Verifying the Relative Efficacy between Continuous Positive Airway Pressure Therapy and Its Alternatives for Obstructive Sleep Apnea: A Network Meta-analysis

Abstract

Obstructive sleep apnea (OSA) is a common breathing disorder, and continuous positive airway pressure (CPAP) therapy together with its alternatives has been developed to treat this disease. This network meta-analysis (NMA) was aimed to compare the efficacy of treatments for OSA. Cochrane Library, MEDLINE, and Embase were searched for eligible studies. A conventional and NMA was carried out to compare all therapies. Sleeping characteristics, including Apnea-Hypopnea Index (AHI), Epworth Sleepiness Scale (ESS), arterial oxygen saturation, and arousal index (AI), and changes of blood pressure were selected as outcomes. A total of 84 studies were finally included after rigorous screenings. For the primary outcomes of AHI and ESS, the value of auto-adjusting positive airway pressure (APAP), CPAP, and oral appliance (OA) all showed statistically reduction compared with inactive control (IC). Similar observation was obtained in AI, with treatments of the three active interventions. A lower effect of IC in SaO₂ was exhibited when compared with APAP, CPAP, and OA. Similar statistically significant results were presented in 24 h systolic blood pressure and 24 h DBP when comparing with CPAP. Our NMA identified CPAP as the most efficacious treatment for OSA patients after the evaluation of sleeping characteristics and blood pressures. In addition, more clinical trials are needed for further investigation due to the existence of inconsistency observed in this study.

Keywords: Apnea–Hypopnea Index; Epworth Sleepiness Scale; blood pressures; network meta-analysis; obstructive sleep apnea.

Figure 1

Flowchart (A) and network plot (B). The network plot show direct comparison of different treatments, with node size corresponding to the sample size. The number of included studies for specific direct comparison decides the thickness of solid lines. Abbreviations: CPAP, continuous positive airway pressure; APAP, auto-adjusting positive airway pressure; IC, inactive control; OA, oral appliance.

Figure 2

Forest plots regarding Apnea–Hypopnea Index, Epworth Sleepiness Scale, arousal index, and SaO₂. Mean difference (MD) with 95% credible interval (CrIs) indicate the relative efficacy. Abbreviations: CPAP, continuous positive airway pressure; APAP, auto-adjusting positive airway pressure; IC, inactive control; OA, oral appliance.

Figure 3

Forest plots regarding 24 h systolic blood pressure (SBP), 24 h diastolic blood pressure, daytime SBP, daytime SBP, nighttime SBP, and nighttime SBP. Mean difference (MD) with 95% credible interval (CrIs) indicate the relative efficacy. Abbreviations: CPAP, continuous positive airway pressure; APAP, auto-adjusting positive airway pressure; IC, inactive control; OA, oral appliance.

Figure 4

Stacked bar charts showing the rankings of four therapies for Apnea–Hypopnea Index, Epworth Sleepiness Scale, arousal index, and SaO₂ at Nadir. The percentage number included in each pair of brackets indicates the cumulative ranking probability of the corresponding therapy. Abbreviations: CPAP, continuous positive airway pressure; APAP, auto-adjusting positive airway pressure; IC, inactive control; OA, oral appliance.

Figure 5

Stacked bar charts showing the rankings of four therapies for 24 h systolic blood pressure (SBP), 24 h diastolic blood pressure, daytime SBP, daytime SBP, nighttime SBP, and nighttime SBP. The percentage number included in each pair of brackets indicates the cumulative ranking probability of the corresponding therapy. Abbreviations: CPAP, continuous positive airway pressure; APAP, auto-adjusting positive airway pressure; IC, inactive control; OA, oral appliance.