eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Palatal & Maxillofacial Surgery

Snoring and Obstructive Sleep Apnea, CPAP: Treatment & Medication

Author: Vittorio Rinaldi, MD, Resident in Otolaryngology, Department of the Campus Bio-Medico, University of Rome
Coauthor(s): Fabrizio Salvinelli, MD, Professor of Otolaryngology, Campus Bio-Medico, University of Rome; Manuele Casale, MD, Specialist in Otolaryngology, Campus Bio-Medico, University of Rome School of Medicine; Francesco Faiella, MD, Resident in Otolaryngology, Campus Bio-Medico University of Rome School of Medicine; Marco Pappacena, MD, Resident, Department of Otolaryngology, Campus Bio-Medico University, Rome; Karen Hall Calhoun, MD, William E Davis Professor and Chair, Department of Otolaryngology-Head and Neck Surgery, University of Missouri
Contributor Information and Disclosures

Updated: Oct 6, 2008

Treatment

Medical Care

The first task in treating patients with sleep disordered breathing (SDB) is to eliminate all possible contributing factors. This includes weight loss for patients who are obese (see Diet) and elimination of alcohol or sedative use, especially near bedtime. Benzodiazepines, narcotics, and barbiturates can worsen sleep-disordered breathing (SDB), or sometimes they initiate it where it had not previously been present.

A 10% weight loss was associated with a 26% decrease in the apnea-hypopnea index in a population-based study. Weight loss should be recommended for all obese patients with sleep apnea; however, weight loss takes time, and only a minority of patients successfully maintains it.

Body positioning during sleep can improve sleep-disordered (SDB) in some patients. Because lying supine can allow gravity to assist in pulling lax tongue muscles back toward the posterior pharyngeal wall, patients should sleep on their sides, on their stomachs, or propped up 60°. These positions can improve sleep-disordered breathing (SDB) in patients whose symptoms occur primarily while supine.

Avoidance of supine sleeping can easily be accomplished with a sock, tennis ball, and safety pins. The tennis ball in a sock is pinned to the back of the pajamas, positioning the tennis ball between the scapulae. When the patient rolls into the supine position during sleep, this lump is uncomfortable enough that the position is immediately shifted, usually without the patient awakening.

In patients with hypothyroidism and sleep-disordered breathing (SDB), thyroid hormone replacement therapy is usually accompanied by an improvement in the sleep-disordered breathing (SDB).

In some individuals, a mouthpiece may improve the anatomy of the airway to the point that snoring or mild obstructive sleep apnea (OSA) can be corrected. Many types of oral appliances have been designed for the treatment of sleep apnea. Most are custom fit to the teeth of both dental arches to reposition the mandible and to enlarge the retropalatal and retrolingual airway space. However, consistent patient tolerance for this treatment is relatively low and it's less effective than continuous positive airway pressure in reducing the frequency of apnea and hypopnea.

n-CPAP is used as follows:

  • When none of the above therapies are appropriate or helpful, n-CPAP is the most effective method to manage OSAS. Patients who are unlikely to benefit from n-CPAP include those with such severe nasal obstruction that n-CPAP cannot be used, patients with such extreme claustrophobia that they cannot tolerate a nasal mask, and patients in whom n-CPAP does not reliably eliminate apneas, hypopneas, and snoring.
  • n-CPAP provides a pneumatic stent for the upper airway, eliminating the airway collapse during inspiration. It is administered by a soft mask that covers the nose only. Sufficient pressure is introduced to eliminate apneas, hypopneas, and snoring.
  • The criterion standard for determining the amount of pressure required to restore upper-airway patency is traditionally determined during polysomnography by trained technicians. In some centers, this is performed as a split-night study, with data from the first half of the night used for diagnosis of sleep-disordered breathing (SDB). Once this diagnosis is made, if the RDI is sufficient to suggest benefit from initiation of n-CPAP (usually an RDI of 20 or more), the second half of the night's study is used to determine the optimal amount of pressure. The disadvantage of the split-night approach is that the second half of a full night study often reveals more severe sleep apnea, so a diagnostic study limited to the first half of the night can underestimate disease severity.
  • The amount of pressure delivered is reported as cm H2 O. An average starting point for CPAP would be 8-10 cm H2 O. Patients report that pressures at these levels feel odd but are tolerable even when beginning treatment and become more tolerable as the patients become accustomed to treatment. Higher levels (>15 cm H2 O) are often not well tolerated.
  • When a second overnight study is logistically difficult, some clinicians empirically start a patient on n-CPAP with a pressure of 8-10 cm H2 O. A new generation of n-CPAP machines, on the basis of the patterns of inspiratory airflow, can sense the amount of pressure needed to overcome upper airway resistance. Patients are sometimes started using these machines without a prior titration study. Alternatively, an autotitrating machine can be used for several nights, the record of amount of pressure required to suppress apneas and hypopneas can be downloaded and studied, and a suitable nightly pressure can be determined in this fashion. Also, the amount of pressure required to suppress snoring can be used as an audible guide to appropriate pressures.
  • A patient who routinely takes sedatives or ingests alcohol during the evening and does not intend to change this should probably be tested after continuing their usual nightly routine. n-CPAP titration without sedatives or alcohol is likely to lead to undertreatment of the SDB at home, when such patterns are resumed.
  • Most patients feel better during the daytime on the first day after beginning n-CPAP. During the first week of treatment, most experience rebound sleep with prolonged episodes of REM sleep. Sleep patterns become more normal after the first week. For these reasons, several weeks of n-CPAP use may be helpful for normalization of sleep patterns in patients with severe sleep apnea who plan to undergo surgery. Sleep patterns should be normalized prior to the planned surgery.
  • Regular use of n-CPAP improves both the patients' and their bed partners' quality of life. The treatment lessens depressive symptoms, and improves daytime functioning, blood pressure and insulin sensitivity. In patients with obstructive sleep apnea (OSA) who receive antihypertensive treatment, long-term CPAP was found to be responsible for a significantly reduction of diastolic blood pressure. Asthmatic OSA patients have fewer nighttime symptoms. Other effects of using CPAP include increased vagal tone, increased cardiac output, increased stroke volume, decreased systemic vascular resistance, and reduced risk of cardiovascular mortality.
  • Most physicians agree that patients with a respiratory disturbance index (RDI) greater than 20 require treatment. n-CPAP can also be useful for patients with a lower RDI, especially if they experience daytime sleepiness or other symptoms. If the severity of the daytime symptoms and the Epworth Sleepiness Scale score are much greater than would be expected with a particular RDI, a trial of n-CPAP can help determine whether elimination of the sleep-disordered breathing (SDB) leads to improvement of the daytime symptoms, or if other factors contribute to the daytime symptoms.
  • Overall compliance rates can be low (46% in one study defining use as at least 4 h/d, 5 d/wk). Noncompliance has been categorized by Zoula et al as tolerance problems, psychological problems and lack of instruction, support, or follow-up. Tolerance problems may be due to side effects (ie, dry mouth, conjunctivitis, rhinorrhea, skin irritation, pressure sores, nasal congestion, epistaxis), mask leaks, difficulty exhaling, aerophagia, chest discomfort, and bed-partner intolerance. Psychological problems include lack of motivation, claustrophobia and anxiety. The points below may assist the physician in improving treatment compliance. Main referred problems include the following:
    • Claustrophobia: Many patients report claustrophobia. They find that the sensation of covering the nose with a mask makes them so uncomfortable that they cannot tolerate wearing the n-CPAP. Sometimes this can be helped with a smaller or more transparent mask design. Use of nasal pillows (inserted into the nostrils) instead of a formal nasal mask may allow such patients to tolerate the n-CPAP.
    • Trouble tolerating initial pressure: Especially when higher pressures (>12-13 cm H2 O) are required for elimination of apneas and hypopneas, patients may find this level of pressure uncomfortable. Many n-CPAP machines have a built-in ramp or gradual increase in pressure. Using this feature, the mask can be placed and pressure begun at a very low and easily tolerated level. Over 30 minutes, the pressure gradually builds to the full amount necessary. Often, the patient can fall asleep during this ramp-up time. The full pressure is not used until the patient is actually asleep.
    • Nasal obstruction
      • Evaluation by an otolaryngologist reveals whether this is predominantly a fixed skeletal obstruction or a soft tissue obstruction potentially modifiable without surgery. Marked septal deviation or turbinate hypertrophy usually requires surgery for resolution. Alar collapse may be adequately treated by internal or external dilators (eg, Breathe Right strip, Nozovent). Surgery is sometimes required for repair of marked alar collapse.
      • Mucosal edema may be due to allergic rhinosinusitis or to vasomotor or irritative rhinitis. Allergy testing and treatment and pharmacotherapy trials (eg, topical steroids or antihistamines, oral antihistamines, or decongestants) may be beneficial.
      • One way to determine whether sufficient potentially reversible mucosal edema exists to pursue that avenue of treatment is the topical decongestant test. The patient uses a nasal topical decongestant (eg, oxymetazoline) at bedtime for several days, with the patient and bed partner observing for any improvements in snoring or apneas. A marked improvement suggests potentially reversible mucosal edema as a main contributor to the nasal obstruction. Failure to improve suggests a fixed skeletal obstruction that requires surgical correction.
      • Sometimes the dryness of the air or its temperature may be irritating to the patient. Use of in-line humidification and warming of the inspired air may alleviate patient discomfort.
    • Facial or nasal pain: Sometimes this pain can be related to a poorly fitting mask. With the many different types of masks available now, different styles and sizes can be tried to select the optimal fit for each individual anatomy. Because the mask is pulled tight against the face, an edentulous anterior maxilla may not provide the resistance necessary for a good fit. Leaving dentures in at night can help with this. If the facial or nasal pain persists despite mask refitting, evaluation for nasal obstruction or chronic sinusitis may be helpful. The CPAP Pro delivery method anchors the tubing to a platform based on an upper retainer, obviating the need for a forehead strap.
    • Dry eye or other eye discomfort: If the mask does not seal well, egress of pressurized air from the upper end of the mask toward the eye may occur, causing dry eye or even exposure keratitis. Mask refitting usually eliminates this problem.
    • Mouth falling open, awakening with dry mouth: Sometimes a chin strap is required to prevent the mouth from opening at night. A commercially available disposable adhesive bandage may used to pull the chin up toward the lower cheeks.
    • Epistaxis: Epistaxis may be related to the high-flow dry air and may be helped by humidification and warming of the inspired air.
    • Nasal drying: Forced dry air can be irritating to the nose, encouraging mucosal inflammation and crusting. Use of humidified air for nCPAP usually eliminates this problem.
    • Other: Pneumopericardium has been reported with n-CPAP. Pneumocephalus has occurred when n-CPAP was used in a patient with cerebrospinal fluid rhinorrhea. Eustachian tube dysfunction, serous otitis media, bulging of the eardrums, and eardrum perforation have also been reported.
  • Although n-CPAP provides good improvement in symptoms and physiologic parameters, compliance with treatment is not good, with regular use sometimes estimated as low as 30%. Rigorous patient education and early reinforcing follow-up may improve long-term use.

Variations of air pressure delivery can sometimes make n-CPAP use more comfortable for patients. Autotitrating positive airway pressure (APAP) continually adjusts the pressure to barely overcome the collapsing forces. Bilevel positive airway pressure (BiPAP) provides higher pressure during inspiration (when the pneumatic splint is needed to prevent obstructive airway collapse) and lower pressure during expiration. C-Flex is another autoadjusting delivery method that increases pressure toward the end of expirations, as collapse would usually begin, and decreases pressure during early expiration. Patients who require higher pressures to overcome obstructive apneas may tolerate these devices better than the one-level n-CPAP, which delivers the higher pressure throughout the entire respiratory cycle.

Following treatment with continuous positive airway pressure (CPAP), some patients with obstructive sleep apnea remain sleepy despite effective CPAP, and attention should be paid to other diagnoses that can be associated to sleepiness. The so called "post-CPAP sleepiness," as a specific disorder, may not exist.

Surgical Care

Surgical care of sleep-disordered breathing (SDB) is discussed in the eMedicine article Snoring/Obstructive Sleep Apnea, Surgery. n-CPAP is often used in the perioperative period to assure good ventilation even in the presence of postsurgical edema. Because of the use of analgesics and swelling of the soft tissues, the pressure needed to maintain a patent airway postoperatively may be greater than the patient had been using prior to surgery.

Consultations

Multidisciplinary sleep teams, including pulmonologists, otolaryngologists, neurologists, and oral-maxillofacial surgeons, may offer the most convenient and comprehensive treatment for these patients.

Diet

Weight reduction in the patient with obesity can dramatically improve sleep-disordered breathing (SDB). Even a modest weight loss can have quite a beneficial effect on the frequency of apneas and hypopneas. Diet and exercise counseling play a major role in the initial therapy for sleep-disordered breathing (SDB). Bariatric surgery may be needed in some cases.

When rapid weight loss occurs after bariatric surgery or successful dieting, the pressure for overcoming apneas and hypopneas is likely to decrease, so retesting is recommended.

Alcohol significantly worsens sleep-disordered breathing (SDB). Eliminating use of alcohol, especially near bedtime, improves sleep-disordered breathing (SDB).

Medication

Protriptyline, a tricyclic antidepressant, is the medication most studied in the treatment of sleep-disordered breathing (SDB) and does improve sleep-disordered breathing (SDB). This effect, however, appears to be mainly due to suppression of REM sleep. Because sleep-disordered breathing (SDB) is often most severe during REM sleep, less REM sleep can mean fewer apneas. Other drugs that have been investigated for treatment of sleep apnea include progestational agents, aminophylline, acetazolamide, L-tryptophan, naloxone, baclofen, bromocriptine, chlorimipramine, and prochlorperazine. None of these have shown a consistently helpful effect on sleep-disordered breathing (SDB).

Because some of the effects of sleep-disordered breathing (SDB) are due to hypoxia during sleep; the administration of oxygen would seem like a reasonable treatment. Although oxygen administration improves the lowest blood-oxygen saturation level during sleep and can improve some of the arrhythmias occurring during desaturation, repeated studies have not demonstrated sustained clinically significant improvement in sleep-disordered breathing (SDB) with oxygen administration. Some prolongation of apneas also occurs, particularly at the beginning of therapy. Oxygen administration may be beneficial in a subset of patients. Some patients with other coexistent pulmonary disorders may also benefit from use of oxygen in conjunction with CPAP.

n-CPAP is effective in improving sleep quality and reducing daytime sleepiness. Long-term treatment with n-CPAP reduces both mortality and the acute blood pressure elevation that occurs with sleep-disordered breathing (SDB). Over time, a trend develops toward baseline blood pressure reduction in hypertensive patients with sleep-disordered breathing (SDB).

Modafinil is a wake-promoting medication used in association with CPAP in obstructive sleep apnea syndrome (OSAS). Modafinil has an action similar to sympathomimetic agents (like amphetamine and methylphenidate), although the pharmacologic profile is not identical to that of sympathomimetic amines. The precise mechanism through which Modafinil promotes wakefulness is unknown. Headache and nervousness are the only adverse events reported. There is no benefit using Modafinil in patients with obstructive sleep apnea (OSA) who are not compliant with CPAP, so it should not be administrated in such cases.

Antidepressants

These agents may suppress REM sleep.


Protriptyline (Vivactil)

Increases synaptic concentration of serotonin, norepinephrine, or both in CNS by inhibiting their reuptake by the presynaptic neuronal membrane.

Adult

10-15 mg PO qhs

Pediatric

Not established

Decreases effects of guanethidine; effects decrease if coadministered with barbiturates, phenytoin, carbamazepine; increases toxicity of alcohol, CNS depressants, sympathomimetics, MAO inhibitors; cimetidine increases levels of protriptyline

Documented hypersensitivity; narrow-angle glaucoma

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in cardiac conduction disturbances, seizure disorders, decreased renal function, and history of hyperthyroidism

Central Nervous System Stimulant, Nonamphetamine

These agents have wake-promoting effects.


Modafinil (Provigil)

Mechanism(s) of action in wakefulness is unknown. Has wake-promoting actions like sympathomimetic agents. Indicated as adjunct treatment to standard therapy for OSAS.

Adult

200 mg PO qam

Pediatric

<16 years: Not established

Metabolized partially by 3A isoform subfamily of hepatic cytochrome P450 (CYP3A4); has the potential to inhibit CYP2C19, suppress CYP2C9, and induce CYP3A4, CYP2B6, and CYP1A2
May decrease levels of cyclosporine or steroidal contraceptives, and to a lesser degree, theophylline; modafinil may increase drug concentration levels of diazepam, propranolol, and phenytoin

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor patients closely, for signs of misuse or abuse, especially those with a history of drug or stimulant abuse such as methylphenidate, amphetamine, and cocaine; leukopenia has been reported in pediatric patients; may cause serious life-threatening rash (ie, Stevens-Johnson Syndrome, toxic epidermal necrolysis, drug rash with eosinophilia and systemic symptoms), hypersensitivity reactions (eg, angioedema, multiorgan reactions), and psychiatric symptoms (eg, anxiety, mania, hallucinations, suicidal ideation)

More on Snoring and Obstructive Sleep Apnea, CPAP

Overview: Snoring and Obstructive Sleep Apnea, CPAP
Differential Diagnoses & Workup: Snoring and Obstructive Sleep Apnea, CPAP
Treatment & Medication: Snoring and Obstructive Sleep Apnea, CPAP
Follow-up: Snoring and Obstructive Sleep Apnea, CPAP
References
[ CLOSE WINDOW ]

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Further Reading

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Keywords

CPAP, apnea, sleep apnea, snoring, obstructive sleep apnea, sleep apnea snoring, obstructive sleep apnea syndrome, OSAS, upper airway obstruction occurring during sleep, sleep-disordered breathing, SDB, upper airway resistance syndrome, UARS, laryngopharyngeal reflux, insomnia, daytime somnolence, narcolepsy, nasal continuous positive airway pressure, n-CPAP, CPAP machine, CPAP machines, CPAP masks, CPAP mask, CPAP apnea, CPAP sleep, sleep apnea treatment, sleep, snore, sleep apnea machine, apnea treatment, sleep disorder

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Contributor Information and Disclosures

Author

Vittorio Rinaldi, MD, Resident in Otolaryngology, Department of the Campus Bio-Medico, University of Rome
Disclosure: Nothing to disclose.

Coauthor(s)

Fabrizio Salvinelli, MD, Professor of Otolaryngology, Campus Bio-Medico, University of Rome
Disclosure: Nothing to disclose.

Manuele Casale, MD, Specialist in Otolaryngology, Campus Bio-Medico, University of Rome School of Medicine
Disclosure: Nothing to disclose.

Francesco Faiella, MD, Resident in Otolaryngology, Campus Bio-Medico University of Rome School of Medicine
Disclosure: Nothing to disclose.

Marco Pappacena, MD, Resident, Department of Otolaryngology, Campus Bio-Medico University, Rome
Disclosure: Nothing to disclose.

Karen Hall Calhoun, MD, William E Davis Professor and Chair, Department of Otolaryngology-Head and Neck Surgery, University of Missouri
Karen Hall Calhoun, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association, American Rhinologic Society, Association for Research in Otolaryngology, Society of University Otolaryngologists-Head and Neck Surgeons, Southern Medical Association, Texas Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Jack A Coleman, MD, Consulting Staff, Franklin Surgical Associates
Jack A Coleman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Sleep Medicine, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Society for Laser Medicine and Surgery, and Association of Military Surgeons of the US
Disclosure: Influent  None Review panel membership; accarent, inc Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert M Kellman, MD, Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York, Upstate Medical University
Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Medical Society of the State of New York
Disclosure: GE Healthcare Honoraria Review panel membership

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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