Sleep apnea medical therapy: Difference between revisions

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==Overview==
==Overview==
If left untreated, sleep apnea can have serious and life-threatening consequences such [[heart disease]], [[hypertension]], automobile accidents due to somnolence, and many other ailments.  Treatment often starts with [[behavioral therapy]]. Medical treatment involves the treatment of the underlying cause and somnolence. Medications, such as [[acetazolamide]] and [[oxygen]] are not routinely used for the treatment of sleep apnea. The most effective treatments help open the airway such as [[continuous positive airway pressure]] (CPAP) and oral appliances.


If left untreated, sleep apnea can have serious and life threatening consequences: [[heart disease]], [[hypertension]], automobile accidents due to excessive daytime sleepiness, and many other ailments. Treatment often starts with [[behavioral therapy]]. Many patients are told to avoid [[alcohol]], sleeping pills, and other [[sedatives]], which can relax throat muscles, contributing to the collapse of the airway at night.<ref name=SleepApneaTreatments />
==Benefits of treatment==
It is not clear that CPAP reduces [[hypertension]] and cardiovascular events; however, the lack of benefit may be partly due to [[Compliance (medicine)|noncompliance]] with therapy<ref name="pmid22618923">{{cite journal |author=Barbé F, Durán-Cantolla J, Sánchez-de-la-Torre M, ''et al.'' |title=Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial |journal=JAMA |volume=307 |issue=20 |pages=2161–8 |year=2012 |month=May |pmid=22618923 |doi=10.1001/jama.2012.4366 |url=http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2012.4366}}</ref>
 
One trial found that treatment may lower blood pressure by about 3 - 5 mm Hg.<ref>Martínez-García M, Capote F, Campos-Rodríguez F, et al. Effect of CPAP on Blood Pressure in Patients With Obstructive Sleep Apnea and Resistant Hypertension: The HIPARCO Randomized Clinical Trial. JAMA. 2013;310(22):2407-2415. {{doi|10.1001/jama.2013.281250}}.</ref><ref name="pmid23598607">{{cite journal| author=Pedrosa RP, Drager LF, de Paula LK, Amaro AC, Bortolotto LA, Lorenzi-Filho G| title=Effects of OSA Treatment on BP in Patients With Resistant Hypertension: A Randomized Trial. | journal=Chest | year= 2013 | volume= 144 | issue= 5 |pages= 1487-94 | pmid=23598607 | doi=10.1378/chest.13-0085 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23598607 }} </ref>
 
==Sleep Apnea Medical Therapy==
The treatment often starts with [[behavioral therapy]]. Many patients are told to lose weight and avoid [[alcohol]], sleeping pills, and other [[sedatives]]. These can relax throat muscles that contribute to the collapse of the airway at night.


Possibly owing to changes in pulmonary oxygen stores, sleeping on one's side (as opposed to on one's back) has been found to be helpful for central sleep apnea with [[Cheyne-Stokes respiration]].<ref name="pmidpmid16944673">{{cite journal| author=Szollosi I, Roebuck T, Thompson B, Naughton MT| title=Lateral sleeping position reduces severity of central sleep apnea / Cheyne-Stokes respiration. | journal=Sleep | year= 2006 | volume= 29 | issue= 8 | pages= 1045-51 | pmid=pmid16944673 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16944673  }} </ref>
Possibly owing to changes in pulmonary oxygen stores, sleeping on one's side (as opposed to on one's back) has been found to be helpful for central sleep apnea with [[Cheyne-Stokes respiration]].<ref name="pmidpmid16944673">{{cite journal| author=Szollosi I, Roebuck T, Thompson B, Naughton MT| title=Lateral sleeping position reduces severity of central sleep apnea / Cheyne-Stokes respiration. | journal=Sleep | year= 2006 | volume= 29 | issue= 8 | pages= 1045-51 | pmid=pmid16944673 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16944673  }} </ref>


==Medical Treatment==
===Weight loss===
Weight loss of 20 kg with a liquid very low energy diet(2.3 MJ/day) for seven weeks can reduce the AHI by 23 and lead to 20% of patients becoming disease free.<ref name="pmid19959590">{{cite journal| author=Johansson K, Neovius M, Lagerros YT, Harlid R, Rössner S, Granath F et al.| title=Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: a randomised controlled trial. | journal=BMJ | year= 2009 | volume= 339 | issue=  | pages= b4609 |pmid=19959590
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19959590 | pmc=PMC2788899| doi=10.1136/bmj.b4609 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
 
===Continuous positive airway pressure===
For moderate to severe sleep apnea, [[CPAP]] therapy is extremely effective in reducing apneas and less expensive than other treatments. It splints the patient's airway open during sleep by means of a flow of pressurized air into the throat. The patient typically wears a plastic facial mask, which is connected by a flexible tube to a small bedside CPAP machine<ref name="cpap-machines">[http://www.cpap-machine-reviews.com General Information about Sleep Apnea Machines]</ref>. The CPAP machine generates the required air pressure to keep the patient's airways open during sleep.
 
There may be low compliance because patients find it uncomfortable<ref name='Hsu2003'>{{Cite journal|author=Hsu AA, Lo C |title=Continuous positive airway pressure therapy in sleep apnoea |journal=Respirology |volume=8 |issue=4 |pages=447–54 |year=2003 |month=December |pmid=14708553 |doi=10.1046/j.1440-1843.2003.00494.x}}</ref>. One way to ensure [[CPAP]] therapy remains comfortable for patients is to ensure the CPAP face mask fits well. [[Eszopiclone]], a [[sedative]], used nightly for 14 nights may provide sustained increase in the patient's compliance<ref name="pmid19920270">{{cite journal| author=Lettieri CJ, Shah AA, Holley AB, Kelly WF, Chang AS, Roop SA et al.| title=Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial. | journal=Ann Intern Med | year= 2009 | volume= 151 | issue= 10 | pages= 696-702 | pmid=19920270 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19920270 | doi=10.1059/0003-4819-151-10-200911170-00006 }}</ref>


===Medications===
Several trials have studied [[continuous positive airway pressure]]:
*[[Acetazolamide]]<ref>{{Cite journal|author=White DP, Zwillich CW, Pickett CK, Douglas NJ, Findley LJ, Weil JV |title=Central sleep apnea: Improvement with acetazolamide therapy |journal=Archives of Internal Medicine |volume=142 |issue=10 |pages=1816–9 |year=1982 |month=October |pmid=6812522 |doi = 10.1001/archinte.142.10.1816 |url=http://archinte.ama-assn.org/cgi/content/abstract/142/10/1816}}</ref><ref name=PsychToday>{{Cite web|url=http://www.psychologytoday.com/conditions/sleep-apnea |title=Sleep Apnea |work=Diagnosis Dictionary |publisher=[[Psychology Today]]}}</ref>  
* Patients with Epworth Sleepiness Scale score >10 has a reduction in daytime symptoms.<ref name="pmid22837377">{{cite journal| author=Weaver TE, Mancini C, Maislin G, Cater J, Staley B, Landis JR et al.| title=Continuous Positive Airway Pressure Treatment of Sleepy Patients with Milder Obstructive Sleep Apnea: Results of the CPAP Apnea Trial North American Program (CATNAP) Randomized Clinical Trial. | journal=Am J Respir Crit Care Med | year= 2012 | volume= 186 | issue= 7 |pages= 677-83 | pmid=22837377 | doi=10.1164/rccm.201202-0200OC | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22837377  }} </ref>
:*Lower blood [[pH]] and encourage respiration
* Patients with Epworth Sleepiness Scale score <10 had no reduction in cardiovascular events.<ref name="pmid22618923">{{cite journal| author=Barbé F, Durán-Cantolla J, Sánchez-de-la-Torre M, Martínez-Alonso M, Carmona C, Barceló A et al.|title=Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial. | journal=JAMA | year= 2012 | volume= 307 | issue= 20| pages= 2161-8 | pmid=22618923 | doi=10.1001/jama.2012.4366 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22618923  }} </ref>
*Low doses of oxygen are also used as a treatment for hypoxia but are discouraged due to side effects.<ref name=PsychToday /><ref name="pmid11181239">{{Cite journal|author=Mayos M, Hernández Plaza L, Farré A, Mota S, Sanchis J |title=[The effect of nocturnal oxygen therapy in patients with sleep apnea syndrome and chronic airflow limitation] |language=Spanish |journal=Archivos de Bronconeumología |volume=37 |issue=2 |pages=65–8 |year=2001 |month=February |pmid=11181239 |url=http://www.elsevier.es/revistas/0300-2896/37/65}}</ref><ref name="pmid2609134">{{Cite journal|author=Breitenbücher A, Keller-Wossidlo H, Keller R |title=[Transtracheal oxygen therapy in obstructive sleep apnea syndrome] |language=German |journal=Schweizerische Medizinische Wochenschrift |volume=119 |issue=46 |pages=1638–41 |year=1989 |month=November |pmid=2609134}}</ref>
* Patients with average AHI of 10 and ESS of 10, who averaged wearing 4 hours of CPAP per night had improvement in quality of life<ref name="pmid31806413">{{cite journal| author=Wimms AJ, Kelly JL, Turnbull CD, McMillan A, Craig SE, O'Reilly JF | display-authors=etal| title=Continuous positive airway pressure versus standard care for the treatment of people with mild obstructive sleep apnoea (MERGE): a multicentre, randomised controlled trial. | journal=Lancet Respir Med | year= 2020 | volume= 8 | issue= 4 | pages= 349-358 | pmid=31806413 | doi=10.1016/S2213-2600(19)30402-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31806413  }} </ref>.
 
Regarding research prior to these trials, the [[Cochrane Collaboration]] concluded "CPAP is effective in reducing symptoms of sleepiness and improving quality of life measures in people with moderate and severe obstructive sleep apnoea (OSA). It is more effective than oral appliances in reducing respiratory disturbances in these people but subjective outcomes are more equivocal. Certain people tend to prefer oral appliances to CPAP where both are effective"<ref name="pmid17054251">{{cite journal |author=Chai CL, Pathinathan A, Smith B |title=Continuous positive airway pressure delivery interfaces for obstructive sleep apnoea |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD005308 |year=2006 |pmid=17054251|doi=10.1002/14651858.CD005308.pub2 |url=http://dx.doi.org/10.1002/14651858.CD005308.pub2 |issn=}}</ref>
 
[[Continuous positive airway pressure]] can be automatically self-adjusting.<ref name="pmid15486338">{{cite journal|author=Whitelaw WA, Brant RF, Flemons WW| title=Clinical usefulness of home oximetry compared with polysomnography for assessment of sleep apnea. | journal=Am J Respir  Crit Care Med | year= 2005 | volume= 171 | issue= 2 | pages= 188-93 | pmid=15486338 | doi=10.1164/rccm.200310-1360OC | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15486338  }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15989309  Review in: ACP J Club. 2005 Jul-Aug;143(1):21]</ref><ref name="pmid11902424">{{cite journal| author=Littner M, Hirshkowitz M, Davila D, Anderson WM, Kushida CA, Woodson BT et al.| title=Practice parameters for the use of auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome. An American Academy of Sleep Medicine report. |journal=Sleep | year= 2002 | volume= 25 | issue= 2 | pages= 143-7 | pmid=11902424 | doi= | pmc= | url= }} </ref>
 
Bi-level positive airway pressure (BiPAP) is often more tolerable, as it decreases the pressure when the patient exhales, reducing respiratory effort.<ref name="pmid19821310">{{cite journal| author=Smith I, Lasserson TJ| title=Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. |journal=Cochrane Database Syst Rev | year= 2009 | volume=  | issue= 4 | pages= CD003531 | pmid=19821310
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19821310 |doi=10.1002/14651858.CD003531.pub3 }}</ref> For both CPAP and BiPAP, there are a wide range of masks, nasal catheters called "nasal pillows", and it may take several devices and expert fitting to find the right appliance for individual patient."The optimum form of CPAP delivery interface remains unclear... nasal pillows or the Oracle oral mask may be useful alternatives when a patient is unable to tolerate conventional nasal masks" according to the [[Cochrane Collaboration]].<ref name="pmid17054251" /> A heated humidifier in the compressed air path also helps compliance by preventing drying of the nasal mucosa.


===Oral appliances===
===Oral appliances===
*''[[Mandibular Advancement Splint]]''
Mandibular advancement devices (MADs) are custom-made, oral appliance placed by general dentists that shifts the lower jaw forward and opens the bite slightly, which opens up the airway
:*A oral appliance placed by general dentists
:*A custom-made mouthpiece that shifts the lower jaw forward and opens the bite slightly, which opens up the airway
:*Oral appliance therapy (OAT) is usually successful in patients with mild to moderate obstructive sleep apnea<ref>{{Cite journal|author=Machado MA, Juliano L, Taga M, de Carvalho LB, do Prado LB, do Prado GF |title=Titratable mandibular repositioner appliances for obstructive sleep apnea syndrome: are they an option? |journal=Sleep & Breathing |volume=11 |issue=4 |pages=225–31 |year=2007 |month=December |pmid=17440760 |doi=10.1007/s11325-007-0109-y}}</ref>
:*OAT is a relatively new treatment option for sleep apnea in the United States, but it is much more common in Canada and Europe


===Continuous positive airway pressure===[[
Regarding oral appliances (mandibular advancement device (MAD)), "CPAP appears to be more effective in improving sleep disordered breathing than OA. The difference in symptomatic response between these two treatments is not significant, although it is not possible to exclude an effect in favour of either therapy. Until there is more definitive evidence on the effectiveness of OA in relation to CPAP, with regard to symptoms and long-term complications, it would appear to be appropriate to recommend OA therapy to patients with mild symptomatic OSAH, and those patients who are unwilling or unable to tolerate CPAP therapy" according to the [[Cochrane Collaboration]].<ref name="pmid16437488">{{cite journal |author=Lim J, Lasserson TJ, Fleetham J, Wright J |title=Oral appliances for obstructive sleep apnoea |journal=Cochrane Database Syst Rev|volume= |issue=1 |pages=CD004435 |year=2006 |pmid=16437488 |doi=10.1002/14651858.CD004435.pub3|url=http://dx.doi.org/10.1002/14651858.CD004435.pub3 |issn=}}</ref>
File:Cpapanwender.jpg|thumb|Patient using a CPAP machine. There are many models of CPAP face masks.]]
For moderate to severe sleep apnea, the most common treatment is the use of a [[Positive airway pressure#Continuous pressure devices|continuous positive airway pressure]] (CPAP) or automatic positive airway pressure (APAP) device<ref name=SleepApneaTreatments>{{Cite web|url=http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_Treatments.html |title=How Is Sleep Apnea Treated? |publisher=[[National Heart, Lung, and Blood Institute]]}}</ref>  
*CPAP therapy is extremely effective in reducing apneas and less expensive than other treatments


*It 'splints' the patient's airway open during sleep by means of a flow of pressurized air into the throat
More recent [[randomized controlled trial]]s report:
*The patient typically wears a plastic facial mask, which is connected by a flexible tube to a small bedside CPAP machine<ref name="cpap-machines">[http://www.cpap-machine-reviews.com General Information about Sleep Apnea Machines]</ref>
* Similar findings in that oral appliances (mandibular advancement device (MAD)) are easier to tolerate, but CPAP is reduces the apnea-hypopnea index (AHI) more. Quality-of-life indicators may be better with appliance.<ref name="pmid23413266">{{cite journal| author=Phillips CL, Grunstein RR, Darendeliler MA, Mihailidou AS, Srinivasan VK, Yee BJ et al.| title=Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. | journal=Am J Respir Crit Care Med | year= 2013 | volume= 187 | issue= 8 | pages= 879-87 | pmid=23413266| doi=10.1164/rccm.201212-2223OC | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23413266  }} </ref>
*The CPAP machine generates the required air pressure to keep the patient's airways open during sleep
* MAD may not affect quality of life or daytime sleepiness, though other benefits may occur, among patients with apnea-hypopnea index (AHI) lower than 30.<ref name="pmid26030264">{{cite journal| author=Marklund M, Carlberg B, Forsgren L, Olsson T, Stenlund H, Franklin KA| title=Oral Appliance Therapy in Patients With Daytime Sleepiness and Snoring or Mild to Moderate Sleep Apnea: A Randomized Clinical Trial. | journal=JAMA Intern Med | year= 2015 | volume= 175 | issue= 8 | pages= 1278-85 | pmid=26030264 | doi=10.1001/jamainternmed.2015.2051 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26030264  }} </ref>
*Many patients refuse to continue the therapy or fail to use their CPAP machines on a nightly basis because they find it uncomfortable<ref name='Hsu2003'>{{Cite journal|author=Hsu AA, Lo C |title=Continuous positive airway pressure therapy in sleep apnoea |journal=Respirology |volume=8 |issue=4 |pages=447–54 |year=2003 |month=December |pmid=14708553 |doi=10.1046/j.1440-1843.2003.00494.x}}</ref>  
*One way to ensure CPAP therapy remains comfortable for patients is to ensure the CPAP face mask fits well
*It is not clear that CPAP reduces [[hypertension]] or cardiovascular events in patients who do not have daytime sleepiness; however, the lack of benefit may be partly due to [[Compliance (medicine)|noncompliance]] with therapy<ref name="pmid22618923">{{cite journal |author=Barbé F, Durán-Cantolla J, Sánchez-de-la-Torre M, ''et al.'' |title=Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial |journal=JAMA |volume=307 |issue=20 |pages=2161–8 |year=2012 |month=May |pmid=22618923 |doi=10.1001/jama.2012.4366 |url=http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2012.4366}}</ref>


===Alternative Therapies===
===Pharmacological Agents===
Other studies have also suggested that strengthening the muscles around the upper airway may combat sleep apnea. A 2001 study investigated changes  after Tongue Muscle Training (ZMT®) in respiratory parameters during night-time sleep of patients with increased respiratory disease index. 40 sleep apnea patients, which up to this time had been treated with nCPAP, underwent electrostimulation of the suprahyoidal musculature for 5 weeks with a special EMS-device. The apnea, hypopnea and desaturation indexes were reduced in 26 of the 40 patients (65%) by an average of approximately one half.<ref>Gessmann HW et al: The Tongue Muscle Training (ZMT®) in nCPAP Patients with Obstructive Sleep Apnea Syndrome (OSAS). PIB Publisher Duisburg, Germany 2001</ref> A 2005 study in the British Medical Journal found that learning and practicing the [[didgeridoo]] helped reduce snoring and sleep apnea as well as daytime sleepiness. This appears to work by strengthening muscles in the upper airway, thus reducing their tendency to collapse during sleep.<ref>{{Cite journal|author=Puhan MA, Suarez A, Lo Cascio C, Zahn A, Heitz M, Braendli O |title=Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial |journal=BMJ |volume=332 |issue=7536 |pages=266–70 |year=2006 |month=February |pmid=16377643 |pmc=1360393 |doi=10.1136/bmj.38705.470590.55}}</ref> A 2009 study published in the American Journal of Respiratory and Clinical Care Medicine found that patients who practiced a series of tongue and throat exercises for 30 minutes a day showed a marked decline in sleep apnea symptoms after three months. Patients experienced an average of 39% fewer apnea episodes after successfully completing the treatments.
*Medications to treat any underlying causes
<ref>{{cite journal |author=Guimarães KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G |title=Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome |journal=Am. J. Respir. Crit. Care Med. |volume=179 |issue=10 |pages=962–6 |year=2009 |month=May |pmid=19234106 |doi=10.1164/rccm.200806-981OC |url=http://ajrccm.atsjournals.org/cgi/pmidlookup?view=long&pmid=19234106}}</ref>  
*Medications to treat somnolence
:*[[Modafinil]] 200-400 mg per day
*[[Acetazolamide]], [[medroxyprogesterone]], [[fluoxetine]], and [[protriptyline]] are ventilatory stimulants that are not routinely used<ref name="HudgelThanakitcharu1998">{{cite journal|last1=Hudgel|first1=David W.|last2=Thanakitcharu|first2=Sitthep|title=Pharmacologic Treatment of Sleep-disordered Breathing|journal=American Journal of Respiratory and Critical Care Medicine|volume=158|issue=3|year=1998|pages=691–699|issn=1073-449X|doi=10.1164/ajrccm.158.3.9802019}}</ref>


[[Cannabis]] derivatives have also been studied in the treatment of sleep apnea. A 2002 study found that orally administered THC was able to stabilize respiration in rats and bulldogs during all sleep stages, decreasing apnea indexes during NREM and REM sleep stages by 42% and 58% respectively.<ref>{{Cite journal|author=Carley DW, Paviovic S, Janelidze M, Radulovacki M |title=Functional role for cannabinoids in respiratory stability during sleep. |journal=Sleep |volume=25 |issue=4 |pages=391–8 |year=2002 |month=June |pmid=12071539}}</ref> A 2013 proof of concept trial found that dronabinol (synthetic THC) was able to reduce apnea indexes by 32% on average in the 17 human subjects that were studied.<ref>{{Cite journal|author=Prasad B, Radulovacki MG, Carley DW |title=Proof of concept trial of dronabinol in obstructive sleep apnea. |journal=Front Psychiatry |volume=4 |issue=1 |year=2013 |month=Jan |pmid=23346060 |pmc=3550518 |doi=10.3389/fpsyt.2013.00001}}</ref> Lead study author Dr. David Carley subsequently received a $5 million grant from the National Institutes of Health (NIH) to conduct a Phase II clinical trial.<ref>{{cite web |url=http://www.businesswire.com/news/home/20120814005790/en/Cortex-Pharmaceuticals-Pier-Pharmaceuticals-Consummate-Merger|title=Cortex Pharmaceuticals and Pier Pharmaceuticals Consummate Merger |author=<!--Staff writer(s); no by-line.--> |date=14 August 2012 |publisher=BusinessWire.com |accessdate=7 August 2013}}</ref>
===Compression stockings===
A small [[randomized controlled trial]] reported that [[compression stocking]]s reduced the number of apneas and hypopnea, perhaps by "prevention of fluid accumulation in the legs during the day, and its nocturnal displacement into the neck at night."<ref name="pmid21836140">{{cite journal| author=Redolfi S, Arnulf I, Pottier M, Lajou J, Koskas I, Bradley TD et al.| title=Attenuation of  Obstructive Sleep Apnea by Compression Stockings in Subjects With Venous  Insufficiency. |journal=Am J Respir Crit Care Med | year= 2011 | volume= | issue= | pages= | pmid=21836140 | doi=10.1164/rccm.201102-0350OC | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21836140  }} </ref>
 
==Oxygen Therapy==
*Low doses are used as a treatment for [[hypoxia]] but are discouraged due to side effects such as a dry or bloody nose, skin irritation from the nasal cannula or face mask, fatigue, and morning headaches<ref name="pmid11181239">{{Cite journal|author=Mayos M, Hernández Plaza L, Farré A, Mota S, Sanchis J |title=[The effect of nocturnal oxygen therapy in patients with sleep apnea syndrome and chronic airflow limitation] |language=Spanish |journal=Archivos de Bronconeumología |volume=37 |issue=2 |pages=65–8 |year=2001 |month=February |pmid=11181239 |url=http://www.elsevier.es/revistas/0300-2896/37/65}}</ref><ref name="pmid2609134">{{Cite journal|author=Breitenbücher A, Keller-Wossidlo H, Keller R |title=[Transtracheal oxygen therapy in obstructive sleep apnea syndrome] |language=German |journal=Schweizerische Medizinische Wochenschrift |volume=119 |issue=46 |pages=1638–41 |year=1989 |month=November |pmid=2609134}}</ref>


==References==
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[[Category:Sleep disorders]]
[[Category:Cardiology]]
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Saarah T. Alkhairy, M.D.

Overview

If left untreated, sleep apnea can have serious and life-threatening consequences such heart disease, hypertension, automobile accidents due to somnolence, and many other ailments. Treatment often starts with behavioral therapy. Medical treatment involves the treatment of the underlying cause and somnolence. Medications, such as acetazolamide and oxygen are not routinely used for the treatment of sleep apnea. The most effective treatments help open the airway such as continuous positive airway pressure (CPAP) and oral appliances.

Benefits of treatment

It is not clear that CPAP reduces hypertension and cardiovascular events; however, the lack of benefit may be partly due to noncompliance with therapy[1]

One trial found that treatment may lower blood pressure by about 3 - 5 mm Hg.[2][3]

Sleep Apnea Medical Therapy

The treatment often starts with behavioral therapy. Many patients are told to lose weight and avoid alcohol, sleeping pills, and other sedatives. These can relax throat muscles that contribute to the collapse of the airway at night.

Possibly owing to changes in pulmonary oxygen stores, sleeping on one's side (as opposed to on one's back) has been found to be helpful for central sleep apnea with Cheyne-Stokes respiration.[4]

Weight loss

Weight loss of 20 kg with a liquid very low energy diet(2.3 MJ/day) for seven weeks can reduce the AHI by 23 and lead to 20% of patients becoming disease free.[5]

Continuous positive airway pressure

For moderate to severe sleep apnea, CPAP therapy is extremely effective in reducing apneas and less expensive than other treatments. It splints the patient's airway open during sleep by means of a flow of pressurized air into the throat. The patient typically wears a plastic facial mask, which is connected by a flexible tube to a small bedside CPAP machine[6]. The CPAP machine generates the required air pressure to keep the patient's airways open during sleep.

There may be low compliance because patients find it uncomfortable[7]. One way to ensure CPAP therapy remains comfortable for patients is to ensure the CPAP face mask fits well. Eszopiclone, a sedative, used nightly for 14 nights may provide sustained increase in the patient's compliance[8]

Several trials have studied continuous positive airway pressure:

  • Patients with Epworth Sleepiness Scale score >10 has a reduction in daytime symptoms.[9]
  • Patients with Epworth Sleepiness Scale score <10 had no reduction in cardiovascular events.[1]
  • Patients with average AHI of 10 and ESS of 10, who averaged wearing 4 hours of CPAP per night had improvement in quality of life[10].

Regarding research prior to these trials, the Cochrane Collaboration concluded "CPAP is effective in reducing symptoms of sleepiness and improving quality of life measures in people with moderate and severe obstructive sleep apnoea (OSA). It is more effective than oral appliances in reducing respiratory disturbances in these people but subjective outcomes are more equivocal. Certain people tend to prefer oral appliances to CPAP where both are effective"[11]

Continuous positive airway pressure can be automatically self-adjusting.[12][13]

Bi-level positive airway pressure (BiPAP) is often more tolerable, as it decreases the pressure when the patient exhales, reducing respiratory effort.[14] For both CPAP and BiPAP, there are a wide range of masks, nasal catheters called "nasal pillows", and it may take several devices and expert fitting to find the right appliance for individual patient."The optimum form of CPAP delivery interface remains unclear... nasal pillows or the Oracle oral mask may be useful alternatives when a patient is unable to tolerate conventional nasal masks" according to the Cochrane Collaboration.[11] A heated humidifier in the compressed air path also helps compliance by preventing drying of the nasal mucosa.

Oral appliances

Mandibular advancement devices (MADs) are custom-made, oral appliance placed by general dentists that shifts the lower jaw forward and opens the bite slightly, which opens up the airway

Regarding oral appliances (mandibular advancement device (MAD)), "CPAP appears to be more effective in improving sleep disordered breathing than OA. The difference in symptomatic response between these two treatments is not significant, although it is not possible to exclude an effect in favour of either therapy. Until there is more definitive evidence on the effectiveness of OA in relation to CPAP, with regard to symptoms and long-term complications, it would appear to be appropriate to recommend OA therapy to patients with mild symptomatic OSAH, and those patients who are unwilling or unable to tolerate CPAP therapy" according to the Cochrane Collaboration.[15]

More recent randomized controlled trials report:

  • Similar findings in that oral appliances (mandibular advancement device (MAD)) are easier to tolerate, but CPAP is reduces the apnea-hypopnea index (AHI) more. Quality-of-life indicators may be better with appliance.[16]
  • MAD may not affect quality of life or daytime sleepiness, though other benefits may occur, among patients with apnea-hypopnea index (AHI) lower than 30.[17]

Pharmacological Agents

  • Medications to treat any underlying causes
  • Medications to treat somnolence

Compression stockings

A small randomized controlled trial reported that compression stockings reduced the number of apneas and hypopnea, perhaps by "prevention of fluid accumulation in the legs during the day, and its nocturnal displacement into the neck at night."[19]

Oxygen Therapy

  • Low doses are used as a treatment for hypoxia but are discouraged due to side effects such as a dry or bloody nose, skin irritation from the nasal cannula or face mask, fatigue, and morning headaches[20][21]

References

  1. ↑ 1.0 1.1 Barbé F, Durán-Cantolla J, Sánchez-de-la-Torre M; et al. (2012). "Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial". JAMA. 307 (20): 2161–8. doi:10.1001/jama.2012.4366. PMID 22618923. Unknown parameter |month= ignored (help)
  2. ↑ Martínez-García M, Capote F, Campos-Rodríguez F, et al. Effect of CPAP on Blood Pressure in Patients With Obstructive Sleep Apnea and Resistant Hypertension: The HIPARCO Randomized Clinical Trial. JAMA. 2013;310(22):2407-2415. doi:10.1001/jama.2013.281250.
  3. ↑ Pedrosa RP, Drager LF, de Paula LK, Amaro AC, Bortolotto LA, Lorenzi-Filho G (2013). "Effects of OSA Treatment on BP in Patients With Resistant Hypertension: A Randomized Trial". Chest. 144 (5): 1487–94. doi:10.1378/chest.13-0085. PMID 23598607.
  4. ↑ Szollosi I, Roebuck T, Thompson B, Naughton MT (2006). "Lateral sleeping position reduces severity of central sleep apnea / Cheyne-Stokes respiration". Sleep. 29 (8): 1045–51. PMID pmid16944673 Check |pmid= value (help).
  5. ↑ Johansson K, Neovius M, Lagerros YT, Harlid R, Rössner S, Granath F; et al. (2009). "Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: a randomised controlled trial". BMJ. 339: b4609. doi:10.1136/bmj.b4609. PMC 2788899. PMID 19959590.
  6. ↑ General Information about Sleep Apnea Machines
  7. ↑ Hsu AA, Lo C (2003). "Continuous positive airway pressure therapy in sleep apnoea". Respirology. 8 (4): 447–54. doi:10.1046/j.1440-1843.2003.00494.x. PMID 14708553. Unknown parameter |month= ignored (help)
  8. ↑ Lettieri CJ, Shah AA, Holley AB, Kelly WF, Chang AS, Roop SA; et al. (2009). "Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial". Ann Intern Med. 151 (10): 696–702. doi:10.1059/0003-4819-151-10-200911170-00006. PMID 19920270.
  9. ↑ Weaver TE, Mancini C, Maislin G, Cater J, Staley B, Landis JR; et al. (2012). "Continuous Positive Airway Pressure Treatment of Sleepy Patients with Milder Obstructive Sleep Apnea: Results of the CPAP Apnea Trial North American Program (CATNAP) Randomized Clinical Trial". Am J Respir Crit Care Med. 186 (7): 677–83. doi:10.1164/rccm.201202-0200OC. PMID 22837377.
  10. ↑ Wimms AJ, Kelly JL, Turnbull CD, McMillan A, Craig SE, O'Reilly JF; et al. (2020). "Continuous positive airway pressure versus standard care for the treatment of people with mild obstructive sleep apnoea (MERGE): a multicentre, randomised controlled trial". Lancet Respir Med. 8 (4): 349–358. doi:10.1016/S2213-2600(19)30402-3. PMID 31806413.
  11. ↑ 11.0 11.1 Chai CL, Pathinathan A, Smith B (2006). "Continuous positive airway pressure delivery interfaces for obstructive sleep apnoea". Cochrane Database Syst Rev (4): CD005308. doi:10.1002/14651858.CD005308.pub2. PMID 17054251.
  12. ↑ Whitelaw WA, Brant RF, Flemons WW (2005). "Clinical usefulness of home oximetry compared with polysomnography for assessment of sleep apnea". Am J Respir Crit Care Med. 171 (2): 188–93. doi:10.1164/rccm.200310-1360OC. PMID 15486338. Review in: ACP J Club. 2005 Jul-Aug;143(1):21
  13. ↑ Littner M, Hirshkowitz M, Davila D, Anderson WM, Kushida CA, Woodson BT; et al. (2002). "Practice parameters for the use of auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome. An American Academy of Sleep Medicine report". Sleep. 25 (2): 143–7. PMID 11902424.
  14. ↑ Smith I, Lasserson TJ (2009). "Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea". Cochrane Database Syst Rev (4): CD003531. doi:10.1002/14651858.CD003531.pub3. PMID 19821310.
  15. ↑ Lim J, Lasserson TJ, Fleetham J, Wright J (2006). "Oral appliances for obstructive sleep apnoea". Cochrane Database Syst Rev (1): CD004435. doi:10.1002/14651858.CD004435.pub3. PMID 16437488.
  16. ↑ Phillips CL, Grunstein RR, Darendeliler MA, Mihailidou AS, Srinivasan VK, Yee BJ; et al. (2013). "Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial". Am J Respir Crit Care Med. 187 (8): 879–87. doi:10.1164/rccm.201212-2223OC. PMID 23413266.
  17. ↑ Marklund M, Carlberg B, Forsgren L, Olsson T, Stenlund H, Franklin KA (2015). "Oral Appliance Therapy in Patients With Daytime Sleepiness and Snoring or Mild to Moderate Sleep Apnea: A Randomized Clinical Trial". JAMA Intern Med. 175 (8): 1278–85. doi:10.1001/jamainternmed.2015.2051. PMID 26030264.
  18. ↑ Hudgel, David W.; Thanakitcharu, Sitthep (1998). "Pharmacologic Treatment of Sleep-disordered Breathing". American Journal of Respiratory and Critical Care Medicine. 158 (3): 691–699. doi:10.1164/ajrccm.158.3.9802019. ISSN 1073-449X.
  19. ↑ Redolfi S, Arnulf I, Pottier M, Lajou J, Koskas I, Bradley TD; et al. (2011). "Attenuation of Obstructive Sleep Apnea by Compression Stockings in Subjects With Venous Insufficiency". Am J Respir Crit Care Med. doi:10.1164/rccm.201102-0350OC. PMID 21836140.
  20. ↑ Mayos M, Hernández Plaza L, Farré A, Mota S, Sanchis J (2001). "[The effect of nocturnal oxygen therapy in patients with sleep apnea syndrome and chronic airflow limitation]". Archivos de Bronconeumología (in Spanish). 37 (2): 65–8. PMID 11181239. Unknown parameter |month= ignored (help)
  21. ↑ Breitenbücher A, Keller-Wossidlo H, Keller R (1989). "[Transtracheal oxygen therapy in obstructive sleep apnea syndrome]". Schweizerische Medizinische Wochenschrift (in German). 119 (46): 1638–41. PMID 2609134. Unknown parameter |month= ignored (help)

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