Residual Sleepiness in Patients with Obstructive Sleep Apnea a Treatment Challenge for Otolaryngologists

APAP users with excessive daytime sleepiness do have some recourse. Physicians can usually receive approval from the insurance company for a traditional in-lab study that will hopefully capture data not recorded by the APAP. EEG tracings can identify arousals, and electrodes attached to the legs can discover restless leg syndrome and periodic limb movement disorder. But insurance approval may not be the only hurdle to overcome. Many people now have high co-pays and large deductibles that can make this additional test a hardship.

In addition to incorrect titration, poor CPAP compliance could be a culprit. CMS defines compliance as wearing the mask four hours a night for five nights a week, but this amounts to only 20 hours of sleep per week, which is less than half of what adults actually require. Some patients are minimally compliant, meeting the technical definition of proper use but not using the device enough to make a meaningful impact on their sleep health. Others see CPAP as a kind of “magic bullet” that will allow them to obtain adequate rest from just four or five hours of sleep.

When searching for the cause of RES, physicians should begin by examining the download from the APAP device. This will give a snapshot of patient compliance, including how many hours they wear the mask and, very importantly, which hours they wear it. Dr. Wardrop pointed out, “A person can be officially compliant, wearing their APAP from 11:00 p.m. to 3:00 a.m. every night, but miss the main hours of REM sleep between 3:00 a.m. and 6:00 a.m., when sleep apnea is at its worst.”

Not all noncompliance is intentional. Some people unknowingly remove the mask during sleep. CPAP machines have alarms that sound when this happens, but, ironically, patients often sleep right through them. Counsel patients to make certain the alarm is on and the volume turned all the way up, and enlist bed partners to wake the patient when they hear it go off or when they hear snoring. If the patient cannot break this habit, he may be a candidate for a mandibular advancement device.

Uncovering the Issues: A Complete Sleep History

When a patient is being treated for OSA, it is tempting to assume that RES is tied to this condition in some way; however, there may be other causes. Lee Shangold, MD, otolaryngologist and sleep lab director at ENT and Allergy Associates, LLP, in Port Jefferson, N.Y., advised, “If patients are getting optimal CPAP treatment, the next step is to go through the differential diagnoses to determine what else could be contributing to their excessive sleepiness.”