Overweight and are unwilling or unable to use CPAP: Learn about new study

The majority of patients are unable to use CPAP and oral appliances are usually the single best treatment. Katy McNulty has informed me of a free study for overweight patients unable or unwilling to utilize CPAP. The study is done in Atlanta but you do not need to live in Atlanta. Morbid obesity is a contraindication to a comfortable oral appliance but merely being overweight is common and oral appliances are usually a comfortable and effective alternative to CPAP.

Please mention I HATE CPAP if you contact Katy and send me your feedback.

STUDY INFORMATION FOLLOWS:

We are conducting a clinical trial in Atlanta that your audience might find interesting. It's for people who are overweight and are unwilling or unable to use CPAP. I pasted the link to the study information below.

http://www.atlantasleep.com/osaovw

	Katy	McNulty
Contact Email:		kmcnulty@neurotrials.com
Contact Phone:		404-851-9934

Pillars Do Not Reduce CPAP Pressure or Increase CPAP compliance.

Patients with sleep apnea are frequently looking for an easy surgical procedure to treat their sleep apnea. Pillar surgery was intially considered to be a treatment for sleep apnea but has been relegated to a treatment for simple snoring coming from the soft palate.

PLACEMENT OF SOFT PALATE PILLARS SHOULD NOT BE CONSIDERED A PRIMARY TREATMENT FOR SLEEP APNEA!

A new study (PubMed abstract below)looked at Pillar Surgery to see if it increased compliance in CPAP users or decreased CPAP pressures. Sadly, this was not the case. The study published in Otolaryngology Head and Neck Surgery concluded that "Pillar implants do not significantly reduce CPAP pressure or increase CPAP compliance compared to sham controls but may subjectively improve CPAP satisfaction. These findings do not presently support the use of Pillar implants as an adjunctive treatment to improve CPAP compliance."

I advise patients who are looking for a surgical "cure" for sleep apnea avoid pillar surgery. Surgical interventions that can "cure sleep apnea" are available. The most successful is bimaxillary advancement. Base of tongue reduction is also successful but I strongly recommend doing it with the somnoplasty method to avoid adverse surgical consequences.

For the severely obese CPAP and tracheotomy are the most successful treatments. Mild to moderate sleep apnea is best treated with CPAP or Oral Appliances.

Otolaryngol Head Neck Surg. 2011 Feb;144(2):230-6. Epub 2010 Dec 29.
Effect of palatal implants on continuous positive airway pressure and compliance.
Gillespie MB, Wylie PE, Lee-Chiong T, Rapoport DM.
Source

Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina 29425-5500, USA. gillesmb@musc.edu
Abstract
OBJECTIVE:

Determine if the Pillar palatal implant system reduces continuous positive airway pressure (CPAP) pressure and improves patient compliance with CPAP therapy.
STUDY DESIGN:

Randomized, double-blind, placebo-controlled study.
SETTING:

Four geographically dispersed tertiary sleep disorder referral centers.
METHODS:

Subjects with mild to moderate sleep apnea dissatisfied with CPAP because of pressure-related complaints were randomized to receive Pillar implants or a sham procedure performed in double-blind fashion. Active and sham groups were compared for changes in therapeutic CPAP pressures (primary outcome) with a 90-day follow-up sleep study and CPAP compliance (secondary outcome) with a 90-day smart card report.
RESULTS:

Twenty-six subjects were randomized to Pillar implants and 25 to a sham implant procedure. There were no differences between groups with regard to demographics and baseline parameters. Both sham and active groups had reduced mean CPAP pressure (-1.1 vs -0.5 cm H(2)O) with no difference between groups (P = .32) at 90-day follow-up. In addition, there was no difference in average daily CPAP use between groups (P = .80). Both groups experienced improvements in Epworth sleepiness scores and Functional Outcome of Sleep Questionnaire scores at 90 days with no differences between groups. The active group reported significantly higher CPAP satisfaction scores than the sham group (P = .04).
CONCLUSION:

Pillar implants do not significantly reduce CPAP pressure or increase CPAP compliance compared to sham controls but may subjectively improve CPAP satisfaction. These findings do not presently support the use of Pillar implants as an adjunctive treatment to improve CPAP compliance.

PMID:
21493422
[PubMed - indexed for MEDLINE]

Adherence to CPAP Improves Quality of Life, Oral Appliances are as Effective as CPAP but show Higher Compliance.

A recent study in Sleep and Breathing Journal,"Adherence to CPAP therapy improves quality of life and reduces symptoms among obstructive sleep apnea syndrome patients"showed significant improvement in patients who used CPAP for 6 months.

A more careful look at the study also shows the major problem with CPAP.

This study looked at 50 patients, 41 men and 9 women who were "compliant" with CPAP usage. This means that they wore CPAP an average of 4-5 hours/night. It is well established that 7-7.5 hours/night is ideal CPAP usage. Standardized tests showed subjective improvement in quality of life but a large group of patients still reported "excessive fatigue" (54.5%), and "decreased energy" (55.3%).

The real danger to using CPAP for 4-5 hours a night is the risk of cardiovascular events including heart attack and stroke. Patients with untreated sleep apnea have an enormous and dangerous increased risk of myocardial infarction and cerebral vascular accidents in the early morning hours, usually between 3 and 5 AM. Patient who wear CPAP for only 4-5 hours are no longer utilizing it during the hours of greatest risk!

The danger of unacceptably low CPAP use (4-5 hours /night) was well documented by an article in Sleep (2011 Jan 1;34(1):105-10.) "Reliable calculation of the efficacy of non-surgical and surgical treatment of obstructive sleep apnea revisited."

The article concludes "Using a mean AHI in CPAP therapy is more realistic than using arbitrary compliance rates, which, in fact, hide insufficient reductions in AHI." Clearly stating 4-5 hour compliance is a poor measure of success.

Compare this information to a recent article in Chest (2011 Jun 2) "Efficacy of An Adjustable Oral Appliance and Comparison to Continuous Positive Airway Pressure For the Treatment of Obstructive Sleep Apnea Syndrome." Where they found high effectiveness of Oral Appliances. Oral Appliances are utilized by most patients for the entire night.





Sleep Breath. 2011 Jun 11. [Epub ahead of print]
Adherence to CPAP therapy improves quality of life and reduces symptoms among obstructive sleep apnea syndrome patients.
Avlonitou E, Kapsimalis F, Varouchakis G, Vardavas CI, Behrakis P.
Source

Sleep Laboratory, Henry Dunant Hospital, Athens, Greece.
Abstract
PURPOSE:

The aim of the study was to asses quality of life and symptoms of obstructive sleep apnea syndrome (OSAS) patients after adhering to 6 months of continuous positive airway pressure (CPAP) treatment.
METHODS:

A group of 50 patients (41 men and 9 women) were diagnosed by polysomnography and treated with CPAP therapy for 6 months. Their symptoms and health-related quality of life were assessed by administering a validated and translated version of the sleep apnea quality of life index (SAQLI). Sleepiness was measured using the Epworth Sleepiness Scale (ESS) and through electronic monitoring of CPAP usage per night of sleep.
RESULTS:

Mean CPAP usage was 4.5 ± 0.5 h per night. Comparisons between quality of life indexes before and after CPAP treatment showed an improvement in the total SAQLI score (3.8 ± 0.9 vs. 5.8 ± 0.8 after CPAP, p < 0.01), in daily functioning (4.2 ± 1.4 vs. 6.0 ± 0.9, p < 0.01), social interactions (4.8 ± 1.3 vs.6.3 ± 0.7, p < 0.01), emotional functioning (4.4 ± 1.4 vs. 5.7 ± 1.0, p < 0.01), symptoms (1.6 ± 0.8 vs. 5.8 ± 1.2, p < 0.01), and in the ESS (13.7 ± 6.5 vs. 3.9 ± 3.8, p < 0.01). Regarding the patients' symptoms, improvement was noticed for "sleepiness while watching a spectacle" (96%), "reading" (95%), "carrying on a conversation" (95%), "driving" (92.9%), "restless sleep" (87.8%), and "urinating more than once per night" (84.8%). Smaller improvements were observed for the reported "dry mouth-throat upon awakening" (36.1%),"excessive fatigue" (54.5%), and "decreased energy" (55.3%).
CONCLUSION:

We conclude that OSAS patients who adhere to nighttime CPAP therapy show significant improvement of their quality of life, daytime sleepiness, and other symptoms after 6 months of treatment with CPAP. The article explains mathematically the problems of considering 4-5 hours as "success. "The more severe the AHI, the more percentage of total sleep time (TST) CPAP must be used to significantly reduce the AHI. Patients with moderate OSA reduce the AHI by 33.3% to 48.3% when using CPAP 4 h/ night (AHI 0-5, respectively). The required nightly percentage use rises as one reduces the AHI target to < 5. CPAP must be used 66.67% to 83.33% per night to reduce the AHI below 5 (AHI of 0 while using CPAP). By using these definitions most CPAP usage of 4-5 hours a night is actually only partial treatment leaving the patient at risk.



Sleep. 2011 Jan 1;34(1):105-10.
Reliable calculation of the efficacy of non-surgical and surgical treatment of obstructive sleep apnea revisited.
Ravesloot MJ, de Vries N.
Source

Sint Lucas Andreas Ziekenhuis, Department of Otolaryngology/Head Neck Surgery, Amsterdam, the Netherlands. m.ravesloot@slaz.nl
Abstract
BACKGROUND:

Various treatment methods exist to treat obstructive sleep apnea (OSA); continuous positive airway pressure (CPAP) is considered the gold standard. It is however a clinical reality that the use of CPAP is often cumbersome. CPAP treatment is considered compliant when used ≥ 4 h per night as an average over all nights observed. Surgery, on the other hand, is regarded as successful when the apnea hypopnea index (AHI) drops at least 50% and is reduced below 20/h postoperatively in patients whose preoperative AHI was > 20/h. The effectiveness of CPAP compliance criteria can be questioned, just as the effectiveness of surgical success criteria has often been questioned.
STUDY OBJECTIVES:

The aim of the study was to compare non optimal use of optimal therapy (CPAP) with the continuous effect (100%) of often non optimal therapy (surgery).
DESIGN:

Using mathematical function formulas, the effect on the AHI of various treatment modalities and their respective compliance and success criteria were calculated.
RESULTS:

The more severe the AHI, the more percentage of total sleep time (TST) CPAP must be used to significantly reduce the AHI. Patients with moderate OSA reduce the AHI by 33.3% to 48.3% when using CPAP 4 h/ night (AHI 0-5, respectively). The required nightly percentage use rises as one reduces the AHI target to < 5. CPAP must be used 66.67% to 83.33% per night to reduce the AHI below 5 (AHI of 0 while using CPAP).
CONCLUSION:

Using a mean AHI in CPAP therapy is more realistic than using arbitrary compliance rates, which, in fact, hide insufficient reductions in AHI.

PMID:
21203364
[PubMed - indexed for MEDLINE]
PMCID: PMC3001787
[Available on 2011/7/1]

Chest. 2011 Jun 2. [Epub ahead of print]
Efficacy of An Adjustable Oral Appliance and Comparison to Continuous Positive Airway Pressure For the Treatment of Obstructive Sleep Apnea Syndrome.
Holley AB, Lettieri CJ, Shah AA.
Source

Pulmonary, Critical Care, and Sleep Medicine, Walter Reed Army Medical Center.
Abstract
BACKGROUND:

We sought to establish the efficacy of an adjustable oral appliance (aOA) in the largest patient population studied to date, and provide a comparison to CPAP.
METHODS:

Retrospective analysis of patients prescribed an aOA. Results of overnight, PSG with aOA titration were evaluated and compared to CPAP. Predictors of a successful aOA titration were determined using a multivariate logistic regression model.
RESULTS:

A total of 497 patients were prescribed an aOA during the specified time period. The aOA reduced the mean AHI to 8.4±11.4, and 70.3%, 47.6%, and 41.4% of patients with mild, moderate, and severe disease achieved an AHI<5, respectively. Patients using an aOA decreased their mean Epworth Sleepiness Score (ESS) by 2.71 (95% CI: 2.3-3.2; p<0.001) at follow-up. CPAP improved the AHI by - 3.43 (95% CI: 1.88-4.99; p<0.001) when compared to an aOA, but when adjusted for severity of disease, this difference only reached significance for patients with severe disease (-5.88 (95% CI: -8.95 - -2.82; p<0.001)). However, 70.1% of all patients achieved an AHI < 5using CPAP, compared to 51.6% for the aOA (p<0.001). On multivariate analysis, baseline AHI was a significant predictor of achieving an AHI < 5 on aOA titration, and age showed a trend toward significance.
CONCLUSIONS:

In comparison to past reports, more patients in our study achieved an AHI < 5 using an aOA. The aOA is comparable to CPAP for patients with mild disease, while CPAP is superior for patients with moderate to severe disease. A lower AHI was the only predictor of a successful aOA titration.

Why CPAP is not effective in treating resistant hypertension. Does CPAP fail to reduce stroke risk and myocardial risk?

I have reviewed several article recently on why CPAP doesn't seem overly helpful in treating hypertension. A new article in Sleep Medicine Review "A systematic review of CPAP adherence across age groups: Clinical and empiric insights for developing CPAP adherence interventions." clearly explains why CPAP is ineffective intreatment of hypertension. IT ISN'T USED or it isn't used enough. The article clearly states "Continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA) but adherence to the treatment limits its overall effectiveness across all age groups of patients", in simple English, CPAP does not work because CPAP is not used!

Numerous studies have shown low CPAP compliance with only 23-42% of patients utilizing CPAP and a recent study showed 60% quit CPAP completely.

CPAP SUCCESS IS DESCRIBED AS USING CPAP 4-5 NIGHTS FOR 4-5 HOURS A NIGHT, THIS TYPE OF SUCCESS CAN KILL YOU OR LEAD TO CARDIOVASCULAR ACCIDENTS AND STROKES. More importantly this horrendous description of success lulls cardiologists into a false sense of security with treatment.

Studies have shown that most heart attacks and strokes occur between 3-5 AM. The typical patient only wears their CPAP for 4-5 hours/ night. Patients who go to sleep with their CPAP at 10 PM and wear it 4-5 hours will be untreated during the critical hours of 3-5 AM.

It is time for the sleep community to recognize that part-time CPAP use can result in deadly outcomes. An article in the Journal of Human Hypertension "Resistant hypertension, obstructive sleep apnoea and aldosterone." state that "CPAP studies do, however, indicate a wide variation in the BP effects of CPAP, with some patients manifesting a large antihypertensive benefit such that a meaningful BP effect can be anticipated in some individuals. OSA is particularly common in patients with resistant hypertension (RHTN)" The wide variation is likely based on CPAP use. CPAP used 4 hours a night is at best 50% effective, and totally ineffective during times of highest risk.

Treatment of Obstructive Sleep Apnea is essential for many reasons. A recent study showed that oral appliances and CPAP are equivlant when objectively titrated. Oral appliances show much higher compliance than CPAP in both time of use and frequency of use. This could correct hormonal changes that occur due to sleep disruption.

"Diagnosis and treatment of primary aldosteronism" is an article published in
Endocrinology Metabolism Clinics of North America (2011 Jun;40(2):313-32) states that "A few simple rules can allow physicians to successfully identify many patients with arterial hypertension caused by PA among the so-called essential hypertensive patients. The hyperaldosteronism and the hypokalemia can be cured with adrenalectomy in practically all of these patients.

The removal of the adrenal gland may cure the hypertension but the cause of adrenal excess is obstructive sleep apnea that is not effectively treated due to short time use of CPAP.

IF PATIENTS ARE NOT RESOLVING HYPERTENSION PROBLEMS AN ORAL APPLIANCE TRIAL SHOULD PRECEDE ADRENALECTOMY.

Many sleep physicians are "married" to CPAP and their blinders make them declare 70-90% success rates in their patients even though objective studies show that their success is due not to high patient compliance but rather success described as 4-5 hours of use.

Cardiologists, endocrinologists and vascular surgeons need to demand higher levels of success from the sleep community. Unfortunately CPAP is the fiscal engine that drives much of sleep medicine. The elimination of stage 4 sleep from sleep reports was due to the inability of CPAP to return a normal Delta Sleep percentage. Research at University of Chicago showed that Growth Hormone is produced during the first period of Delta Sleep as a quick example. Dumbing down of sleep medicine is inexcusable. Currently Sleep Labs Accredited by the AASM are not even allowed to break Slow Wave sleep into stage 3 and 4.


Sleep Med Rev. 2011 Jun 6. [Epub ahead of print]
A systematic review of CPAP adherence across age groups: Clinical and empiric insights for developing CPAP adherence interventions.
Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE.
Source

University of Pennsylvania School of Nursing, Biobehavioral Health Sciences Division, USA; Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA.
Abstract

Continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA) but adherence to the treatment limits its overall effectiveness across all age groups of patients. Factors that influence adherence to CPAP include disease and patient characteristics, treatment titration procedures, technological device factors and side effects, and psychological and social factors. These influential factors have guided the development of interventions to promote CPAP adherence. Various intervention strategies have been described and include educational, technological, psychosocial, pharmacological, and multi-dimensional approaches. Though evidence to date has led to innovative strategies that address adherence in CPAP-treated children, adults, and older adults, significant opportunities exist to develop and test interventions that are clinically applicable, specific to sub-groups of patients likely to demonstrate poor adherence, and address the multi-factorial nature of CPAP adherence. The translation of CPAP adherence promotion interventions to clinical practice is imperative to improve health and functional outcomes in all persons with CPAP-treated OSA.

Copyright © 2011 Elsevier Ltd. All rights reserved.

J Hum Hypertens. 2011 Jun 9. doi: 10.1038/jhh.2011.47. [Epub ahead of print]
Resistant hypertension, obstructive sleep apnoea and aldosterone.
Dudenbostel T, Calhoun DA.
Source

Vascular Biology and Hypertension Program, Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA.
Abstract

Obstructive sleep apnoea (OSA) and hypertension commonly coexist. Observational studies indicate that untreated OSA is strongly associated with an increased risk of prevalent hypertension, whereas prospective studies of normotensive cohorts suggest that OSA may increase the risk of incident hypertension. Randomized evaluations of continuous positive airway pressure (CPAP) indicate an overall modest effect on blood pressure (BP). Determining why OSA is so strongly linked to having hypertension in cross-sectional studies, but yet CPAP therapy has limited BP benefit needs further exploration. The CPAP studies do, however, indicate a wide variation in the BP effects of CPAP, with some patients manifesting a large antihypertensive benefit such that a meaningful BP effect can be anticipated in some individuals. OSA is particularly common in patients with resistant hypertension (RHTN). The reason for this high prevalence of OSA is not fully explained, but data suggest that it may be related to the high occurrence of hyperaldosteronism in patients with RHTN. In patients with RHTN, it has been shown that aldosterone levels correlate with severity of OSA and that blockade of aldosterone reduces the severity of OSA. Overall, these findings are consistent with aldosterone excess contributing to worsening of underlying OSA. We hypothesize that aldosterone excess worsens OSA by promoting accumulation of fluid within the neck, which then contributes to increased upper airway resistance.Journal of Human Hypertension advance online publication, 9 June 2011; doi:10.1038/jhh.2011.47.

PMID:
21654850
[PubMed - as supplied by publisher]

Prog Cardiovasc Dis. 2009 Mar-Apr;51(5):371-80.
Sleep apnea, aldosterone, and resistant hypertension.
Pimenta E, Calhoun DA, Oparil S.
Source

Department of Hypertension and Nephrology, Dante Pazzanese Institute of Cardiology, Sao Paulo, SP, Brazil. espimenta@hotmail.com
Abstract

Obstructive sleep apnea, aldosterone excess, and resistant hypertension are common comorbidities in obese patients. The mechanisms that link these conditions are not fully elucidated, but sympathetic nervous system activation, sodium retention, renin-angiotensin-aldosterone system stimulation, endothelial dysfunction, and increased production of reactive oxidative species may be contributing factors. Patients diagnosed with this triad should be treated with low-salt diet, weight-loss counseling, and continuous positive airway pressure, as well as aggressive antihypertensive therapy, usually with multiple agents, including a mineralocorticoid receptor antagonist. Patients with aldosterone-producing adenoma may require adrenalectomy.

PMID:
19249443
[PubMed - indexed for MEDLINE]

Endocrinol Metab Clin North Am. 2011 Jun;40(2):313-32.
Diagnosis and treatment of primary aldosteronism.
Rossi GP.
Source

Molecular Hypertension Laboratory, Dipartimento di Medicina Clinica e Sperimentale (DMCS) 'G. Patrassi' - Internal Medicine 4, University of Padua, University Hospital Padua, Via Giustiniani, 2, 35126 Padua, Italy.
Abstract

Moreover, in a substantial proportion of them, the blood pressure can be normalized or markedly lowered if a unilateral cause of PA is discovered. Hence, the screening for PA can be rewarding both for the patient and for the clinician, particularly in those cases where hypertension is severe and/or resistant to treatment, in which the removal of an APA can allow blood pressure to be brought under control despite withdrawal of, or a prominent reduction in, the number and doses of antihypertensive medications.

Copyright © 2011 Elsevier Inc. All rights reserved.

PMID:
21565669
[PubMed - in process]

Cardiologists embrace oral appliances as an alternative treatment to CPAP for sleep apnea

Cardiologists have long recognized that sleep apnea is a leading cause of hypertension (high blood pressure), heart attacks and strokes. Cardiologists have referred patients for sleep studies and CPAP therapy for years. Cardiologists have become disillusioned by the poor compliance with CPAP that has been documented in patients with sleep apnea. The majority of patients with mild apnea as well as moderate and severe sleep apnea reject CPAP in large numbers. A recent study showed 60% of patients abandon CPAP therapy.

Cardiologists who are proponents of sleep apnea treatment are referring more and more patients for oral appliance therapy as an alternative to CPAP. They recognize that CPAP therapy is worthless if it is not used. Oral appliances are considered a first line treatment for mild to moderate sleep apnea. Oral appliance therapy is also an alternative to CPAP for severe sleep apnea when patients do not toleratte CPAP.

THE MAJORITY OF PATIENTS DO NOT TOLERATE CPAP!!! MEDICARE IS NO LONGER COVERING CPAP THERAPY FOR PATIENTS WHO DO NOT USE CPAP ON A REGULAR BASIS. MOST PATIENTS DO NOT USE CPAP ON A REGULAR BASIS.

Cardiologists are more comfortable referring patients for CPAP but have come to realize that patients are much more compliant with oral applainces than CPAP.

This means that patients use their oral appliances to treat their sleep apnea. Cardiologists know this is vital to their patients health. While CPAP may be more effective for some patients it is a total treatment failure for those patients who do not use their CPAP.

In addition to heart attacks and stroke untreated sleep apnea can also cause short term memory loss, lead to drammatic increases n motor vehicle accidents because patients with untreated sleep apnea have slower reaction times than patients who are legally intoxicated. Untreated sleep apnea can increase severity and speed of onset of Alzheimer's and Dementia, is implicated in up to 80% of ADD and ADHD in children, can increase the severity of metabolic problems from diabetes to obesity.

The National Sleep Foundation has declared that oral appliances are a therapy whose time has come!

The American Academy of Sleep Medicine considers oral appliances to be a first line treatment for mild to moderate sleep apnea.

The American Academy of Dental Sleep Medicine has published reports on the success of treating severe sleep apnea with comfortable oral appliances.

MORBIDLY OBESE PATIENTS SHOULD STILL CONSIDER CPAP AS THE TREATMENT OF CHOICE. A RECENT STUDY SHOWED THAT PROPERLY TITRATED ORAL APPLIANCES ARE EQUALLY EFFECTIVE TO CPAP FOR SLEEP APNEA PATIENTS.

THE UNITED STATES GOVERNMENT HAS ENDORSED ORAL APPLIANCES FOR TREATING SLEEP APNEA BY ACCEPTING DENTAL SLEEP MEDICINE FOR COVERAGE UNDER MEDICARE.

THE NEW MEDICARE POLICY ALSO RECOGNIZES THE DISMAL COMPLIANCE RATES OF CPAP WITH NEW MINIMAL USAGE REQUIREMENT FOR CPAP COVERAGE. THIS NEW POLICY WILL BENEFIT EVERYONE AS MANUFACTURERS AND DME'S WORK TO INCREASE COMPLIANCE WITH CPAP.

Structural Changes to Brain from Sleep Apnea and Correction with Treatment.

Can the brain recover from damage caused by Sleep Apnea. The answer is yes according to a study done in Italy that showed that in addition to clinical improvement there was also brain-structural recovery. The study emphasizes that adherence to CPAP therapy is key. Unfortunately 60% of patients are not adherent to CPAP therapy and even those that are adherent average only 4-5 hours of use a night which has been shown to be far less that ideal. A recent article "Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea."in Am J Respir Crit Care Med. 2010 Apr 1;181(7):650-2 showed that treatment of hypertension with CPAP required an average of 5.6 hours of nightly CPAP use. The actual conclusion was " In nonsleepy hypertensive patients with OSA, CPAP treatment for 1 year is associated with a small decrease in BP. This effect is evident only in patients who use CPAP for more than 5.6 hours per night."

if 5.6 hours of nightly use is necessary for improvement and if the typical patient only uses cpap 4-5 nights for 4-5 hours than we should not expect improvement in hypertension. Does the same hold true for repair of structural damage from sleep apnea?

THE REAL ADVANTAGE TO ORAL APPLIANCES IN TREATING APNEA IS THAT PATIENTS GENERALLY USE THEM ALL NIGHT LONG. IF ORAL APPLIANCE ARE NOT EFFECTIVE IN A SMALL NUMBER OF CASES CPAP SHOULD BE UTILIZED. PATIENTS WHO USE THEIR CPAP ALL NIGHT/EVERY NIGHT NEED NOT CONSIDER THE ORAL APPLIANCE ALTERNATIVE.

This interesting study published in abstract form in sleep explains the importance of treatment of sleep apnea. The study "BRAIN STRUCTURAL CHANGES IN OSA PATIENTS BEFORE AND AFTER TREATMENT" by Ferini Strambi L, Canessa N, Castronovo V,Alemanno F, Aloia MS5, Marelli S1, Falini A6, Cappa SF2,3,4 concludes that "Conclusion: Our study provide evidence of a neuro-structural damage in OSA patients (decrease of grey-matter volume compared with controls) affecting specific cerebral regions and an increase of grey-matter volume in specific hippocampal and frontal brain regions with treatment. This study offers hope to patients and physicians that adherence to CPAP therapy can lead not only to clinical, but also to brain-structural recovery.

Am J Respir Crit Care Med. 2010 Apr 1;181(7):718-26. Epub 2009 Dec 10.
Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea.
Barbé F, Durán-Cantolla J, Capote F, de la Peña M, Chiner E, Masa JF, Gonzalez M, Marín JM, Garcia-Rio F, de Atauri JD, Terán J, Mayos M, Monasterio C, del Campo F, Gomez S, de la Torre MS, Martinez M, Montserrat JM; Spanish Sleep and Breathing Group.

Collaborators (16)
Coordinating Center, Institut de Recerca Biomèdica Lleida, Lleida, Spain. fbarbe@arnau.scs.es
Comment in:

Am J Respir Crit Care Med. 2010 Apr 1;181(7):650-2.
Abstract
RATIONALE: Continuous positive airway pressure (CPAP) is the current treatment for patients with symptomatic obstructive sleep apnea (OSA). Its use for all subjects with sleep-disordered breathing, regardless of daytime symptoms, is unclear. Objectives: This multicenter controlled trial assesses the effects of 1 year of CPAP treatment on blood pressure (BP) in nonsymptomatic, hypertensive patients with OSA. METHODS: We evaluated 359 patients with OSA. Inclusion criteria consisted of an apnea-hypopnea index (AHI) greater than 19 hour(-1), an Epworth Sleepiness Scale score less than 11, and one of the following: under antihypertensive treatment or systolic blood pressure greater than 140 or diastolic blood pressure greater than 90 mm Hg. Patients were randomized to CPAP (n = 178) or to conservative treatment (n = 181). BP was evaluated at baseline and at 3, 6, and 12 months of follow-up. MEASUREMENTS AND MAIN RESULTS: Mean (SD) values were as follows: age, 56 +/- 10 years; body mass index (BMI), 32 +/- 5 kg x m(-2); AHI, 45 +/- 20 hour(-1); and Epworth Sleepiness Scale score, 7 +/- 3. After adjusting for follow-up time, baseline blood pressure values, AHI, time with arterial oxygen saturation less than 90%, and BMI, together with the change in BMI at follow-up, CPAP treatment decreased systolic blood pressure by 1.89 mm Hg (95% confidence interval: -3.90, 0.11 mm Hg; P = 0.0654), and diastolic blood pressure by 2.19 mm Hg (95% confidence interval: -3.46, -0.93 mm Hg; P = 0.0008). The most significant reduction in BP was in patients who used CPAP for more than 5.6 hours per night. CPAP compliance was related to AHI and the decrease in Epworth Sleepiness Scale score. CONCLUSIONS: In nonsleepy hypertensive patients with OSA, CPAP treatment for 1 year is associated with a small decrease in BP. This effect is evident only in patients who use CPAP for more than 5.6 hours per night. Clinical trial registered with www.clinicaltrials.gov (NCT00127348).

PMID: 20007932 [PubMed - indexed for MEDLINE]