Advanced Telemedicine for Obstructive Sleep Apnea: Expert Commentary

Telemedicine is reshaping the delivery of care for obstructive sleep apnoea, accelerated by the pandemic and growing pressures on sleep medicine services. In this expert commentary, Professor Johan Verbraecken, the first author of a recent European Respiratory Society consensus statement, outlines the evidence, debates and future priorities for integrating telemedicine into the diagnosis, treatment and long-term management of this common sleep disorder. Care for patients with obstructive sleep apnoea (OSA) is highly specialised, requiring close monitoring of adherence to treatment, as affected individuals are often older and frequently present with multiple comorbidities. The high prevalence of OSA also places considerable strain on healthcare services, leading to long waiting times – a challenge that telemedicine has the potential to alleviate. Nevertheless, before the Covid-19 pandemic, telemedicine was not routinely integrated into the services of many national health systems. The pandemic has since accelerated a paradigm shift in sleep medicine, with lasting changes anticipated not only in the management of OSA but also across the broader spectrum of sleep disorders and other medical conditions. Rationale for telemedicine consensus in OSA In response to this, a multidisciplinary European Respiratory Society (ERS) task force convened to evaluate the scientific evidence for telemedicine interventions in daily practice, summarise the current state of the art, and possibly examine models of e-Health to be applied for the entire management of OSA. After an initial discussion of recent developments in the field, the panel decided to focus on four content areas, representing approaches to telemedicine that were discussed intensively in the scientific community at the time, but which had significant knowledge gaps due to insufficient evidence or mixed results. The areas of focus were diagnosis and titration, treatment adherence, paediatric applications, and technology and e-Health. Findings in each content area were discussed in smaller working groups, which then drafted the final statements. The panels met in person at different times during the ERS annual Congress and also engaged in intensive email exchanges to reach consensus, which was then published as the ERS statement on advanced telemedicine for OSA (e-Sleep). Technology in OSA taking centre stage The area that sparked the most debate during the ERS consensus statement discussions was technology as this is advancing so quickly that many of the reviewed studies are now obsolete. Home-based diagnostic procedures and telemonitoring of continuous positive airway pressure (CPAP) treatment are currently standard practice. The panel concentrated on evidence from a scientific perspective, considering the various stages of the diagnostic and treatment process for OSA where telemedicine could also be applied. Potential telemedicine management models were also considered, as the best and most sustainable approach may differ across countries due to their reimbursement policies. In this context, multimodal telemedicine emerged as a promising strategy for the future. Key telemedicine practice statements The ERS task force did not make specific recommendations but rather provided an evidence-based overview of current OSA knowledge and daily practice in a series of statements. The task force also clarified limitations that require further attention and research to allow for the development of future recommendations. These consensus statements can be summarised as follows: Use of telemedicine for diagnosing OSA in adults is technically feasible, including teleconsultation to discuss home-based sleep study results, which can reduce costs and improve patient satisfaction. Unsupervised auto-CPAP home titration, followed by pressure and treatment adjustments via telemedicine, achieves CPAP pressure settings and adherence similar to those achieved with in-person titration over one to 12 months. Telemonitoring of CPAP treatment is possible with current technology and mostly shows non-inferiority compared with standard care. Still, ceiling effects on adherence are evident when standard care is already of high quality, and the cost-effectiveness of health services remains unclear. Big data studies also allow detailed exploration of issues associated with PAP treatment for which data are scarce, such as the effects of mask resupply, trajectories of CPAP use, and CPAP mode changes on adherence to treatment. Telemedicine visits for children are achievable, but their broader use in paediatrics lags behind that in adults. Monitoring CPAP devices via telemedicine in children with OSA is also feasible, and adherence appears to improve with a patient engagement programme. Multimodal telemedicine, which combines telemonitoring from CPAP, motivational messages, lifestyle counselling and physiological measurements – including blood pressure, nocturnal pulse oximetry and physical exercise – has the potential to offer an integrated approach. Finally, the benefits of telemedicine need to be balanced with the resources required for effective delivery. The widespread use of consumer electronics, such as wearables and smartphones, offers new possibilities for e-Health practices and telemedicine services, though the precision of current consumer devices remains uncertain. Telemedicine priorities and care models After considering the evidence set out in the ERS consensus statement, in my opinion, the most promising approach to telemedicine for OSA is CPAP tele-titration. This is due to the fact that it globally leads to cost reductions from reduced hospital stays, lower travel costs and increased productivity. Despite high expectations from patients, providers and healthcare policymakers, there are limited data on the effectiveness of tele-diagnosis and tele-titration in complex or specialised populations, such as chronic heart failure, renal failure, stroke or atrial fibrillation. While evidence supports tele-interventions for uncomplicated OSA, it does not for complicated cases. Therefore, stratifying patients to determine suitability for telemedicine is essential. As the characteristics of the populations studied remain very general, evidence is lacking regarding the impact of gender, age, OSA phenotypes on symptoms or disease severity. The impact of educational and socioeconomic status, and lack of exposure to new technologies and apps, has also not been well addressed. Nevertheless, good patient satisfaction has been reported among patients with limited technological expertise. Individual and economic factors must therefore be considered when choosing between remote, hybrid or in-person care models. These include travel distance, waiting times for sleep clinics and laboratories (and thus access to care), the need for physical examination, and patients’ ability and confidence in using technology. Additional considerations include the time and financial costs of travel or missed work, children’s stress levels, patient and parental preferences, the availability of the technological infrastructure required for telemedicine, and reimbursement policies, which, as previously mentioned, vary from country to country, but also between patient groups. Given that telemedicine is defined as the remote delivery of care using technology, it makes sense to prioritise people living in remote rural areas, which vary widely across regions. Patients with poor CPAP compliance and those prone to significant treatment side effects could also be followed more closely. So, this is not necessarily limited to rural areas. Aligning telemedicine disciplines and governance As highlighted in the ERS consensus statement, significant hurdles to the safe implementation of telemedicine include legal, technological and ethical issues surrounding data ownership and curation; the use of different CPAP brands; the lack of standardisation of parameters across providers, which prevents interoperability for healthcare professionals and complicates data management within existing electronic patient files; and the implications for financial resources, including reimbursement. From a data safety and healthcare regulation perspective, there is ongoing debate about which data should be classified as general wellness and lifestyle data and which as healthcare data for medical diagnostic purposes. Many regulatory aspects of this kind of application are also open to debate. Last but not least, easy connectivity to external caregivers and adequate training for physicians and nurses are crucial. Therefore, alignment between healthcare authorities, technology providers and medical centres is mandatory to overcome these barriers. Closing the evidence gaps The main question that should be prioritised for future research is the cost-effectiveness of telemedicine in daily practice from the perspectives of healthcare providers, patients and health authorities. This leads to the broader issue of the target population: whether the entire CPAP-treated population should be included or only particular phenotypes that are best served by different aspects of telemedicine. The success of telemedicine might depend on identifying which groups respond most effectively to telemedicine strategies, taking into account factors such as age, education, socioeconomic background, geographic location, race, phenotype, cluster and comorbidities. Targeted considerations may be required for specific groups, including focusing interventions on patients with identified issues and ensuring that limited clinical hours are dedicated primarily to CPAP patients who truly need extra support. Closely linked to this, it could also be questioned whether an integrated multimodal approach that optimises CPAP adherence in relation to OSA comorbidity outcomes is cost-effective. Conclusion As the ERS consensus statement shows, telemedicine offers clear opportunities to improve access, efficiency, and continuity of care for patients with OSA, particularly amid growing service pressures and workforce constraints. However, its successful integration into routine practice requires careful patient stratification, robust evidence on cost-effectiveness, and close alignment between clinical needs, technology and health system governance. As digital tools continue to evolve, a targeted, multimodal and patient-centred approach, supported by further high-quality research, will be essential. This will ensure that telemedicine enhances, rather than compromises, the quality and equity of OSA care. Author