ERS/ESRS guideline: CPAP strongly recommended for sleepy patients, a shared decision for others

Design

Clinical practice guideline (GRADE, systematic review, Evidence-to-Decision)

Population

Adults with obstructive sleep apnoea

Primary outcome

Patient-centred and prognostic outcomes of CPAP vs no or sham treatment

Effect

Strong recommendation with daytime sleepiness; conditional for BP and other groups

The European Respiratory Society and European Sleep Research Society published a joint clinical practice guideline on CPAP for adult obstructive sleep apnoea on 11 October. A multidisciplinary panel including patient representatives commissioned a systematic review, graded evidence with GRADE, and voted on recommendations.

The headline is a strong recommendation for CPAP in patients with excessive daytime sleepiness. More broadly, the panel conditionally suggests CPAP for its effects on sleepiness, other patient-reported outcomes and blood pressure, with specific conditional recommendations in moderate-to-severe disease, older adults, and people with hypertension, including resistant hypertension. For patients without sleepiness (allowing for other symptoms), for reducing recurrence of atrial fibrillation, and for improving glycaemic control, the panel suggests either CPAP or no treatment — meaning the evidence does not support routine prescription for those goals alone.

This matters because CPAP is often prescribed on the apnoea–hypopnoea index alone, or promised to improve diabetes or prevent AF recurrence. The guideline ties the decision to symptoms and patient goals. In India, where CPAP is usually paid for out of pocket, matching the device to patients most likely to benefit is especially relevant.

• Offer CPAP to every patient with obstructive sleep apnoea and excessive daytime sleepiness.
• In patients with resistant hypertension and sleep apnoea, consider CPAP as part of blood pressure management.
• In patients without sleepiness, base the CPAP decision on other symptoms and patient preference, not the AHI alone.
• Do not prescribe CPAP solely to lower HbA1c or prevent AF recurrence; the guideline does not support it for those goals alone.
• Review adherence early; benefit depends on nightly use.

Why it matters

It moves CPAP decisions away from the apnoea index alone and towards symptoms and patient-centred goals.

Don't overread it

A conditional 'CPAP or no treatment' suggestion is not advice against CPAP; it means the choice depends on the patient.

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