CPAP

A more recent advancement of AP has come from the application of a controlled cathodic cnrrent which can be utililzed to shift the corrosion potential back to the passive zone. This (refinement) technique is usually termed the cathodic potential adjustment protection (CPAP). 

The main therapy for obstructive sleep apnea is nasal continuous positive airway pressure (CPAP) therapy because of its effectiveness. 

FIGURE 38-1. Primary assessment and initial treatment for complaint of excessive daytime sleepiness. RLS, restless-legs syndrome NPSG, nocturnal polysomnography OSA, obstructive sleep apnea DA, dopamine agonist MSLT, multiple sleep latency test BZDRA, benzodiazepine receptor agonist SNRI, serotonin and norepinephrine reuptake inhibitor TCA, tricyclic antidepressant CPAP, continuous positive airway pressure. 

CH returns to the clinic 3 months later. The physician previously diagnosed him with obstructive sleep apnea and RLS. He received a prescription for CPAP, for OSA and ropinirole 0.5 mg at bedtime for RLS at his last visit. Via phone calls, his ropinirole dose has been increased to 3 mg at bedtime. He has received moderate relief of his RLS symptoms, but on occasion, he still awakens and cannot fall back asleep. His sleepiness and RLS symptoms are improved ESS 13/24. 

How would you assess the patient s CPAP therapy and adherence ... 

Evaluate CPAP therapy annually or at any time individuals experience symptoms (e.g., daytime sleepiness) despite CPAP therapy. For example, change in pressure settings to alleviate OSA may be needed if weight gain occurs. 

Monitor compliance with CPAP therapy. CPAP machines have a built-in compliance meter to measure the hours used at effective pressure. Patients should use CPAP therapy for at least 5 hours each night. In addition to alleviating sleep-disordered breathing, CPAP therapy may improve cardiovascular outcomes. 

CPAP Continuous positive airway pressure EGD Esophagogastroduodenoscopy... 

FIGURE 72-1. Algorithm for treatment of dyssomnias. (BZDRA, benzodiazepine receptor agonist CPAP, continuous positive airway pressure.) (Adapted and reprinted with permission from Jermain DM, Sleep disorders. IntJann M, ed. Pharmacotherapy Self-Assessment Program, 2nd ed. Kansas City, MO, American College of Clinical Pharmacy, 1995 139-154.)... 

Apply Positive Pressure Ventilation using PEEP at 4 cm/water or CPAP mask. 

Patients suspected of having sleep apnea should undergo a sleep study. If sleep apnea is diagnosed, these patients should be treated with weight reduction, a continuous positive airway pressure (CPAP) machine, and, in extreme cases, surgery. Sleep apnea patients in general should not be prescribed sedative-hypnotics. 

OF digoxin, insulin, oral hypoglycemics, Li EMS Consider CPAP/BiPAP use if h5rpoxia or sev e resp distress is present... 

Naughton MT, Benard DC, Liu PP, et al. Effects of nasal CPAP on sympathetic activity in patients with heart failure and central sleep apnea. Am J Respir Crit Care Med. Aug 1995 152(2) 473-479. 

CPAP (continuous positive airway pressure) device—A mask worn over the nose during sleep that constantly and gently pumps air through the nasal passages to prevent sleep apnea. 

Wittig R, Zorick F, Conway W, Ward J, Roth T. Normalization of the MSLT after six weeks of CPAP for sleep apnea syndrome. Presented at the first annual meeting of the Association of Professional Sleep Societies, Columbus, OH, 1986. 

MWT trial duration will be 20 min. The rationales for this decision are that the 20-minute trial MWT has been used in both clinical and research settings and has been validated against longer MWT trials. Moreover, pilot data showed that an MWT with 20-minute trials statistically distinguishes subjects on active CPAP from subjects on sham CPAP. 

Psychomotor vigilance task performance has also been shown to be sensitive to reduced behavioral alertness associated with obstructive sleep apnea syndrome (OSAS), and the efficacy of interventions for OSAS. Performance of patients with OSAS is impaired on tasks that rely on the ability to sustain attention (85,86). As a measure of behavioral alertness, PVT performance has been demonstrated to be a sensitive method for assessing the attentional capability of patients with OSAS (32,87,88). Kribbs and colleagues (89) found that PVT performance and sleepiness, measured by the MSLT, both reflected the benefits of CPAP use (reduction in respiratory events during sleep). Similarly, the PVT has been used to demonstrate the positive effects of modafinil (a wake-promoting compound) on the capacity to sustain attention in a group of OSAS patients (34). 

Kribbs NB, Pack AI, Kline LR, Getsy JE, Schuett JS, Henry JN, Maislin G, Dinges DF. Effects of one night without nasal CPAP treatment on sleep and sleepiness in patients with obstructive sleep apnea. Am Revi Respir Dis 1993 147 1162-1168. 

The MSLT has been performed in patients with UARS, and abnormal results have been reported, but the test is often borderline normal, equating well with the complaint of fatigue. No systematic study of cognitive function has been performed in UARS patients, and investigation of mental lapses using tests such as the psychomotor vigilance task (PVT), a reaction-time test, is also lacking. But reevaluation of subjects treated with nasal CPAP demonstrated that sleep efficiency and MSLT scores improve (28). 

Some of the respiratory disturbances experienced by Parkinson s patients are similar in nature to that experienced by non-Parkinson s patients with sleep-related respiratory disturbances. Hence the same treatments may be used in both patient groups, depending on the stage of the Parkinson s. Continuous positive airway pressure (CPAP) can improve sleep in Parkinson s patients, but is not suitable during the advanced stages of Parkinson s. Alternatively, upper-airway surgery may provide some relief. Neither of these measures, however, alleviates the respiratory disturbance that may be due to the muscle rigidity associated directly with Parkinson s disease. 

George CF. Reduction in motor vehicle colhsions following treatment of sleep apnoea with nasal CPAP. Thorax 2001 56(7) 508-512. 

McMahon JP, Foresman BH, Chisholm RC. The influence of CPAP on the neurobe-havioral performance of patients with obstructive sleep apnea hypopnea syndrome a systematic review. Wmj 2003 102(1) 36 13. 

McArdle N, Kingshott R, Engleman HM, Mackay TW, Douglas NJ. Partners of patients with sleep apnoea/hypopnoea syndrome effect of CPAP treatment on sleep quality and quality of life. Thorax 2001 56(7) 513—518. 

Within the last few years, the role of wake-promoting medication has received renewed and increasing attention with development of modafinil. Although the mechanism through which modafinil works remains to be determined, the low abuse potential (51) and absence of cardiovascular effects (52,53), combined with its clear wake-promoting properties, increase the potential uses for this drug. Studies have shown consistent increases in alertness for narcolepsy (54), in sleep apnea patients (treated with CPAP) with residual sleepiness (55), for shift work sleep disorder (56), and for sleep deprivation (57). 

There is emerging evidence that OSA may be a pro-inflammatory disorder with elevated circulating cytokines [60]. Abdominal visceral fat is a major reservoir of cytokines, and obesity is a leading risk factor for the presence of OSA [60], The mechanism(s) whereby pro-inflammatory cytokines are elevated in OSA is not fully elucidated, but may be related to the excessive sympathetic nervous system activation notable in OSA. Tumor necrosis factor (TNF)-a and interleukin (IL)-6 levels are elevated in OSA [61,62] and the circadian rhythm of TNF-a is disrupted in OSA [63]. IL-6 levels are higher again in OSA patients with systemic hypertension compared to normotensive apneics [60], IL-6 levels return to normal in OSA patients treated effectively with CPAP [64]. Other mediators of inflammation elevated in OSA include intercellular adhesion molecule-1 and C-reactive protein, the latter being synthesized primarily in hepatocytes in response to IL-6 [60], The presence of these and other pro-inflammatory cytokines may link to the increased prevalence of cardiovascular morbidity in OSA. 

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