Obstructive sleep apnea continuous positive airway pressure

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. 

Means MK, Lichstein KL, Edinger JD, et al. Changes in depressive symptoms after continuous positive airway pressure treatment for obstructive sleep apnea. Sleep Breath 2003 7(1) 31—42. 

Krieger J, Meslier N, Lebrun T, et al. Accidents in obstructive sleep apnea patients treated with nasal continuous positive airway pressure a prospective study. The Working Group ANTADIR, Paris and CRESGE, Lille, France. Association Nationale de Traitement a Domicile des Insuffisants Respiratoires. Chest 1997 112 1561-1566. 

Grunstein RR (2005) Chapter 89 - Continuous Positive Airway Pressure Treatment for Obstructive Sleep Apnea-Hypopnea Syndrome, Principles and Practice of Sleep Medicine, 4th edition ed. Elsevier Saunders, Philadelphia... 

Yokoe T, Minoguchi K, Matsuo H, Oda N, Minoguchi H, Yoshino G, Hirano T, Adachi M (2003) Elevated levels of C-reactive protein and interleukin-6 in patients with obstructive sleep apnea syndrome are decreased by nasal continuous positive airway pressure. 

Black JE, Hirshkowitz M (2005) Modafinil for treatment of residual excessive sleepiness in nasal continuous positive airway pressure-treated obstructive sleep apnea/hypopnea syndrome. Sleep 28 464-471... 

Modafinil is itself an adjunct to standard treatments for obstructive sleep apnea/hypopnea syndrome (OSAHS) if continuous positive airway pressure (CPAP) is the treatment of choice, a maximal effort to treat first with CPAP should be made prior to initiating modafinil and CPAP should be continued after initiation of modafinil... 

Nonpharmacologic interventions such as weight loss, removing an obstruction in the airway, and or nasal continuous positive airway pressure are considered first-line therapies for obstructive sleep apnea. 

Ventilators are either negative-pressure or positive-pressure. Negative-pressure ventilation involves directing air directly into the lungs, and positive-pressure ventilation involves directing air into the trachea. Some ventilators require intubation, the placement of a tube into the trachea from the nose or mouth. Ventilation requiring intubation is typically used for patients who will require ventilation for a protracted period. Other ventilators work with a breathing mask that can be placed over the mouth and nose. With the increase in respiratory-related sleep disorders (such as obstructive sleep apnea), use of two positive airway pressure systems—continuous positive airway pressure (CPAP) and bilevel positive pressure ventilators (BiPAP)—has become very common. 

OHS may present with various possible sleep respiratory patterns (obstructive apneas, hypoventilation, and sometimes, central apneas, or a combined pattern) (7) and needs polysomnographic evaluation to adapt the ventilatory treatment, which is then mandatory (Fig. 3) either as nasal continuous positive airway pressure (nCPAP) or bi-level positive airway pressure ventilation, generally with oxygen supplementation if severe desaturation is present. 

Shivaram U, Cash ME, Beal A. Nasal continuous positive airway pressure in decompensated hypercapnic respiratory failure as a complication of sleep apnea. Chest 1993 104 770-774. Sturani C, Galavotti Y, Scarduelli C, et al. Acute respiratory failure due to severe obstructive sleep apnea syndrome, managed with nasal positive pressure ventilation. Monaldi Arch Chest Dis 1994 49 558-560. 

Obstruction of the upper or lower airways may cause an increase in respiratory load. Obstructive sleep apnea (OSA) is less common in children than in adults. In this age group, enlarged tonsils and adenoids play a predominant role (3). Noninvasive continuous positive airway pressure (CPAP) ventilation has proved its efficacy and is proposed as a first therapeutic option if tonsillectomy and adenoidectomy are not able to relieve upper airway obstruction (4,5). Congenital abnormalities of the upper airways, such as laryngomalacia, tracheomalacia, or Pierre Robin syndrome, may also cause severe upper airway obstruction (6). Even in young infants, noninvasive CPAP may correct the alveolar hypoventilation (7). 

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