Successful treatment of obstructive sleep apnea with use of nasal continuous positive airway pressure in three patients with mucosal hemangiomas of the oral cavity

Cysts and benign tumors are uncommon causes of obstructive sleep apnea (OSA), and surgical removal is usually favored. In patients in whom an operation poses a high risk, however, nasal continuous positive airway pressure (CPAP) may prove beneficial. We describe three patients with hemangiomas of the oral cavity in whom polysomnography revealed moderate to severe OSA. In all three patients, nasal CPAP effectively decreased sleep-related disordered breathing events and dramatically improved their sleep. To our knowledge, this is the first report of OSA associated with hemangiomas involving the upper airway. Our experience suggests that nasal CPAP therapy is effective and well tolerated in such patients.     

Surgical treatment of obstructive sleep apnea

THE PRIMARY TREATMENT for obstructive sleep apnea (OSA) has been continuous positive airway pressure (CPAP) therapy, but the minimum acceptable number of hours of nightly CPAP use remains unclear. INTEGRATED SOFT TISSUE and bone surgery may be a viable alternative for patients who have rejected CPAP as a treatment option. Formal sleep testing has shown that surgery and CPAP therapy are equally successful at resolving OSA. REPEAT SLEEP TESTING conducted several years after patients have undergone combined soft tissue and bone surgery has demonstrated consistent and reliable surgical results. Patients with OSA should be offered surgery as an alternative to life-long CPAP treatment or as an option when CPAP therapy has not been successful.     

Atrial natriuretic peptide release during sleep in patients with obstructive sleep apnoea before and during treatment with nasal continuous positive airway pressure

1. Plasma levels of atrial natriuretic peptide (ANP) were measured in seven patients with obstructive sleep apnoea (OSA) while they were awake, during repetitive apnoea and during treatment with nasal continuous positive airway pressure (CPAP). 2. ANP levels in both pulmonary artery and peripheral venous samples were elevated during apnoeic sleep and reduced when apnoea was prevented by nasal CPAP. Mean values of pulmonary artery ANP were 116.3 +/- 17.9 pg/ml during apnoea and 64.8 +/- 15.2 pg/ml (P less than 0.05) on nasal CPAP. 3. It is concluded that there is increased ANP release during sleep in patients with OSA and that CPAP treatment normalizes ANP secretion. These findings may explain previously identified urinary abnormalities in OSA.     

Improvement in Headaches With Continuous Positive Airway Pressure for Obstructive Sleep Apnea: A Retrospective Analysis

Objective.— We aimed to identify clinical features in patients with severe headaches that predicted obstructive sleep apnea (OSA) and determine clinical and sleep study characteristics that predicted headache improvement with continuous positive airway pressure (CPAP). Background.— Many patients with headaches complain of sleep symptoms and have OSA. There is often improvement of headaches with CPAP treatment. Methods.— We conducted a retrospective chart review of all patients referred to adult neurology clinic for headaches and sent for polysomnography between January 2008 and December 2009. Follow‐up ranged from 18 to 42 months. Results.— Eighty‐two headache patients (70 females, 12 males) were studied. Mean age was 45 ± 13 years (females 45 ± 13, males 43 ± 11) and mean body mass index was 32 ± 9. Headache types included 17% chronic migraine without aura, 22% episodic migraine without aura, 32% migraine with aura, 21% tension‐type headache, 6% chronic post‐traumatic headache, 11% medication overuse headache, and 7% other types. All patients were receiving standard treatment for their headaches by their neurologist. Fifty‐two patients (63%) had OSA. Increasing age, female gender, and chronic migraine without aura were predictive of OSA. Of the patients with OSA, 33 (63%) used CPAP and 27 (82%) were adherent to CPAP. Headache improvement was reported by 40 patients (49%) due to either standard medical therapy or CPAP. Patients with OSA who were CPAP adherent (21/27) were more likely to have improvement in headaches than patients intolerant of CPAP (2/6), those that did not try CPAP (8/19), and those who did not have OSA (16/30) (P = .045). Of the 33 patients who used CPAP, 13 reported improvement in headaches specifically due to CPAP therapy and 10 additional patients noted benefit in sleep symptoms. The presence of witnessed apneas (P = .045) and male gender (P = .021) predicted improvement in headaches due to CPAP. Conclusions.— Headache patients should be evaluated for the presence of OSA. Treating OSA improves headaches in some patients.     

Factors Influencing the Use and Nonuse of Continuous Positive Airway Pressure Therapy: A Comparative Case Study

The rates of sustained use of continuous positive airway pressure (CPAP) therapy among adults with obstructive sleep apnea (OSA) appear consistently suboptimal, despite the efficacy of this treatment. Using semistructured interviews, this study identified facilitators and barriers toward CPAP therapy after treatment initiation among patients with OSA. A purposive sample of eight patients representing extreme differences in CPAP use was recruited from a multisite sleep disorders clinic at a tertiary health center. Perceived physical, psychological, and social factors were found to influence both CPAP use and nonuse. It was revealed that the way patients feel about themselves influences the ways in which they manage their OSA with or without CPAP. This study underlines the necessity of working with patients and their families to create social environments that are both accepting and supportive of patients with OSA.     

Treatment of obstructive sleep apnea in primary care

Obstructive sleep apnea should be suspected in patients who are overweight snore loudly, and have chronic daytime sleepiness. The diagnosis of sleep apnea may be confirmed by sleep laboratory studies. Patients' symptoms and the frequency of respiratory events on laboratory testing are important factors in determining the severity of disease. In patients with mild sleep apnea, conservative treatment measures include getting sufficient sleep, abstaining from the use of alcohol and sedatives, losing weight, and avoiding the supine position during sleep. Continuous positive airway pressure (CPAP) is the most consistently effective treatment for clinically significant obstructive sleep apnea. In general, heavier patients with thicker necks require higher pressure settings. As patients age or gain weight, additional pressure may be necessary. Bilevel pressure machines or machines that slowly ramp up the pressure may increase patient acceptance of CPAP therapy. Complications of CPAP use include nasal dryness and congestion, claustrophobia, facial skin abrasions, air leaks, and conjunctivitis. Strategies to improve patient compliance include allowing patients to try a number of masks to find the most comfortable fit, adding humidification, treating nasal disease and, most importantly, providing close follow-up and encouragement. Oral appliances are inconsistently effective in the management of obstructive sleep apnea but may be an option in patients with mild disease who cannot tolerate CPAP. Palatal surgery often decreases snoring but may not reduce the occurrence of sleep apnea. Patients with severe disease and intolerance of CPAP may be candidates for more invasive surgical procedures. Supplemental oxygen and drug therapy may have limited, adjunctive roles in the treatment of obstructive sleep apnea.     

Obstructive sleep apnoea causes transient and sustained systemic hypertension

Apnoea with associated fall in arterial oxygen tension results in increased blood pressure and a striking surge in sympathetic activity, which can be measured as high catecholamine levels or increase in muscle sympathetic nerve activity. Following the termination of apnoea with resumption of breathing, sympathetic nerve activity decreases and blood pressure returns to lower values. Sympathetic mediated alternations in peripheral vascular resistance best explain these findings. Hypertension during wakefulness in untreated patients with apnoea is also associated with high sympathetic nervous system activity. Nasal continuous positive airway pressure (CPAP) has been shown to lower blood pressure in some hypertensive obstructive sleep apnoea (OSA) patients. Recently, previously untreated OSA patients exhibiting awake sympathetic hyperexcitation demonstrated striking attentuation of the response following initiation of effective CPAP therapy. Accordingly, the common problem of systemic hypertension found in untreated OSA appears to be mediated by sympathetic excitation and responds to effective CPAP therapy.     

Can nasal continuous positive airway pressure decrease clinic blood pressure in patients with obstructive sleep apnea?

Obstructive sleep apnea (OSA) is commonly associated with systemic hypertension and now recognized as an independent risk factor for daytime hypertension. We aimed to study the short- and long-term effect of nasal continuous positive airway pressure (CPAP) in hypertensive and normotensive patients with OSA. Forty-six patients with moderated to severe OSA were treated with nasal CPAP and followed after one year of treatment. Clinic blood pressure, heart rate, and body weight were taken before and followed up for one year after beginning nasal CPAP. In this study 25 patients with OSA were found to have hypertension (54.3%). The hypertensive group showed a significant reduction in clinic blood pressure after nasal CPAP, whereas the normotensive group showed no changes. The subgroup of hypertensive patients with OSA who had no anti-hypertensive medication revealed a decrease in clinic blood pressure comparable to those with anti-hypertensive drugs. The heart rate was not significantly changed in any patients. There was no significant correlation between the decrease in body weight and the reduction in blood pressure. These results suggest that nasal CPAP alone might have a substantial blood pressure lowering effect in hypertensive patients with OSA. This effect could decrease the morbidity and mortality related to cardiovascular complications in patients with OSA.     

Contemporary issues in the diagnosis and treatment of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common disease associated with signifi cant morbidity and use of health care resources. Therapy with continuous positive airway pressure (CPAP) devices has low risk and a potentially large benefit in treating this disease. The Centers for Medicare and Medicaid Services (CMS) recently issued a memo revising their earlier position that authorized payment for CPAP only if formal polysomnography (PSG) was performed and was diagnostic for OSA. The revised memo states that CMS will be pay for CPAP therapy for 12 weeks (and subsequently if OSA improves) for adults diagnosed with either PSG or with unattended home sleep monitoring devices. The use of portable home monitoring devices can greatly increase access to diagnosis and treatment of OSA. However, these devices must be used as part of a comprehensive sleep evaluation program that includes access to board-certifi ed sleep specialists, PSG facilities, and therapists experienced in fi tting and troubleshooting CPAP devices.     

Sleep and medical disorders

Extensive evidence links cardiovascular disease and sleep disordered breathing. OSA has adverse effects on blood pressure, cardiovascular status,and mortality. Effective CPAP therapy can improve blood pressure and cardiac function in patients who have OSA. Patients who have congestive heart failure have a high prevalence of sleep-disordered breathing, with OSA occurring in 30% of such patients and Cheyne-Stokes respiration in 40%.CPAP is the preferred mode of therapy for both types of sleep-disordered breathing in patients who have coexistent congestive heart failure. Nocturnal worsening of asthma is a common manifestation of this disease that indicates increased disease severity. Therapy focuses on judicious use of long-acting bronchodilators, and the presence of OSA should also be considered. COPD is frequently associated with impaired sleep, likely because of chronic dyspnea and sleep-associated hypoxemia. Appropriate therapy again includes long-acting bronchodilators and possibly nocturnal supplemental oxygen.Gastroesophageal reflux during sleep may lead to prolonged episodes of esophageal acid exposure and may be a common sequela of OSA, perhaps triggering nocturnal worsening of asthma. Endstage renal disease and chronic dialysis are commonly associated with a host of troublesome sleep problems,including OSA, RLS, PLMD, and daytime sleepiness.     

Optimal treatment of obstructive sleep apnea and excessive sleepiness

Introduction  Collapsibility of the upper airway in obstructive sleep apnea (OSA) causes repeated arousals from sleep, decreased oxygen saturation of the blood, and excessive sleepiness (ES). Patients with OSA are at increased risk of cardiovascular and cerebrovascular disease, and experience occupational and vehicular accidents more frequently than the general population. Furthermore, the life expectancy of patients with untreated OSA is significantly reduced. Methods  A MEDLINE search of articles published between 2003 and 2008 was conducted using the search terms: obstructive sleep apnea [ti/ab] AND treatment; obstructive sleep apnoea [ti/ab] AND treatment; and excessive sleepiness [ti/ab] AND treatment. Searches were limited to articles in English; clinical trials; meta-analyses; practice guidelines; randomized, controlled trials; and reviews. Results  Continuous positive airway pressure (CPAP) is the reference-standard treatment for patients with OSA. CPAP addresses the symptoms of OSA and reduces the risk of heart disease and depression associated with this sleep disorder. However, the efficacy of CPAP is contingent on patient adherence, and ≥4 hours of therapy per night are required for patients with OSA to experience significant clinical benefits. However, reports of nonadherence to CPAP therapy range from 29% to 83%. Other therapies are available for patients who refuse or cannot adhere to CPAP treatment, including dental devices and surgery, but these treatments are generally considered to be less efficacious. A significant number of patients continue to experience residual ES despite CPAP treatment. Pharmacologic therapies, eg, modafinil and armodafinil, may be of use in patients with OSA to improve tolerance with CPAP or to address residual ES. Conclusion  There are a variety of treatments available for patients with OSA. Successful treatment involves encouraging patient compliance with CPAP or oral appliances. Primary-care physicians play a crucial role in recognizing this disorder and ensuring the best possible outcome through support and education.     

The effect of snoring and obstructive sleep apnea on the sleep quality of bed partners

OBJECTIVE: To measure the effect of snoring and obstructive sleep apnea (OSA) on the sleep of snorers' bed partners and to determine whether a bed partner's sleep improves when snoring and OSA are treated. MATERIALS AND METHODS: We studied 10 married couples in which 1 member was undergoing polysomnography to evaluate suspected OSA. The patients and their spouses underwent simultaneous polysomnography. Midway through the 1-night study, the patients received nasal continuous positive airway pressure (CPAP) with the pressure adjusted to eliminate snoring and obstructive breathing events. Apnea-hypopnea index (episodes/hours of sleep time), arousal index (arousals/hours of sleep time), and sleep efficiency (percent time asleep) were calculated to measure sleep quality. RESULTS: The patients (all male) demonstrated a median (range) apnea-hypopnea index of 26 (3-75) that decreased to 7 (0-34) during the trial of nasal CPAP therapy (P < .05). During the CPAP trial, the median (range) arousal index of the spouses decreased from 21 (14-34) to 12 (4-27) (P < .01), and the spouses' median (range) sleep efficiency increased from 74% (56%-80%) to 87% (64%-95%) (P < .01). CONCLUSION: The elimination of snoring and OSA in these patients was associated with an improvement in the quality of their bed partners' sleep, as indicated by improved sleep efficiency and continuity, even when the spouses had been habitually exposed to snoring and OSA. Assuming that 480 minutes were spent in bed for sleep, a 13% improvement in sleep efficiency (i.e., from 74% to 87%) translates to an additional 62 minutes of sleep per night for the spouses of snorers with OSA.     

Case report of new-onset obstructive sleep apnea after carbon monoxide poisoning

Obstructive sleep apnea (OSA) is characterized by repetitive intermittent oxygen desaturation during sleep. Carbon monoxide poisoning (COP) is the second most common cause of death among non-medicinal poisonings, and oxygen therapy is the current standard of treatment for COP. We herein report a case of a 50-year-old woman diagnosed with severe OSA associated with COP. Both the OSA and COP gradually resolved by automatic continuous positive airway pressure (CPAP) therapy. New OSA symptoms appeared following the development of delayed encephalopathy after acute COP (DEACMP) 3 weeks later. Severe OSA was diagnosed 76 days after COP with an apnea–hypopnea index of 66 events/hour, and CPAP therapy was immediately administered. The patient’s DEACMP symptoms and OSA both improved with CPAP therapy (her apnea–hypopnea index decreased to 32.4 and 16.5 events/hour at 161 and 204 days after COP, respectively). To our knowledge, this is the first case report of OSA caused by COP based on the occurrence and disappearance of OSA symptoms and laboratory findings associated with the emergence and improvement of DEACMP.     

Life changes in individuals diagnosed with sleep apnea while accommodating to continuous positive airway pressure (CPAP) devices.

Continuous positive airway pressure (CPAP) devices are effective in preventing the sequela of obstructive sleep apnea (OSA); however, compliance with the device is problematic. This study's purpose is to longitudinally discover OSA patients experiences with CPAP. A hermeneutic phenomenological approach was used to obtain narrative stories for interpretive analysis. 20 patients were prescribed CPAP at an urban sleep center Five themes and one constitutive pattern included (1) trouble using CPAP, (2) needing to persist through initial and recurring frustration, (3) difficulty recognizing subtle improvements, (4) accessing help and problem solving, and (5) becoming part of the routine or abandoning the device. Perseverence through tribulations by developing a positive mind-set was the constitutive pattern. The implications are that rehabilitation nurses should understand the difficulties with CPAP compliance so that they may assist patients with device issues and offer encouragement.     

Implementing protocol for obstructive sleep apnea screening in the primary care setting

Aim1) To implement obstructive sleep apnea (OSA) screening of at -risk patients in a primary care setting; 2) to evaluate and refer screened participants to sleep studies since early identification of OSA symptoms is an important initial step in reducing the burden of undiagnosed OSA disease.MethodParticipants completed the STOP-Bang questionnaire and those considered to be at risk were referred for sleep studies for disease identification, categorization, and treatment.ResultsPrevalent OSA screening and referral rates at the clinic prior to project implementation was 3% and 0% respectively, compared to the corresponding rates of 43% and 39% post project implementation. Out of 187 participants screened between January and April 2018, 61% had scores of 3 and higher on the STOP-Bang questionnaire, however, only 39% of the at-risk participants agreed to undergo sleep studies. Those who declined sleep study referrals were mostly participants who were not experiencing higher burden of sleep deprivation. Out of 45 participants who underwent sleep studies, 67% were diagnoses with moderate to severe OSA with recommendations to initiate continuous positive airway pressure (CPAP) machine therapy.ConclusionMost primary care providers do not routinely screen at-risk patients for OSA despite existing clinical practice guideline recommending early and accurate diagnosis of OSA for this population. The Stop -Bang screening tool can reliably predict the presence of moderate to severe OSA. Early identification of OSA risks in the primary care setting through routing screening is very imperative in order to minimize its effects on cardiovascular morbidity and mortality. The obtained results highlight the potentially high unmet need for screening and treatment of OSA in the primary care setting.     

Sleep apnea and hypertension

Obstructive sleep apnea (OSA) is strongly associated with hypertension. The seventh report of the joint national committee (JNC-VII) guidelines have placed OSA at the top of the list to induce secondary hypertension. Severe OSA patients revealed the high prevalence of hypertension. Compared with normal subjects, patients with OSA had a higher 24-hour blood pressure, especially nighttime blood pressure. More recently, prospective data showed that sleep apnea syndrome was an independent risk for onset of hypertension. There is a lot of evidence that demonstrates that treating OSA using continuous positive airway pressure (CPAP) is an effective for management of OSA.     

Continuous positive airway pressure increases heart rate variability in heart failure patients with obstructive sleep apnoea

Patients with heart failure or OSA (obstructive sleep apnoea) have reduced HF-HRV (high-frequency heart rate variability), indicating reduced cardiac vagal modulation, a marker of poor prognosis. CPAP (continuous positive airway pressure) abolishes OSA in patients with heart failure, but effects on daytime HF-HRV have not been determined. We hypothesized that, in patients with heart failure, treatment of coexisting OSA by CPAP would increase morning HF-HRV. In 19 patients with heart failure (left ventricular ejection fraction <45%) and OSA (>/=20 apnoeas and hypopnoeas/h of sleep), HF-HRV was quantified before and 1 month after randomization to a control or CPAP-treated group. In the control group (n=7), there were no changes in HF-HRV over the 1 month study during wakefulness in the morning. In the CPAP-treated group (n=12) HF-HRV increased significantly during wakefulness in the morning [from 2.43+/-0.55 to 2.82+/-0.50 log(ms(2)/Hz); P=0.002] due to an increase in transfer function between changes in lung volume and changes in HF-HRV (92.37+/-96.03 to 219.07+/-177.14 ms/l; P=0.01). In conclusion, treatment of coexisting OSA by nocturnal CPAP in patients with heart failure increases HF-HRV during morning wakefulness, indicating improved vagal modulation of heart rate. This may contribute to improved prognosis.     

Improving Obstuctive Sleep Apnea Care in the Postanesthesia Care Unit

PurposeThe purpose of this quality improvement project was to improve care of obstructive sleep apnea (OSA) patients through increased staff recognition of OSA in the postanesthesia care unit (PACU).DesignRetrospective chart review with implementation of best practice guideline form to front of patient's chart.MethodsBaseline data were collected during June 2020. Staff education was provided on current hospital policy of OSA patients. Implementation of a care guideline sheet was added to the front of patient charts for patients meeting inclusion criteria; it consisted of continuous pulse oximetry, 30-degree head of bed elevation, continuous positive airway pressure (CPAP) therapy, 1 hour minimum postoperative observation, nonopioid analgesics, and referral to polysomnography. A retrospective chart review was performed following the OSA guideline intervention.FindingsBoth pre- (N = 413) and postintervention (N = 420) groups had statistically similar demographics. CPAP use increased from 16 to 22 (t = 0.890; P = .336). The number of patients experiencing dyspnea decreased from 10 to 8 (t = 0.263; P = .608). The number of patients experiencing acute respiratory events (AREs) decreased from 24 to 18 (t = 1.012; P = .314).ConclusionThere were no significant statistical findings. However, increased recognition of OSA patients by PACU staff can lead to improved care alterations.     

What role do adrenoreceptor polymorphisms play in modifying cardiovascular responses in obstructive sleep apnoea?

OSA (obstructive sleep apnoea) is a common condition that is strongly associated with cardiovascular disease. It is remains unclear what role OSA plays in determining cardiovascular risk. The immediate physiological changes that occur during upper airway obstruction are potential contributors to cardiovascular risk in OSA. These changes include increased sympathetic activity, which is responsive to treatment of OSA with CPAP (continuous positive airway pressure). In this issue of Clinical Science, the possible role of a common polymorphism in the beta1-adrenoreceptor [R389G (Arg389Gly)] has been investigated by B?rgel and co-workers. Measurements of heart rate and blood pressure in untreated OSA patients were not related to the R389G polymorphism. There were changes in heart rate and diastolic blood pressure with CPAP treatment that were related to this polymorphism. Reduction in heart rate with CPAP treatment was associated with the R389R genotype. By contrast, a reduction in diastolic blood pressure was associated with the Gly389 carriers. These findings are intriguing, but difficult to fully explain. Further study is needed to determine if there is an important role of the R389G polymorphism in modifying cardiovascular responses among OSA patients.     

Selective effects of CPAP on sleep apnoea-associated manifestations

Background   Visceral adiposity and obstructive sleep apnoea (OSA) may be independently associated with daytime sleepiness/low performance, insulin resistance, hypercytokinaemia, and/or hypertension. The objectives of this study are to simultaneously test these associations at baseline and after 3 months of continuous positive airway pressure (CPAP) therapy.
Materials and methods   Sixteen obese men with OSA; 13 non-apnoeic, obese controls, and 15 non-obese controls were monitored in the sleep laboratory for four consecutive nights. Objective measures of daytime sleepiness and performance, serial 24 h plasma measures of interleukin-6 (IL-6), tumour necrosis factor-α (TNF-α), TNF receptor 1 (TNF-r1) and adiponectin, fasting blood glucose and insulin, visceral adiposity and blood pressure were obtained. Sleep apnoeics were re-assessed using the same protocol after 3 months of CPAP.
Results   At baseline, IL-6, TNF-r1, and insulin resistance were highest in OSA patients, intermediate in obese controls, and lowest in non-obese controls ( P  < 0·05). Visceral fat was significantly greater in sleep apnoeics than obese controls and predicted insulin resistance and IL-6 levels, whereas OSA predicted TNF-r1 levels ( P  < 0·05). CPAP decreased daytime sleepiness and blood pressure ( P  < 0·05), but did not affect fasting glucose or insulin or around the clock adiponectin, IL-6, TNF-α, or TNF-r1 levels.
Conclusions   In obese sleep apnoeics, visceral fat is strongly associated with insulin resistance and inflammation. CPAP decreases sleepiness and moderates hypertension but does not affect visceral adiposity, insulin resistance, hypoadiponectinaemia or hypercytokinaemia, all of which are independent risk factors for cardiovascular disease and diabetes.