Sleep apnea medical therapy
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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
- Modafinil 200-400 mg per day
- Acetazolamide, medroxyprogesterone, fluoxetine, and protriptyline are ventilatory stimulants that are not routinely used[18]
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
- ↑ 1.0 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) - ↑ 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.
- ↑ 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.
- ↑ 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). - ↑ 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.
- ↑ General Information about Sleep Apnea Machines
- ↑ 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) - ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 11.0 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.
- ↑ 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
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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) - ↑ 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)