Obstructive Sleep Apnea — SCE Respiratory MCQ

Correct answer: B — Oral appliance therapy may be offered

The correct answer is B, oral appliance therapy may be offered. NICE NG202 on obstructive sleep apnoea/hypopnoea syndrome (OSAHS) recommends a customised or semi-customised mandibular advancement splint (MAS) as an alternative to CPAP for people with mild, moderate or severe OSAHS who cannot tolerate or decline CPAP. In this patient with obesity and confirmed CPAP intolerance, an oral appliance is the appropriate next step rather than abandoning treatment, since it improves airway patency by advancing the mandible and tongue base during sleep, reducing upper airway collapse. This is a guideline-endorsed, evidence-based second-line option and should be offered with appropriate follow-up to titrate fit and confirm symptomatic and AHI/ODI improvement. Why the other options are wrong: A, Bilevel PAP is mandatory for all: Bilevel PAP is reserved for select cases such as coexisting hypoventilation or CPAP pressure intolerance, not a mandatory universal alternative, and it does not address simple CPAP intolerance in isolation. C, Tracheostomy should be first line: Tracheostomy is an invasive last resort reserved for severe, life-threatening OSA unresponsive to all other measures, never a first-line alternative when non-invasive options like MAS remain untried. D, No therapy unless severe oxygen desaturations: Untreated OSAHS carries cardiovascular, metabolic and accident risk regardless of desaturation severity, so withholding treatment is inappropriate and contrary to guidance to offer effective alternatives. E, Chronic opioids to induce sleep: Opioids depress respiratory drive and worsen upper airway collapse and central apnoeas, making them contraindicated in OSA rather than therapeutic. Key point: NICE NG202 supports mandibular advancement splints as the evidence-based alternative to CPAP across mild to severe OSAHS when CPAP is declined or not tolerated.

Reference: NICE Guideline NG202: Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s (2021, updated), section on mandibular advancement splints, https://www.nice.org.uk/guidance/ng202