Continuous positive airway pressure (CPAP) therapy has long been the standard treatment for obstructive sleep apnea (OSA), but new findings suggest some patients may achieve lasting benefits with a simpler approach. A Spanish trial found that positional therapy was effective and well tolerated in selected patients with positional OSA, with improvements persisting after the treatment ended.

OSA is among the most common chronic conditions managed in pulmonology clinics and accounts for approximately half of the cases seen in sleep units, according to the Spanish Society of Pulmonology and Thoracic Surgery. Characterized by repeated upper airway obstruction during sleep, the condition is associated with oxygen desaturation, sleep fragmentation, and significant long-term health consequences, making effective and acceptable treatment a clinical priority.

CPAP remains the standard first-line treatment. However, findings from the PAVLOV trial, a multicenter study conducted at 12 Spanish hospitals, suggest that positional therapy may be an effective alternative for selected patients with positional OSA.

The study evaluated a positional device designed for patients with positional OSA, a common subtype in which airway collapse occurs predominantly when individuals sleep in the supine position. The device monitors the body position and emits a gentle vibration when patients roll onto their backs, encouraging them to return to a lateral sleeping position without fully waking.

Speaking with Univadis Spain, part of the Medscape Professional Network, the first author of the study, Irene Cano-Pumarega, MD, PhD, pneumologist and head of the sleep unit at Ramón y Cajal Hospital in Madrid, Spain, said, “The primary objective was to conduct a cost-effectiveness analysis of positional therapy as an alternative to CPAP. Because CPAP is currently the only sleep apnea treatment reimbursed by Spain’s healthcare system, we wanted to determine whether positional therapy could also be incorporated into routine care.”

According to Cano, the study’s second objective was to assess whether after completing treatment and discontinuing the positional device, patients learned to avoid sleeping on their backs and, as a result, maintained improvements in their sleep apnea.

Effective Option

The findings, which received the award for the best scientific paper at the most recent meeting of the Spanish Sleep Society, suggest that positional therapy could serve as a first-line treatment for a substantial proportion of patients with positional OSA.

“The results show that it is an effective treatment that is much better tolerated than CPAP,” Cano said. “They also suggest that patients who respond to positional therapy continue to do well after the device is withdrawn.”

The trial enrolled 184 patients with positional OSA. The participants were randomly assigned to receive either CPAP or positional therapy, with 92 patients in each group.

“Before enrollment, all participants underwent sleep studies to confirm positional OSA. The study included patients with mild, moderate, or severe disease. Positional OSA is very common and occurs in approximately 56%-75% of patients with sleep apnea,” Cano said.

Comparable Outcomes

After 6 months of treatment, participants underwent repeat sleep studies to assess treatment effectiveness.

Researchers found favorable responses in both groups. Overall, 64% of the patients receiving CPAP and 52% of those using the positional device met the study’s definition of treatment response.

Researchers defined a responder as a patient with a residual Apnea-Hypopnea Index of fewer than 15 events per hour at the end of the study and at least a 50% reduction from baseline.

The study also highlighted differences in treatment tolerability.

“During the 6-month treatment period, 26 patients discontinued CPAP because of intolerance. In contrast, patients using the positional device gradually adapted to sleeping on their sides and avoided returning to the supine position,” said Cano.

According to Cano, the benefit persisted after the treatment ended.

“One year after discontinuing the device, 72% of patients remain responders, which is a very high percentage,” she said.

Clinical Integration

Cano believes that the findings support the broader use of positional therapy within Spain’s healthcare system.

“In Spain, CPAP is covered by the public healthcare system, whereas positional devices are not and typically cost between €650 and €700,” she said.

She emphasized that positional therapy would be the most appropriate treatment for patients with positional OSA who do not experience excessive daytime sleepiness.

Researchers are also conducting additional analyses to identify clinical, anthropometric, and sleep-related characteristics that predict which patients are most likely to respond to positional therapy and maintain long-term benefits.

“We have analyzed the initial results and are now carrying out a more detailed statistical analysis of the full dataset,” Cano concluded.

Cano reported that Philips supplied the positional devices used in the study. 

This story was translated from Univadis Spain, part of the Medscape Professional Network.