Sleep Apnea

Description

Treatment

Treatment for sleep apnea depends on the severity of the problem. Given data on the long-term complications of sleep apnea, it is important for patients to treat the problem as they would any chronic disease. Simply trying to treat snoring will not treat sleep apnea. Because of its association with heart problems and stroke, sleep apnea that does not respond to lifestyle measures should be treated by a physician, ideally a sleep disorders specialist.

At this time, the most effective treatments for sleep apnea are devices that deliver slightly pressurized air to keep the throat open during the night. There are a number of variations available.

Continuous Positive Airflow Pressure (CPAP)

Currently, the best treatment for severe obstructive and mixed sleep apnea is a system known as continuous positive airflow pressure (CPAP), sometimes referred to as nasal continuous positive airflow pressure (nCPAP). It is safe and effective in sleep apnea patients of all ages, including children. It should be noted that patients with apnea but no daytime sleepiness report little or no benefit from CPAP, although it is still not known if CPAP has benefits on the heart regardless of its effect on sleepiness.

It works in the following way.

• The device itself is a machine weighing about five pounds that fits on a bedside table.
• A mask containing a tube connects to the device and fits over just the nose.
• The machine supplies a steady stream of air through a tube and applies sufficient air pressure to prevent the tissues from collapsing during sleep.

Benefits from CPAP

Effects on Sleep and Wakefulness. A major 2003 analysis confirmed the benefits of CPAP on both objective and subjective measures of sleep. After using CPAP regularly many patients report the following benefits:

• Restoration of normal sleep patterns.
• Greater alertness and less daytime sleepiness.
• Less anxiety and depression and better mood.
• Improvements in work productivity.
• Better concentration and memory. (Some adults with symptoms of attention deficit hyperactivity disorder have improved after CPAP treatments for apnea.) In two studies, however, equal improvements were also observed in people on sham CPAP, suggesting that the actual cognitive benefits from CPAP may be modest.
• Patients bed partners, too, report improvement in their own sleep when their mates use CPAP (even though objective sleep tests showed no real difference in the partners' sleep quality).

If patients do not experience less sleepiness after a period of time and are still complying with the regimen, then the airflow pressure may not be high enough. Patients may require retesting. It should be noted that many patients report feeling more alert after CPAP treatments even if objective laboratory tests fail to show significant differences in the number of apneas and wake-up periods.

Protection from Accidents. Studies suggest that treatment with CPAP can reduce the risk for accidents. In one 2001 study, untreated patients had a risk for automobile accidents that was three times the risk in the general population. When these patients were treated, their risk fell to normal.

Effects on the Heart and Circulation. It is still not clear how significant the effects of CPAP are on health, including helping to prevent heart and circulation problems. Although studies are mixed, there is increasing evidence that the use of CPAP may reduce serious cardiovascular conditions. Studies published in 2004 have suggested that CPAP treatment may improve cardiac function and prevent new cardiac events (such as heart attacks) in patients with congestive heart failure and coronary artery disease. A 2003 study reported improved heart function and lower blood pressure in heart failure patients given CPAP for sleep apnea. In another 2003 study, reducing sleep apneas by 90% with continuous positive airway pressure (CPAP) lowered blood pressure significantly, suggesting that this therapy could reduce heart disease by 37% and stroke by 56%. Treatment for sleep apneas must be very effective, however, to have any benefits on blood pressure. Even a 50% reduction in apneas has no effect.

Effects on Other Medical Conditions. Some studies suggest other benefits with the use of CPAP:

• Patients report fewer morning headaches.
• In some studies, patients have reported reduction in abdominal fat even if they failed to lose actual pounds. (Abdominal fat has been related to a higher risk for diabetes and heart disease.)
• In one case report, CPAP therapy halted progression of eye deterioration due to normal-pressure glaucoma. More research is warranted.
• One study suggested that CPAP may improve thinking and concentration in people with impaired mental function from sleep apnea.
• CPAP may have some modest effects on the lungs in patients with both apnea and chronic obstructive lung disease (such as emphysema).

Side Effects and Getting Used to the Device

Unfortunately continuous positive airflow pressure (CPAP) devices are often cumbersome. All patients should be warned that the first few nights of CPAP therapy are unnerving:

• The device often produces anxiety, primarily because of the mask. Starting out with low pressure to get used to the mask may help.
• Patients may actually experience less sleep or sleep of a different quality in the beginning.

Nearly all patients complain about at least one side effect. Nearly half of complaints are related to the mask. Many can be alleviated with a well-chosen mask that is comfortable and reduces leakage as much as possible. In general complaints include the following:

• Irritation in the nose and throat. The most common complaints are nasal congestion and sore or dry mouth, which are caused by leakage that dries the airway. (This may be severe in elderly people or patients who have had uvulopalatopharyngoplasty, a surgical treatment for sleep apnea. Such patients are more likely to stop using CPAP.) Chin straps, nasal saline sprays, or humidifiers may prevent these side effects. Heated humidification devices are also now available for CPAP users.
• Excessive application of pressure making exhalation difficult.
• A feeling of claustrophobia is a major factor in noncompliance, which may be alleviated with a lightweight and transparent mask or with masks known as nasal pillows, which are used only around the nostrils.
• Up to 30% of patients experience irritation and sores over the bridge of the nose. Getting a properly fitted and cushioned mask can help reduce this effect.
• Eye irritation or conjunctivitis.
• Upper respiratory infections. It is very important to keep the unit clean.
• Patients may also experience chest muscle discomfort for a while, which is caused by an increase in lung volume.
• There have been reports of severe side effects, including heart rhythm disorders (arrhythmias), severe nose bleeding, and air pockets in the skull. These complications are very rare, however, and occur in only a few patients out of thousands. In a 2003 study, for example, patients on CPAP were followed for a year and there were no arrhythmias that required attention.
• In addition to initial difficulties with its use, the fixed CPAP needs to be periodically readjusted. Many patients may be trained to adjust the CPAP at home, thereby avoiding trips to the sleep professional for machine adjustments and making the process more convenient.

Although studies have reported that long-term compliance with CPAP systems is low, with about one-third of patients giving up the treatment, recent information suggests that it is improving, probably due to better technologies and better education. Patient education and support groups, a dedicated nurse to ensure close follow-up of patients (particularly in the first two weeks of therapy), and ready access to physicians to make adjustments as needed have all been shown to improve compliance greatly. Not surprisingly, patients whose symptoms are noticeably relieved by the procedure early on are more likely to continue the therapy.

Other Devices to Improve Airway Pressure

Bilevel Positive Airway Pressure. Bilevel systems (e.g., BiPAP) appear to be particularly helpful for patients with coexisting lung disease and those with excessive levels of carbon dioxide. These devices have a sensing feature that helps determine and vary the appropriate pressure depending on whether a person is breathing in or out. Greater pressure is needed on inhalation and less on exhalation. (These machines are more expensive than the CPAP and may not be covered by insurance.)

Automatic Titrating (Auto)-CPAP Pressure Devices. Even more sophisticated systems are available called auto-CPAP devices, which automatically customize air pressure for the individual patient. They usually employ one of three methods:

• Overall pressure is kept low until a specific problem is detected. At that time the pressure is automatically increased rapidly.
• Pressure is low when there are no problems but is raised gradually when they are detected.
• Pressure is gradually raised and lowered in response to problems or their absence. In addition, the device can change depending on problems within single breaths.

Brands include AutoAdjust, Virtuoso, and AutoSet. These devices are more expensive than those that provide continuous airflow. Still, studies suggest they are as effective as manual CPAP, and a 2003 study indicated that they may improve compliance, particularly in patients who require high CPAP use. They may be specifically beneficial for those who require varying levels of pressure due to other conditions, such as seasonal allergies. They are also proving to be very useful as home diagnostic tools for sleep apnea. Auto-CPAP devices are not currently recommended for all patients, however, including those with congestive heart failure or serious lung disease (e.g., chronic obstructive lung disease).