Use Of Continuous Positive Airway Pressure Therapy Research Articles

The Effect of Continuous Positive Airway Pressure (CPAP) Therapy on Serum Caspase-3 Level in Patients with Obstructive Sleep Apnea (OSA).

Intermittent hypoxemia has an important role in the physiopathogenesis of obstructive sleep apnea (OSA) complications. Increased apoptosis due to intermittent hypoxemia may be an important clinical entity in OSA. In this study, we aimed to evaluate caspase-3 enzyme level, which is an indirect marker of increased apoptosis in patients with OSA and to evaluate the effect of OSA treatment with continuous positive airway pressure on caspase-3 enzyme level. This study included 141 consecutive patients admitted to the sleep-disordered breathing laboratory within 6 months. Caspase-3 was measured in routine blood samples obtained on the morning of polysomnography (PSG) performed at night. The compliance of the patients to CPAP treatment was evaluated and caspase-3 levels were checked again after treatment. A total of 141 patients, 39 females (27,7%) and 102 males (72,3%) were included in the study. The mean age of the patients was 49 ± 12 years (min-17, max-77). According to PSG results, OSA was detected in 95.7% (135/141) of the cases. Mild OSA was 35 (24.8%), moderate OSA 39 (27.7%) and severe OSA 61 (43.3%) cases. Median caspase-3 enzyme levels were similar in men and women in the study group. There was no statistically significant difference in hemogram parameters and caspase-3 enzyme levels between the groups divided according to the presence and severity of OSA. It was determined that caspase-3 enzyme level did not change significantly after 3 months of CPAP treatment in OSA compared to pretreatment. Caspase-3 was found to have a negative correlation with both the percentage of daily use of CPAP therapy and the percentage of CPAP device use for more than 1 h per night. It was found that the control caspase-3 level decreased statistically significantly as the percentage of daily use of CPAP therapy increased (r = -0.397, p = 0.030). It was found that the control caspase-3 level decreased statistically significantly as the percentage of CPAP therapy use for more than 1 h per night increased (r = -0.411, p = 0.024). The results of this study did not reveal a relationship between the severity of OSA and caspase-3 levels. However, blood caspase-3 levels decreased as treatment compliance increased, suggesting that CPAP treatment may correct increased apoptosis in OSA. There is a need for more comprehensive studies on this issue.

Sleep Restfulness in Patients with Obstructive Sleep Apnea Undergoing Continuous Positive Airway Pressure Therapy.

Objective Sleep restfulness is closely associated with mortality. Thus, it is an important sleep-related symptom in the general population. However, it is rarely evaluated in patients with obstructive sleep apnea (OSA) syndrome. The present study examined the importance of sleep restfulness in patients with OSA receiving continuous positive airway pressure (CPAP) therapy. Materials and Methods We administered sleep-related questionnaires, which included items such as subjective sleep duration and sleep restfulness, to 775 patients with OSA receiving CPAP therapy. Sleep restfulness was rated using a 5-point Likert-type scale, with the score of 5 indicating restfulness. Good adherence to CPAP therapy was defined as the use of CPAP therapy for at least 4 h per night in 70% of nights. Results We excluded 105 patients with lacking data. Thus, 670 patients were finally examined. In total, 29 (4.3%), 124 (18.5%), 139 (20.8%), 235 (35.1%), and 143 (14.3%) patients answered restless (1), somewhat restless (2), neither (3), somewhat restful (4), and restful (5) respectively. A total of 467 (69.7%) patients had good adherence to CPAP therapy. Multivariate logistic regression analysis showed that sleep restfulness was independently and positively associated with subjective sleep duration (≥ 7 hours) and good adherence to CPAP therapy. Conclusion Sleep restfulness was associated with subjective sleep duration and good adherence to CPAP therapy in patients with OSA. Favorable outcomes are significantly correlated with good adherence to CPAP therapy. Thus, sleep restfulness can be an indicator of a subtype that has favorable outcomes in patients after CPAP therapy.

CPAP setup by mail: we're not there yet.

CPAP setup by mail: we're not there yet.

Opioids and obstructive sleep apnea.

Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):647-652.

ADHERENCE TO AN OSA PROTOCOL AND PREOPERATIVE SCREENING: INSIGHT FROM AN URBAN ACADEMIC CENTER

TOPIC: Sleep Disorders TYPE: Original Investigations PURPOSE: Moderate to severe Obstructive Sleep Apnea (OSA) is estimated to affect 6-17% of the general adult population, though the majority of patients with OSA remain undiagnosed. OSA is a risk factor for multiple complications in surgical patients during the perioperative period. The Society of Anesthesia and Sleep Medicine (SASM) guidelines recommend preoperative screening for OSA in elective surgery patients. A questionnaire asking about Snoring, daytime Tiredness, Observed apneas, Hypertension, Body mass index (BMI)>35 kg/m2, Age >50years, Neck circumference >16” in females / >17” in males and Gender (STOP-BANG), has been validated as a screening tool for OSA. The diagnosis of OSA and the use of continuous positive airway pressure (CPAP) therapy may be associated with a reduction in postoperative complications. However, the role of enhanced monitoring and protocolized postoperative care is not clear. Our institution designed a protocol to screen patients for OSA in presurgical clinic visit (STOP-Bang questionnaire), followed by an order set including enhanced monitoring in those with known or suspected OSA. This study evaluated the rate of adherence to preoperative screening and to the post-operative protocol in patients with identified as a known or suspected OSA. METHODS: A retrospective chart review was conducted to identify the rate of adherence to MetroHealth’s perioperative OSA protocol in patients with known or suspected OSA. Inclusion criteria included age ≥ 18 years and patients with overnight hospital stay after elective surgery. Charts of patients visiting the pre-surgical evaluation clinic during September 2019 were reviewed to determine rates of pre-operative screening and post-operative adherence to the protocol (dedicated “OSA beds” on the surgical floors, specific order set for opioids). RESULTS: A retrospective review of 534 patient charts was conducted. Utilizing the STOP-Bang questionnaire, 94.5% (505/534) of patients were screened at the presurgical clinic. Out of those screened, 20.2% had known OSA, and 21.2% were found to be at risk of OSA (STOP-Bang score 3 or more). 24.3% of patients with known OSA and 23.8% with suspected OSA were admitted following surgery The majority of patients, 80.9% of patients in the OSA group and 90% of patients in the at-risk group, were assigned to the correct OSA protocol beds. However, only 7.7% of patients with OSA received CPAP postoperatively. 84.6% of OSA patients received oral opioids and 76.9% received IV opioids. 78.2% of patients at risk of OSA received oral opioids and 73.9% received IV opioids. CONCLUSIONS: The overwhelming majority of patients were screened for OSA at pre-surgical evaluation, and most were placed in the correct post-operative monitored setting. The use of CPAP therapy postoperatively was poor. CLINICAL IMPLICATIONS: This study demonstrates the challenges of implementing a perioperative protocol following screening patients during pre-surgical evaluation. The implications of cases where the protocol is not followed, and the lack of CPAP use postoperatively, are being further investigated. DISCLOSURES: No relevant relationships by Dennis Auckley, source=Web Response No relevant relationships by Sunjeet Kaur, source=Web Response No relevant relationships by Nhi Lam, source=Web Response No relevant relationships by Nicoleta Olteanu, source=Web Response

Continuous Positive Airway Pressure Effectively Alleviates Arrhythmias in Patients with Obstructive Sleep Apnea: Possible Relationship with Counteracting Oxidative Stress.

This work is aimed at exploring the clinical efficacy of continuous positive airway pressure (CPAP) in treatment of patients with arrhythmias combined with obstructive sleep apnea (OSA). Through evaluating serum native thiol, malonaldehyde (MDA) and nicotinamide adenine dinucleotide phosphate oxidase (NADPH oxidase) in these patients and describing the effects on oxidative parameters of CPAP therapy for 3 months, we confirmed the impact of oxidative stress on arrhythmias. A total of 64 patients with OSA combined with arrhythmias were collected from April 2014 to April 2017 with full clinical information. Patients were divided into two groups (paired experiment design): 32 patients in group A (control group), who received unchanged anti-arrhythmia treatment and 32 patients in group B, who were subjected to unchanged pharmacological anti-arrhythmia therapy combined with CPAP. OSA related parameters were compared between the two groups after 3-month therapy. And the levels of parameters of oxidative stress in patients were measured before and after CPAP therapy. After 3 months of CPAP therapy, compared with the control group, the percentage of sage N3 (NREM 3) and stage R (REM) in total sleep time was significantly increased, while apnea-hypopnea index (AHI) and the Epworth Sleepiness Scale (ESS) score were evidently decreased. Meanwhile, the lowest oxygen saturation (LSpO2) was also elevated after CPAP treatment for 3 months. The CPAP therapy significantly prevented the occurrence of arrhythmias (P<0.05). Both the MDA level and NADPH oxidase levels were significantly lower in the group B than in the group A (P<0.05). But serum native thiol was improved by CPAP treatment (P<0.05). In conclusion, proper use of CPAP therapy provides significant benefits for the treatment of arrhythmia in patients with OSA.

Sleep Apnea, the Risk of Developing Heart Failure, and Potential Benefits of Continuous Positive Airway Pressure (CPAP) Therapy.

BackgroundWhether there is an association between sleep apnea (SA) and the risk of developing heart failure (HF) is unclear. Furthermore, it has never been established whether continuous positive airway pressure (CPAP) therapy can prevent development of HF. We aimed to investigate SA patients’ risk of developing HF and the association of CPAP therapy.Methods and ResultsUsing nationwide databases, the entire Danish population was followed from 2000 until 2012. patients with SA receiving and not receiving CPAP therapy were identified and compared with the background population. The primary end point was first‐time hospital contact for HF and adjusted incidence rate ratios of HF were calculated using Poisson regression models. Among 4.9 million individuals included, 40 485 developed SA during the study period (median age: 53.4 years, 78.5% men) of whom 45.2% received CPAP therapy. Crude rates of HF were increased in all patients with SA relative to the background population. In the adjusted model, the incidence rate ratios of HF were increased in the untreated SA patients of all ages, compared with the background population. Comparing the CPAP‐treated patients with SA with the untreated patients with SA showed significantly lower incidence rate ratios of HF among older patients.ConclusionsIn this nationwide cohort study, SA not treated with CPAP was associated with an increased risk of HF in patients of all ages. Use of CPAP therapy was associated with a lower risk of incident HF in patients >60 years of age, suggesting a protective effect of CPAP therapy in the elderly.

Post cardiac surgery patients' experiences using continuous positive airway pressure (CPAP) via mask therapy to treat post-surgical atelectasis

ObjectiveCardiac surgery procedure especially CABG is usually associated with post-surgical atelectasis. CPAP via mask therapy is one of the intervention treatments to re-open collapsed alveoli (atelectasis) after cardiac surgery. This study aims to evaluate the compliance and periodicity of CPAP via mask therapy use to treat or prevent post-surgical atelectasis after CABG. MethodsSixty two post cardiac surgery patients who used CPAP via mask therapy every two or four hours were invited to participate in this study. All the participants used CPAP machine in the first three post- cardiac surgery days during waking hours. The participants were given a questionnaire to answer before hospital discharge. The questionnaire was composed of items about the compliance, the periodicity of CPAP therapy use and the side effects of the CPAP mask used such as pain over bridge of the nose, dry mouth, allergy or teeth and gum pain. Also, the questionnaire was linked to informal open-end question to clarify the patient'shistory of these illnesses before the use of CPAP therapy. ResultSixty two patients participated in this study from the two difference frequency group (CPAP therapy every two or four hours) with response rate approximately 85%. Twenty seven males and three females belonged to the CPAP2hr group (ages; 58 ± 6.4 years). Twenty eight males and four females were in the CPAP4hr group (ages; 57 ± 7.2 years). All the participants started to use CPAP therapy in the first post-operative day immediately after extubation from mechanical ventilation. No one from either of the groups suffered from nose bleeding, excessive sneezing, eczema or asthma either before or after therapy. More than halfof the participants (60%) complained a dry mouth after the therapy. Twenty eight participants (93%) from CPAP2hrs group reported treatment compliance from CPAP machine use and 27 participants (84%) in CPAP4hrs group. ConclusionThe result showed high acceptance rate of compliance toward CPAP therapy use especially in CPAP2hrs group.

Acceptance of Telemonitoring Among Patients with Obstructive Sleep Apnea Syndrome: How is the Perceived Interest by and for Patients?

Obstructive sleep apnea syndrome, a chronic respiratory disease, requires regular adherence to Continuous Positive Airway Pressure (CPAP) therapy. Telemonitoring may be relevant to support adherence, but nonetheless this raises ethical issues around the intrusive nature of the daily life of patients Objective: To explore the acceptance of telemonitoring by patients and the impact of this on adherence. A prospective and observational study has been performed with 160 patients who initiated their CPAP therapy. The acceptability of telemonitoring was studied using an attitudes' scale of 8 items. A total of 160 patients (111 men, 49 women) responded to the questionnaire at 1 month upon treatment. The adoption of both telemonitoring and adherence behavior were observed at 10 months of therapy. A majority (78%) of patients expressed a favorable attitude toward telemonitoring, but nearly 40% consider this device like intrusive. However, at 10 months of treatment, 78% of patients are still telemonitored. We did not observe a significant difference between telemonitoring patients and nontelemonitoring patients with respect to the mean duration of use of CPAP therapy. However, the risk of stopping CPAP therapy is significantly more important in patients who refused telemonitoring. It seems reductive to consider telemonitoring as a simple tool of surveillance to support adherence. It may be preferable to consider telemonitoring as a follow-up proposal. This will allow for more reactive management and close to the needs of the patients, in particular as telemonitoring is, in general, well accepted by patients.

Effects of continuous positive airway pressure therapy on plasma aldosterone levels in patients with obstructive sleep apnea: A meta-analysis.

Obstructive sleep apnea (OSA) is an independent risk factor for cardiovascular diseases. Aldosterone was reported to be increased in patients with OSA and correlated with OSA severity. Many studies investigated the effect of continuous positive airway pressure (CPAP) therapy on plasma aldosterone concentrations (PAC) in OSA patients. The results, however, were inconsistent. In the present study, we aimed to evaluate the effects of CPAP therapy on PAC by performing a meta-analysis. Literature search was carried out in electronic databases including PubMed/Medline, Cochrane Library, Embase and Web of Science. Eligible full-text articles were identified, and important data were extracted. Pooled analysis was performed using the STATA12.0 and RevMan 5.2. Standardized mean difference (SMD) was calculated to estimate the treatment effects. A total of eight studies involving 219 patients were included for our final analysis. PAC was found unchanged after CPAP treatment in OSA patients (SMD=-0.36, 95% CI:-0.91 to 0.18, Z=1.32, P=0.19). Meanwhile, CPAP therapy showed no impact on PAC (SMD=-0.21, 95% CI:-0.85 to 0.42, Z=0.66, P=0.51) in a separate meta-analysis including 3 randomized controlled trials. In conclusion, the evidence for the use of CPAP therapy to decrease PAC in OSA patients is low, and further studies are still warranted.

PP.16.02] EFFECT OF CONTINUOUS POSITIVE AIRWAY PRESSURE THERAPY ON BLOOD PRESSURE IN PATIENTS WITH MODERATE-SEVERE OBSTRUCTIVE SLEEP APNEA AND DIFFICULT-TO-CONTROL ARTERIAL HYPERTENSION

Objective: A non-dipping profile has been found in 50–85% of patients with OSA and its frequency increases with OSA severity. Also, lack of nocturnal dipping is related to an increased risk of cardiovascular (CV) events. Our aim was to assess the effect of continuous positive airway pressure (CPAP) therapy in patients with moderate-severe OSA and difficul-to-control arterial hypertension (DtC-HTN). Design and method: We included 101 hypertensive patients with moderate-severe OSA referred to our department for uncontrolled hypertension between 2012 and 2015. For each patient we recorded demographic and anthropometric data, parameters obtained through blood pressure (BP) monitoring (ABPM/24 h using ABPM-05, Meditech device; BP recordings at 15 minutes intervals during daytime and 30 minutes intervals during nighttime) and dipping status. Inclusion criteria were: DtC-HTN in spite of taking at least three antihypertensive drugs at optimal doses, including a diuretic, with mean 24h-BP values >130/80 mmHg and moderate-severe OSA diagnosed through respiratory polygraphy (no electroencephalography recordings) and defined as apnea-hypopnea index (AHI) greater than 15 events per hour. Exclusion criteria were presence of secondary causes of resistant HTN, estimated glomerular filtration rate (eGFR) using CKD-EPI study equation < 30 ml/min/1.73 m2, previous or current use of CPAP therapy, poor adherence to antihypertensive drugs and insomnia. All patients underwent CPAP treatment (manual titration). After 3 months an ABPM/24 h was performed. No changes were made to antihypertensive medication between the two ABPM recordings Results: See table. After 3 months of CPAP therapy, these patients displayed a significant reduction in daytime (−4.04 mmHg) and especially nighttime systolic BP (−7.24 mmHg), with no significant variations in diastolic BP. Thus, there was an increase in the percentage of patients who recovered their dipping profile.Conclusions: In adults with moderate-severe OSA and DtC-HTN under maximal antihypertensive therapy, 3-months treatment with CPAP has improved the mean 24h-BP values. Thus, CPAP treatment may reduce risk of incidence of fatal and non-fatal CV events in OSA patients as compared with untreated OSA patients.

Differences of brain electrical activity between moderate and severe obstructive sleep apneic patients: a LORETA study.

The effects of initiation of continuous positive airway pressure (CPAP) therapy on electroencephalographic (EEG) background activity were investigated in patients exhibiting both moderate (n=13) and severe (n=12) obstructive sleep apnea syndromes in the testing of the potential differences of alterations of brain electrical activity caused by chronic hypoxia between these two groups. A normal control group (n=14) was also examined. Two EEG examinations were achieved in each group: before and after first-time CPAP therapy. Low-resolution electromagnetic tomography (LORETA) was implemented towards localizing the generators of EEG activity in separate frequency bands. Prior to CPAP treatment, as a common direction of change, analysis with LORETA demonstrated increased activity in comparison with the patient and control groups. In the moderate group, significant changes were detected in the alpha2 band in the posterior cingulate cortex as well as in the beta1 band in the right posterior parietal cortex and the left supramarginal gyrus. In the severe group, significant changes were found in theta and alpha1 bands in the posterior cingulate cortex. Following CPAP treatment, these significant differences vanished in the severe group. In the moderate group, significantly decreased activity was seen in the beta3 band in the right fusiform gyrus. These findings potentially suggest a normalizing effect of CPAP therapy on EEG background activity in both groups of obstructive sleep apnea syndrome patients. Compensatory alterations of brain electrical activity in regions associated with influencing successful memory retrieval, emotional perception, default mode network, anorexia and fear network caused by chronic intermittent hypoxia could possibly be reversed with the use of CPAP therapy.

Effect of CPAP Therapy in Improving Daytime Sleepiness in Indian Patients with Moderate and Severe OSA

Obstructive Sleep Apnoea (OSA) is a highly prevalent disease and a major public health issue in India. Excessive daytime sleepiness is an almost ubiquitous symptom of OSA. Epworth Sleepiness Scale (ESS) score is a validated objective score to measure the degree of daytime sleepiness. Continuous Positive Airway Pressure (CPAP) therapy has been established as the gold standard treatment modality for OSA patients. A few Indian studies have reported the effectiveness of CPAP therapy in improving ESS scores after 1st month of CPAP use. To observe both, short-term (one month) and long-term (three month) effects of CPAP therapy on ESS scores in moderate to severe OSA patients. The patients complaining of excessive day-time sleepiness, snoring and choking episodes during sleep, consecutively presenting to medicine OPD over a period of 2 years, were subjected to Polysomnography (PSG). Seventy-three patients with apnoea-hypopnea index (AHI) ≥15 were categorised as having moderate to severe forms of OSA (moderate OSA with AHI=15-30 and severe OSA with AHI >30), and were scheduled for an initial trial of CPAP therapy. Forty-seven patients reported good tolerance to CPAP therapy after a trial period of 2 weeks and comprised the final study group. ESS scores in these patients were recorded at the baseline, and after 1st and 3rd month of CPAP therapy, and statistically analysed for significance. Mean ESS score at the baseline among moderate and severe OSA patients were 13.67±2.29 and 16.56 ±1.87, respectively. ESS score in both these subgroups improved significantly to 11.63±3.79, p=0.022, CI (0.3293-4.0106)} and 14.13 ±3.74, p < 0.001, CI (1.2991-4.5408), respectively after one month of CPAP therapy. Likewise, mean ESS scores among moderate and severe OSA patients improved significantly to 9.84 ±2.97, p = 0.022, CI (0.3293-4.0106) and 12.29 ±3.97, p <0.001, CI (2.9414-6.1385), respectively after three months of CPAP therapy. The result of the present study shows that CPAP therapy is significantly effective in improving ESS scores in Indian patients having moderate to severe OSA. Benefits in daytime sleepiness were observed after short-term as well as long-term use of CPAP therapy.

High Flow Nasal Cannula Therapy for Improving Obstructive Sleep Apnea: A Case Report

Obstructive sleep apnea (OSA) is due to upper airway obstruction leading to intermittent hypoxia, sleep fragmentation, metabolic syndrome, increased cardiovascular morbidity and mortality.1-3 At present, continuous positive airway pressure (CPAP) is the most effective and widely used therapy.4 However, about 50% of patients with OSA will either refuse or not tolerate the use of CPAP therapy.5,6 The adherence to CPAP treatment seems even lower in stroke or heart failure patients.7 Therefore, improved therapeutic strategies are required to treat OSA. Recently, high flow nasal cannula (HFNC) therapy was developed for critically ill patients. It could increase pharyngeal pressure by delivering warm and humidified air through the nose.8 We report herein a case of a patient in whom HFNC was used for OSA treatment.

Cardiovascular risk in patients with sleep apnoea with or without continuous positive airway pressure therapy: follow-up of 4.5 million Danish adults.

The prognostic significance of age and continuous positive airway pressure (CPAP) therapy on cardiovascular disease in patients with sleep apnoea has not been assessed previously. Using nationwide databases, the entire Danish population was followed from 2000 until 2011. First-time sleep apnoea diagnoses and use of CPAP therapy were determined. Incidence rate ratios (IRRs) of ischaemic stroke and myocardial infarction (MI) were analysed using Poisson regression models. Amongst 4.5 million individuals included in the study, 33 274 developed sleep apnoea (mean age 53, 79% men) of whom 44% received persistent CPAP therapy. Median time to initiation of CPAP therapy was 88 days (interquartile range 34-346). Patients with sleep apnoea had more comorbidities compared to the general population. Crude rates of MI and ischaemic stroke were increased for sleep apnoea patients (5.4 and 3.6 events per 1000 person-years compared to 4.0 and 3.0 in the general population, respectively). Relative to the general population, risk of MI [IRR 1.71, 95% confidence interval (CI) 1.57-1.86] and ischaemic stroke (IRR 1.50, 95% CI 1.35-1.66) was significantly increased in patients with sleep apnoea, in particular in patients younger than 50 years (IRR 2.12, 95% CI 1.64-2.74 and IRR 2.34, 95% CI 1.77-3.10, respectively). Subsequent CPAP therapy was not associated with altered prognosis. Sleep apnoea is associated with increased risk of ischaemic stroke and MI, particularly in patients younger than 50 years of age. CPAP therapy was not associated with a reduced rate of stroke or MI.

Association between continuous positive airway pressure and changes in serum leptin in patients with obstructive sleep apnoea: a meta-analysis

The role of leptin in the development of obstructive sleep apnoea (OSA) has been identified. However, the effects of OSA treatment using continuous positive airway pressure (CPAP) on serum leptin levels remain controversial. To address this issue, a meta-analysis was conducted to evaluate the effects of CPAP therapy on serum leptin levels in OSA. A comprehensive literature search was performed to identify studies that focused on the effects of CPAP therapy (treatment duration, ≥4 weeks) on the serum leptin levels of OSA patients. Standardised mean difference (SMD) was used to analyse the summary estimates for CPAP therapy. Fifteen studies involving 427 patients were included in the meta-analysis. Results indicate that the overall SMD of the leptin levels before and after CPAP therapy was 0.137 (95% confidence interval (CI) 0.002 to 0.272); test for overall effect z=1.99 (P=0.046). Sources of heterogeneity were not found by subgroup and meta-regression analyses. Subgroup analyses showed that differences in OSA severity, baseline body mass index, compliance, CPAP duration and leptin assay did not affect the effectiveness of CPAP therapy. The evidence for the use of CPAP therapy on decrease of leptin levels in OSA patients is low, and stronger evidence is needed.

Outcomes of Therapy for Hypersomnia for Obstructive Sleep Apnea

Hypersomnia, or excessive daytime sleepiness, is common with obstructive sleep apnea (OSA) but normally improves with use of continuous positive airway pressure (CPAP) therapy. OSA is well known for breathing disturbances associated with variations in heart rate, arousals, and resulting sleepiness in the daytime. Some people continue to experience hypersomnia despite routine use of CPAP therapy. Assessment of OSA patients who continue to complain of excessive sleepiness despite CPAP use must include an initial assessment of therapy compliance. If other potential causes of hypersomnia are not found or thought to be the issue, then treatment with medication is warranted.

When Pressure is Positive: A Literature Review of the Prehospital Use of Continuous Positive Airway Pressure

Heart failure poses a significant burden of disease, resulting in 2,658 Australian deaths in 2008, and listed as an associated cause of death in a further 14,466 cases. Common in the hospital setting, continuous positive airway pressure (CPAP) therapy is a non-invasive ventilation technique used to prevent airway collapse and manage acute pulmonary edema (APO). In the hospital setting, CPAP has been known to decrease the need for endotracheal intubation in patients with APO. Therefore the objective of this literature review was to identify the effectiveness of CPAP therapy in the prehospital environment. A review of selected electronic medical databases (Cochrane, Medline, EMBASE, and CINAHL) was conducted from their commencement date through the end of May 2012. Inclusion criterion was any study type reporting the use of CPAP therapy in the prehospital environment, specifically in the treatment of heart failure and acute pulmonary edema. References of relevant articles were also reviewed. The literature search located 1,253 articles, 12 of which met the inclusion criteria. The majority of studies found that the use of CPAP therapy in the prehospital environment is associated with reduced short-term mortality as well as reduced rates of endotracheal intubation. Continuous positive airway pressure therapy was also shown to improve patient vital signs during prehospital transport and reduce myocardial damage. The studies conducted of prehospital use of CPAP to manage APO have all demonstrated improvement in patient outcomes in the short term. Available evidence suggests that the use of CPAP therapy in the prehospital environment may be beneficial to patients with acute pulmonary edema as it can potentially decrease the need for endotracheal intubation, improve vital signs during transport to hospital, and improve short-term mortality.

A retrospective analysis of 4000 patients with obstructive sleep apnea in Okinawa, Japan

The causes and risks of death, and role of severity of obstructive sleep apnea (OSA), obesity, and pulmonary function (PF) in OSA patients treated with or without continuous positive airway pressure (CPAP) have been questioned. Using the Okinawa Nakamura Sleep (ONSLEEP) registry, we studied 4000 patients with an obstructive apnea-hypopnea index (AHI) of >5 events/h. Kaplan-Meier analysis determined survival rates based on use of CPAP therapy and OSA severity. Multivariate Cox proportional hazard analysis determined effects of AHI, body mass index (BMI), PF, and use of CPAP. A total of 135 deaths (3.4%) were registered at the end of follow-up period (62.0 ± 43.4 months, mortality rate 8 per 1000 patient-years). Main causes of death were cardiovascular diseases. Multivariate predictors of mortality were male sex, age, BMI, and PF. Although both AHI and use of CPAP tended to affect prognosis, both effects were insignificant. Mortality rate was ∼9-fold higher in non-CPAP users with pulmonary impairment (PI) than non-CPAP users with normal lung function. The mortality rate of non-obese (BMI < 25 kg/m2) OSA patients with PI was ∼10-fold higher than that of non-obese patients with normal PF. In patients with OSA, body weight and PI, but not AHI, independently predict mortality. CPAP therapy reduced the risk of death in OSA. The risk of mortality was lowest, as 3 per 1000 patient-year, with normal PF and non-CPAP treatment.

Prevalence of unspecified sleep apnea and the use of continuous positive airway pressure in hospitalized patients, 2004 national hospital discharge survey

Diagnosed obstructive sleep apnea affects 2-4% of middle aged Americans and represents a substantial health care burden. Despite its prevalence, little is known about the demographic characteristics or clinical management of sleep apnea patients hospitalized for other comorbidities and surgeries. The aim of this study was to provide a broad characterization of the epidemiology of sleep apnea in hospitalized patients in the United States and to describe the trends in the management of their sleep apnea during their hospitalizations. Using the 2004 National Hospital Discharge Survey (NHDS), a nationally representative sample of discharges from nonfederal acute care hospitals in the United States, cases of sleep apnea were obtained from hospital discharge records coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The specific objectives of this study were to: (1) describe the prevalence of hospitalized unspecified sleep apnea individuals according to age, gender, and comorbidities; (2) estimate prevalence of the use of continuous positive airway pressure (CPAP) therapy during hospitalization and describe those uses according to hospital ownership and size. A retrospective analysis of data of hospitalized patients with unspecified sleep apnea from the 2004 National Hospital Discharge Survey (NHDS) was completed. In 2004, the NHDS collected data for approximately 371,000 discharges from a sample of 439 nonfederal short-stay hospitals. An estimated 34.9 million inpatients were discharged from nonfederal short-stay hospitals in 2004. Patients diagnosed with unspecified sleep apnea were identified using the International Classification of Diseases (Ninth Revision), Clinical Modification (ICD-9-CM) code of 780.57, which, before 2005, was the sole diagnostic code under which obstructive sleep apnea was listed. A subset of these patients, those receiving CPAP therapy, was further identified using the ICD-9-CM procedural code 93.90. Review of weighted discharge data identified a total of 293,478 estimated cases of unspecified sleep apnea. Approximately 64% of these individuals were between the ages 40 and 69 years old with a gender distribution of 55.3% males. The most common diagnoses in hospitalized sleep apnea patients were morbid obesity, congestive heart failure, coronary artery disease, exacerbation of COPD, and pneumonia. Sleep apnea was managed through the standardized therapy, CPAP, in 5.8% of hospitalized patients and CPAP therapy was more likely to be utilized in sleep apnea patients hospitalized in a government hospital than in a for-profit hospital. In conclusion, only a small percentage (5.8%) of patients diagnosed with unspecified sleep apnea in the 2004 NHDS were provided with CPAP therapy during hospitalization. There appear to be institutional differences in the utilization of CPAP therapy in hospitals across the United States. These findings suggest that in the United States, the management of sleep apnea in hospitalized patients is deficient, and the use of CPAP therapy in the hospital warrants further investigation.