Most Effective Sleep Apnea Treatment

Cure Sleep Apnea Without Cpap

In these real-life case studies youll learn in-depth about the lives and treatments of 9 people who have conquered their apnea. Specifically, youll learn: 1. When they first suspected they had sleep apnea. 2. Symptoms that made them first think they had sleep apnea. 3. Steps they took to get diagnosed. 4. How they felt when they were diagnosed (what was going through their mind) 5. The quality of their sleep before their apnea treatment, and how they felt during the day. 6. What they did to try to get a good nights sleep before their successful treatment. 7. What they did to try to overcome fatigue during the day. 8. A description of exactly what their treatment involved. 9. How they found out about the treatment. 10. Side effects of their treatment. 11. Obstacles they encountered during their treatment, and how they overcame those obstacles. 12. How long it took before the quality of their sleep improved. 13. How long it took before they felt better (more rested) during the day. 14. How long its been since they conquered their sleep apnea. 15. Resources they recommend for others who suffer from sleep apnea, and would like to follow their treatment (the name of specific doctors and medical centers) 16. Final words of advice for people who have just been diagnosed with sleep apnea. Here Is a Tiny Sample of What Youll Get When You Download Your Copy Of Cure Your Sleep Apnea Without Cpap: 78 pages of actionable information on alternative, non-Cpap sleep apnea treatments. 9 case studies of men and women who have completely cured their sleep apnea without Cpap. 7 types of alternative treatments that are proven to cure sleep apnea (detailed descriptions) 12 action steps for each alternative treatment, so you know exactly how to take action on each treatment. 7 quick fix sleep treatments that can help you get a better nights sleep Tonight. 69 hand-picked web links for further information on alternative sleep apnea treatments. 31 diagrams explaining alternative sleep apnea treatments Continue reading...

Cure Sleep Apnea Without Cpap Summary


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My Cure Sleep Apnea Without Cpap Review

Highly Recommended

The author has done a thorough research even about the obscure and minor details related to the subject area. And also facts weren’t just dumped, but presented in an interesting manner.

As a whole, this e-book contains everything you need to know about this subject. I would recommend it as a guide for beginners as well as experts and everyone in between.

Diagnosis Of Sleep Apnea

Modern diagnosis of sleep apnea has its roots in the landmark descriptions by Gastaut (2,3), Jung and Kuhlo (4), and others (5,6). Since these early descriptions of polygraphic recordings, the nocturnal, attended in-lab polysomnogram has become the standard for diagnosing OSA. In the early days of our understanding of the condition, the patient presented at advanced stages with severe symptoms, cardiovascular comorbidities, and a prominent history of loud snoring and witnessed apneic episodes. Over the years, a wider spectrum of disease severity has emerged and it is clear that many patients are minimally affected or not symptomatic at all. These patients are usually brought to attention because of their bed partner's descriptions of snoring and concerns about not breathing. This has increased the demands on in-lab polysomnography, still a limited resource, and prompted alternative strategies for diagnosing sleep apnea.

Intermittent piece or continuous positive airway pressure CPAP

Spontaneous breathing is allowed for increasingly prolonged periods with a rest on mechanical ventilation in between. The use of a 'T' piece for longer than 30min may lead to basal atelectasis since the endotracheal tube bypasses the physiological PEEP effect of the larynx. It is therefore common to use 5cmH2O CPAP as spontaneous breathing periods get longer. In the early stages of weaning, mechanical ventilation is often continued at night to encourage sleep, avoid fatigue and rest respiratory muscles.

What Is The Appropriate Apneahypopnea Index Definition Of Obstructive Sleep Apnea By Portable Monitoring

Historically, hypopneas (decreased airflow) have been used to characterize OSA and studies have suggested that hypopneas may have the same clinical significance as apneas in many patients (63). However, the standard method of measuring airflow with a thermistor may leave many hypopneas unrecognized by this technique (13). In addition, partial upper airway obstruction that leads to increased amplitude Methods to capture more subtle hypopneas and measure airflow more quantitatively have become available. These currently focus around nasal pressure measurement which is an indirect measure of airflow and more sensitive than thermistors (13). Nasal pressure has been favorably compared against pneumotachograph airflow in OSA and appears more accurate than thermistor airflow (65,66). In addition, the use of an esophageal balloon or tube to measure intrathoracic pressure swings is recommended to determine the presence of RERAs (13). Based on this newer technology, definitions of hypopnea and...

Continuous Positive Airway Pressure Therapy See Also Chapter

CT and MRI techniques have shown significant increases in upper airway caliber during wakefulness with the use of CPAP in normals and patients with OSA (19,26,42,149,150). The predominant change in airway dimension with the application of CPAP is an increase in the airway's lateral axis (Figs. 11-14). A dose-dependent relationship between increasing CPAP settings (up to 15 cm H2O) and airway volume, airway area, and lateral airway dimension has been observed in normal subjects (42). Thinning of the lateral walls has shown in an MRI study to be inversely related to the CPAP level used (26). The administration of CPAP has little influence on the anteroposterior configuration of the airway. But CPAP significantly increases upper airway caliber and decreases airway edema.

Continuous positive airway pressure

Continuous positive airway pressure (CPAP) is the addition of positive pressure to the expiratory side of the breathing circuit of a spontaneously ventilating patient who may or may not be intubated. This sets the baseline upper airway pressure above atmospheric pressure, prevents alveolar collapse and possibly recruits already collapsed alveoli. It is usually administered in increments of 2.5cmH2O to a maximum of 10cmH2O and applied via either a tight-fitting face mask (face CPAP), nasal mask (nasal CPAP) or expiratory limb of a 'T' piece breathing circuit. A high flow (i.e. above peak inspiratory flow) inspired air-oxygen supply, or a large reservoir bag in the inspiratory circuit, is necessary to keep the valve open. CPAP improves oxygenation and may reduce the work of breathing by reducing the alveolar-to-mouth pressure gradient in patients with high levels of intrinsic PEEP. Transient periods of high CPAP (e.g. 40cm H2O for 40s) may be a useful manoeuvre for recruiting collapsed...

Continuous Positive Airway Pressure and Central Apnea

Regardless of the mechanism, nasal CPAP has been documented to be effective in eliminating both mixed and obstructive apneas (15). Some central apneas (see Chapter 19), particularly those observed in patients with predominantly obstructive events, are also eliminated by nasal CPAP (15). Clearly, some central apneas are associated with increased upper airway resistance and it could be argued that it is better to consider apnea classification as being CPAP responsive or CPAP nonresponsive. CPAP may also be effective in controlling central apneas associated with cardiac failure (see section Continuous Positive Airway Pressure and Cardiac Failure). In some instances, CPAP alone will not control severe mixed central and obstructive apneas and adjunctive entrainment of low concentrations of carbon dioxide, with CPAP, or the use of other noninvasive ventilatory techniques, may further reduce the respiratory disturbance index (RDI) in such individuals (16).

Initiation of Continuous Positive Airway Pressure in the Home Setting

There may be theoretical economic advantages from starting CPAP at home and avoiding a formal in-laboratory polysomnographic (PSG) CPAP titration. However, outcome studies showing true cost versus benefit analyses are not available. Current reviews and guidelines do not advocate home commencement of CPAP, particularly using auto-titrating devices (46). This is a controversial area as it implies a major change of practice in sleep centers. One study has observed poorer CPAP adherence in patients assessed only with respiratory monitoring (47) another study has shown poorer adherence outcomes with patients having initial unattended CPAP PSG at home (48). Conversely, equivalence of outcomes between in-laboratory and home-based studies have also been reported (19,30,49). Other workers have found reasonable utility with unattended in-hospital CPAP titration in patients with mild-to-moderate disease but not severe OSA (50). Some studies have suggested that equations can be determined which...

Long Term Use of Continuous Positive Airway Pressure

Covert objective monitoring of CPAP has demonstrated that adherence with nasal CPAP is substantially less than in studies where adherence is reported on the basis of subjective patient data (86), with only 46 of patients having used nasal CPAP equal to or greater than four hours for 70 of the observed nights. Adherence at one month predicted adherence at three months (86,91). Other studies have generally confirmed this degree of usage. Published CPAP follow-up cohorts are biased by the same factors that affect clinical trials of pharmaceuticals. Patient populations are often highly selected for intellectual capacity, geographical access, health consciousness, and lack of comorbidities all factors that may affect adherence in the real world. More large open studies from a variety of sleep clinics (92) would provide better information on true CPAP adherence. Attempts to improve CPAP adherence have involved technical refinements of devices, including the implementation of...

Management Of Continuous Positive Airway Pressure Failure

What constitutes CPAP failure This is a subjective issue and, in the absence of hard data addressing the diverse health consequences of varying exposures of CPAP for sleep apnea, practice varies from center to center. CPAP failure certainly includes those cases with continuing significant sleepiness or other sequelae of sleep apnea. An objective measure of CPAP failure (as measured by usage of the CPAP therapy) has been defined (a priori) as the use of CPAP for less than four hours per night on 70 of the nights and or lack of symptomatic improvement (86). This figure equates to a minimum acceptable average usage of only 2.7 hours per night. This figure was essentially an arbitrary threshold, based on the authors' expert clinical opinion (86). Some have adopted a policy of reclaiming loaned CPAP machines if use is less than two hours per night (92). Sometimes patients will use CPAP effectively but only for part of their total sleep time. This may represent CPAP failure depending on the...

Health Outcomes And Continuous Positive Airway Pressure

Over the past decade, there have been a number of RCTs that have demonstrated the effectiveness of CPAP in improving neurobehavioral outcomes such as daytime sleepiness and blood pressure, in patients with moderate-to-severe OSA (99,105,106). Benefits have also been demonstrated in OSA subgroups such as those patients with coincident Alzheimer's disease and OSA (107). Different parameters of sleep patterns improve over a defined time scale but mostly within one month of establishing CPAP in severe OSA patients (33). Depression symptoms associated with untreated OSA may ameliorate with successful institution of CPAP therapy (108). However, the evidence for benefits is less clear in patients with more severe disease without significant sleepiness (98) or in patients with mild disease (109). Researchers have employed either an oral placebo or sham sub-therapeutic CPAP as control arms in RCTs examining the effects of CPAP. There is no perfect placebo for CPAP and each approach has...

Continuous Positive Airway Pressure And Cardiac Failure

Sleep apnea of both central and obstructive nature is common in patients with cardiac failure (123). It has been suggested that OSA may cause or exacerbate ventricular dysfunction by a number of mechanisms. These include increasing left ventricular afterload through the combined effects of elevations in systemic blood pressure and the generation of exaggerated negative intrathoracic pressure, and by activating the sympathetic nervous system through the influence of hypoxia and arousals from sleep (124). Use of nasal CPAP in OSA and in cardiac failure patients for one month (125) and three months (126), respectively, leads to improvement in left ventricular function. A number of studies have reported the presence of central sleep apnea in patients with ventricular dysfunction. Central apnea appears to be an adverse prognostic factor in such patients (127). Studies, including some with a randomized controlled design, have demonstrated improvement in various endpoints, including reduced...

Central Sleep Apnea See Also Chapter

Central sleep apnea (CSA) is a sleep-related breathing disorder that requires careful consideration when evaluating treatment options. The etiology of CSA may impact treatment decision algorithms and must be closely evaluated before determining the appropriate modality of therapy. Patients with alveolar hypoventilation or idio-pathic CSA will likely benefit from PAP therapy, especially in patients with waking hypercapnea with worsening hypoxemia during sleep, as well as patients complaining of excessive daytime sleepiness. Frequently, patients who have been diagnosed with idiopathic CSA will in fact have secondary causes of central events, including unrecognized upper airway obstruction causing nasopharyngeal or non-nasal pharyngeal reflexive central events (51,52). PAP clearly has a role in treating these patients whereas patients with true idiopathic CSA prove to be somewhat more difficult to appropriately treat. While adequate ventilation may be accomplished with a pressure- or...

Medications Or Substances That May Worsen Obstructive Sleep Apnea Or Its Symptoms See Also Chapter

Effective, nonpharmacologic treatment of OSA, particularly CPAP, has been shown to improve comorbid medical conditions (e.g., heart failure, hypertension) and decrease healthcare resource utilization (11,24). Effective CPAP can also improve the safety of concomitant medication that can worsen OSA such as sedative hypnotics, anesthetics, analgesics, anticonvulsants, antihistamines, and antipsychotics (25,26). Table 2 lists medications that may be dangerous for individuals with sleep apnea, the mechanism of worsening apnea, and any special considerations for use. Even though CPAP can improve the safety of these concomitant medications, clinician monitoring with polysomnography in a sleep lab may be needed to facilitate TABLE 2 Medications or Substances That May Worsen Obstructive Sleep Apnea TABLE 2 Medications or Substances That May Worsen Obstructive Sleep Apnea

Nasal Continuous Positive Airway Pressure

Nasal CPAP treatment has been used in the initial description of UARS (2). It was demonstrated that CPAP was able to resolve inspiratory flow limitation by increasing the upstream pressure. Sleepiness as assessed by the multiple sleep latency test (MSLT) was also significantly improved. However, in this patient sample as well as in samples which followed (55,61,62) adherence with CPAP treatment continues to be a problem. Sleep-onset insomnia may be an important factor for this low adherence in that inspiratory load compensation at sleep onset may not be the only reason for the development of sleep instability at sleep onset. The addition of the therapeutic interface may add to sleep-onset disturbance and aggravate sleep-maintenance insomnia. Despite the limited adherence with CPAP in the treatment of UARS, it still constitutes the first line of treatment. Side effects are limited and, unlike surgery, CPAP does not result in potential side effects that are nonreversible. The advantage...

Effect of Sleep Apnea on Epilepsy

OSA causes disruption and fragmentation of night sleep with intermittent hypox-emia. This provokes a state of chronic sleep deprivation that could decrease the seizure threshold in epileptic patients such that mild or even asymptomatic OSA might cause seizure exacerbation. Further, it is possible that epileptic patients have a low tolerance for intermittent hypoxemia thereby acting as a potential trigger for seizures in susceptible individuals. Also, disruption and fragmentation of the sleep architecture caused by the respiratory events provides a substrate for frequent transitional sleep states, for example, sleep stage changes, and arousals, which also activate epileptogenesis in susceptible individuals. Thus coexistent sleep apnea in patients with epilepsy can worsen seizure frequency, be responsible for poor response to conventional antiseizure medications and even lead to refractory seizures. Additionally, OSA can contribute further to impairment in daytime functions and quality...

Effect of Insomnia on Sleep Apnea Treatment Outcomes

In addition to the role of insomnia in prevalence and diagnosis of sleep apnea, it must also be appreciated that it can have profound effect on treatment outcomes as well. For those practicing clinical sleep medicine, it is not difficult to understand that associated complaints of insomnia or depression, which are common in patients with SDB may contribute significantly not only to initial difficulty with acceptance and adjustment to CPAP therapy, but also contribute to suboptimal adherence for continued long-term use. This has been addressed to some extent by Engleman and Wild (44). Krakow et al. (45) demonstrated clinical cures or near-cures with combined cognitive behavioral therapy and CPAP treatment for SDB in 15 out of 17 subjects with SDB and chronic insomnia. It must also be noted that sedatives and hypnotics used for insomnia may have adverse effects on sleep apnea (46).

Sleep Apnea And Depression

OSA may affect more than 50 individuals over the age of 65 while depressive symptoms may be encountered in as much as 26 of a random community population of the elderly (4). As in adults apnea may have a profound effect on the pediatric age group as well (47,48) but may be difficult to recognize due to the subtle nature of the disorder, lack of daytime sleepiness, behavior problems including inattention, hyperactivity, and aggressiveness suggestive of attention-deficit hyper-activity disorder. In clinical practice the presence of depressive symptoms in patients with OSA are often noted and treated pharmacologically. On the other hand, the possibility of sleep apnea is not considered routinely in the evaluation of the depressed patient.

Relation Between Obstructive Sleep Apnea and Depression

OSA leads to EDS, fatigue, and impairment in daytime functioning in various neu-ropsychological, cognitive, behavioral, and social domains. Thus the symptoms of OSA can mimic symptoms of an MDD, leading to an erroneous diagnosis of depression, complicating the diagnosis, and management of both conditions. For over two decades clinical studies have suggested a relationship between OSA and depression. In recent years, a number of studies have confirmed an increasing prevalence and severity of depression in patients with OSA. Sharafkhaneh et al. (49) studied the prevalence of comorbid psychiatric conditions in 4,060,504 Veterans Health Administration beneficiaries with and without sleep apnea. They found a statistically significantly greater prevalence of depression (21.8 ), anxiety (16.7 ), PTSD (11.9 ), psychosis (5.1 ), and bipolar disorders (3.3 ) in patients with sleep apnea as compared with patients without sleep apnea. While several investigators have reported an increasing...

Therapy for Obstructive Sleep Apnea Effects upon Cardiovascular Disease

CPAP remains the most effective therapy for OSA. Although adherence with CPAP therapy can be challenging, it is widely accepted that adherence with this therapy will control OSA at least 90 of the time. Two studies have assessed the relative benefits of therapy with effective versus subtherapeutic, or sham, CPAP upon blood pressure (76,77). Both studies demonstrated that effective CPAP therapy significantly reduced nocturnal and diurnal blood pressures in comparison to sham CPAP therapy. Two studies confirm that CPAP therapy in patients with OSA and concurrent congestive heart failure can also improve both cardiac function and quality of life. Kaneko et al. (78) treated 12 OSA patients with congestive heart failure for one month with CPAP. Treated patients demonstrated a 10 mmHg reduction in daytime systolic blood pressure in conjunction with an improvement in left ventricular ejection fraction from 25 to 34 . A control group of 12 similar patients demonstrated no significant changes....

Obstructive sleep apnea syndrome

This sleep disorder occurs in 5 to 15 of adults. It is characterized by recurrent discontinuation of breathing during sleep for at least 10 seconds. Abnormal oxygen saturation and sleep patterns result in excessive daytime fatigue and drowsiness. Loud snoring is typical. Overweight, middle-aged men are particularly predisposed to sleep apnea. Weight loss can be helpful in obese patients. 2. Diagnosis is by polysomnography. Use of hypnotic agents is contraindi-cated since they increase the frequency and the severity of apneic episodes.

Postoperative CPAP administration

CPAP delivered during the postoperative period increases lung volumes and systemic oxygenation. Even intermittent CPAP allows as good a recovery of vital capacity and inspiratory reserve volume as other types of chest physiotherapy. Postoperative atelectasis formation and pneumonia can be decreased.

Noninvasive facemask CPAP to prevent intubation

In some patients with acute respiratory insufficiency mask CPAP therapy has been used as the sole mode of ventilatory support (Fig 1). This type of therapy is also effective in some trauma patients presenting with hypoxemia, thereby avoiding endotracheal intubation. Furthermore, spontaneous breathing through a CPAP face mask results in a better Pao2 after coronary artery bypass surgery. CPAP applied to patients presenting with postextubation hypoxemia persisting after chest physiotherapy can also be treated satisfactorily with CPAP alone at a level of 5 to 10 cmH 2O. Carbon dioxide retention producing hypercarbia can be seen during mask CPAP ventilation and has been regarded as a relative contraindication to its use. This should not prevent a therapeutic trial. However, this is acceptable only in situations where adequate staffing and capability to measure arterial blood gases are available so that these patients can be monitored very closely. Indeed, non-invasive ventilatory support...

Survey Of Sleep Apnea In The

Although medical science first described OSA in 1973 (7), the first reference to OSA in any reported legal decision appeared seven years later in 1980 in the social security benefits case of Parks v. Harris (8). Claimant Parks sued to overturn his benefits denial on the basis of his recently diagnosed sleep apnea. A vocational expert testified that if Parks suffered from uncontrolled somnolence due to a sleep disorder, then Parks was likely disabled for purpose of the Social Security Act (8). Because continuous positive airway pressure (CPAP) treatment for OSA appeared a year later in 1981 (9), it is not surprising that the case failed to consider disease treatment as a factor in determining disability status. Legal recognition of OSA as a disease grew slowly after Parks. Only 12 reported cases followed in the entire decade of the 1980s. The law's notice of OSA has increased significantly since 1990, with over 753 additional reported and nonre-ported federal and state cases mentioning...

Physicians Duties to Diagnose and Treat Obstructive Sleep Apnea

In March 1986, a family practice resident at the defendant hospital examined Mr. Cornett, who complained of chest pains and sleep apnea. The resident referred the patient to the hospital's endocrinology clinic for acromegaly. The hospital failed to schedule the appointment (46). Seven months later, Mr. Cornett presented at the hospital's emergency room believing he was in a diabetic coma. He again explained his four- to five-year history of sleep apnea, and Mr. Cornett fell asleep during his diabetes testing, which proved negative. Concerned about Mr. Cornett's somnolence, the emergency room physician ordered arterial blood gas testing, which indicated elevated carbon dioxide levels and low oxygen levels. The emergency room physician testified at trial that Mr. Cornett requested treatment for sleep apnea because he had fallen asleep while driving. The doctor diagnosed acromegaly and sleep apnea. To confirm the diagnosis of acromegaly, the physician ordered diagnostic tests at the...

Effect of Treatment of Sleep Apnea on Depression

The belief that depression is an actual phenomenon seen increasingly in patients with sleep apnea is well documented by numerous studies showing significant improvement in depression, daytime sleepiness, and quality of life following treatment of sleep apnea with CPAP (58-63). Schwartz et al. (62) demonstrated this effect in patients with RDI 15 and in patients with and without antidepressant pharmacotherapy. Hilleret et al. (64) reported an interesting case of a 50-year-old man with no previous history of bipolar disorder, diagnosed with severe depression and resistant to seven weeks of treatment with venlafaxine and trazodone. A diagnosis of OSA and use of CPAP was followed a few days later by a mood switch to first hypomania and then a mixed disorder. Thus OSA might not only be associated with a depressive syndrome but its presence may also be responsible for failure to respond to appropriate pharmacological treatment. Furthermore, undiagnosed OSA might be exacerbated by adjunct...

Uvulopalatopharyngoplasty Uvulopalatal Flap

Redundant Pharyngeal Tissue

Ikematsu (57) is credited with developing the uvulopalatopharyngoplasty (UPPP) for the treatment of habitual snoring. This technique was later adapted to treat SDB and snoring by Fujita et al. (29) in 1981. Since this time, multiple variations have FIGURE 2 (See color insert.) Uvulopalatopharyngoplasty. (A) This patient demonstrates tonsillar hypertrophy, an elongated uvula and redundant tissue of the lateral pharyngeal wall resulting in a narrowed airway space. (B) Removal of the tonsils, lateral pharyngeal wall mucosa, and soft palate mucosa has enlarged the airway. (C) Excised surgical specimen. FIGURE 2 (See color insert.) Uvulopalatopharyngoplasty. (A) This patient demonstrates tonsillar hypertrophy, an elongated uvula and redundant tissue of the lateral pharyngeal wall resulting in a narrowed airway space. (B) Removal of the tonsils, lateral pharyngeal wall mucosa, and soft palate mucosa has enlarged the airway. (C) Excised surgical specimen.

Continuous Positive Airway Pressure Mode of Action

The concept of CPAP in managing respiratory failure is relatively old (11). However, the original experiments using CPAP in sleep apnea followed from the notion that closure of the oropharynx in OSA results from an imbalance of the forces (12) that normally keep the upper airway open. In the first description of CPAP use for treatment of OSA in 1981 (2), it was suggested that nasal CPAP acts as a pneumatic splint to prevent collapse of the pharyngeal airway, by elevating the pressure in the oropharyngeal airway and reversing the transmural pressure gradient across the pharyngeal airway (Fig. 1). This notion has been subsequently confirmed by a number of studies which either demonstrate the pneumatic splint effect by endoscopic or other imaging, or show that CPAP does not increase upper airway muscle activity by reflex mechanisms (13). Detailed magnetic resonance imaging has confirmed that CPAP increases airway volume and airway area, and reduces lateral pharyngeal wall thickness and...

Relation Between Sleep Apnea and Insomnia

Looking at the reverse picture, what is the prevalence of SDB in insomnia patients Research shows that these numbers are similarly high. Guilleminault et al. (37) documented SDB in 83 of 394 postmenopausal women complaining of chronic insomnia using PSG studies with pressure transducer and esophageal manometry. The SDB was classified mainly in the low AHI range. Similarly, Lichstein et al. (38) reported sleep apnea in 29 to 43 of a recruited sample of older individuals with (41) reported similar findings in another study in which 42 of 157 sleep apnea patients had at least one problematic insomnia symptom, with a prevalence of sleep onset insomnia of 6 , sleep maintenance insomnia of 26 , and early morning awakening in 19 . Patients with sleep onset insomnia had a significantly lower AHI and arousal index. There was a significant inverse relationship between sleep onset insomnia and measures of daytime sleepiness. On the contrary, subjects with repeated awakenings had more severe...

Relation Between Sleep Apnea and Periodic Limb Movement During Sleep

Researchers have tried to assess the role of PLMS in the development of EDS in patients with OSA before treatment and in residual sleepiness in successfully CPAP-treated patients. The appearance of PLMS or enhancement with CPAP has also been reported (101). Haba-Rubio et al. (95) compared PSG, MSLT, and ESS in 57 consecutively diagnosed patients with severe OSA, before and after one year of treatment with CPAP. A total of 38.5 had significant PLMS in absence of apneas with CPAP. They did not find any correlation in the PLMS patient group between PLM index, ESS score, and mean sleep latency by MSLT, before or after treatment with CPAP. It may be mentioned that in the absence of esophageal pressure monitoring during PSG, RERAs may not be entirely evaluated or eliminated with CPAP, and or frank apneas or hypopneas may be converted to RERAs by CPAP resulting in persistence of respiratory-related leg movements that are misinterpreted as PLMS. Also, in the process of CPAP titration,...

Physicians Duty to Obtain Patients Informed Consent for Obstructive Sleep Apnea Surgery

Physicians have a general duty to provide their patients with sufficient information concerning their diagnosis, the nature and reason for the proposed treatment, the risks or dangers involved, the prospects for success and alternatives methods of treatment and the risks and benefits of such treatment (49). An unpublished decision of the Tennessee Court of Appeals discusses a physician's duty to inform a sleep apnea patient of CPAP treatment before performing uvulopalatopharyngo-plasty (UPPP) (50). The case involved a board-certified otolaryngologist who scheduled a nonurgent tonsillectomy for his 49-year-old male patient. The patient asked whether the procedure would help his snoring. Examining the patient further, the physician diagnosed mild sleep apnea and recommended surgical treatment. The patient testified at trial that he heard the doctor say that the doctor would trim his uvula, but the physician's notes indicated surgery discussed, risks, and complications, schedule...

Regulatory Screening for Obstructive Sleep Apnea in Safety Sensitive Positions

Because sleep apnea is a relatively common medical condition which, if untreated, contributes to daytime sleepiness and impaired job performance (2), public policy suggests that certain industries directly affecting public safety screen employees in safety-sensitive positions for sleep apnea or other fatigue-enhancing sleep disorders. Thus, each of the air, rail, ferry, distance trucking, and nuclear power industries have or propose regulatory fitness for duty programs addressing OSA. Individuals with suspected or untreated sleep apnea (symptoms of snoring and hyper-somnolence) should be considered medically unqualified to operate a commercial vehicle until the diagnosis has been dispelled or the condition has been treated successfully. In addition, as a condition of continuing qualification, commercial drivers who are being treated for sleep apnea should agree to continue uninterrupted therapy as long as they maintain their commercial driver's license. They should also undergo yearly...

Continuous positive airways pressure CPAP

Cpap And The Pressure Curve

The application of positive pressure in a closed breathing system through spontaneous breath cycles is known as CPAP it increases mean airway pressure and may decrease the work of breathing by moving tidal ventilation to a more compliant part of the volume-pressure curve ( Fig 1). CPAP acts as a pneumatic splint, promoting alveolar re-expansion in areas of atelectasis, and may prevent the need for endotracheal intubation and conventional ventilation in certain patients. The hemodynamic effects of CPAP are dependent upon myocardial filling pressures and underlying cardiac function. Cardiac index improves in patients with left ventricular failure by reducing pre- and afterload, but falls in hypovolemic states. Mild lung injury may respond to CPAP, but tracheal intubation and mechanical ventilation are usually required. Fig. 1 Pulmonary pressure-volume relationship. Lung compliance (the change in lung volume per unit alteration in pressure) is improved with increasing lung volume. CPAP...

CPAP and intracranial pressure regulation

Cpap And Intracranial Pressure

Some concern may arise when CPAP is delivered to patients with increased intracranial pressure. Positive intrathoracic pressure may indeed decrease venous return and act as a resistive component to venous return from the head, thus increasing intracranial venous pressure and eventually parenchymal intracranial pressure. Decreased systemic venous return may also decrease cardiac output and blood pressure which will decrease oxygen delivery and perfusion to the already jeopardized cerebral tissues. A CPAP level of 10 to 15 cmH2O increases cerebrospinal fluid pressure by 3 to 5 cmH2O. The use of CPAP greater than 5 cmH2O in this type of patient must be accompanied by frequent monitoring of the patient's neurological status. McGuire et, ( ( demonstrated that, compared with T-piece breathing, CPAP reduces the total inspiratory work without negative effects on cerebral perfusion pressure. The reduction in the work of breathing appears to be related to the minimization of the...

Relation Between Sleep Apnea and Parasomnias

OSA-induced arousals from REM sleep may mimic RBD ( pseudo-RBD ), with immediate post-arousal dream-related, complex or violent behaviors. Since OSA is a very common sleep disorder and OSA is most severe during REM sleep, this form of parasomnia may be more prevalent than currently believed. Iranzo and Santamaria (112) reported 16 patients presenting with dream-enacting behaviors and unpleasant dreams, in whom VPSG excluded RBD and was diagnostic of severe OSA, also demonstrating that the reported abnormal behaviors occurred only during apnea-induced arousals. Further, CPAP therapy eliminated the abnormal behaviors, unpleasant dreams as well as the snoring and daytime 5. Nasal CPAP therapy of OSA may result in SWS rebound with emergent confusional arousals, sleepwalking, sleep terrors, or a combination thereof. Millman et al. (119) report two episodes of sleepwalking in an adult on nasal CPAP during SWS rebound.

Pharmacologic Therapy Of Obstructive Sleep Apnea Drugs that Increase Respiratory Drive See Also Chapter

Patients with OSA have compromised upper airway anatomy making the airway more vulnerable to collapse (76-80). During wakefulness, reflex mechanisms lead to increased upper airway dilator muscle activity keeping the collapsible part of the upper airway open (79,81). However, with sleep onset, these reflex mechanisms are lost resulting in a fall in upper airway dilator muscle activity, and upper airway collapse in those anatomically susceptible (82). A variety of respiratory stimulants have been used to increase upper airway muscle activity during sleep in an attempt to treat patients with sleep apnea. Thus far, the results have been disappointing and no drug can currently be recommended. The prevalence of sleep apnea increases after menopause, suggesting that female hormones may play a protective effect on sleep-disordered breathing (83). Medroxyprogesterone (Cycrin , Provera ) is a respiratory stimulant and has been used to treat OSA by increasing central neural drive to the...

Continuous Positive Airway Pressure Reimbursement In The United States

Patients with suspected OSA are mandated to undergo a diagnostic study in a facility-based polysomnography laboratory with a minimum of 120 minutes of recorded sleep. This stipulation was largely inserted to emphasize the CMS bias against empiric or portable sleep study diagnosis of OSA. An apnea-hypopnea index (AHI) of 15 events per hour is required in order to qualify for coverage, unless the patient has symptoms of hypersomnolence or cardiovascular consequences such as hypertension, in which case they need only demonstrate five events per hour. Access to alternative treatment such as auto-titration CPAP (APAP) or bilevel PAP (BPAP) is surprisingly easy since the criteria are not specified for APAP at all because the reimbursement is equivalent to simple CPAP and the only stipulation necessary to utilize BPAP is for the physician to stipulate that CPAP has been tried and proven ineffective. The ineffectiveness of the CPAP can be on the basis of intolerance or poor response and the...

Laboratory Diagnosis Of Sleep Apnea

Obstructive Sleep Apnea Event

Attended laboratory-based polysomnography has been and remains a de facto gold standard for diagnosis of sleep-disordered breathing, even though the utility of a single overnight recording for diagnosis or exclusion of significant sleep has never been clearly addressed in the literature. It is clear that there is considerable night-to-night variability in AHI particularly, when the AHI is low (29-32). Standard overnight polysomnography involves (i) recordings of sleep-related electroencephalography (EEG), electromyography (EMG) of the chin and leg muscles, electrooculography (EOG), and electrocardiography (ECG) (ii) oxygen saturation and (iii) measures of respiratory effort and airflow. Examples of typical polysomnography are shown in Figure 1. This figure shows clear-cut repetitive obstructive apneic events and for these patients a diagnosis of sleep apnea may be established on more simple recordings. This has led to a number of recording devices ranging from simple oximetry, snoring...

Continuous Positive Airway Pressure and Adherence to Therapy

Nasal CPAP is the therapy of choice for OSA. While CPAP therapy is effective for resolving upper airway obstruction, adherence to therapy is overall poor, from 46 to 89 depending on the definition of adherence (85-87). Results of studies to determine the role of gender in predicting adherence to CPAP are conflicting, with men more likely to be adherent to therapy in some (88,89), while women are more likely in others (90). Measures to improve adherence, including warm air, humidification, and education, may improve CPAP adherence (91,92), although differential effects of these interventions by gender have not been investigated.

Continuous Positive Airway Pressure And Cardiovascular Outcomes

The present evidence for a significant protective or ameliorating effect of CPAP against adverse cardiovascular outcomes in OSA is mixed, especially in the management of mild OSA. In a large observational cohort study, there was an increased risk of stroke and death, which persisted after allowing for other risk factors including hypertension however, CPAP use did not appear to provide protection against adverse outcomes in this study (112). In contrast, in case-control studies, there is some evidence of cardiovascular benefit from nasal CPAP therapy in severe sleep apnea. Long-term CPAP therapy seemed to provide a protective benefit against death from established cardiovascular disease though there was no difference in the development of new cases of hypertension, cardiac disorder or stroke between CPAP-treated and untreated groups (113). In a large Spanish study patients with untreated severe OSA had a higher incidence of both fatal and nonfatal cardiovascular events than untreated...

Reactive Oxygen Metabolites ROMs as an Index of Oxidative Stress in Obstructive Sleep Apnea Patients

Gourgoulianis OBSTRUCTIVE SLEEP APNEA (OSA) SYNDROME Obstructive sleep apnea syndrome, a common disorder characterized by repetitive pharyngeal collapse during sleep, is receiving increased attention because of convincing data showing important neurocognitive and cardiovascular sequelae (1-9). Dilator muscles and soft tissues are crucial to maintenance of pharyngeal patency since there is no bony support in the region behind the tongue and soft palate (10-12). Change in the activation of pharyngeal dilator muscles with the onset of sleep is the seminal event in individuals susceptible to pharyngeal collapse (13). Most OSA patients have an anatomically small upper airway with augmented pharyngeal dilator muscle activation maintaining airway patency while awake, but not during sleep. However, individual variability in several phenotypic characteristics may ultimately determine who develops apnea and how severe the apnea will be. These include (1) upper airway...

The Physical Examination For Adult Sleep Apnea

Abbreviations NSAIDs, nonsteroidal anti-inflammatory drugs OSA, obstructive sleep apnea. Many population-based studies have shown that hypertension is independently associated with sleep-disordered breathing studies (105-110). Blood pressure has been integrated into several clinical prediction rules for sleep apnea (4,12,17,18). One study found hypertension to have an adjusted OR of 11.9 for an AHI 30 (17). More recently, a causal relationship has been suggested by a number of studies that have shown an improvement in hypertension with sleep apnea treatment (70-72). Although a number of different measures of obesity have been used in clinical studies the BMI is probably the best and certainly the most practical. It has been found to be strongly associated with the presence of sleep apnea (4,12-15,18,108,111-115) and has been incorporated into a number of clinical prediction rules (4,13,14,18) for this disorder (see also Chapter 2). Neck circumference is, in part, a surrogate for...

Baseline Indicators Influencing Continuous Positive Airway Pressure Usage

Identification of claustrophobia prior to initiating CPAP using a 15-item Fear and Avoidance Scale predicted lower CPAP adherence at three months (95). Remedial measures to address such identified claustrophobia, logically, may improve adherence in those subjects. A patient's reporting initial problems after the first night of CPAP (using auto-titration) was the most powerful predictor of lower hours of CPAP on time at one-month follow-up (88). Recent life events and living alone were less robust predictors of adherence. In the same study, pretreatment measures of anxiety or depression failed to predict one-month adherence. Contrariwise, in another study low CPAP adherence predicted high anxiety scores, and low CPAP adherence and excessive daytime sleepiness predicted high depression scores in a questionnaire-based study of OSA patients (96). Predominant nose breathing rather than mouth breathing at outset predicted better adherence with CPAP at one year follow-up in moderate-severe...

Relation Between Sleep Apnea and Restless Legs Syndrome

RLS and OSA are two common sleep disorders but there is not much in the peer-reviewed literature to define or evaluate a possible relationship between the two. In a study by Lakshminarayanan et al. (93) a prevalence of clinically significant RLS with symptoms at least two to three days per week in 8.3 was reported in 60 sequentially polysomnographically studied patients with clinically significant sleep apnea (RDI 10). This figure is, however, not dissimilar to the prevalence figure for RLS, although age-matched spouses used as controls showed a prevalence of RLS at 2.5 . In a study Rodrigues et al. (94) observed improvement in sleep apnea and RLS symptoms in 17 patients with coexistent RLS and OSA following CPAP therapy. Coexistence of RLS symptoms can have significant impact on the adjustment, tolerance, and adherence to CPAP treatment of OSA. Similarly, arousals and sleep fragmentation from OSA can cumulatively worsen symptoms secondary to RLS.

Continuous Positive Airway Pressure Cost And Reimbursement Issues

In Australia, for the majority of those requiring it, the cost of CPAP is borne directly by the patient, or indirectly by the patient through his her coverage in a health insurance fund. Such funds, and wherein medical devices such as CPAP are covered under the specific scheme, reimburse approximately 30 to 50 of retail cost. Percentage reimbursement can be significantly better, even 100 , in smaller boutique health insurance schemes. Approximately 43 of Australians (2006 statistics) carry some level of private health insurance. Australian patients requiring CPAP who do not carry private health insurance must meet the full cost of purchase costs approximate AUD 1300 to 1500 (CPAP machine, mask with tubing). Many patients will not readily acquire CPAP because of this financial hurdle. For impecunious patients requiring CPAP, there are schemes across all states in Australia, administered by state health departments through public hospitals, whereby after medical criteria for CPAP are...

Peep Cpap and autoPEEP

Passive expiratory airflow dynamics and the necessity for long expiratory times have lead to the concept of 'auto-PEEP' and to consideration of the potential gains that might be achieved by the addition of PEEP or continuous positive airways pressure (CPAP). Although there is anecdotal evidence supporting the use of PEEP and CPAP, undesirable effects on the cardiovascular system, particularly in a volume-depleted patient, represent a significant hazard. If one of the major goals is to avoid overdistention of the alveoli and minimize the effects on the cardiovascular system, PEEP offers little or no benefit during controlled mechanical ventilation of asthma. If PEEP is required for purposes of oxygenation, its effect on lung volume must be assessed and compensated for by reductions in VT or respiratory rate. In general, improved oxygenation, together with relief of mucus plugging, will follow reversal of bronchospasm.

Hypercapnic Central Sleep Apnea

The loss of wakefulness stimulus to breathe is associated with decreased alveolar ventilation and increased arterial partial pressure of carbon dioxide (Pco2). However, the manifestations depend on the underlying clinical condition. Therefore, removal of the wakefulness stimulus to breathe results in profound hypoventilation in patients afflicted with conditions associated with impaired diurnal ventilation, such as neuromuscular disease or abnormal respiratory mechanics. Hypoventilation manifests as a central apnea or hypopnea the ensuing transient arousal partially restores alveolar ventilation until sleep resumes. Thus, central apnea under these circumstances represents nocturnal ventilatory failure in patients with marginal ventilatory status or worsening of existing chronic ventilatory failure. Patients with this condition have blunted chemoreflex responsiveness, either due to weakness of the respiratory muscles or due to impaired pulmonary mechanics rather than diminished central...

CPAP Airway 3D Volumes

Polysomgnography Diagrams

FIGURE 4.11 Volumetric magnetic resonance imaging reconstruction of the upper airway in a normal subject with progressively greater continuous positive airway pressure (CPAP) (0 to 15 cm H2O) settings. (See p. 78) FIGURE 4.11 Volumetric magnetic resonance imaging reconstruction of the upper airway in a normal subject with progressively greater continuous positive airway pressure (CPAP) (0 to 15 cm H2O) settings. (See p. 78) FIGURE 11.2 Uvulopalatopharyngoplasty. (See p. 19S) FIGURE 11.2 Uvulopalatopharyngoplasty. (See p. 19S) FIGURE 15.4 (A) Child awake and (B) asleep while wearing a continuous positive airway pressure mask during polysomnography monitoring in a sleep laboratory. Note wires connected to recording electrodes that are placed on the face and on the scalp, which are hidden beneath the head wraps used to prevent dislodgement of electrodes. FIGURE 15.4 (A) Child awake and (B) asleep while wearing a continuous positive airway pressure mask during polysomnography monitoring...

Relation Between Sleep Apnea and Narcolepsy

BMI, which predisposes to the development of OSA. On average, narcoleptics have a BMI 10 to 20 higher than the normal population (70,71). A reduced metabolic rate, decreased motor activity or abnormal eating behavior have been suggested as possible explanations. SDB is found in 10 to 20 of patients (72). Chokroverty (73) documented repeated apneic episodes in 11 out of 16 narcoleptic subjects. Sleep apnea was predominantly central but obstructive and mixed apneas were also noted. In 1972, Guilleminault et al. (74) reported central sleep apnea in two patients with narcolepsy and later extended this observation and found central and OSA in a large number of patients with narcolepsy (75). Laffont et al. (76) noted sleep apnea (both central and obstructive) in five patients with narcolepsy.

Effect of Treatment of Sleep Apnea on Epilepsy

Several researchers have demonstrated the effect of treating OSA on seizure frequency in patients with epilepsy. In one of the earlier studies, Devinsky et al. (11) showed a clear reduction in seizure frequency in four out of five patients with refractory partial epilepsy and sleep apnea, following treatment of sleep apnea with continuous positive airway pressure (CPAP). Vaughn et al. (22) evaluated response to treatment of sleep apnea in 10 patients with seizures and sleep apnea. Eight patients received CPAP and two patients were treated with positional therapy. Three patients became seizure free, and the others also showed a significant reduction in seizure frequency with treatment of sleep apnea. Malow et al. (23) selected 13 adults and five children from a clinic population based on seizure frequency and risk for OSA. Six out of 13 adults and three out of five children with epilepsy met PSG criteria for OSA. Of these, three adults and one child were treated with CPAP and all four...

Legal Obligations Of Persons With Obstructive Sleep Apnea

Tort law presupposes some uniform standard of reasonable conduct for the protection of others against unreasonable risks (12). As such, persons generally have a duty to conform their conduct in light of the apparent risk (13). Applied to persons suffering from disease, general negligence principles recognize that it is reasonable conduct for such persons to refrain from seeking treatment (14). Nonetheless, the law requires persons with specific types of infections or mental or physical conditions to take reasonable precautions to protect the health and well-being of third parties (15). Thus, persons who are aware of their sleep apnea and its effects on their daytime performance have joined the class of individuals charged with a duty to take reasonable precautions in light of their disease.

Obstructive Sleep Apnea

According to Medicare guidelines, revised in 2002, CPAP is indicated for patients with an apnea-hypopnea index (AHI) 15 events hour (moderate severity), regardless of symptoms and for patients with an AHI 5 and 14 (mild severity) with excessive daytime somnolence, impaired cognition, mood disorders, insomnia or with the comorbidities of hypertension, ischemic heart disease, or stroke (47). However, the Medicare list of acceptable ICD-9 (International Classification of Diseases, ninth revision) codes that support medical necessity which justify the use of polysomnography to screen for and or diagnose sleep-related breathing disorders includes only diagnoses of sleep disturbances or of hypersomnolence, disregarding comorbidities (48).

Complex Sleep Apnea

Central and obstructive apneas may occur in the same individual, either simultaneously within a single breath as a mixed apnea, or as sequential breathing events (33). The majority of OSA patients can be expected to respond favorably to CPAP but CPAP often initially exaggerates central sleep apnea (CSA) and some patients identified as having OSA, develop frequent central apneas and or Cheyne-Stokes respiratory (CSR) pattern after application of CPAP. This is an increasingly recognized but not new clinical problem encountered when patients with significant OSA develop CSA when exposed to CPAP (34,35). These patients that develop new or very prominent CSA during CPAP titration are now referred to as complex sleep In this study, the mean age (near 55 years) and total diagnostic AHI (near 30 events hour) were similar between the groups but there were a few distinguishing features between the patients with OSA versus CompSA. The CompSA patients were more likely to be males (82.4 vs. 63.9 p...

Sleep apnoea

Apnoea is defined as the complete cessation of respiratory airflow for 10 or more seconds. (35 Apnoea can occur during any sleep stage, but is particularly likely to occur during the period of rapid eye movement sleep. It is important to remember that normal people have apnoeic episodes during sleep. When apnoeic events are frequent and prolonged, they lead to chronically disrupted sleep and excessive daytime somnolence. This defines the condition known as sleep apnoea. When severe, sleep apnoea can be complicated by hypoxia, arrhythmias, and heart failure. Sleep apnoea can be central, obstructive, or a mixture of the two. Central sleep apnoea is caused by an abnormal central drive to the respiratory muscles. Congestive heart failure is the most common cause, followed by neurological disorders involving the brainstem and respiratory centres. Obstructive sleep apnoea is more common it is estimated that 4 per cent of middle-aged men are affected. Obesity is a major risk factor, but is...

Sleep apnea

Obstructive sleep apnea is typically associated with an increased body mass index and was not considered a major issue in PD. However, the occurrence of sleep apnea in PD is more frequent than previously suspected. In one study, 31 of PD patients assessed with polysomnography were shown to have a significant apnea (Ferini-Strambi et al., 1992), and in another, 20 had moderate to severe sleep apnea (Arnulf et al., 2002) despite a normal body mass index. Snoring, one of the symptoms of sleep apnea, has been shown to predict the occurrence of daytime sleepiness (Hogl et al., 2003 Braga-Neto et al., 2004). Polysomnographic studies in PD demonstrate a greater frequency of sleep apnea than normal controls, with obstructive events being most common (Maria et al., 2003).

Other Diagnostic Approaches

Disorders of the sleep-wake rhythm (75) and are even quite good in estimating sleep time in patients with sleep apnea (76), they cannot really be used to diagnose sleep apnea (77). Other surrogate markers have been used to detect sleep apnea including cyclical changes in heart rate on 24-hour Holter monitoring (78) and pulse transit time (79-81). While both of these reflect physiologic changes accompanying obstructive events, the sensitivity and specificity of these are insufficient (owing to wide extremes in spectrum of disease) to warrant routine use. In assessing the validity and applicability of any ambulatory diagnostic system, several standards should be met (82). These include (i) an independent blind comparison with a reference standard (ii) an appropriate spectrum of patients (iii) avoidance of work-up bias (iv) methods for performing the test described in detail, allowing for duplication of the study (v) adequate description of study population (vi) adequate sample size...

What Can Be Supported By The Evidence

A. is less likely to detect other evidence of OSA including RERAs and subtle hypopneas and will not allow the determination of REM AHI This review at this point has concentrated on the diagnosis of OSA without considering that PSG is used to monitor CPAP titration during sleep. To date, there appears to be only one study that examined a Level III portable monitoring montage to titrate CPAP during an attended study (70). In addition, the use of an attended portable monitor to make a diagnosis during the first half of the night followed by a CPAP titration during the second half of the night (split-night study) has not been examined. For these reasons, use of a portable monitor to both diagnose and titrate CPAP cannot be well-supported by evidence.

What Other Options May Be Considered

The availability of treatment including PSG titration for CPAP. The approach to CPAP titration is beyond the scope of this chapter there has been a trend to use auto-titrating positive airway pressure (APAP) machines unattended in the patient's home (see also Chapter 8). The reader is referred to an evidence-based review of the topic and guidelines published by the AASM (77,78) and a Canadian technology review (79), which indicate that unattended use for CPAP titration is not established for CPAP na ve patients. Subsequent to publication of the guidelines, at least one study has provided evidence that APAP can lead to favorable outcomes in CPAP na ve patients (80). In general, such an approach should only be carried out with the knowledge that the evidence for the efficacy of unattended home CPAP titration in CPAP na ve patients is in evolution.

Upper Airway During Sleep

FIGURE 6 State-dependent magnetic resonance imaging in the retro-palatal region of a normal subject (apnea-hypopnea index 0 events hour). Airway area is smaller during sleep in this normal subject. The state-dependent change in airway caliber is secondary to reductions in the lateral and anterior-posterior airway dimensions. Source From Ref. 138. FIGURE 6 State-dependent magnetic resonance imaging in the retro-palatal region of a normal subject (apnea-hypopnea index 0 events hour). Airway area is smaller during sleep in this normal subject. The state-dependent change in airway caliber is secondary to reductions in the lateral and anterior-posterior airway dimensions. Source From Ref. 138.

Weight Loss See Also Chapter

The importance of obesity in OSA patients has been discussed in prior sections of this chapter. Several predominantly uncontrolled studies have been performed to investigate the effect of various methods of nonsurgical weight loss (diet, behavior, and activity) on sleep apnea (53,145-147). In general, such studies have shown that significant weight loss (approximately 10 ) is associated with varying degrees of improvement in sleep apnea (53,145). Importantly, weight loss is challenging to sustain and therefore re-emergence of apnea may occur. Examining the effect of weight loss on airway properties, investigators have reported that OSA patients who achieved a mean reduction of 17 in body weight demonstrated significant decreases in airway collapsibility i.e., critical closing pressure (Pcrit) and, in turn, significant decreases (greater than a 50 decrement) in disordered breathing (74). Three-dimensional MRI in obese normal women (AHI 5 events per hour) has demonstrated that a 17.7...

Maintenance of Wakefulness Test

The maintenance of wakefulness test (MWT) is procedurally similar to the MSLT. The major differences are (i) the person being tested is told to attempt to remain awake at the beginning of each test session, (ii) the individual is seated rather than laying down in bed, (iii) each test session is 40 minutes in duration, and (iv) poly-somnography the night before testing is not required. Thus, the MWT is used to assess an individual's capability to not be overwhelmed by sleepiness. In a sense, this test is gauging the strength of the wakefulness system (34). If the wakefulness system fails, sleepiness becomes manifest. In the MWT there is no other task than remaining awake and concurrent EEG-EOG-EMG monitoring is conducted to verify success or failure (35,36). In some ways the MWT is a simulation of sedentary inactivity in a nonstimulating environment. Like the MSLT, there are four to six sessions, scheduled at two-hour intervals beginning approximately two hours after awakening from the...

Initiation of Treatment in Decompensated Patients with Cardiorespiratory Failure

Patients with carbon dioxide retention, heart failure, and extreme nocturnal hypox-emia (i.e., SaO2 50 or less), require close supervision when commencing CPAP. Such patients may have confusion at night from delirium (due to their blood gas derangement) that may be exacerbated by someone trying to place a mask on their face. The nurse or technician needs to provide close attention throughout the night, in case the patient tries to repeatedly pull off the mask. After the first few nights, these patients typically settle down and sleep with CPAP without the need for intensive monitoring or intervention. The previous choice of therapy for these patients was endotracheal intubation or urgent tracheostomy. Intubation may still be the appropriate option however, in trained hands, nasally applied CPAP or noninvasive ventilation (see Chapter 10) will readily control the breathing disturbance during sleep. CPAP may not adequately normalize gas exchange in many of these patients, as they may...

Problems And Side Effects See Also Chapter

Side effects reported by the patient are usually, but not exclusively, related to pressure or airflow or the mask-face interface. The minimization of side effects is important for effective CPAP usage patients who complain of side effects use CPAP less frequently than those without side effects (51). A nonspecific claustrophobic feeling may be reported by patients but this often involves either mask interface problems, nasal congestion, or exhalation difficulties that are discussed below. Dangerous complications of nasal CPAP therapy are extremely rare and represent isolated case reports in the literature including pulmonary barotrauma, pneumocephalus, increased intraocular pressure, tympanic membrane rupture, cerebrospinal fluid (CSF) leak and meningitis (52), massive epistaxis, and subcutaneous emphysema after facial trauma (53). It is clear that caution should be used when implementing CPAP therapy post-neuro, -airway, or -facial surgery. Irritating side effects such as aerophagy...

Pressure Level and Airflow

Although frequently mentioned as a problem, there is no convincing evidence that the CPAP pressure level actually impairs adherence. Some patients may complain of initial increased resistance to exhalation or the sensation of too much pressure in the nose. For these patients, a CPAP unit with a pressure ramp may be considered. Ramp is a standard feature on most contemporary CPAP devices. The ramp allows the pressure to increase gradually over a set time interval (usually 5-30 minutes) to the optimal CPAP pressure. No studies have been performed to show that a ramp feature improves acceptance or adherence with CPAP however, interestingly, a case of ramp abuse has been reported where continuous patient application of the ramp function led to undertreatment of sleep apnea (65). Alternatively, a BPAP system, in which inspiratory and expiratory positive airway pressure (PAP) can be adjusted independently, may be used, as this approach lowers mean airway pressure and resistance to...

Comparison With Other Treatments

One of the great advantages of nasal CPAP is that it is immediately and demonstrably efficacious in relieving OSA (2,74). Although that effect is often clinically obvious as early as the CPAP titration night, this beneficial effect of reducing or normalizing the RDI has been convincingly demonstrated in follow-up PSG studies between two weeks and three months after CPAP initiation. This normalization is in contrast to other treatments including sham CPAP, other placebo, conservative management and positional therapy (75-78). Another advantage is that it can be offered on a trial basis and withdrawn if not tolerated, in contrast to surgical options. This is particularly important in milder cases of OSA, or where the contribution of OSA to the patient's symptomatology is unclear. A few studies have attempted to compare CPAP with other treatments for OSA using formal protocols. There is a dearth of adequate studies comparing the results of surgical interventions for OSA and those that...

Adherence See Also Chapter 9 General Issues

It is widely acknowledged that CPAP is an effective treatment for OSA but just as readily recognized that there are significant limitations to patients' effective use of this treatment modality. In addition to adherence, various other terms such as compliance, acceptance, and others have been used by authors when reporting studies describing utilization of prescribed CPAP treatment. These terms need standardized definitions and use to allow valid across-studies interpretation of results (85). True efficacy studies have yet to be performed. Such studies would need to measure not only the CPAP usage and residual breakthrough respiratory events, but also the total amount of sleep. Thus, a measure of not only protected sleep (as measured on the CPAP device), but also the amount of unprotected sleep, without CPAP therapy. Nevertheless, when one looks at all the CPAP usage data currently available, adherence with CPAP devices compares favorably with medication use in various other chronic...

Acceptance and Purchase

We do not know how many people with moderate-to-severe OSA avoid initial consultation with a sleep physician, or seek primary referral to surgeons or dentists, because they will not entertain even the possibility of using CPAP. The percentage of patients who refuse CPAP after an in-hospital trial is variable (89). CPAP purchase rates after PSG CPAP titration are over 50 , based on a calculation comparing new CPAP machine sales provided by manufacturers with national insurance data on multiple sleep study frequency (90). In other words, over 50 of patients completing a sleep laboratory trial end up purchasing a CPAP machine or having one purchased for them by the health system.

Technique of Chronic Auto Positive Airway Pressure Treatment

The upper and lower pressure limits could be placed as wide as possible (4-18 cm H2O) or narrowed based on information from a previous CPAP titration or previous nights of APAP use. Some patients find starting at 4 cm H2O uncomfortable and it may take some APAP machines several minutes to reach a pressure level that they find comfortable. In this case the lower pressure could be increased to 6-10 cm H2O. Awakening with the feeling of insufficient pressure could be another situation in which the lower pressure limit should be increased. Bloating or evidence of excessive mouth leak might be an indication to lower the upper pressure limit. Alternatively, if the 90th percentile pressure essentially equals the upper pressure limit, then a higher upper pressure limit is likely needed (especially if the residual AHI is high).

Benefits Of Continuous Positive Pressure Therapy

Further studies have shown that significant reductions in adverse cardiovascular disease outcomes may be obtained with successful treatment of OSA (5,10). CPAP reduces blood pressure in hypertensive patients (21,22), reverses hemodynamic changes in the cerebral circulation (23), and may reduce pulmonary pressures in OSA patients (24). Moreover, CPAP has been shown to prevent OSA-associated bradyarrhythmias (25,26), decrease recurrence of atrial fibrillation after cardioversion (27), and abolish ventricular arrhythmias (28,29). Furthermore, patients with congestive heart failure (CHF) and OSA have shown a marked improvement in left ventricular ejection fraction and functional class after initiation of CPAP therapy (30,31). In addition, CPAP produces many other sustained benefits that may have significant impact on long-term health outcomes, in particular, those processes that appear to contribute to the pathogenesis of cardiovascular disease. These benefits include decreased platelet...

Indications To Treat With Positive Airway Pressure

All of these data suggest that CPAP should exert a favorable effect on patients with OSA, and in particular, patients with OSA and cardiovascular disease. However, unequivocal data showing long-term benefits with cardiovascular endpoints are still lacking. So, in turn, the question of which patients with OSA that will derive benefit from treatment remains somewhat controversial. Practice parameters developed by the American Academy of Sleep Medicine and published in 2006 describe the indications for PAP therapy the main indications are described in this section (43).

Perioperative Management

There are few studies looking directly at the risk of postoperative complications associated with OSA, however, the American Society of Anesthesiologists (ASA) have recognized the risk of postoperative complications associated with patients who have undiagnosed OSA and thereby published practice guidelines outlining recommendations of how to identify and treat patients at risk. The ASA practice parameters suggest that preoperatively, anesthesiologists should work with surgeons to develop a protocol whereby patients in whom the possibility of OSA is suspected on clinical grounds are evaluated long enough before the day of surgery to allow preparation of a perioperative management plan. The recommendations go on to include preoperative preparation where preoperative initiation of CPAP should be considered, particularly if OSA is severe. As previously stated, because of their propensity for airway collapse and sleep deprivation, patients with OSA are especially susceptible to the...

Predictors of Adherence

Studies of CPAP nonadherence have found that the most consistent indicator of continued CPAP use is perceived improvement in sleepiness (136). In some studies, CPAP adherers have been found to be more educated and have greater daytime somnolence, while nonadherers have less severe disease and concurrent medical problems (131,132). Side effects of CPAP therapy, although often cited as a primary reason for discontinuing treatment (137,138), produce only minimal adherence improvements when treated (139). Factors such as type of mask (139), titration method (auto vs. standard) (128-140), and delivery method of PAP (CPAP vs. bilevel ventilation) (141) do not reliably produce improvements in adherence or in OSA-related symptoms. Perhaps the strongest effects on predicting adherence have been demonstrated by measures of behavioral attitudes toward CPAP use. In a seminal study, Stepnowsky et al. (142) examined the predictive utility of behavioral attitudes based on psychological theories of...

Pictorial Sleepiness Scale

Maldonado et al. (11) sought to develop a nonverbal sleepiness scale that could be used to test young children or poorly educated adults. Subject groups were asked to rank in order seven cartoon faces designed to depict different sleepiness levels. Results were used to transform rankings into linear measures that eliminated two faces. A new subject group ranked the remaining five cartoons and a scale was constructed. The scale correlated significantly with KSS and SSS when tested in groups of normal control adults, sleep apnea patients, shift workers, and school children. The authors envision using this scale clinically and for research. It remains to be seen whether this scale will gain popularity.

Surgical Treatment Summary

Apnea-hypopnea index 20 events per hour of sleepa Oxygen desaturation nadir 90 Excessive daytime sleepiness alleviated Response equivalent to CPAP on full-night titration aA reduction of the apnea-hypopnea index by 50 or more is considered a cure if the preoperative apnea-hypopnea index is less than 20. Abbreviation CPAP, continuous-positive airway pressure. Source From Ref. 18.

Laser Assisted Uvulopalatoplasty

LAUP is associated with significant palatal edema, and concerns exist regarding the safety of performing this procedure in the office. Terris et al. (104) noted a four-fold increase in the apnea index and a significant narrowing of the airway at 72 hours following LAUP. These findings prompted them to discourage LAUP in patients with moderate or severe sleep apnea. Other complications, such as palatal incompetence and hemorrhage, have been reported . With the advent of less painful techniques, the popularity of LAUP has waned (105). In fact, a variety of procedures are now available with similar cure rates to treat the palate with less pain and morbidity.

Airway Bypass Surgery Tracheotomy

Tracheotomy was once the only treatment available for SDB. By creating an external opening in the trachea, the obstructing tissue of the upper airway was bypassed. This provided immediate resolution of airway obstruction during sleep. However, tracheotomy is poorly accepted by patients. This prompted a search for more conservative site-specific surgical procedures. In addition, the advent of CPAP provided a nonsurgical method to prevent upper airway obstruction. The efficacy of CPAP has markedly reduced the number of patients needing tracheotomy (51). Yet, indications still exist for the insertion of a tracheotomy tube. A tracheotomy should be inserted when there is a need to secure an airway prior to a multi-phased protocol. Furthermore, it should be considered in morbidly obese patients with severe SDB and an oxygen desaturation below 70 , especially in those who cannot tolerate CPAP. Patients with significant cardiac disease may not be able to tolerate hypoxemia following surgery...

Types Of Oral Appliances

Oral appliances used for OSA generally fall into one of two classes, viz. mandibular advancement splints (MAS) and tongue retaining devices (TRD). MAS induce protrusion of the mandible by anchoring a removable device to part of or the entire upper and lower dental arches, while TRD use a suction cavity to protrude the tongue out of the mouth. MAS are far more widely used in clinical practice and there is an extensive literature on their use, compared to TRD. There are many designs available, but they generally fall into either one-piece (monobloc) or two-piece (duobloc) configurations (Figs. 1 and 2). Beyond this, they can differ substantially in size, type of material, degree of customization to the patient's dentition,

Cardiovascular Risk Factor Reduction

Patients with OSA are at increased risk of developing cardiovascular disease (21). In part, this is related to the concomitant presence of a variety of cardiovascular risk factors. That is, these patients have a high prevalence of the following male gender, smoking, diabetes, obesity, hypertension, and increased cholesterol (22). We recommend a low threshold for screening all patients with sleep apnea for the presence of hypercholesterolemia, hypertension, and diabetes and initiating appropriate therapy if indicated.

Correction Of Other Medical Disorders

Treatment of hypothyroidism, acromegaly, and nasal congestion may improve the severity of OSA. OSA is common in patients with hypothyroidism, and it is believed that hypothyroidism predisposes to the development of OSA (50). The mechanism for this association may include weight gain, tongue enlargement, muscle dysfunction, and changes in respiratory drive. In patients with sleep apnea, the prevalence of undiagnosed hypothyroidism has been reported in the range of 3.1 to 11.5 (51,52). Whether all patients with OSA should be screened for hypothyroidism is controversial (53). Nevertheless, treatment of hypothyroid-ism may lead to an improvement of OSA (54), and is likely to improve symptoms of daytime fatigue and promote weight loss (55). Treatment of hypothyroidism masquerading as OSA so called secondary sleep apnea may result in resolution of symptoms (56). Having a low threshold for testing thyroid function in patients with OSA is recommended. Acromegaly is a rare disease...

Cardiovascular Consequences

In younger adults, SDB has been shown to be a risk factor for hypertension (27-29). Even minimal amounts of SDB (AHI 0.1-4.9), considered by most not to be pathologic, have been shown to increase the risk of developing hypertension compared to an AHI of zero (29). A link between apnea severity and elevations in blood pressure has also been reported. A study by Lavie et al. (27) showed that each additional apneic event per hour of sleep increased the odds of hypertension by 1 , and each oxygen desaturation of 10 increased the odds by 13 . The relationship between SDB and hypertension in older adults however is not as clear. There are studies that have reported an association between hypertension and SDB in the older adult (30,31), but more recent data from the Sleep Heart Health Study suggested that there was no association between SDB and systolic diastolic hypertension in those aged 60 years (32). A recent study in middle-aged adults found that severe SDB was associated with...

Clinical Assessment And Management Of Sleepdisordered Breathing Presentation

Insomnia may also be a presenting complaint in older patients who suffer from SDB. The fragmented or restless sleep due to frequent nocturnal awakenings following the apneic events may result in a subjective complaint of difficulty sleeping, often labeled as insomnia. In addition, SDB may present with a nocturnal confusion and or daytime cognitive impairment, including difficulties with concentration, attention, and memory.

Treatment of Sleep Disordered Breathing in the Elderly

Patients should be counseled on weight loss and smoking cessation if indicated. For those with positional-related SDB, that is, with more apneic events typically occurring in the supine position, avoidance of this position and attempting to sleep on their side should be indicated and may be effective. Continuous positive airway pressure (CPAP) is the gold standard for the treatment of SDB (see also Chapter 6). CPAP is a device that provides continuous positive pressure via the nasal or oral airway passages, which creates an opening in the airway to permit inspiration. CPAP has been shown to be a very effective and safe treatment for SDB if used correctly (70). Beneficial effects of CPAP in older adults with SDB have been shown in several studies. Guilleminault et al. (71) found improved nocturia, daytime somnolence, depression ratings, and quality of life scores in older males after treatment of SDB with CPAP. Another study reported that treatment of SDB with CPAP resulted in...

Surgery and Site of Upper Airway Collapse

Surgical success for uvulopalatopharyngoplasty (UPPP) in OSA is only 5 in patients with an obstruction at the base of the tongue (76). Since most patients present with multiple sites of upper airway obstruction during sleep (77), diagnostic techniques must be developed which can improve surgical outcome. However, this quest is hindered by the fact that upper airway obstruction during sleep is a dynamic process. Varying sites of obstruction have been documented within one individual (78,79).

Nonhypercapnic Central Apnea

Nonhypercapnic central apnea is due to transient instability of the ventilatory control system, rather than a ventilatory control defect. Apnea occurs in cycles of apnea alternating with hyperpnea. Typically, patients with nonhypercapnic central apnea demonstrate increased chemoresponsiveness (4,5), in contradistinction to blunted chemoresponsiveness noted in hypercapnic central apnea. Nonhypercapnic central apnea occurs in a variety of clinical conditions including obstructive sleep apnea, congestive heart failure (CHF), and metabolic disorders. Male gender and older age are demographic risk factors for the development of central apnea.

Pathogenesis Of Central Apnea During Sleep

Breathing during non-rapid eye movement (NREM) sleep is critically dependent on chemical stimuli, especially Pco2 (6), owing to the removal of the wakefulness drive to breathe. NREM sleep unmasks a highly sensitive hypocapnic apneic threshold. Thus, central apnea occurs if arterial Pco2 is lowered below the apneic threshold (6). Hypocapnia during sleep is the most ubiquitous and potent influence leading to the development of central apnea. Experimental paradigms used to produce hypocapnic central apnea include nasal mechanical ventilation (Fig. 1) and brief (3-5 minutes) hypoxic exposure. Both methods increase minute ventilation and alveolar ventilation and decrease arterial Pco2. Termination of hyperventilation would result in hypopnea or apnea depending on the degree of hypocapnia (7-10). Central apnea does not occur as an isolated event but as periodic breathing consisting of cycles of recurrent apnea or hypopnea alternating with hyperpnea. While hypocapnia can produce the initial...

Congestive Heart Failure

CHF is associated with CSR, characterized by a crescendo-decrescendo breathing pattern with central apnea or hypopnea occurring at the nadir of ventilatory drive. The prevalence of sleep apnea in patients with CHF is about 50 (30,39-41). In one prospective study, Javeheri et al. demonstrated that 51 of male patients with CHF had sleep-disordered breathing, 40 had CSA, and 11 had obstructive apnea. In another study, Sin et al. (35) identified CHF patients at high risk for the presence of sleep apnea in 450 consecutive patients with CHF who underwent polysomnography. Using an apnea-hypopnea index cutoff of 10 per hour of sleep, 302 patients had sleep-disordered breathing (66 ). Risk factors for CSA were male gender, atrial fibrillation, age 60 years, and daytime hypocapnia (Pco2 38 mmHg). In contrast, risk factors for OSA differed by gender. Body mass index was the only independent determinant in men age more than 60 years was the only independent determinant for women. Overall, there...

Cerebrovascular Disease

Sleep apnea occurs frequently after a cerebrovascular accident (CVA) (32,46,47), and is an independent prognostic determinant of mortality following a first episode of stroke (48). CSA is the predominant type of sleep-disordered breathing in 40 of patients of sleep apnea after a CVA (47). The natural history of CSA with neurological recovery is yet to be determined. FIGURE 2 Awake and asleep eupneic PETCO2 during stable breathing and apnea threshold during sleep. In the control group (open circles) there was a consistent and significant increase in eupneic Pco2 during sleep (p 0.01). In the central sleep apnea (CSA) group (triangles), there was no difference in eupneic Pco2 between sleep and wakefulness (p 0.2). In both groups, the apnea threshold was below both the sleep and awake eupneic PETCO2. The threshold was closer to eupnea level in the CSA group compared with the control group. *p 0.05 compared with awake PETCO2 +p 0.05 compared with sleep as well as awake PETCO2. Source Ref....

Clinical Features And Diagnosis

The presenting symptoms for patients with hypercapnic CSA may include symptoms of the underlying disease and features of sleep apnea. These symptoms include daytime sleepiness, snoring, and poor nocturnal sleep, as well as morning headache, peripheral edema, and dyspnea. Patients with nonhypercapnic central apnea can present with symptoms similar to obstructive sleep apnea including snoring and excessive daytime sleepiness. Alternatively, patients with CSA may present with insomnia and poor nocturnal sleep.

Other Forms of Cognitive Impairment

Lewy body dementia is also associated with cognitive decline and particular impairment of visual spatial tasks. These disorders are noted to have high prevalence of sleep-related complaints based on survey questionnaires, but no study has shown the prevalence of polysomnographic abnormalities in these patients (13). A case report suggests that individuals with autonomic features may have SRBD (14). Cheyne-Stokes breathing and OSA are common findings, but there is no clear link between this form of dementia and sleep apnea. In many of these individuals, treatment follows the same recommendations as those with Alzheimer's disease. A subgroup of these individuals will have loss of REM sleep atonia and have periods of dream enactment, consistent with a diagnosis of REM sleep behavior disorder. This can become quite dangerous if the patient has a CPAP machine and uncontrolled nocturnal events. For these patients, adequate control of the nocturnal events is paramount. This may take a...

Mentally Handicapped Individuals

Individuals with mental handicaps may have a variety of sleep issues. Although there are no large studies, these individuals are noted to have SRBD and frequently require treatment. Over half of children with Down's syndrome have obstructive or central sleep apnea (15). Although these patients frequently have anatomical features contributing to the obstruction, the brain dysfunction may also play a role in their SRBD. Patients with other etiologies for chronic encephalopathies such as Prader-Willi syndrome also appear to have a high prevalence of SRBD (16). In our experience, CPAP can be used effectively in patients with mental handicaps. Individuals usually have improved behavior and are less irritable following successful employment of therapy. Patients may respond well to positive reinforcement and incentive programs such as star charts rewarding adherence with therapy. The healthcare provider should insist upon the inclusion of the therapy into the daily routine. If possible, the...

Parkinsons Disease and Other Neurodegenerative Disorders

Parkinson's disease (PD) is characterized by a progressive loss of dopaminergic neurons, resulting in bradykinesia and a resting tremor. This disorder is reported to have a higher prevalence of sleep apnea ranging from 20 to 43 of the patients (41,42). The high prevalence of sleep apnea in this population occurs despite their lower average BMI that makes oxygen desaturation less prominent. Hogl (43) found snoring to be associated with daytime sleepiness. Yet, several investigators did not demonstrate a relationship of daytime sleepiness to AHI and the impact on the cardiovascular system is unknown (41). Treatment for these individuals should include CPAP therapy. This requires the patient to have enough dexterity to manipulate the mask or have available assistance. Additionally, the medication therapy for the PD should be maximized to improve sleep and reduce rigidity that may be adding to the respiratory dysfunction (44). We have found patients note that they feel better with therapy...

Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease, affects approximately 30,000 individuals in the United States. This progressive and fatal illness results from degeneration of motor neurons in the brain, brainstem, and spinal cord. Skeletal muscle weakness such as that involving the extremities is observed first, but with time, bulbar, diaphragmatic and chest wall weakness cause respiratory compromise and eventual dependency upon mechanical ventilation. Although the exact prevalence of sleep apnea is not known in this population, respiratory insufficiency and failure are common. Most patients die from respiratory failure within five years from the onset of symptoms. Respiratory insufficiency may occur during sleep despite normal daytime pulmonary function (53,54). One controlled study demonstrated a higher, though mild, AHI compared to controls. However, the subjects' sleep apnea predominated in REM sleep and consisted of periods of hypoventilation that...

Asthma See Also Chapter

Nocturnal worsening of asthma is also apparently linked to snoring and sleep-disordered breathing. Chan et al. (18) evaluated nine patients with asthma and concurrent OSA, noting that all patients had frequent nocturnal exacerbations of their asthma. After initiating effective CPAP therapy, all patients demonstrated marked improvement in their asthma, with decreased symptoms, improved PEFR, reduced need for bronchodilator therapy, and resolution of their nocturnal worsening (Fig. 1). Guilleminault et al. (19) subsequently reported two separate populations of asthmatics, one group of middle-aged males with confirmed OSA, and a second group of younger males with recurrent snoring. Nocturnal worsening of asthma resolved in both groups after initiating CPAP therapy. Yigla et al. (20) studied 22 consecutive patients with severe, unstable asthma. Subsequent polysomno-graphy detected OSA in 21 (95.5 ) of these patients, although the patient group had a normal mean body mass index. These...

Cardiovascular Disease

Recent studies provide strong evidence that OSA is associated with several physiologic processes that could increase risk for cardiovascular disease. First, it has been well established that OSA is associated with sympathetic activation (65). This is most pronounced in association with obstructive apneas and hypopneas during FIGURE 4 (See color Insert.) Potential interactions between OSA, systemic inflammation, and their possible link to cardiovascular disease. Abbreviations ROS, reactive oxygen species ICAM-1, intercellular adhesion molecule-1 IL-8, interleukin-8 MCP-1, monocyte chemoattractant protein-1 NO, nitric oxide OSA, obstructive sleep apnea. FIGURE 4 (See color Insert.) Potential interactions between OSA, systemic inflammation, and their possible link to cardiovascular disease. Abbreviations ROS, reactive oxygen species ICAM-1, intercellular adhesion molecule-1 IL-8, interleukin-8 MCP-1, monocyte chemoattractant protein-1 NO, nitric oxide OSA, obstructive sleep apnea. sleep,...

Concluding Note and Future Directions

Obstructive sleep apnea (OSA) and other sleep-related breathing disorders are arguably the number one health problem in the United States if not the entire world. Given the high prevalence, it is amazing that this problem was completely unknown to the general public as well as health professionals as recently as 1965 and mostly unknown until the late 1970s. In addition to the actual obstructive sleep disorder itself, there are strong associations with cardiovascular disease, fatigue, mental impairment, diabetes, obesity, and probably a host of other less well-documented associations. One of the problems we have encountered is that this area of human behavior is strange and frightening to many people. Some years ago, we showed a film clip of patients being treated with continuous positive airway pressure (CPAP) to a group of burly, tough, long-haul truck drivers. They were visibly shaken by the strangeness of patients sleeping with CPAP machines. Therefore, bestowing the benefits of...

Sleeprelated Breathing Disorders Clinical Features

Abbreviation AHI, apnea-hypopnea index. were classified as having OSA median apnea-hypopnea index (AHI) 7.1 per hour , and another 122 (15 ) had primary snoring without OSA. The remaining 667 (80 ) had neither snoring nor OSA. Functional outcomes were assessed with two parent ratings scales of behavior problems the Child Behavioral Checklist and the Conners Parent Rating Scale-Revised Long. Children with SDB had significantly higher odds of elevated problem scores in the following domains externalizing, hyperactive, emotional lability, oppositional, aggressive, internalizing, somatic complaints, and social problems. The authors concluded that children with relatively mild SDB, ranging from primary snoring to OSA, have a higher prevalence of problem behaviors, with the strongest, most consistent associations for externalizing, hyperactive-type behaviors. An interesting finding in this study was that only 55 of the parents of children diagnosed by polysomnography with OSA reported loud...

Reasonable Care and the Sudden Blackout Doctrine

Under these principles, knowledge of one's sleep apnea and a propensity for drowsy driving alone will likely be insufficient to invoke the defense. An OSA driver who has been properly warned against sleepy driving and placed on a treatment regimen would very likely have knowledge sufficient to make a sleep episode foreseeable. Thus, much like the diabetic driver who crashed after he skipped lunch and felt hypoglycemic, but neglected to stop and eat (23), the sleepiness of a noncompli-ant CPAP driver with OSA is likely foreseeable, opening the recalcitrant OSA patient to liability for injuries caused by falling asleep at the wheel.

Myasthenia Gravis and Lambert Eaton Syndrome

Sleep apnea has been reported in approximately 60 of patients with MG (70,71). The respiratory events occur predominantly in REM sleep and are associated with oxygen desaturations (70,72). Patients who are most vulnerable to the development of sleep apnea and oxygen desaturations are individuals with longer duration of the disease, older age, increased BMI, abnormal total lung capacity, and abnormal daytime blood gas concentrations (72,73). Patients with mild stable MG had infrequent respiratory abnormalities that were predominant in REM sleep (74). Our knowledge of patients with LES is limited. Other than one patient presented with rapidly progressive respiratory failure requiring ventilatory support, there are no reports of SRBD in these patients (75). sleepiness. Optimization of the MG treatment with anticholinesterase agents may partially improve their ventilatory function, therefore leading to decreased respiratory disturbance during sleep (79). For some select patients...

Anesthetics Opioids and Barbiturates

Recommendations for safe perioperative care in the OSA patient include the use of CPAP preoperatively, consideration of intubation over fiberoptic bronchoscope during surgery, and the use of CPAP and regional anesthesia postoperatively rather than the continuous administration of opiates (26). Nasal CPAP can eliminate the postoperative risk of hypoxemia, which would then allow the use of adequate parenteral or oral analgesics. Analgesia has been achieved safely with intravenous morphine sulfate or meperidine hydrochloride (Demerol ) (intensive care unit) and oral oxycodone (OxyContin , Roxicodone ), while patients were receiving CPAP during all periods of sleep after surgery. There were no significant reductions in SpO2 regardless of the severity of OSA syndrome or obesity (26). All opiates have the potential to worsen sleep apnea, compromise breathing, and even cause sleep apnea is some cases. Opioids depress respiration, by direct effect on brainstem respiratory centers and by...

Clinical Prediction Models

Well-established sleep apnea is characterized by loud snoring, witnessed apneic episodes, disturbed nocturnal sleep, daytime sleepiness, and impaired cognition and is typically associated with obesity and (in men) a large neck size. Given this profile, it is not surprising that clinical prediction models would arise in an effort to diagnose OSA in larger populations. Virtually all of these studies have been done in sleep clinic populations rather than in the general population. One of the earliest studies showed that witnessed apneic episodes combined with loud snoring predicted an apnea-hypopnea index (AHI) 10 with a sensitivity of 78 and specificity of 67 (1l). Crocker et al. (12) used an alternative approach and developed a statistical model using clinical data to predict disturbance of sleep-disordered breathing in 114 consecutive patients. Witnessed apneic episodes, hypertension, body mass index (BMI), and age provided a sensitivity of 92 but a specificity of only 51 for an AHI...

Techniques And Modes Of Imaging The Upper Airway

Anatomic Radiology Oral Cavity

Provided collectively important information pertaining to the maintenance of airway patency and pathogenesis of airway collapse. During wakefulness, pharyn-geal patency is maintained predominantly by activation of pharyngeal dilator muscles (11). During apnea, it has been demonstrated that genioglossus and tensor palatine activation is primarily influenced by negative pressure in the airway (7,11). The negative pressure milieu is amplified during apnea due to greater inspiratory effort and increased tonic muscular activity (11). Further evidence demonstrates that administration of nasal continuous positive airway pressure (CPAP) reduces the accentuated genioglossus response to apnea to normal levels (7). However, the accentuated genioglossus electromyographic activation in apneics does not necessarily indicate that the tongue is moving since electromyographic activity does not correlate with mechanical action. Newer imaging techniques such as computed tomography (CT) and magnetic...

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