When CPAP Fails: Expert Discussion on How to Counsel Patients With OSA

Primary care physicians should discuss alternative treatment options with patients with obstructive sleep apnea (OSA) who are struggling with positive airway pressure (PAP) adherence, according to Sairam Parthasarathy, MD, professor of medicine at the University of Arizona.

In this interview from SLEEP 2026, Parthasarathy said PAP therapy remains an important treatment option for OSA, but adherence challenges should prompt clinicians to broaden the conversation rather than allow patients to remain untreated. For patients who cannot tolerate PAP or are not using it consistently, he said primary care physicians do not necessarily need to determine eligibility for every alternative therapy, but they should know enough to introduce available options and refer appropriately.

Those options may include oral appliance therapy, hypoglossal nerve stimulation (HNS), and, for selected patients with obesity-related OSA, weight-loss therapies that may improve apnea severity. Parthasarathy emphasized that treatment selection should be individualized and based on a shared decision-making process that accounts for the patient’s clinical profile, comorbidities, lifestyle, preferences, and affordability.

The discussion comes amid growing attention to the cardiovascular consequences of untreated OSA. In the same interview, Parthasarathy noted that untreated disease is associated with increased risk for major cardiovascular events and said clinicians should be more proactive in detecting sleep apnea and counseling patients about treatment. He encouraged primary care physicians to become more comfortable with the basics of OSA severity, treatment options, and next steps when patients do not succeed with PAP.

For clinicians in primary care, the key takeaway is practical: PAP intolerance should not be the endpoint of OSA management. Instead, it should trigger a broader discussion about alternative therapies, referral pathways, and the importance of treating OSA to improve symptoms, quality of life, and potentially long-term cardiovascular risk.

Dr Parthasarathy has no relevant disclosures.