Obstructive sleep apnea treatment

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. 

Modafinil is a stimulant medication used to improve wakefulness in patients with narcolepsy, obstructive sleep apnea/hypopnea syndrome (as adjunct to standard treatments for the underlying disorder), and shift work sleep disorder. Controlled and open trials provided data on the efficacy and safety of modafinil in patients with narcolepsy (Besset et al. 1996 Billiard et al. 1994 Broughton et al. 1997 Mitler et al. 2000 U.S. Modafinil in Narcolepsy Multicenter Study Group 1998, 2000). Modafinil has a long duration of action and low potential for dependence and may be a reasonable first choice in the treatment of mild to moderate narcolepsy (Silber 2001). There is also considerable interest in the potential use of modafinil in the treatment of ADHD, and studies are in progress. 

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. 

Mostly older data suggested daytime impairments similar to the obstructive sleep apnea syndrome. A Gallup poll in 1991 found subjects with insomnia complained more of lack of concentration, memory impairment, and difficulty enjoying family and social relationships compared to those without insomnia (59). The Gallup poll also found that 5% of insomniacs, compared to 2% without insomnia, reported a motor-vehicle crash related to fatigue at some time in their lives. Balter and Uhlenhuth in 1992 reported that insomniacs before treatment were more than four times as likely as controls to report a motor-vehicle accident or other serious accidents within the past year (60). 

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. 

Bahammam A, Delaive K, Ronald J, Manfreda J, Roos L, Rryger MH. Health care utilization in males with obstructive sleep apnea syndrome two years after diagnosis and treatment. Sleep 1999 22(6) 740-747. 

Tousignant P, Cosio MG, Levy RD, Groome PA. Quality adjusted life years added by treatment of obstructive sleep apnea. Sleep 1994 17(1 ) 52—60. 

Yuen K, Goldstein M, Pelayo R, Guilleminault C. Prospective study of health-related quality of life in obstructive sleep apnea before and after treatment. Sleep 2001 24(suppl) A284-285. 

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... 

Schmidt-Nowara W, Lowe A, Wiegand L, Cartwright R, Perez-Guerra F, Menn S (1995) Oral appliances for the treatment of snoring and obstructive sleep apnea a review. Sleep 18 501-510... 

Cistulli PA, Gotsopoulos H, Marklund M, Lowe AA (2004) Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliances. Sleep Medicine Reviews 8 443... 

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... 

The armodafinil development program was very similar to the development program previously undertaken for modafinil (or racemic API). Four double-blind and two opened-label clinical trials (1090 patients enrolled with 645 receiving active treatment with armodafinil and 445 receiving placebo) have evaluated the efficacy and safety of armodafinil for the treatment of excessive sleepiness (ES) associated with obstructive sleep apnea (OSA), shift-work disorder (SWD), and narcolepsy.24... 

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... 

INDICATIONS FOR GROWTH HORMONE TREATMENT GH deficiency in children is a weU-accepted cause of short stature replacement therapy is used to treat children with severe GH deficiency. GH therapy has been extended to children with other conditions associated with short stature despite adequate GH production, including Turner s syndrome, Prader-Willi syndrome (in the absence of morbid obesity or obstructive sleep apnea), chronic renal insufficiency, children bom small for gestational age, and children with idiopathic short stature (i.e., more than 2.25 standard deviations below mean height for age and sex but normal laboratory indices of GH levels). 

Sleep complaints are very common among patients taking methadone maintenance treatment for opioid dependency and cause considerable distress to both individuals and their partners. In 71 patients taking methadone maintenance treatment, sleep-disordered breathing was a problem in 42% obstructive sleep apnea occurred in 35% and central sleep apnea in 14% [115. Obstructive sleep apnea was associated with a higher body mass index, a longer duration of methadone treatment, and being non-Caucasian. 

Karimi M, Koranyi J, Franco C, Peker Y, Eder DN, Angelhed JE, Lonn L, Grote L, Bengtsson BA, Svensson J, Hedner J, Johannsson G. Increased neck soft tissue mass and worsening of obstructive sleep apnea after growth hormone treatment in men with abdominal obesity. J Clin Sleep Med 2010 6(3) 256-63. 

Winslow DH, Bowden CH, EHDonato KP, McCuUough PA. A randomized, double-blind, placebo-controUed study of an oral, extended-release formulation of phentermine/topiramate for the treatment of obstructive sleep apnea in obese adults. Sleep 2012 35(ll) 1529-39. 

Piper AJ, Sullivan CE. Effects of short term NIPPY in the treatment of patients with severe obstructive sleep apnea and hypercapnia. Chest 1994 105 434-440. 

Waters KA, Everett F, Sillence DO, et al. Treatment of obstructive sleep apnea in achondroplasia evaluation of sleep, breathing, and somatosensory-evoked potentials. Am J Med Genet... 

Scharf MB, Cohen AP. Diagnostic and treatment implications of nasal obstruction in snoring and obstructive sleep apnea. Ann AUergy Asthma Immunol 1998 81 279-287. 

Clinical Management of Chronic Obstructive Pulmonary Disease, edited by T. Similowski, W. A. Whitelaw, and J.-P. Derenne Sleep Apnea Pathogenesis, Diagnosis, and Treatment, edited by A. I. Pack... 

OHS, previously called the Pickwickian syndrome (6), is defined as the association of obesity, sleep-disordered breathing (SDB) with daytime h)q)ersomnolence, and hypercapnia (Pacc>2 > 45 mmHg) in the absence of any other respiratory disease (Fig. 1). SDB can present as obstructive apneas and hypopneas, obstructive hypoventilation due to increased upper airway resistance, and/or central hypoventilation (7). The prevalence of OHS is 36% in patients with BMI between 35 and 40 kg/m, and 48%, if BMI equals or exceeds 50 (8). Without adequate treatment, patients with OHS develop cor pulmonale and recurrent episodes of hypercapnic respiratory failure, and loss of survival (Fig. 2). OHS is one of the many etiologies of CRF and has become a growing indication to initiate longterm noninvasive ventilation (NIV) in most European countries (9,10). 

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. 

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