Comparison of the effects of continuous positive airway pressure and mandibular advancement devices on sleepiness in patients with obstructive sleep apnoea: a network meta-analysis.
BACKGROUND
Excessive daytime sleepiness is the most important symptom of obstructive sleep apnoea and can affect work productivity, quality of life, and the risk of road traffic accidents. We aimed to quantify the effects of the two main treatments for obstructive sleep apnoea (continuous positive airway pressure and mandibular advancement devices) on daytime sleepiness and to establish predictors of response to continuous positive airway pressure.


METHODS
We searched MEDLINE and the Cochrane Library from inception to May 31, 2015, to identify randomised controlled trials comparing the effects of continuous positive airway pressure, mandibular advancement devices or an inactive control (eg, placebo or no treatment) on the Epworth Sleepiness Scale (ESS, range 0-24 points) in patients with obstructive sleep apnoea. We did a network meta-analysis using multivariate random-effects meta-regression to assess the effect of each treatment on ESS. We used meta-regression to assess the association of the reported effects of continuous positive airway pressure versus inactive controls with the characteristics of trials and their risk of bias.


RESULTS
We included 67 studies comprising 6873 patients in the meta-analysis. Compared with an inactive control, continuous positive airway pressure was associated with a reduction in ESS score of 2·5 points (95% CI 2·0-2·9) and mandibular advancement devices of 1·7 points (1·1-2·3). We estimated that, on average, continuous positive airway pressure reduced the ESS score by a further 0·8 points compared with mandibular advancement devices (95% CI 0·1-1·4; p=0·015). However, there was a possibility of publication bias in favour of continuous positive airway pressure that might have resulted in this difference. We noted no evidence that studies reporting higher continuous positive airway pressure adherence also reported larger treatment effects (p=0·70).


CONCLUSIONS
Continuous positive airway pressure and mandibular advancement devices are effective treatments for reducing daytime sleepiness in patients with obstructive sleep apnoea. Continuous positive airway pressure seemed to be a more effective treatment than mandibular advancement devices, and had an increasingly larger effect in more severe or sleepier obstructive sleep apnoea patients when compared with inactive controls. However, mandibular advancement devices are an effective alternative treatment should continuous positive airway pressure not be tolerated.


BACKGROUND
Swiss National Science Foundation and the University of Zurich Clinical Research Priority Program Sleep and Health.
Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland.
Daniel J
DJ
Bratton
Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland.
Thomas
T
Gaisl
Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland.
Christian
C
Schlatzer
Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland; Zurich Centre for Integrative Human Physiology, University of Zurich, Zurich, Switzerland; Centre for Interdisciplinary Sleep Research, University of Zurich, Zurich, Switzerland. Electronic address: malcolm.kohler@usz.ch.
Malcolm
M
Kohler
D000328:Adult; D045422:Continuous Positive Airway Pressure / Q000295:instrumentation*; D006970:Disorders of Excessive Somnolence / Q000209:etiology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D019186:Mandibular Advancement / Q000295:instrumentation*; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D020181:Sleep Apnea, Obstructive / Q000150:complications / Q000628:therapy*; D016896:Treatment Outcome