A joint European Respiratory Society and European Sleep Research Society guideline, in the European Respiratory Journal, used systematic review and GRADE to assess CPAP against no or sham treatment across subgroups of adults with obstructive sleep apnoea.
The one strong recommendation is for CPAP in patients with excessive daytime sleepiness. CPAP is conditionally suggested for OSA generally, for its effects on sleepiness, other patient-reported outcomes and blood pressure, with further conditional recommendations for moderate to severe OSA, older adults, and patients with hypertension or resistant hypertension. For patients without sleepiness, those with atrial fibrillation (to reduce recurrence) and those with impaired glucose metabolism (to improve glycaemia), the panel suggests either CPAP or no treatment, taking other symptoms into account.
This moves the decision away from the apnoea–hypopnoea index alone towards symptoms and the outcome the patient cares about. It also tempers the expectation, common in cardiology and diabetes clinics, that CPAP will reduce AF recurrence or improve glucose control.
In practice: treat sleepy patients with CPAP; discuss it with others in terms of the benefit they would value; and do not prescribe CPAP solely to prevent AF recurrence or improve HbA1c.
- Offer CPAP to every adult with obstructive sleep apnoea and excessive daytime sleepiness
- Consider CPAP for patients with resistant hypertension or moderate to severe apnoea
- Discuss CPAP as optional for patients without sleepiness, guided by other symptoms
- Do not prescribe CPAP solely to reduce atrial fibrillation recurrence or lower HbA1c
- Assess sleepiness with a structured tool such as the Epworth scale before deciding
Why it matters
It reframes CPAP as a symptom treatment first, not a fix for every comorbidity.
Don't overread it
Conditional recommendations reflect uncertain evidence; they allow either choice, not a ban on CPAP.
The statistics, in plain English
A strong GRADE recommendation means the panel was confident benefits outweigh harms for almost everyone; a conditional one means most people would choose it but many would not, so the decision should be shared.
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