and
strength of orofacial structures. At the same time, OMT
favors a good performance of respiration, mastication,
deglutition, and speech. Guimarães et al. demonstrated
that oropharyngeal exercises target soft palate elevation
and that they recruit several upper airway muscles, such as
the tensor and the levator veli palatini, as well as the muscle
fibers of the palatopharyngeal and palatoglossal muscle,
tongue repositioning, and training of the mandibular
elevation in order to avoid mouth opening during the night
(55). One of the goals of training was to increase the tone
of the elongated soft palate and uvula, as it is well-known
that elongation of this structure is associated with higher
rates of obstructive apnea, AHI, and respiratory
disturbance index (56). The study included 31 patients with
moderate OSA and divided them into two groups: the first
group received placebo, and the other group received OMT
targeting the lateral pharyngeal wall, the tongue, and the
soft palate (55). After three months of exercise training,
AHI was reduced by 39% and the lowest oxygen saturation
during sleep was elevated. Another recent review
demonstrated a 50% reduction of AHI in patients with
OMT (57). Also, in cases of a mean baseline ESS score
greater than 10, patients showed a significant improvement
after OMT, with a mean reduction of six points (58). More
recently, Ieto et al. have shown that after 3 months of
oropharyngeal exercises, subjects showed a 36% reduction
in snoring frequency and a 59% reduction in the overnight
power of snoring (59). In addition, another study showed
that oropharyngeal exercises cause various effects in the
treatment of mild to moderate obstructive sleep apneal
syndrome, such as: the significant reduction of the patients’
neck circumference, the improvement of symptoms like
daytime sleepiness and snoring intensity, the significant
improvement in sleep indices minimum oxygen saturation,
SaO2 < 90 %, sleep efficiency, arousal index, and total
sleep time N3 stage of sleep. Although it is not clear how
OMT can influence the collapsibility of the upper airway
during sleep, it has been speculated that OMT can
influence the remodeling of the upper airway. The
oropharyngeal exercises are a complex and integrated
approach, which is why clinicians cannot quantify the
improvement of each exercise. In addition, the exercises
must be performed with a specific frequency (two or three
times a day) and this may limit the clinical applicability.
Therefore, how well patients adhere to oropharyngeal
exercises in ‘real-world’ clinical practice is still unknown
Over the past years, due to the increasing prevalence of
OSA, new therapies beyond CPAP have been developed
and are now currently available. The first treatment option
in selected cases with mild OSA is OA, but new evidence
also suggests that OA may be effective in selected
moderate to severe OSA cases.
Even though the role of OA is similar to that of CPAP
in clinical practice, clinicians may not achieve the abolition
of all obstructive events during sleep by means of OA.
There is currently an alternative therapy to CPAP or OA
for subjects with mild to moderate OSA, consisting in the
use of upper airway stimulation devices. The principle of
oropharyngeal exercises is repetitive muscle training, with
specific gains in the endurance of muscles, tonicity, and
coordination that may improve the condition of muscle
fatigue in subjects with OSA and act on the equilibrium of
contraction between the different muscles that involve the
velopharyngeal, oropharyngeal, and hypo pharyngeal
In addition, they can decrease the volume of specific
structures and fat in the pharyngeal-dilating muscles, thus
also reducing the potential upper airway collapse in apneic
subjects. However, these hypotheses have not yet been
verified. Because the benefit of all these techniques is
heterogeneous, the major challenge is to associate specific
OSA therapies with maximum efficacy and optimal patient
Conflict of interest disclosure
There are no known conflicts of interest in the
publication of this article. The manuscript was read and
approved by all authors.
Therapeutic alternatives with CPAP in obstructive sleep apnea
Compliance with ethical standards
Any aspect of the work covered in this manuscript has
been conducted with the ethical approval of all relevant
bodies and that such approvals are acknowledged within
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