Continuous Positive Airway Pressure Initiation Research Articles

Variability of breathing during wakefulness while using CPAP predicts adherence.

The standard therapy for obstructive sleep apnoea (OSA) is continuous positive airway pressure (CPAP) therapy. However, long-term adherence remains at ~50% despite improvements in behavioural and educational interventions. Based on prior work, we explored whether regularity of breathing during wakefulness might be a physiologic predictor of CPAP adherence. Of the 117 consecutive patients who were diagnosed with OSA and prescribed CPAP, 79 CPAP naïve patients were enrolled in this prospective study. During CPAP initiation, respiratory signals were collected using respiratory inductance plethysmography while wearing CPAP during wakefulness in a seated position. Breathing regularity was assessed by the coefficient of variation (CV) for breath-by-breath estimated tidal volume (VT ) and total duration of respiratory cycle (Ttot). In a derivation group (n = 36), we determined the cut-off CV value which predicted poor CPAP adherence at the first month of therapy, and verified the validity of this predetermined cut-off value in the remaining participants (validation group; n = 43). In the derivation group, the CV for estimated VT was significantly higher in patients with poor adherence than with good adherence (median (interquartile range): 44.2 (33.4-57.4) vs 26.0 (20.4-33.2), P < 0.001). The CV cut-off value for estimated VT for poor CPAP adherence was 34.0, according to a receiver-operating characteristic (ROC) curve. In the validation group, the CV value for estimated VT >34.0 confirmed to be predicting poor CPAP adherence (sensitivity, 0.78; specificity, 0.83). At the initiation of therapy, breathing regularity during wakefulness while wearing CPAP is an objective predictor of short-term CPAP adherence.

Correlates of Pediatric CPAP Adherence.

Obstructive sleep apnea (OSA) is a common pediatric condition characterized by recurrent partial or complete cessation of airflow during sleep, typically due to inadequate upper airway patency. Continuous positive airway pressure (CPAP) is a therapeutic option that reduces morbidity. Despite efforts to promote use, CPAP adherence is poor in both pediatric and adult populations. We sought to determine whether demographics, insurance status, OSA severity, therapeutic pressure, or comorbid conditions were associated with pediatric CPAP adherence. A retrospective review of adherence download data was performed on all pediatric patients with initiation or adjustment of CPAP treatment over a one-year period with documented in-laboratory CPAP titration. Patients were grouped as CPAP adherent or non-adherent, where adherence was defined as > 70% nightly use and average usage ≥ 4 hours per night. Differences between the groups were analyzed by χ(2) test. Overall, nearly half of participants were CPAP adherent (49%, 69/140). Of the demographic data collected (age, ethnicity, sex, insurance status), only female sex was associated with better adherence (60.9% vs 39.5% of males adherent; odds ratio [OR] = 2.41, 95%CI = 1.20-4.85; p = 0.01). Severity of OSA (diagnostic apnea-hypopnea index [AHI] and degree of hypoxemia), therapeutic pressure, and residual AHI did not impact CPAP adherence (p > 0.05). Patients with developmental delay (DD) were more likely to be adherent with CPAP than those without a DD diagnosis (OR = 2.55, 95%CI = 1.27-5.13; p = 0.007). Female patients with trisomy 21 tended to be more adherent, but this did not reach significance or account for the overall increased adherence associated with female sex. Our study demonstrates that adherence to CPAP therapy is poor but suggests that female sex and developmental delay are associated with better adherence. These findings support efforts to understand the pathophysiology of and to develop adherence-promoting and alternative interventions for pediatric OSA.

Early Bubble Continuous Positive Airway Pressure: Investigating Interprofessional Best Practices for the NICU Team.

Premature neonates delivered <32 completed weeks gestation are unprepared to handle the physiologic demands of extrauterine life. Within the respiratory system, alveolar instability and collapse can cause decreased functional residual capacity, impaired oxygenation, and hypoxemia leading to respiratory distress syndrome. Supportive measures are indicated immediately after birth to establish physiologic stability including bubble continuous positive airway pressure (CPAP) or endotracheal intubation and mechanical ventilation. CPAP is a noninvasive, gentle mode of ventilation that can mitigate the effects of lung immaturity, but prolonged use can increase the risk for nasal breakdown. Strategies to mitigate this risk must be infused as best practices in the NICU environment. The purpose of this article is to propose an evidence-based best practice care bundle for the early initiation of CPAP in the delivery room and associated skin barrier protection strategies for premature neonates <32 weeks gestation and weighing <1,500 g.

Complex sleep apnea at auto-titrating CPAP initiation: prevalence, significance and predictive factors.

Obstructive sleep apnea (OSA) patients may develop central respiratory events under continuous positive airway pressure (CPAP), referred to as complex sleep apnea (CompSA). We aimed to assess prevalence and predictive factors of complex apnea and to evaluate treatment response to CPAP. Within a retrospective cohort study, we assessed clinical data of OSA patients, attending the sleep lab during a 15-months period. Included participants underwent two consecutive polysomnographies; baseline diagnosis and treatment trial. Complex apnea patients, defined by a central apnea index ≥ 5 per hour during pressure auto-titration, were compared to remainders. Among 263 included patients, the prevalence of complex apnea was 9.1%. The mean apnea hypopnea index only dropped from 52.7 to 39.9 per hour in CompSA patients, while it improved from 40.9 to 7.3 in patients without CompSA. Although a decreased sleep-fragmentation under CPAP was observable in both groups, the enhancement of Non-REM sleep was superior in patients without CompSA. The CompSA patients showed higher median apnea-hypopnea, mixed apnea and central apnea indices at baseline and displayed higher rates of comorbid heart failure and obstructive pulmonary disease, but no higher severity of associated daytime fatigue and sleepiness symptoms. Despite evidenced partial improvement of obstructive events, nocturnal hypoxemia and sleep fragmentation, the occurrence of complex apnea presented here as a clear therapeutic failure of auto-titrating CPAP and was associated with heart failure, COPD and higher central and mixed apnea indices at baseline.

Sleep Duration is increased but not Physical Activity in Somnolent Moderate to Severe Obstructive Sleep Apnea Patients Treated by Continuous Positive Airway Pressure

Background and objective: Obstructive Sleep apnea syndrome (OSA) is associated with poor sleep, a decreased quality of life (QoL) and low physical activity (PA). With treatment, sleep quality is improved and one may then expect a reduction in daytime sleepiness and an increase in sleep duration, PA and QoL. The present study was aimed to assess changes in sleep duration in somnolent obese moderate to severe OSA patients before and after treatment with continuous positive airway pressure (CPAP). As secondary aims, changes in PA, QoL and daytime sleepiness before and after treatment with CPAP were also assessed, together with the proportion of sleep time spent with CPAP after 3 months of treatment. Methods: In this prospective multicentric study, 150 moderate to severe somnolent OSA patients were evaluated using actigraphy, QoL questionnaire and Epworth Sleepiness Scale before and 3 months after CPAP initiation. Results: Baseline short sleep time was associated with OSA severity (p<0.001). CPAP treatment increased time spent sleeping: 362 ± 105 to 389 ± 90 Daytime sleepiness and quality of life improved by treatment, but PA did not increase. A larger proportion of the night spent with CPAP was associated with less daytime sleepiness and with a better QoL. Conclusions: Mean 5 day sleep duration, assessed by actigraphy, is increased by CPAP treatment in somnolent OSA patients. However, despite longer sleep, physical activity is not improved in contrast with a decrease in daytime sleepiness and an improvement in the quality of life. The reduction of both daytime sleepiness and the improvement in the quality of life increased in parallel with the proportion of night spent with CPAP.

Continuous Positive Airway Pressure Device Time to Procurement in a Disadvantaged Population

Introduction. The management of obstructive sleep apnea (OSA) in patients who cannot afford a continuous positive airway pressure (CPAP) device is challenging. In this study we compare time to CPAP procurement in three groups of patients diagnosed with OSA: uninsured subsidized by a humanitarian grant (Group 1), uninsured unsubsidized (Group 2), and those with Medicare or Medicaid (Group 3). We evaluate follow-up and adherence in Group 1. We hypothesize that additional factors, rather than just the ability to obtain CPAP, may uniquely affect follow-up and adherence in uninsured patients. Methods. 30 patients were in Groups 1 and 2, respectively. 12 patients were in Group 3. Time of CPAP procurement from OSA diagnosis to CPAP initiation was assessed in all groups. CPAP adherence data was collected for Group 1 patients at 1, 3, 6, and 9 months. Results. There were no significant differences between groups in gender, age, body mass index, or apnea hypopnea index. The mean time to procurement in Group 1 was shorter compared to Group 2 but not significant. Compared to both Group 1 and Group 2, Group 3 patients had significantly shorter times to device procurement. Conclusion. Time to procurement of CPAP was significantly shorter in those with Medicaid/Medicare insurance compared to the uninsured.

HIF-Mediated Changes in Erythropoiesis and Gene Expression in Chronic Intermittent Hypoxia Due to Obstructive Sleep Apnea

1st, 2nd, and 3rdauthors deserve equal credit.Red cell mass is tightly controlled by hypoxia, a process regulated by hypoxia-inducible transcription factors (HIFs). Obstructive sleep apnea (OSA) involves chronic intermittent hypoxia during sleep and has multiple organismal detrimental effects including hypertension, diabetes, cognitive impairment, heart attacks, and thrombotic complications. Polycythemia is not recognized as a feature of OSA, but we see occasional patients with polycythemia and OSA whose hematocrits are normalized by successful therapy with continuous positive airway pressure (CPAP).We set out to analyze the effect of OSA on erythropoiesis in 18 non-smoking OSA patients without any chronic pulmonary disease and with normal hematocrits. Their blood was drawn before and after an overnight polysomnography (PSG) and, to account for possible circadian oscillation changes, at the same time of day. Patients ranged in OSA severity based on apnea-hypopnea index from mild to severe. An average of 98.5 minutes was spent with oxygen saturations of 89% or lower, with a 4% oxygen desaturation index of 22.9/hr. The average lowest oxygen saturation value was 78%, 6/18 subjects had hypertension and 4/18 diabetes. Three of these patients achieved remission of OSA over 3 months of successful therapy with CPAP, and were reanalyzed.We considered the possibility that daily rapid changes from hypoxia to normoxia can lead to overcorrection of augmented erythropoiesis by preferential destruction of erythrocytes made in hypoxia; i.e. neocytolysis. We attempted to replicate data using our neocytolysis mouse model in OSA patients wherein neocytolysis is mediated by excessive generation of ROS from increased reticulocyte mitochondrial mass due to HIF-regulated reduction of Bnip3L levels upon return to normoxia. The reticulocyte-derived ROS then destroy hypoxia-produced young RBCs having reduced catalase (CAT) downregulated by increased miR-21 (see J. Song at this ASH). We also analyzed HIFs levels by QT-PCR of selected HIF-regulated gene transcripts (GLUT1, HK1, VEGFA, and PDK1) and the principal HIF inhibitor, PHD2, in reticulocytes. HK1 transcripts were higher in OSA patients than in controls. The expression of other HIF-targeted genes in OSA patients showed the same trend with HK1 expression but did not reach statistical significance.In uncontrolled OSA (before and after overnight PSG), there were significant changes in CAT and BNIP3L transcript levels in reticulocytes compared to CPAP-corrected OSA. We found that CAT and BNIP3L transcript levels increased after CPAP treatment, indicating that in uncontrolled OSA, catalase and BNIP3L are low, causing generation of excessive ROS from mitochondria and, in keeping with this observation, we observed a significant decrease in miR21 leading to increased CAT. Compared to after correction of OSA, these BNIP3L and CAT changes would account for the absence of polycythemia during OSA. Increased mitochondrial mass generates additional ROS, thus replicating mouse neocytolysis in human OSA. Pre-OSA HIF activity is not markedly different from post-OSA HIF activity, perhaps reflecting the limitations of analyzing terminally differentiated cells. It is likely that miRNA changes in reticulocytes do not reflect acute changes that are present in erythroid progenitors with transcriptional activity. This limitation will be corrected by repeated analyses performed a few days after initiation of CPAP therapy.We also analyzed erythropoiesis and observed a decreasing trend in erythropoietin level and erythroferrone transcripts after correction of OSA, findings compatible with augmented erythropoiesis in uncontrolled OSA.Correlation of these and future data with those few OSA subjects who develop erythrocytosis is expected to uncover individual variations in hypoxic response leading to changes in HIFs response. Elucidation of erythroid, inflammatory (granulocyte analyses) and thrombotic (platelet analyses) OSA complications offers the possibility of targeted interventions by HIF inhibitors (i.e., digoxin) and/or HIF augmentation (PHD2 inhibitors). DisclosuresNo relevant conflicts of interest to declare.

Decisive situations influencing continuous positive airway pressure initiation in patients with obstructive sleep apnea syndrome – A critical incident technique analysis from the personnel’s perspective

Background: Continuous positive airway pressure is an effective treatment of obstructive sleep apnea syndrome, but adherenceto treatment is low. Interventions such as encouragement, education and cognitive behavioural therapy have affected adherenceto continuous positive airway pressure treatment positively. Currently there are no studies regarding the situation for personnelduring the initiation process of treatment.Purpose: The purpose was to describe situations influencing the initiation of continuous positive airway pressure in patientswith obstructive sleep apnea syndrome from a personnel perspective.Materials and methods: A qualitative approach using critical incident technique was used. Data were collected through semistructuredinterviews. Thirty one informants were strategically selected from sixteen centres in Sweden.Results: Motivation, a prepared patient, communicational aspects and participation of family were described as pedagogicalcircumstances. External conditions, practical experience, the patient’s state of health and adaption to the mask were describedas practical circumstances. The personnel handled the situations in a theoretical, practical and/or an emotional way.Conclusions: A better understanding of situations creating barriers or being facilitators, as well as ways to handle these situations,can be used to develop the role of personnel during the initiation process in order to increase continuous positive airwaypressure adherence.

Nocturnal pulse rate and symptomatic response in patients with obstructive sleep apnoea treated with continuous positive airway pressure for one year.

Obstructive sleep apnoea (OSA) is the most common form of sleep-disordered breathing and a known risk factor for cardiovascular disease. We hypothesised that in patients with OSA the characteristics of nocturnal pulse rate (PR) are associated with changes in blood pressure and daytime sleepiness, following commencement of continuous positive airway pressure (CPAP) therapy. Pulse oximetry data, demographics, daytime sleepiness and blood pressure were recorded at baseline and at one year follow up. Patients with OSA were grouped according to positive and negative changes in the PR (ΔPR) response during the first night of pulse oximetry before commencement of CPAP. A total of 115 patients (58 with OSA and 57 matched subjects without OSA) were identified and included in the analysis. The scale of improvement in daytime sleepiness could be predicted by a negative or positive ΔPR, as recorded in the initial screening pulse oximetry [ΔESS -5.8 (5.1) vs. -0.8 (7.2) points, P<0.05]. A negative correlation was observed between mean nocturnal PR and changes in systolic blood pressure (SBP) after one year of CPAP treatment (r=-0.42, P<0.05). Mean nocturnal PR prior to CPAP initiation was associated with changes in SBP at one year follow up. A descending nocturnal PR in patients with OSA, prior to CPAP initiation, might help to identify a symptomatic response from long term CPAP treatment.

Positive airway pressure in patients with coronary artery disease and obstructive sleep apnea syndrome.

We designed a prospective nonrandomized study aiming at assessing the impact of continuous positive airway pressure (CPAP) after a new diagnosis of obstructive sleep apnea syndrome (OSAS) in patients with coronary artery disease (CAD). Consecutive patients referred to coronary angiography underwent an overnight sleep study during their hospital stay. Among those with angiographically confirmed CAD and a new diagnosis of moderate or severe OSAS, we compared the 3-year major adverse cardiac or cerebrovascular event (MACCE)-free survival stratified by CPAP at discharge. Of 496 patients undergoing an overnight sleep study, 129 had angiographically confirmed CAD and presented with moderate or severe OSAS. The incidence of 3-year MACCE was significantly lower in the CPAP-treated group (n = 17) than in the untreated group (n = 112; 12 vs. 44%, P = 0.02). After adjusting for differences in baseline characteristics, CPAP was significantly associated with a decreased risk of MACCE [adjusted hazard ratio 0.18, 95% confidence interval (CI) 0.04-0.78, P = 0.02]. Among men, CPAP was associated with a significant 3-year risk reduction in MACCE (adjusted hazard ratio 0.12, 95% CI 0.02-0.87, P = 0.04), whereas no significant benefit of CPAP was seen in women (adjusted hazard ratio 2.1, 95% CI 0.10-41.6, P = 0.63). The statistical interaction between CPAP and sex trended to be significant (adjusted P for interaction = 0.10). In patients with OSAS and CAD, the initiation of CPAP is associated with a significant reduction in MACCE compared with patients left untreated.

Continuous positive airway pressure treatment for obstructive sleep apnoea: Maori, Pacific and New Zealand European experiences

Continuous positive airway pressure (CPAP) is an effective treatment of obstructive sleep apnoea (OSA), but can be limited by poor adherence. In New Zealand (NZ), ethnicity has been shown to be a predictor of CPAP adherence. This study aimed to explore Maori , Pacific and NZ European patients' experience of CPAP treatment. Patients identifying as Maori , Pacific, or NZ European ethnicity referred for CPAP treatment for OSA attended separate, 1.5-hour group discussions facilitated by a health care worker of the same ethnic group, using an interview template. Thematic analysis was applied to the discussion transcripts independently by two investigators, following published guidelines. Five Maori , five Pacific, and eight NZ Europeans participated (mean age 47, range 30-71 years, mean ± standard deviation CPAP adherence 6.32 ± 1.25 hours/night). Patients in all three groups reported that they had little knowledge of OSA or CPAP prior to treatment initiation. All groups identified barriers to treatment (both at the CPAP initiation phase and long term), reported feelings of being 'overwhelmed' with information during the initial CPAP education session, and discussed the importance of successful role models. Family and friends were generally reported as being supportive of CPAP therapy. The three groups all reported similar initial CPAP experiences, highlighting access barriers to publicly funded assessment and treatment pathways, and sleep health knowledge as key issues. Educational resources to improve access, enable self-management, and increase community awareness of OSA would help overcome some of the issues identified in this study.

Pressure-dependent hemodynamic effect of continuous positive airway pressure in severe chronic heart failure: A case series

Two third of stable severe Chronic Heart Failure (CHF) patients are affected by central or obstructive sleep disordered breathing (SDB). Although Continuous Positive Airway Pressure (CPAP) is a validated treatment for obstructive sleep apnea (OSA) in CHF [ [1] Kaneko Y. Floras J.S. Usui P.K. et al. Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea. N Engl J Med. 2003; 348: 1233-1241 Crossref PubMed Scopus (902) Google Scholar ], its interest in central sleep apnea (CSA) associated with CHF remains still controversial. The CANPAP randomized controlled trial showed an increase in event rates and mortality occurring during the first months of CPAP initiation [ [2] Bradley T.D. Logan A.G. Kimoff R.J. et al. Continuous airway pressure for central sleep apnea and heart failure. N Engl J Med. 2005; 353: 2025-2033 Crossref PubMed Scopus (947) Google Scholar ]. It suggests that CPAP may have an early adverse effect in some CHF patients suffering from CSA. Using CPAP in CHF patients, when filling pressures are high, the cardiac output seems to increase, and when pressures are low, it seems to decrease. Potentially, upward titration of CPAP reduced cardiac output in some patients and may then be deleterious [ [2] Bradley T.D. Logan A.G. Kimoff R.J. et al. Continuous airway pressure for central sleep apnea and heart failure. N Engl J Med. 2005; 353: 2025-2033 Crossref PubMed Scopus (947) Google Scholar ]. As recently highlighted by a Task Force report [ [3] Aurora R.N. Chowdhuri S. Ramar K. et al. The treatment of central sleep apnea syndromes: practice parameters with an evidence-based literature review and meta-analyses. Sleep. 2012; 35: 17-40 PubMed Google Scholar ], a clear limitation of most of the studies in the field is that CPAP therapy was not titrated. In clinical practice, CPAP titration in CHF is mainly addressing the correction of SDB but its impact on hemodynamic should probably be included in the titration process in CHF patients [ [4] Jaffuel D. Combes N. Jaber S. Heterogeneity of response to constant positive pressure in patients with heart failure and co-existing central and obstructive sleep apnea: why?. Chest. 2013; 143: 11833 Crossref Scopus (3) Google Scholar ]. A more careful CPAP titration might avoid some adverse events.

S4 Short term use of continuous positive airway pressure (CPAP) by obese patients with obstructive sleep apnoea syndrome (OSAS) diagnosed during assessment for bariatric surgery

Around one in three patients with OSAS is unable to continue with CPAP. The reasons for this are still poorly understood. Patients being assessed for Bariatric Surgery are informed that...

CPAP‐induced mania in bipolar disorder: a case report

In this case report we present our clinical observations of two patients with bipolar disorder with comorbid obstructive sleep apnea (OSA) who were treated with continuous positive airway pressure (CPAP) for their sleep apnea. Bipolar disorder is a psychiatric disorder characterized by the presence of one or more episodes of mania and frequent episodes of depression. This disorder affects approximately 0.8% of the adult population, with estimates from community samples ranging between 0.4% and 1.6%. OSA syndrome is a severe sleep disorder with a prevalence of 2-4% in the general population, the risk of which is increased by obesity. The prevalence of OSA is expected to be high in bipolar disorder due to high comorbid obesity. It is expected that improvement in OSA in patients with bipolar disorder with CPAP will improve mood and other symptoms of bipolar disorder. However, there is a relative lack of data examining this aspect. In both cases of bipolar disorder, CPAP was started after a polysomnographic diagnosis of OSA and CPAP titration study indicating that most of the apneas/hypopneas were eliminated with a significant improvement in oxygen saturation. To our surprise, we noted that in both of these cases initiation of CPAP resulted in manic symptoms. Clinicians need to monitor patients with bipolar disorder closely for worsening of manic symptoms when they are started on CPAP for underlying OSA.

Nocturnal Diaphoresis Secondary to Mild Obstructive Sleep Apnea in a Patient with a History of Two Malignancies

Numerous medical disorders, including obstructive sleep apnea, may cause nocturnal diaphoresis. Previous work has associated severe obstructive sleep apnea with nocturnal diaphoresis. This case report is of import as our patient with severe nocturnal diaphoresis manifested only mild sleep apnea, and, for years, his nocturnal diaphoresis was ascribed to other causes, i.e., first prostate cancer and then follicular B-cell lymphoma. Additionally, it was the nocturnal diaphoresis and not more common symptoms of obstructive sleep apnea, such as snoring, that led to the definitive diagnosis of his sleep apnea and then to treatment with a gratifying resolution of his onerous symptom.

Willingness score obtained after a short CPAP trial predicts CPAP use at 1 year

To predict continuous positive airway pressure (CPAP) adherence at 1 year. We followed consecutive OSA patients scheduled for CPAP initiation for 1 year. Patients completed a self-efficacy questionnaire (5 = low, 25 = high score) before CPAP initiation. After CPAP initiation, we enquired about patients' satisfaction in CPAP trial and their eagerness and willingness to continue CPAP therapy (0 = unsatisfied, uneager, or refused CPAP; 100 = satisfied, eager, or willing to continue CPAP treatment). Of the 580 patients we followed, 377 continued CPAP therapy beyond 1 year. A low willingness score (<50) was expressed by 77 patients but only 7 of them used CPAP >4 h daily at 1 year, yielding a specificity of 97 % in predicting CPAP failure. At 1 year, patients with a self-efficacy score >20, expressed prior to CPAP initiation, used CPAP more often than the patients with a score <20 (average use 4.4 ± 2.2 h vs. 3.7 ± 2.3 h, p<0.001). A low score of willingness to continue CPAP therapy after a short trial predicts CPAP failure and poor CPAP adherence at 1 year.

Effects of Armodafinil on Simulated Driving and Self-Report Measures in Obstructive Sleep Apnea Patients prior to Treatment with Continuous Positive Airway Pressure

Obstructive sleep apnea (OSA) has been associated with an increased risk of motor vehicle crashes. This driving risk can be reduced (≥ 50%) by treatment with continuous positive airway pressure (CPAP). However residual excessive daytime sleepiness (EDS) can persist for some patients who regularly use CPAP. The current study was designed to assess the effect of armodafinil on simulated driving performance and subsequent CPAP treatment compliance in newly diagnosed OSA patients with EDS during a 2-week "waiting period" prior to initiation of CPAP. Sixty-nine newly diagnosed OSA patients, awaiting CPAP therapy, were randomized (1:1) to placebo or armodafinil (150 mg/day) treatment. Simulated driving tests and self-report measures were completed at baseline, after 2 weeks of drug treatment, and following 6 weeks of CPAP treatment. CPAP compliance was evaluated at the end of 6 weeks of CPAP. Compared to placebo, armodafinil improved simulated driving safety performance in OSA patients awaiting CPAP therapy (p = 0.03). Improvement was seen in lane position deviation (p = 0.002) and number of lane excursions (p = 0.02). Improvement was also observed on measures of sleepiness using the Epworth Sleepiness Scale (ESS) and sleep related quality of life. Following 6 weeks of CPAP, there was also significant improvement observed on multiple measures of simulated driving performance. CPAP compliance did not differ between armodafinil-treated and placebo-treated patients (p = 0.80). Armodafinil was found to improve simulated driving performance in OSA patients with EDS prior to initiation of CPAP. Treatment with armodafinil showed no effect on subsequent CPAP compliance.

CPAP therapy in patients with idiopathic pulmonary fibrosis and obstructive sleep apnea: does it offer a better quality of life and sleep?

The recent literature shows an increased incidence of obstructive sleep apnea (OSA) in patients with idiopathic pulmonary fibrosis (IPF). On the other hand, there are no published studies related to continuous positive airway pressure (CPAP) treatment in this patient group. Our aim was to assess the effect of CPAP on sleep and overall life quality parameters in IPF patients with OSA and to recognize and overcome possible difficulties in CPAP initiation and acceptance by these patients. Twelve patients (ten males and two females, age 67.1 ± 7.2years) with newly diagnosed IPF and moderate to severe OSA, confirmed by overnight attended polysomnography, were included. Therapy with CPAP was initiated after a formal in-lab CPAP titration study. The patients completed the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), the Functional Outcomes in Sleep Questionnaire (FOSQ), the Fatigue Severity Scale (FSS), the SF-36 quality of life questionnaire, and the Beck Depression Inventory (BDI) at CPAP initiation and after 1, 3, and 6months of effective CPAP therapy. A statistically significant improvement was observed in the FOSQ at 1, 3, and 6months after CPAP initiation (baseline 12.9 ± 2.9 vs. 14.7 ± 2.6 vs. 15.8 ± 2.1 vs. 16.9 ± 1.9, respectively, p = 0.02). Improvement, although not statistically significant, was noted in ESS score (9.2 ± 5.6 vs. 7.6 ± 4.9 vs. 7.5 ± 5.3 vs. 7.7 ± 5.2, p = 0.84), PSQI (10.7 ± 4.4 vs. 10.1 ± 4.3 vs. 9.4 ± 4.7 vs. 8.6 ± 5.2, p = 0.66), FSS (39.5 ± 10.2 vs. 34.8 ± 8.5 vs. 33.6 ± 10.7 vs. 33.4 ± 10.9, p = 0.44), SF-36 (63.2 ± 13.9 vs. 68.9 ± 13.5 vs. 72.1 ± 12.9 vs. 74.4 ± 11.3, p = 0.27), and BDI (12.9 ± 5.5 vs. 10.7 ± 4.3 vs. 9.4 ± 4.8 vs. 9.6 ± 4.5, p = 0.40). Two patients had difficulty complying with CPAP for a variety of reasons (nocturnal cough, claustrophobia, insomnia) and stopped CPAP use after the first month, despite intense follow-up by the CPAP clinic staff. Heated humidification was added for all patients in order to improve the common complaint of disabling nocturnal cough. Effective CPAP treatment in IPF patients with OSA results in a significant improvement in daily living activities based on the FOSQ, namely an OSA-specific follow-up instrument. Improvement was also noted in other questionnaires assessing quality of life, though not to a statistically significant degree, probably because of the multifactorial influences of IPF on physical and mental health. The probability of poor CPAP compliance was high and could only be eliminated with intense follow-up by the CPAP clinic staff.

“Myxedema Madness” Associated with Newly Diagnosed Hypothyroidism and Obstructive Sleep Apnea

This is the case report of a 32-year-old obese male with a history of agitation, hallucinations, and delirium, recently diagnosed with primary hypothyroidism; he gave a several month history of fatigue with nocturnal snoring and frequent awakening. Polysomnogram revealed severe OSA; initiation of CPAP and levothyroxine resulted in immediate improvement. The lack of a previous psychiatric history and acuteness of presentation was consistent with hypothyroid psychosis complicated by sleep deprivation cause by untreated OSA. Primary hypothyroidism is a common disorder often associated with depression. It is rarely associated with psychosis and was first described as "myxoedematous madness" in 1949. It has not been previously reported to cause psychosis when associated with obstructive sleep apnea. This case illustrates the need for examination of potential multiple organic causes in a patient who presents with psychosis in the critical care setting.

Allergic Rhinitis and Changing Nasal Congestion after Continuous Positive Airwary Pressure

Objective: Among continuous positive airway pressure (CPAP) users, self-reported allergic rhinitis has been associated with relative worsening of subjective nasal congestion. This study’s aims were to test the associations between objective allergic rhinitis status and 1) change in objective nasal congestion after CPAP initiation, or 2) objective CPAP use. Method: Objective allergic rhinitis status was established by skin-prick test of 17 region-specific aeroallergens in CPAP patients with baseline turbinate hypertrophy. Objective nasal congestion was measured by acoustic rhinometry (combined bilateral minimal cross-sectional area, MCA) at baseline and 3-months later in subjects using CPAP. Objective CPAP use was measured at 12 months. Results: This cohort study included n = 81 subjects from a larger parent trial on turbinate hypertrophy in CPAP patients. In this cohort, MCA did not change significantly in subjects with allergic rhinitis (n = 51, paired t-test P = .18) or in controls (n = 30, paired t-test P = .67) after initiation of CPAP, and there was no significant difference in change between groups ( t-test P = .28). CPAP use in allergic rhinitis subjects (1.9 ± 2.7 h/night) was not significantly different from controls (2.4 ± 3.0 h/night; Mann-Whitney U test, P = .28), but statistical power was limited for the observed difference (power 12%). Conclusion: Allergic rhinitis did not predict worsening of objective nasal congestion with CPAP initiation or decreased CPAP use, but confounding, eligibility criteria, limits of objective nasal measurements, and insufficient statistical power may have blunted a true effect. Further studies are needed.