Chapter 37: Pulmonary Disorders

APNEA, CENTRAL SLEEP (CSAS)

Population

• – Adults.

Recommendations

American Academy of Sleep Medicine 2012

• – Primary CSAS

  • Use positive airway pressure therapy.

  • Limited evidence to support the use of acetazolamide for CSAS.

  • Consider zolpidem or triazolam if patients are not at high risk for respiratory depression.

• – CSAS related to CHF

  • Nocturnal oxygen therapy.

  • CPAP therapy targeted to normalize the apnea-hypopnea index.

• – CSAS related to ESRD

  • Options for therapy include CPAP, nocturnal oxygen, and bicarbonate buffer use during dialysis.

Source

• – http://www.guideline.gov/content.aspx?id=35175

APNEA, OBSTRUCTIVE SLEEP (OSA)

Population

• – Adults.

Recommendations

AASM 2017, 2019

• – Diagnosis

  • Test for OSA in conjunction with a comprehensive sleep evaluation.

  • Diagnose OSA when apnea-hypopnea index (AHI) is ≥5 events/h. Severe OSA is AHI ≥ 30 events/h.

  • Use a polysomnogram or home sleep apnea testing with a technically adequate device to diagnose OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate-to-severe OSA.

  • Use a polysomnogram, rather than home sleep apnea testing, to diagnose OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep-related hypoventilation, chronic opioid medication use, and history of stroke or severe insomnia.

  • If a single home sleep apnea testing is negative, inconclusive, or technically inadequate, a polysomnogram be performed for the diagnosis or exclusion of OSA.

• – Treatment with Positive Airway Pressure (PAP)

  • Treat OSA with PAP, either Continuous PAP (CPAP) or auto-adjusting PAP (APAP).

  • Choose CPAP and APAP rather than Bi-level PAP (BPAP) because BPAP is more costly and does not prevent obstructive breathing events at low expiratory pressure levels. Patients with a PAP requirement over 20 cm H₂O will require BPAP because of the limitation of settings on CPAP.

  • Alternatives to PAP include weight loss, positional therapy, oral appliance therapy, surgical management of anatomical nasal obstruction, or maxillomandibular advancement.

  • To improve adherence, choose nasal or intranasal mask interface rather than oronasal or oral, use heated humidification (reduces sleepiness, dry mouth/throat/nose, nasal congestion, hoarseness, headache, epistaxis), and offer educational, behavioral, and other troubleshooting interventions particularly in the setting of PTSD/anxiety.

Comments

1. Excessive daytime sleepiness: PAP, when compared to no treatment, shows significant improvement in sleepiness.

2. Impaired sleep: mixed data that PAP will alleviate this symptom.

3. HTN: BP reduction is clinically significant on PAP therapy, but patients without sleep symptoms may benefit enough from standard anti-HTN treatment to not need PAP if PAP is burdensome to their sleep cycle.

4. CV events/mortality: insufficient evidence to recommend PAP as a means to reduce CV events or CV mortality.

Sources