Treatment:

Treatment for sleep apnea depends on the severity of the problem. Given the data on the long-term complications of sleep apnea, it is important for patients to treat the problem as they would any chronic disease. Simply trying to treat snoring will not treat sleep apnea. Because of its association with heart problems and stroke, sleep apnea that does not respond to lifestyle measures should be treated by a doctor, ideally a sleep disorders specialist.

At this time, the most effective treatments for sleep apnea are devices that deliver slightly pressurized air to keep the throat open during the night. There are a number of such devices available.

Continuous Positive Airflow Pressure (CPAP)

The best treatment for severe obstructive and mixed sleep apnea is a system known as continuous positive airflow pressure (CPAP), sometimes referred to as nasal continuous positive airflow pressure (nCPAP). It is safe and effective in sleep apnea patients of all ages, including children. CPAP may not recommended for patients who have mild-to-moderate apnea as identified in sleep studies but who do not have daytime sleepiness, as they generally report little or no benefit from this treatment.

CPAP has been shown to be superior to oral appliances made and temperature-controlled radiofrequency tissue ablation. It has not been directly compared to tonsillectomy or uvulopalatopharyngoplasty in good quality studies. Overall, CPAP is considered first-line treatment for mild, moderate, or severe obstructive sleep apnea.

CPAP works in the following way:

• The device itself is a machine weighing about 5 pounds that fits on a bedside table.
• A mask containing a tube connects to the device and fits over just the nose.
• The machine supplies a steady stream of air through a tube and applies sufficient air pressure to prevent the tissues from collapsing during sleep

Effects on Sleep and Wakefulness. A major 2003 analysis confirmed the benefits of CPAP on both objective and subjective measures of sleep. After using CPAP regularly many patients report the following benefits:

• Restoration of normal sleep patterns.
• Greater alertness and less daytime sleepiness.
• Less anxiety and depression and better mood.
• Improvements in work productivity.
• Better concentration and memory. Some adults with symptoms of attention deficit hyperactivity disorder have improved after CPAP treatments for apnea. In two studies, however, equal improvements were also observed in people on sham CPAP, suggesting that the actual cognitive benefits from CPAP may be modest.
• Patients' bed partners also report improvement in their own sleep when their mates use CPAP, even though objective sleep tests showed no real difference in the partners' sleep quality.

If patients comply with the CPAP regimen but do not feel less sleepy after a period of time, or their sleep apnea symptoms don't improvement, the airflow pressure may not be high enough. Patients may need to be retested. Likewise, if patients have started using an oral appliance or had a surgical procedure, their doctor problably needs to reevaluate them. Many patients report feeling more alert after CPAP treatments even if objective laboratory tests fail to show significant differences in the number of apneas and wake-up periods.

Side Effects and Getting Used to the Device

CPAP works well for both adults and children, but many patients have problems getting used to the device. Unfortunately, CPAP devices are often cumbersome, which can lead to patients becoming discouraged and stopping treatment. All patients should be warned that the first few nights of CPAP therapy are unnerving. The mask may cause some patients to feel anxious. Starting out with low pressure to get used to the mask may help. Patients may actually sleep less, or have different sleep quality, at the start of treatment.

Nearly all patients complain of at least one side effect. Nearly half of complaints are related to the mask. Many of these problems can be minimized with a well-chosen mask that is comfortable and reduces leakage as much as possible. Thorough education and ongoing support are essential for successful treatment with CPAP.

Common complaints include:

• Irritation in the nose and throat. The most common complaints are nasal congestion and sore or dry mouth, which are caused by leakage that dries the airway. (This may be severe in elderly people or patients who have had uvulopalatopharyngoplasty, a surgical treatment for sleep apnea. Such patients are more likely to stop using CPAP.) Chin straps, nasal salt water sprays, or humidifiers may prevent these side effects. Heated humidification devices are also now available for CPAP users.
• Excessive application of pressure making exhalation difficult.
• A feeling of claustrophobia is a major factor in noncompliance. This can be improved by a lightweight and transparent mask or with masks known as nasal pillows, which are used only around the nostrils.
• Up to 30% of patients have irritation and sores over the bridge of the nose. Getting a properly fitted and cushioned mask can help reduce this problem.
• Eye irritation or conjunctivitis.
• Upper respiratory infections. It is very important to keep the unit clean.
• Patients may also feel temporary chest muscle discomfort, which is caused by an increase in lung volume.
• Severe side effects are very rare but may include heart rhythm disorders (arrhythmias), severe nose bleeding, and air pockets in the skull.
• In addition to initial difficulties with its use, the fixed CPAP needs to be periodically readjusted. Patients can be trained to adjust the CPAP at home, thereby avoiding trips to the sleep professional for machine adjustments and making the process more convenient.

Studies have reported that long-term compliance with CPAP systems is low, with about one-third of patients giving up the treatment. Compliance may be improving, however, probably due to better technologies and better education. Factors that may help include:

• Patient education and support groups
• Adedicated nurse to ensure close follow-up of patients (particularly in the first 2 weeks of therapy)
• Access to doctors to make adjustments as needed have all been shown to greatly improve compliance

(However, sleeping pills do not appear to help patients adapt to the device.) Not surprisingly, patients whose symptoms are noticeably relieved by the procedure early on are more likely to continue the therapy.

Because many patients find CPAP uncomfortable and difficult, they tend not to use it for the duration of the entire night. However, while some patients’ daytime sleepiness may improve after 4 - 6 hours of CPAP use each night, maximum benefits in quality of life require at least 7.5 hours of nightly CPAP use. It appears that longer nightly duration of CPAP use is best for achieving normal daytime functioning.

Other Related Devices

Bilevel Positive Airway Pressure. Bilevel positive airway pressure (BPAP) systems may be particularly helpful for patients with coexisting lung disease and those with excessive levels of carbon dioxide. These devices have a sensing feature that helps determine and vary the appropriate pressure depending on whether a person is breathing in or out. Greater pressure is needed on inhalation and less on exhalation. These machines are more expensive than the CPAP and may not be covered by insurance.

Autotirtating Positive Airway Pressure Devices. Traditional CPAP devices provide a set pressure based on findings from polysomnography. Autotitrating positive airway pressure (APAP) devices are also available. These devices automatically customize air pressure for the individual patient. For some patients, APAP devices can be used to begin therapy at home without any supervision.

Patients with chronic lung disease, heart failure, obesity hypoventilation syndrome, who do not snore, or who have central sleep apnea syndrome are not considered candidates for APAP.

APAP devices usually use one of three methods:

• Overall pressure is kept low until a specific problem is detected. At that time the pressure is automatically increased rapidly.
• Pressure is low when there are no problems but is raised gradually when they are detected.
• Pressure is gradually raised and lowered in response to problems or their absence. In addition, the device can change depending on problems within single breaths.

APAP devices are more expensive than CPAP devices. However, APAP devices may improve compliance, particularly in patients who have needed high CPAP use. They may be especially helpful for patients who require varying levels of pressure due to other conditions, such as seasonal allergies. They may also be useful as home diagnostic tools for sleep apnea.

Medications

In general, drugs have not been very beneficial except for specific situations. Medications that treat accompanying disorders associated with sleep apnea may be helpful. The following may be helpful for certain patients:

• Modafinil (Provigil), which is also used to treat narcolepsy, was approved by the FDA in 2004 as the first drug to treat the sleepiness associated with obstructive sleep apnea. However, Provigil is meant to be used in combination with -- not as a substitute for -- standard apnea treatments such as CPAP. Sleep experts stress that patients who take Provigil should adhere to CPAP treatment as the drug treats only the symptom of sleepiness, not the underlying health risks associated with sleep apnea. [Modafinil can cause rare, but serious, side effects such as life-threatening rash. For more information on this drug and its side effects, see In-Depth Report #98: Narcolepsy.]
• Thyroid hormone may help sleep apnea in those with low thyroid (hypothyroidism).

Note on Sedatives. Sedatives, narcotics, and anti-anxiety drugs can actually worsen the breathing disturbances and arousal conditions that occur with sleep apnea. These substances cause the soft tissues in the throat to sag and diminish the body's ability to inhale. Apnea sufferers should never use sleeping pills or tranquilizers. Apnea patients undergoing surgery should be sure that their surgeons, anesthesiologists, and other doctors are aware of their sleeping disorder in considering sedatives, anesthetics, and medications taken to relieve pain due to surgery.