chapter  22
32 Pages

Continuous positive airway pressure therapy for sleep disordered breathing in adults A K Simonds

Sleep apnoea syndromes 292

Obstructive sleep apnoea, hypertension, ischaemic heart disease and stroke 294

Sleep disordered breathing and heart failure 295

Obstructive sleep apnoea and the metabolic syndrome 295

Obstructive sleep apnoea, cognitive effects and driving 295

Assessment and investigation 296

Pathophysiology and mechanism of action of CPAP in OSA 299

Indications for continuous positive airway pressure 300

Body position modification 301

Weight reduction 302

Oral devices 302

Devices to promote nasal patency 304

Upper airway surgery 304

Cardiac pacing/resynchronization 307

Pharmacological treatment 307

Other interventions 307

Effects of CPAP in obstructive sleep apnoea 308

CPAP therapy in central sleep apnoea 308

Choice of CPAP equipment for domiciliary use 308

Mask selection 309

Starting continuous positive airway pressure 309

CPAP or bilevel pressure support ventilation? 311

Compliance 311

Practical problems 312

Common questions about CPAP from patients 315

References 316

Continuous positive airway pressure (CPAP) therapy was introduced as a treatment for obstructive sleep apnoea (OSA) by Sullivan and colleagues1 in 1981. It has revolutionized the approach to this condition, virtually abolishing the need for tracheostomy which was previously recommended for severe OSA. There is now a large evidence base, including meta-analyses,2,3 supporting the use of CPAP in moderate and severe OSA, where it has been shown to reverse daytime sleepiness. However, controversy remains regarding the effectiveness of CPAP in mild OSA,4,5 and the extent of the association between OSA and cardiovascular/cerebrovascular disease. There is increasing interest in the impact of CPAP on insulin resistance, the metabolic syndrome6 and the cognitive impairment often seen in OSA patients. CPAP also has a role in patients with acute hypoxaemia due to conditions such as pneumonia and pulmonary oedema (described in Chapter 5); and has a debatable role in central sleep apnoea. As the major application is in OSA, this use will be covered in detail. Alternative approaches including weight loss strategies, the mandibular advancement splint/oral devices, upper airway surgery and pharmacological measures will be compared and contrasted with CPAP.