Clinical perspective on non-sleepy obstructive sleep apnea; to treat or not to treat?

Randomized controlled trials have not demonstrated cardiometabolic benefits of PAP therapy in non-sleepy individuals with OSA, though these studies are limited by poor PAP adherence and imprecise tools for identifying high-risk patients. As such, a pragmatic trial of PAP may be a reasonable strategy in non-sleepy people with moderate-to-severe OSA, cardiovascular comorbidities, or other OSA-related complications; provided patients are counseled about the challenges of adherence and the uncertain benefits in this population. Looking ahead, management of non-sleepy OSA will likely be guided by individualized, risk-based approaches incorporating physiological endotyping, objective biomarkers of cardiovascular risk, and patient preferences.