Medication and Behavioral Therapy

Treatment for sleep disorders related to an underlying psychological or neurological condition may include medication and behavioral therapy.

Obstructive Sleep Apnea Treatment & Management

Approach Considerations

Obstructive sleep apnea (OSA) should be diagnosed and treated promptly. Board-certified sleep specialists evaluate polysomnography (PSG) results and make treatment recommendations for OSA patients. Treatment depends in part on the severity of the sleep-disordered breathing (SDB). People with mild apnea have a wider variety of options, while people with moderate-to-severe apnea should be treated with nasal continuous positive airway pressure (CPAP).

General and behavioral measures, such as weight loss, avoidance of alcohol for 4-6 hours prior to bedtime, and sleeping on one’s side rather than on the stomach or back, are elements of conservative nonsurgical treatment. In a 2006 practice parameter, both weight loss and positional therapy were rated as “guidelines,” indicating a patient care strategy with a moderate degree of evidence.

Because obesity is a major predictive factor for OSA, weight reduction reduces the risk of OSA. The best data suggest that a 10% reduction in weight leads to a 26% reduction in the respiratory disturbance index (RDI). Benefits of weight reduction in patients with SDB include the following:

  • Decreased RDI
  • Lowered blood pressure
  • Improved pulmonary function and arterial blood gas values
  • Improved sleep structure and snoring
  • Possible reduction of optimum CPAP pressure required

Weight gain is one of the most important determinants of relapse of OSA after surgical treatment. Although accomplishing and maintaining weight reduction are difficult, the results are extremely beneficial when patients can do so. The treatment approach to SDB is not complete if weight reduction is not addressed in patients who are obese.

Mechanical measures include positive airway pressure with a CPAP or bilevel positive airway pressure (BiPAP) device and oral appliance (OA) therapy. CPAP is the standard treatment option for OSA and generally can reverse this condition quickly with the appropriate titration of devices.

OAs are indicated for (1) patients with mild-to-moderate OSA who prefer oral appliances to CPAP devices, (2) patients with mild-to-moderate OSA who do not respond to CPAP therapy, and (3) patients with mild-to-moderate OSA in whom treatment attempts with CPAP devices fail. They should not be considered effective therapy for patients with severe OSA.

Pharmacologic therapy is not part of primary treatment. No clinically useful drug therapy is currently available, except in certain cases of excessive sleepiness remaining after apparently successful treatment.

From least invasive and effective to most invasive and effective, treatments can be summarized as follows:

  • All patients should be offered nasal CPAP therapy first.
  • In patients with mild-to-severe obstructive sleep apnea who refuse or reject nasal CPAP therapy, BiPAP therapy should be tried next. If this therapy fails or is rejected, OA therapy should be considered.
  • OAs may be considered first-line therapy for patients with mild OSA, particularly if they are unwilling to try nasal CPAP therapy.
  • All interventions to improve tolerance of CPAP therapy should be attempted prior to deciding that treatment has failed in a particular patient.
  • Patients in whom noninvasive medical therapy (eg, CPAP, BiPAP, OAs) fails should be offered surgical options. Patients should be made aware of the success rates for each surgical procedure. They should be informed that they might require more than 1 surgical procedure, some fairly extensive, to cure OSA. Refer patients only to centers that have personnel experienced in these special surgical techniques.

Improving treatment adherence is important to the care of OSA patients. Whereas adherence in OSA patients is comparable to that in patients taking medications, such as statins, a body of research on adherence seems to have been largely ignored and needs to be integrated into sleep medicine clinical practice.

Studies showing how to improve CPAP adherence exist as well and should be integrated into a standard CPAP follow-up program to improve adherence; the same could be said for OA therapy to the degree that some of the methods and assessment are common to both treatments.

Unlike CPAP/BiPAP treatment adherence, OA treatment adherence is not objectively measured. Therefore, studies comparing adherence between OA and CPAP/BiPAP therapy cannot be considered with confidence in the outcome. As when CPAP/BiPAP did not have objective adherence data, OA treatment adherence is probably lower than published values that have relied on patient or practitioner self-report.

Sleep-related breathing disorder continuum

The concept of the sleep-related breathing disorder (SRBD) continuum (see Pathophysiology) suggests that optimal OSA treatment must correct OSA, upper airway resistance syndrome (UARS), and snoring. If it does not eliminate all 3 problems, the symptoms and the pathophysiological process that was evident at the start of disease recur. Therefore, in the treatment of SRBD, CPAP corrects OSA first, UARS next, and snoring last.

An unlikely occurrence is snoring being corrected before OSA and/or UARS; if this is thought to have occurred, then consideration should be given to the integrity of the snoring microphone.

Consider whether snoring has been correctly interpreted on PSG during a CPAP titration. When a mask leak occurs, the noise may be transferred by the microphone to the PSG snore channel and may sound like snoring. One can determine the difference between snoring and a CPAP mask leak because snoring occurs at the point of peak inspiration and the beginning of expiration; mask leak occurs during expiration.

Consider whether the patient has had upper airway (UA) corrective surgery. If pharyngeal tissue has been eliminated, snoring may not occur, but OSA can develop (so-called silent apnea).


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