Obstructive sleep apnea (OSA) afflicts at least 2 to 4% of the adult population. The standard of treatment is either continuous or bilevel positive airway pressure (CPAP or BiPAP), according to the American Academy of Sleep Medicine’s 2006 practice parameters (see sidebar).
Explore this issue:March 2007
Positive airway pressure is a unique treatment option in that is has almost 100 percent efficacy under ideal circumstances, said Eric J. Kezirian, MD, MPH, Director of the Division of Sleep Surgery and Assistant Professor in the Department of Otolaryngology-Head and Neck Surgery at the University of California, San Francisco. Unfortunately, the effectiveness is limited by patient tolerance and adherence.
In studies, investigators have found that there are certain factors as to why patients do or do not tolerate positive airway pressure therapy, Dr. Kezirian continued. These factors can include, but are not limited to:
- Symptoms (people who are more tired may experience the largest improvement in energy levels after CPAP, and therefore have the strongest motivation).
- Anatomy (narrow nasal passages make nasal CPAP more difficult to tolerate).
- Personality (some people do not give up easily and will find a way to make CPAP more comfortable for themselves).
- Age (older adults tolerate CPAP better than younger adults).
- Technology (some devices are easier to wear; adding heated humidification will moisten the air and make CPAP more comfortable).
For some OSA patients, sleep medications can help those who are attempting to use CPAP or BiPAP overcome the initial difficulties in tolerating this treatment, when such difficulties exist, said Dr. Kezirian. They should be considered a temporary measure to help patients become accustomed to the device and promote long-term tolerance and adherence.
Sleep Meds and OSA Patients
A study published in the November 2006 issue of CHEST found that sleep medications might actually do little to help aid CPAP usage. Capt. David A. Bradshaw, MD, and his colleagues at the Naval Medical Center in San Diego hypothesized that giving an oral hypnotic medication to a group of male patients referred for CPAP treatment would help them to acclimate to CPAP and increase the number of hours they slept while using CPAP.
The researchers had previously discovered that, in a laboratory setting, a hypnotic medication often facilitates sleep during CPAP titration studies and that OSA patients who report significant insomnia are generally less tolerant of CPAP, but sometimes increase usage when provided a hypnotic medication.
In this study, all 72 patients (mean age 38 ± 7 years) participated in the standardized one-on-one CPAP training and were also randomized to receive zolpidem (10 mg), a placebo pill, or neither (standard care) for the first 14 days of CPAP treatment. Zolpidem is a relatively short-acting (half-life 1.5 to 2.4 hours) nonbenzodiazepine (imidazopyridine) hypnotic agent widely used for the treatment of insomnia. Patients taking zolpidem or a placebo were instructed to take one pill each night, 30 minutes before bedtime.