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    CPAP Treatment


    Continuous positive airway pressure (CPAP) has become the first line of treatment for obstructive sleep apnea and for some forms of central sleep apnea. CPAP therapy was first developed in 1980 by Colin E. Sullivan, professor of medicine at the University of Sydney in Australia. In the beginning CPAP therapy received just little acceptance until the mid-1980s when reports of its efficiency became more and more common.

    CPAP works by creating a pneumatic splint for the upper airway. A flow generator sends pressurized air through air tubing and a mask (usually a nasal mask) and through the nose to the upper airway. The pressurized air prevents the soft tissues of the upper airway from narrowing and collapsing.

    For proper CPAP treatment, flow generator pressures are set high enough to prevent apneas and hypopneas during all sleep stages and in all sleep positions.


    Titration and Mask Fitting

    Titration and mask fitting will greatly affect the patient's comfort. Higher pressures will more likely cause noise disturbances or nasal irritation. These CPAP side effects can be minimized with appropriate CPAP equipment selection and heated humidification. For patients who do not tolerate CPAP well, bi-level therapy or AutoSet therapy may be the answer.

    Mask fitting is an essential element of a sleep apnea patient's success with positive airway pressure therapy because it affects compliance, treatment efficacy, and possible side effects. Demands on mask stability increase as pressure increases. Higher pressures often result in air leak and patient discomfort, and certain CPAP masks will not perform as well as others. Most CPAP accessories require tighter CPAP headgear at higher pressures, and tightening may cause pressure sores. Some CPAP accessories such as nasal and full face CPAP masks have become very popular among clinicians and patients because of their stability and comfortable design, which performs well without tight CPAP headgear, even at high pressures.


    Initial Response to Treatment

    When patients with severe sleep apnea begin CPAP therapy, they often experience a few days of sleep rebound, in which they have more REM and delta sleep than normal. Sleep apnea patients may only notice the difference on the first night of treatment when sleep often seems intense. Once a patient's sleep debt resolves, sleep patterns will return to that of a normal, healthy sleeper.

    Nasal congestion in most sleep apnea patients will experience some degree of self-limiting nasal congestion when beginning CPAP therapy. Approximately 10 of CPAP users will have some congestion after the first six months of treatment. Symptoms may result for a variety of reasons:
    Pressure-sensitive mucosal receptors responding with vasodilation and mucus production
    Fixed nasal obstruction (from either polyps or deviated septum)
    Allergic rhinitis

    Heated humidification can help with all of these conditions, though for fixed obstruction it definitely represents a secondary mode of treatment. Passive humidifiers may also help, but studies show that heated humidification is far more effective. AutoSet therapy may also resolve nasal congestion and irritation because it lowers mean treatment pressures, thereby reducing pressure-related side effects.


    Hypertension, CHF, and Stroke

    Researchers have known for some time that patients with hypertension, CHF, and stroke have much higher rates of obstructive sleep apnea than the general population, but now researchers have compiled the data to help explain this relationship.

    The link between obstructive sleep apnea and hypertension has now been firmly established. Recent studies by Lavie et al and Nieto et al indicate a strong relationship between obstructive sleep apnea and hypertension. Even more significant, a study by Peppard et al showed a causal, dose-related relationship between obstructive sleep apnea and hypertension. All three of these studies screened for confounding risk factors.

    Hypertension increases one's risk of stroke and cardiac disease, which helps explain the increased rates of obstructive sleep apnea in these populations. What seems clear is that CPAP and other forms of positive airway pressure therapy help treat obstructive sleep apnea and prevent the progress of other cardiopulmonary diseases.

    CPAP therapy can also accelerate recovery for obstructive sleep apnea patients who are recovering from events related to cardiovascular diseases.