Healthcare and Medicine Reference
In-Depth Information
Medical Therapy for Obstructive
Sleep Apnea
Charles W. Atwood, Jr., Patrick J. Strollo, Jr., and Rachel Givelber
Chapter
106
tial and consistent results that justify the use of these classes
of medications for routine treatment of OSA. Administration
of supplemental oxygen therapy has also been used to treat
the hypoxemia in OSA. Oxygen therapy has not been proved
to improve outcomes in OSA, although treatment of severe
hypoxemia that cannot be achieved by interventions that are
primarily directed at maintaining upper airway patency is
generally considered to be reasonable. Caution is advisable in
this circumstance because apneas may be longer during deliv-
ery of supplemental oxygen.
Perhaps the most common and justifiable use of medication
in OSA management is to improve alertness when sleepiness
persists despite the successful amelioration of apneas and
hypopneas with positive pressure therapy. Amphetamines and
methylphenidate may be used for this purpose, but they have
common side effects and can lead to dependence. A safer
choice for promoting wakefulness in this setting is modafinil
or armodafinil. These alertness promoting medications are
approved for OSA patients who are adherent to CPAP therapy
but still have excessive sleepiness.
Abstract
Positive airway pressure therapy, oral appliances, and surgery
are considered the mainstays of sleep apnea therapy for
obstructive sleep apnea (OSA), but a variety of medical thera-
pies are occasionally appropriate as part of a primary therapy
management strategy for obstructive apneas and hypopneas.
In other cases, medical therapy may be a useful adjunct to
positive airway pressure therapy in selected cases. Among
these medical therapies is weight loss, which may the result
of dietary manipulation or surgery. Weight loss can partially
ameliorate or even reverse OSA. Alcohol and sedatives can
also interact with OSA in a way that can worsen OSA symp-
toms, and consequently, these patients should refrain from
these agents close to bedtime.
Several medications are thought to affect OSA. Methylxan-
thines, progestational agents, selective serotonin reuptake
inhibitors, and mixed serotonin receptor antagonists have
each been studied with respect to OSA. Although positive
studies exist, in aggregate the evidence provides no substan-
The principal therapy for obstructive sleep apnea (OSA)
remains positive pressure delivered by a nasal or naso-oral
interface (see Chapter 107). Oral appliances can also be
useful in selected patients who cannot tolerate positive
airway pressure (see Chapter 109). However, other medical
options may be important as an adjunct to these treatment
options or as a therapeutic intervention alone if the patient
cannot accept or tolerate positive airway pressure or oral
appliance therapy as a primary treatment. The focus of this
chapter is to review these options.
loading of the anterior neck, which can simulate the clini-
cal scenario of excessive adipose tissue deposits in this
area. 1 Further support for a significant pathophysiologic
role of cervical obesity is provided by the observation that
changes in pressure surrounding the neck are transmitted
to the airway lumen and that cyclic pressure fluctuations
in the pharyngeal fat pad coincide with intrapharyngeal
pressure fluctuations.2,3 2 , 3 These data also support the impor-
tance of the observation that OSA patients have thick
necks 4 and that increased neck circumference is a predic-
tive factor for OSA. 5-7 Furthermore, velopharyngeal col-
lapsibility increases with increasing neck circumference,
at least in awake OSA patients. 8
The presence of intrapharyngeal fat deposition may
also be important in the pathophysiology of OSA (see
Chapter 101). Several groups of investigators have observed
increased intrapharyngeal adipose tissue or increased
lateral fat pad size on computed tomography and magnetic
resonance imaging of OSA patients. 9-12 The significance of
a space-occupying intrapharyngeal mass on pharyngeal
function has been demonstrated in an animal model with
increased upper airway resistance, which is related to the
magnitude of inflation of a balloon catheter in the region
of the upper airway lateral fat pad. 3 , 13 In summary, upper
airway closure during sleep partly depends airway size and
shape as well as external tissue pressures from lateral pha-
ryngeal fat pads exerting pressure on the airway lumen.
Furthermore, to the extent that upper airway patency is
increased by greater lung volume and reduced by decreased
lung volume, greater truncal obesity leading to decreased
lung volume may be another mechanism contributing to
airway closure during sleep.
It has been well documented that either medical or sur-
gical weight reduction can have a substantial positive
BEHAVIORAL INTERVENTIONS
Good medical care requires a comprehensive examination
of the patient's lifestyle and an understanding of how it
may predispose to, or interact with, underlying medical
problems. This is particularly true in patients with OSA.
A number of lifestyle practices place persons at increased
risk for OSA or worsen existing OSA. Modification of this
behavior can favorably affect risk. These behavioral risks
are described next. Multiple interventions may be appro-
priate in a given patient.
Weight Loss
A detailed discussion of upper airway physiology in OSA
is provided in Chapter 101. To place the importance of
weight reduction as a target for intervention in many OSA
patients it is important to recognize the pathophysiologic
contribution of obesity to this disorder. This issue is dis-
cussed in depth in Chapters 101 and 115. The adverse
effect of obesity on upper airway function may be mediated
through several pathways, one of which is a direct influ-
ence on upper airway geometry. Studies in animals have
indicated that upper airway resistance is influenced by mass
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