Positive Airway Pressure Therapy of OSA

Max Hirshkowitz; Amir Sharafkhaneh

doi:10.1055/s-2005-864209

Seminars in Respiratory and Critical Care Medicine, Table of Contents

Semin Respir Crit Care Med 2005; 26(1): 68-79
DOI: 10.1055/s-2005-864209

Published 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Positive Airway Pressure Therapy of OSA

Max Hirshkowitz¹ ^, ² ^, ³ ^, ⁴ , Amir Sharafkhaneh² ^, ³ ^, ⁴

¹Departments of Psychiatry, Houston, Texas
²Medicine, Baylor College of Medicine, Houston, Texas
³Houston VAMC Sleep Center, Houston, Texas
⁴Methodist Hospital Sleep Diagnostic Laboratory, Houston, Texas

Abstract

ABSTRACT

Positive airway pressure is standard therapy for patients with obstructive sleep apnea. It comes in three basic varieties: (1) continuous positive airway pressure (CPAP), (2) bilevel positive airway pressure (BPAP), and (3) autotitrating positive airway pressure (APAP). When properly titrated, positive airway pressure devices minimize the number of sleep-related breathing disorder events, often producing dramatic results. Sleep-related breathing may completely normalize, specific stages of sleep may selectively rebound due to having been chronically suppressed, sleep microstructure may improve, and the patient may awaken feeling refreshed for the first time in years. The specific indications and criteria for recommending APAP, BPAP, and CPAP therapy are reviewed. The titration process is presented in a step-by-step manner and titration grading is explained. Issues surrounding the interface, acceptance, utilization, and side-effects are discussed. Finally, we present an assortment of approaches for troubleshooting clinical problems commonly encountered among patients being treated with positive airway pressure therapy.

KEYWORDS

Sleep apnea - continuous positive airway pressure - bilevel positive airway pressure - autotitrating positive airway pressure

Full Text

References

REFERENCES

1 Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993; 328 1230-1235
2 Guilleminault C, Partinen M, Querasalva M A, Hayes B, Dement W C, Ninomurcia G. Determinants of daytime sleepiness in obstructive sleep-apnea. Chest. 1988; 94 32-37
3 Flemons W W, Tsai W. Quality of life consequences of sleep-disordered breathing. J Allergy Clin Immunol. 1997; 99 S750-S756
4 Weiss J W, Launois S H, Anand A, Garpestad E. Cardiovascular morbidity in obstructive sleep apnea. Prog Cardiovasc Dis. 1999; 41 367-376
5 Findley L J, Weiss J W, Jabour E R. Drivers with untreated sleep apnea: a cause of death and serious injury. Arch Intern Med. 1991; 151 1451-1452
6 Quan S F, Howard B V, Iber C et al.. The Sleep Heart Health Study: design, rationale, and methods. Sleep. 1997; 20 1077-1085
7 Nieto F J, Young T B, Lind B K et al.. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA. 2000; 283 1829-1836
8 Decary A, Rouleau I, Montplaisir J. Cognitive deficits associated with sleep apnea syndrome: a proposed neuropsychological test battery. Sleep. 2000; 23 369-381
9 Engleman H M, Kingshott R N, Martin S E, Douglas N J. Cognitive function in the sleep apnea/hypopnea syndrome (SAHS). Sleep. 2000; 23(Suppl 4) S102-S108
10 Weaver T E, Laizner A M, Evans L K et al.. An instrument to measure functional status outcomes for disorders of excessive sleepiness. Sleep. 1997; 20 835-843
11 Sullivan C E, Issa F G, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet. 1981; 1 862-865
12 Van de Graaff W B. Thoracic influence on upper airway patency. J Appl Physiol. 1988; 65 2124-2131
13 Hoffstein V, Zamel N, Phillipson E A. Lung volume dependence of pharyngeal cross-sectional area in patients with obstructive sleep apnea. Am Rev Respir Dis. 1984; 130 175-178
14 Fromm Jr R E, Varon J, Lechin A E, Hirshkowitz M. CPAP machine performance and altitude. Chest. 1995; 108 1577-1580
15 Naughton M T, Benard D C, Rutherford R, Bradley T D. Effect of continuous positive airway pressure on central sleep apnea and nocturnal PCO2 in heart failure. Am J Respir Crit Care Med. 1994; 150(6 Pt 1) 1598-1604
16 Naughton M T, Liu P P, Bernard D C, Goldstein R S, Bradley T D. Treatment of congestive heart failure and Cheyne-Stokes respiration during sleep by continuous positive airway pressure. Am J Respir Crit Care Med. 1995; 151 92-97
17 Hirshkowitz M, Littner M, Kuna S T, Berry R, Norris M, Almenoff P. Sleep-Related Breathing Disorders: Sourcebook. 2nd ed. Milwaukee, WI; HAIG 2003
18 Berry R B, Parish J M, Hartse K M. The use of auto-titrating continuous positive airway pressure for treatment of adult obstructive sleep apnea. An American Academy of Sleep Medicine review. Sleep. 2002; 25 148-173
19 Littner M, Hirshkowitz M, Davila D et al.. Practice parameters for the use of auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome. An American Academy of Sleep Medicine report. Sleep. 2002; 25 143-147
20 Sanders M H, Kern N B, Costantino J P et al.. Adequacy of prescribing positive airway pressure therapy by mask for sleep apnea on the basis of a partial-night trial. Am Rev Respir Dis. 1993; 147 1169-1174
21 Meyer T J, Pressman M R, Benditt J et al.. Air leaking through the mouth during nocturnal nasal ventilation: effect on sleep quality. Sleep. 1997; 20 561-569
22 Sanders M, Series F. New development in positive pressure therapy for sleep apnea. In: Pack AI Sleep Apnea: Pathogenesis, Diagnosis, and Treatment New York; Marcel Dekker 2002: 495-522
23 Mortimore I L, Whittle A T, Douglas N J. Comparison of nose and face mask CPAP therapy for sleep apnoea. Thorax. 1998; 53 290-292
24 ATS Statement . Indications and standards of use of nasal continuous positive airway pressure in sleep apnea syndromes. Am J Respir Crit Care Med. 1994; 150 1738-1745
25 Strolo P J, Sanders M H, Atwood C W. Positive pressure therapy. Clin Chest Med. 1998; 19 55-68
26 Nino-Murcia G, McCann C C, Bliwise D L, Guilleminault C, Dement W C. Compliance and side effects in sleep apnea patients treated with nasal continuous positive airway pressure. West J Med. 1989; 150 165-169
27 Hoffstein V, Viner S, Mateika S, Conway J. Treatment of obstructive sleep apnea with nasal continuous positive airway pressure. Patient compliance, perception of benefits, and side effects. Am Rev Respir Dis. 1992; 145 841-845
28 McArdle N, Devereux G, Heidarnejad H, Engleman H M, Mackay T W, Douglas N J. Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med. 1999; 159 1108-1114
29 Stauffer J L, Fayter N A, MacLurg B J. Conjunctivitis from nasal CPAP apparatus. Chest. 1984; 86 802

Max HirshkowitzPh.D.

VAMC Sleep Center 111i, 2002 Holcombe Blvd.

Houston, TX 77030

Email: maxh@bcm.tmc.edu