Comparative efficacy of non-pharmacological interventions for adults with sleep apnea: A systematic review and network meta-analysis

Spyridon N Papageorgiou; Ioannis Konstantinidis; Alexandra K Papadopoulou; Fani Apostolidou-Kiouti; Ioannis Avgerinos; Athanasia Pataka; Theodore Eliades; Apostolos Tsapas; Anna-Bettina Haidich

doi:10.1016/j.sleep.2025.02.008

Comparative efficacy of non-pharmacological interventions for adults with sleep apnea: A systematic review and network meta-analysis

Sleep Med. 2025 Apr:128:130-138. doi: 10.1016/j.sleep.2025.02.008. Epub 2025 Feb 4.

Authors

Spyridon N Papageorgiou¹, Ioannis Konstantinidis², Alexandra K Papadopoulou³, Fani Apostolidou-Kiouti⁴, Ioannis Avgerinos⁵, Athanasia Pataka⁶, Theodore Eliades⁷, Apostolos Tsapas⁸, Anna-Bettina Haidich⁴

Affiliations

¹ Clinic of Orthodontics and Pediatric Dentistry, Center for Dental Medicine, University of Zurich, Zurich, Switzerland. Electronic address: snpapage@gmail.com.
² Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Pittsburgh School of Medicine, and Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.
³ Division of Orthodontics, University Clinics of Dental Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland; Discipline of Orthodontics, School of Dentistry, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
⁴ Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece.
⁵ Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece.
⁶ Respiratory Failure Unit, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
⁷ Clinic of Orthodontics and Pediatric Dentistry, Center for Dental Medicine, University of Zurich, Zurich, Switzerland.
⁸ Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece; Harris Manchester College, University of Oxford, Oxford, UK.

PMID: 39933212
DOI: 10.1016/j.sleep.2025.02.008

Abstract

Background: Sleep apnea is associated with cardiovascular risk, work productivity, occupational/traffic accidents, and quality-of-life (QoL); however uncertainty exists regarding optimal treatment. We performed a systematic review on the efficacy of non-pharmacological interventions for adults with sleep apnea.

Method: We searched MEDLINE, Scopus, Virtual-Health-Library and Web-of-Science through June 2023 for parallel/cross-over randomized trials on adults with sleep apnea (apnea-hypopnea-index>5 events/hour). Study selection, data extraction and risk-of-bias assessment were performed in duplicate, followed by frequentist network meta-analyses.

Results: Ultimately, 197 unique trials were included (15,931 patients; mean age 51.4 years; 78.9 % male) assessing 25 treatments. Positive Airway Pressure (PAP) (alone or combined with health behaviour modification) consistently improved more apnea-hypopnea-index or daytime sleepiness and physical/mental QoL in obstructive sleep apnea (OSA) patients compared to all other interventions but was not always well-tolerated. Mandibular advancement devices (MAD) yielded the greatest improvement in depression, while also improving objective/subjective apnea-outcomes, and physical/mental QoL-albeit less than PAP and less for moderate/severe cases. Acupuncture, health behaviour modifications, surgical maxillomandibular advancement, minor oral surgery, oropharyngeal training, oxygen supplementation, or electrical neurostimulation might improve apnea-related outcomes, but weak evidence exists. Finally, electrical neurostimulation performed best for central sleep apnea and PAP performed best for positional OSA. Confidence in the network meta-analysis estimates was low due to non-adherence issues that was rarely directly assessed in included trials with objective measures.

Conclusion: PAP (alone or with co-interventions) performed best for the treatment of adult OSA patients regardless of disease severity. For patients not tolerating PAP, MADs might be a good alternative, but confer smaller improvements overall. However, adherence issues and the heterogenous response increase the complexity of OSA treatment.

Keywords: Apnea; Meta-analysis; Randomized controlled trial; Sleep apnea syndrome; Systematic review.

Publication types

Systematic Review
Network Meta-Analysis

MeSH terms

Adult
Continuous Positive Airway Pressure / methods
Humans
Mandibular Advancement
Quality of Life
Sleep Apnea Syndromes* / therapy
Sleep Apnea, Obstructive* / therapy
Treatment Outcome