Should we treat with CPAP severe non-sleepy OSA individuals without underlying cardiovascular disease?

The majority of the current international obstructive sleep apnea (OSA) guidelines base the recommendation to treat OSA with continuous positive airway pressure (CPAP) on the presence of symptoms (principally, albeit not exclusively on daytime hypersomnolence). In non-sleepy patients, even with severe OSA, controversies remain, as clear evidence supporting CPAP treatment of this subgroup of OSA patients is lacking. However, given the non-negligible proportion of non-sleepy OSA patients, clinicians often face a serious dilemma since CPAP treatment in these patients may prove to be not cost-effective. Here, we propose a simple 3-steps-based algorithm that attempts to better phenotype non-sleepy OSA patients prior to reaching a CPAP treatment decision while also considering a series of clinically relevant elements in the process that may improve with CPAP therapy. Such algorithm focuses on the presence of several OSA symptoms that are susceptible to benefit from treatment and also relies on OSA phenotypes that need to be considered in an effort to achieve optimal cardiovascular prevention. Here, we attempt to establish a framework for clinicians who are evaluating severe non-sleepy OSA patients in their practices. However, the algorithm proposal needs to be extensively validated before being systematically implemented in clinical settings.