Individualized treatment selection for obstructive sleep apnea: network meta-analysis focusing on position dependent patients.

INTRODUCTION

Obstructive sleep apnea (OSA) affects nearly 1 billion adults worldwide. Treatment options include positive airway pressure (PAP), oral appliance therapy, and positional therapy. Few studies have comprehensively compared these treatments using network meta-analysis. This study aimed to compare the effectiveness of different non-surgical OSA treatments across several clinically relevant outcomes.

METHODS

A systematic review and network meta-analysis were conducted following PRISMA guidelines. We searched MEDLINE, Embase, CENTRAL, Web of Science, and ClinicalTrials.gov through October 2025. Randomized controlled trials comparing PAP therapy, oral appliance therapy, positional therapy, or control in adults with OSA were included. Primary outcomes were AHI reduction and Epworth Sleepiness Scale (ESS) improvement. Secondary outcomes included oxygen saturation. Bayesian network meta-analysis was performed, with treatment rankings using surface under the cumulative ranking curve (SUCRA).

RESULTS

Eighteen trials involving 1,520 participants were included. For AHI reduction, PAP therapy was most effective (mean difference: -17.39 events/hour, 95% CI: -23.13 to -12.74), followed by oral appliance therapy (-10.76 events/hour) and positional therapy (-10.05 events/hour). PAP therapy ranked first with 100% probability, while oral appliance therapy and positional therapy showed similar effectiveness. For ESS improvement, PAP showed slight superiority. In position-dependent OSA, oral appliance therapy ranked first with 40% probability. Moderate heterogeneity was found (I² = 32–52%).

CONCLUSIONS

PAP therapy is the most effective treatment for OSA, while oral appliance and positional therapies offer viable alternatives, especially for position-dependent OSA patients. However, moderate heterogeneity (I² = 32–52%) was observed across analyses, which may affect the certainty of these conclusions. Treatment selection should consider patient-specific factors, and findings should be interpreted acknowledging this methodological limitation.