The role of nasal patency in obstructive sleep apnea: an expert consensus

Obstructive sleep apnea (OSA) is estimated to affect up to 1 billion people worldwide, although the majority of the disease remains undiagnosed and untreated. OSA has major cardiometabolic and neurocognitive sequelae, making effective treatment a public-health priority. Nasal positive airway pressure (PAP) therapy remains the most effective non-surgical therapy, and provides transformative benefits for some patients. However, tolerance and long-term adherence remain problematic for a substantial subset of patients, particularly those with nasal airway obstruction (NAO). Inadequate nasal patency increases resistance and hinders effective PAP use, prompting many patients to struggle with or abandon therapy. This challenge underscores the need to identify strategies that optimize PAP adherence through improved nasal function. A converging body of physiological evidence, large-scale observational data, and controlled clinical trials demonstrates that nasal airway obstruction, particularly at the nasal valve, can be a fundamental limitation to continuous positive airway pressure (CPAP) success. To address this challenge, a multidisciplinary expert panel of clinicians in sleep medicine, otolaryngology, and pulmonology medicine convened to review the physiologic mechanisms linking nasal resistance to upper-airway collapsibility, evaluate outcomes after restoration of nasal patency, and examine the role of minimally invasive therapies such as temperature-controlled radiofrequency (TCRF) remodeling. The group concluded that nasal obstruction management and optimization should be viewed as an integral component of OSA management, with the goal of improving CPAP adherence and patient outcomes.