Advances in Therapy

, Volume 26, Issue 3, pp 295–312

Optimal treatment of obstructive sleep apnea and excessive sleepiness

Review

Abstract

Introduction

Collapsibility of the upper airway in obstructive sleep apnea (OSA) causes repeated arousals from sleep, decreased oxygen saturation of the blood, and excessive sleepiness (ES). Patients with OSA are at increased risk of cardiovascular and cerebrovascular disease, and experience occupational and vehicular accidents more frequently than the general population. Furthermore, the life expectancy of patients with untreated OSA is significantly reduced.

Methods

A MEDLINE search of articles published between 2003 and 2008 was conducted using the search terms: obstructive sleep apnea [ti/ab] AND treatment; obstructive sleep apnoea [ti/ab] AND treatment; and excessive sleepiness [ti/ab] AND treatment. Searches were limited to articles in English; clinical trials; meta-analyses; practice guidelines; randomized, controlled trials; and reviews.

Results

Continuous positive airway pressure (CPAP) is the reference-standard treatment for patients with OSA. CPAP addresses the symptoms of OSA and reduces the risk of heart disease and depression associated with this sleep disorder. However, the efficacy of CPAP is contingent on patient adherence, and ≥4 hours of therapy per night are required for patients with OSA to experience significant clinical benefits. However, reports of nonadherence to CPAP therapy range from 29% to 83%. Other therapies are available for patients who refuse or cannot adhere to CPAP treatment, including dental devices and surgery, but these treatments are generally considered to be less efficacious. A significant number of patients continue to experience residual ES despite CPAP treatment. Pharmacologic therapies, eg, modafinil and armodafinil, may be of use in patients with OSA to improve tolerance with CPAP or to address residual ES.

Conclusion

There are a variety of treatments available for patients with OSA. Successful treatment involves encouraging patient compliance with CPAP or oral appliances. Primary-care physicians play a crucial role in recognizing this disorder and ensuring the best possible outcome through support and education.

Keywords

armodafinil continuous positive airway pressure excessive sleepiness modafinil obstructive sleep apnea 

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References

  1. 1.
    Institute for Clinical Systems Improvement web site. Healthcare guideline: Diagnosis and treatment f obstructive sleep apnea in adults. 6th edition. 2008. Available at: http://www.icsi.org/guidelines_and_more/. Accessed December 10, 2008.
  2. 2.
    Seneviratne U, Puvanendran K. Excessive daytime sleepiness in obstructive sleep apnea: prevalence, severity, and predictors. Sleep Med. 2004;5:339–343.PubMedGoogle Scholar
  3. 3.
    Hirshkowitz M. The clinical consequences of obstructive sleep apnea and associated excessive sleepiness. J Fam Pract. 2008;57(suppl. 8):S9–S16.PubMedGoogle Scholar
  4. 4.
    Mojon DS, Hess CW, Goldblum D, et al. Normaltension glaucoma is associated with sleep apnea syndrome. Ophthalmologica. 2002;216:180–184.PubMedGoogle Scholar
  5. 5.
    Engleman H, Joffe D. Neuropsychological function in obstructive sleep apnoea. Sleep Med Rev. 1999;3:59–78.PubMedGoogle Scholar
  6. 6.
    Lindberg E, Carter N, Gislason T, Janson C. Role of snoring and daytime sleepiness in occupational accidents. Am J Respir Crit Care Med. 2001;164:2031–2035.PubMedGoogle Scholar
  7. 7.
    Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology. 2006;104:1081–1093.PubMedGoogle Scholar
  8. 8.
    Doherty LS, Kiely JL, Lawless G, McNicholas WT. Impact of nasal continuous positive airway pressure therapy on the quality of life of bed partners of patients with obstructive sleep apnea syndrome. Chest. 2003;124:2209–2214.PubMedGoogle Scholar
  9. 9.
    Margel D, Cohen M, Livne PM, Pillar G. Severe, but not mild, obstructive sleep apnea syndrome is associated with erectile dysfunction. Urology. 2004;63:545–549.PubMedGoogle Scholar
  10. 10.
    Parish JM, Lyng PJ. Quality of life in bed partners of patients with obstructive sleep apnea or hypopnea after treatment with continuous positive airway pressure. Chest. 2003;124:942–947.PubMedGoogle Scholar
  11. 11.
    Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328:1230–1235.PubMedGoogle Scholar
  12. 12.
    Netzer NC, Hoegel JJ, Loube D, et al. Prevalence of symptoms and risk of sleep apnea in primary care. Chest. 2003;124:1406–1414.PubMedGoogle Scholar
  13. 13.
    Bixler EO, Vgontzas AN, Lin HM, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001;163:608–613.PubMedGoogle Scholar
  14. 14.
    Morrish E, Shneerson JM, Smith IE. Why does gender influence survival in obstructive sleep apnoea? Respir Med. 2008;102:1231–1236.PubMedGoogle Scholar
  15. 15.
    Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep. 1997;20:705–706.PubMedGoogle Scholar
  16. 16.
    Kapur V, Strohl KP, Redline S, Iber C, O’Connor G, Nieto J. Underdiagnosis of sleep apnea syndrome in US communities. Sleep Breath. 2002;6:49–54.PubMedGoogle Scholar
  17. 17.
    Wahner-Roedler DL, Olson EJ, Narayanan S, et al. Gender-specific differences in a patient population with obstructive sleep apnea-hypopnea syndrome. Gend Med. 2007;4:329–338.PubMedGoogle Scholar
  18. 18.
    Doghramji PP. Recognition of obstructive sleep apnea and associated excessive sleepiness in primary care. J Fam Pract. 2008;57(suppl. 8):S17–S23.PubMedGoogle Scholar
  19. 19.
    Goldstein IB, Ancoli-Israel S, Shapiro D. Relationship between daytime sleepiness and blood pressure in healthy older adults. Am J Hypertens. 2004;17:787–792.PubMedGoogle Scholar
  20. 20.
    Newman AB, Spiekerman CF, Enright P, et al. Daytime sleepiness predicts mortality and cardiovascular disease in older adults. The Cardiovascular Health Study Research Group. J Am Geriatr Soc. 2000;48:115–123.PubMedGoogle Scholar
  21. 21.
    Chervin RD. Sleepiness, fatigue, tiredness, and lack of energy in obstructive sleep apnea. Chest. 2000;118:372–379.PubMedGoogle Scholar
  22. 22.
    Basta M, Lin HM, Pejovic S, Sarrigiannidis A, Bixler E, Vgontzas AN. Lack of regular exercise, depression, and degree of apnea are predictors of excessive daytime sleepiness in patients with sleep apnea: sex differences. J Clin Sleep Med. 2008;4:19–25.PubMedGoogle Scholar
  23. 23.
    Barceló A, Barbé F, de la Peña M, et al. Insulin resistance and daytime sleepiness in patients with sleep apnoea. Thorax. 2008;63:946–950.PubMedGoogle Scholar
  24. 24.
    Hoddes E, Zarcone V, Smythe H, Phillips R, Dement WC. Quantification of sleepiness: a new approach. Psychophysiology. 1973;10:431–436.PubMedGoogle Scholar
  25. 25.
    Akerstedt T, Gillberg M. Subjective and objective sleepiness in the active individual. Int J Neurosci. 1990;52:29–37.PubMedCrossRefGoogle Scholar
  26. 26.
    Bittencourt LRA, Silva RS, Santos RF, Pires ML, Mello MT. Excessive daytime sleepiness. Rev Bras Psiquiatr. 2005;27(suppl. 1):S16–S21.Google Scholar
  27. 27.
    Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14:540–545.PubMedGoogle Scholar
  28. 28.
    Benbadis SR, Mascha E, Perry MC, Wolgamuth BR, Smolley LA, Dinner DS. Association between the Epworth sleepiness scale and the multiple sleep latency test in a clinical population. Ann Intern Med. 1999;130:289–292.PubMedGoogle Scholar
  29. 29.
    Chervin RD, Aldrich MS. The Epworth Sleepiness Scale may not reflect objective measures of sleepiness or sleep apnea. Neurology. 1999;52:125–131.PubMedGoogle Scholar
  30. 30.
    Sullivan SS, Kushida CA. Multiple sleep latency test and maintenance of wakefulness test. Chest. 2008;134:854–861.PubMedGoogle Scholar
  31. 31.
    Littner MR, Kushida C, Wise M, et al. Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test. Sleep. 2005;28:113–121.PubMedGoogle Scholar
  32. 32.
    Barvaux VA, Aubert G, Rodenstein DO. Weight loss as a treatment for obstructive sleep apnoea. Sleep Med Rev. 2000;4:435–452.PubMedGoogle Scholar
  33. 33.
    Heath M. Management of obstructive sleep apnoea. Br J Nurs. 1993;2:802–804.PubMedGoogle Scholar
  34. 34.
    Lugaresi E, Cirignotta F, Montagna P. Pathogenic aspects of snoring and obstructive apnea syndrome. Schweiz Med Wochenschr. 1988;118:1333–1337.PubMedGoogle Scholar
  35. 35.
    Oksenberg A, Khamaysi I, Silverberg DS, Tarasiuk A. Association of body posture with severity of apneic events in patients with severe nonpositional obstructive sleep apnea. Chest. 2000;118:1018–1024.PubMedGoogle Scholar
  36. 36.
    Chan ASL, Lee RWW, Cistulli PA. Non-positive airway pressure modalities: mandibular advancement devices/positional therapy. Proc Am Thorac Soc. 2008;5:179–184.PubMedGoogle Scholar
  37. 37.
    Höijer U, Ejnell H, Hedner J, Petruson B, Eng LB. The effects of nasal dilation on snoring and obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 1992;118:281–284.PubMedGoogle Scholar
  38. 38.
    Kohler M, Bloch KE, Stradling JR. The role of the nose in the pathogenesis of obstructive sleep apnoea and snoring. Eur Respir J. 2007;30:1208–1215.PubMedGoogle Scholar
  39. 39.
    Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet. 1981;1:862–865.PubMedGoogle Scholar
  40. 40.
    Weaver TE, Chasens ER. Continuous positive airway pressure treatment for sleep apnea in older adults. Sleep Med Rev. 2007;11:99–111.PubMedGoogle Scholar
  41. 41.
    Sanders MH, Kern N. Obstructive sleep apnea treated by independently adjusted inspiratory and expiratory positive airway pressures via nasal mask. Chest. 1990;98:317–324.PubMedGoogle Scholar
  42. 42.
    Kakkar RK, Berry RB. Positive airway pressure treatment for obstructive sleep apnea. Chest. 2007;132:1057–1072.PubMedGoogle Scholar
  43. 43.
    Schäfer H, Ewig S, Hasper E, Lüderitz B. Failure of CPAP therapy in obstructive sleep apnoea syndrome: predictive factors and treatment with bilevel-positive airway pressure. Respir Med. 1998;92:208–215.PubMedGoogle Scholar
  44. 44.
    Loube DI, Gay PC, Strohl KP, Pack AI, White DP, Collop NA. Indications for positive airway pressure treatment of adult obstructive sleep apnea patients: a consensus statement. Chest. 1999;115:863–866.PubMedGoogle Scholar
  45. 45.
    Arias MA, Garcia-Rio F, Alonso-Fernandez A, et al. CPAP decreases plasma levels of soluble tumour necrosis factor-alpha receptor 1 in obstructive sleep apnoea. Eur Respir J. 2008;32:1009–1015.PubMedGoogle Scholar
  46. 46.
    Dorkova Z, Petrasova D, Molcanyiova A, Popovnakova M, Tkacova R. Effects of continuous positive airway pressure on cardiovascular risk profile in patients with severe obstructive sleep apnea and metabolic syndrome. Chest. 2008;134:686–692.PubMedGoogle Scholar
  47. 47.
    Jelic S, Padaletti M, Kawut SM, et al. Inflammation, oxidative stress, and repair capacity of the vascular epithelium in obstructive sleep apnea. Circulation. 2008;117:2270–2278.PubMedGoogle Scholar
  48. 48.
    Lanfranchi P, Somers VK. Obstructive sleep apnea and vascular disease. Respir Res. 2001;2:315–319.PubMedGoogle Scholar
  49. 49.
    Becker HF, Jerrentrup A, Ploch T, et al. Effect of nasal continuous positive airway pressure treatment on blood pressure in patients with obstructive sleep apnea. Circulation. 2003;107:68–73.PubMedGoogle Scholar
  50. 50.
    Carneiro G, Togeiro SM, Hayashi LF, et al. Effect of continuous positive airway pressure therapy on hypothalamic-pituitary-adrenal axis and 24-h blood pressure in men with obstructive sleep apnea syndrome. Am J Physiol Endocrinol Metab. 2008;295:E380–E384.PubMedGoogle Scholar
  51. 51.
    Dopp JM, Reichmuth KJ, Morgan BJ. Obstructive sleep apnea and hypertension: mechanisms, evaluation, and management. Curr Hypertens Rep. 2007;9:529–534.PubMedGoogle Scholar
  52. 52.
    Krahn LE, Miller BW, Bergstrom LR. Rapid resolution of intense suicidal ideation after treatment of severe obstructive sleep apnea. J Clin Sleep Med. 2008;4:64–65.PubMedGoogle Scholar
  53. 53.
    Patel SR, White DP, Malhotra A, Stanchina ML, Ayas NT. Continuous positive airway pressure therapy for treating sleepiness in a diverse population with obstructive sleep apnea: results of a metaanalysis. Arch Intern Med. 2003;163:565–571.PubMedGoogle Scholar
  54. 54.
    Phillips CL, Yee B, Yang Q, et al. Effects of continuous positive airway pressure treatment and withdrawal in patients with obstructive sleep apnea on arterial stiffness and central BP. Chest. 2008;134:94–100.PubMedGoogle Scholar
  55. 55.
    Schwartz DJ, Karatinos G. For individuals with obstructive sleep apnea, institution of CPAP therapy is associated with an amelioration of symptoms of depression which is sustained long term. J Clin Sleep Med. 2007;3:631–635.PubMedGoogle Scholar
  56. 56.
    Cross MD, Mills NL, Al-Abri M, et al. Continuous positive airway pressure improves vascular function in obstructive sleep apnoea/hypopnoea syndrome: a randomized controlled trial. Thorax. 2008;63:578–583.PubMedGoogle Scholar
  57. 57.
    Jing J, Huang T, Cui W, Shen H. Effect on quality of life of continuous positive airway pressure in patients with obstructive sleep apnea syndrome: a meta-analysis. Lung. 2008;186:131–144.PubMedGoogle Scholar
  58. 58.
    Koga S, Ikeda S, Urata J, Kohno S. Effect of nasal continuous positive airway pressure in men on global left ventricular myocardial performance in patients with obstructive sleep apnea syndrome. Am J Cardiol. 2008;101:1796–1800.PubMedGoogle Scholar
  59. 59.
    Ruttanaumpawan P, Gilman MP, Usui K, Floras JS, Bradley TD. Sustained effect of continuous positive airway pressure on baroreflex sensitivity in congestive heart failure patients with obstructive sleep apnea. J Hypertens. 2008;26:1163–1168.PubMedGoogle Scholar
  60. 60.
    Schahin SP, Nechanitzky T, Dittel C, et al. Longterm improvement of insulin sensitivity during CPAP therapy in the obstructive sleep apnea syndrome. Med Sci Monit. 2008;14:CR117–CR121.PubMedGoogle Scholar
  61. 61.
    Gauthier L, Laberge L, Beaudry M, Laforte M, Rompre PH, Lavigne GJ. Efficacy of two mandibular advancement appliances in the management of snoring and mild-moderate sleep apnea: a crossover randomized study. Sleep Med. 2008 [Epub ahead of print].Google Scholar
  62. 62.
    Gotsopoulos H, Chen C, Qian J, Cistulli PA. Oral appliance therapy improves symptoms in obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med. 2002;166:743–748.PubMedGoogle Scholar
  63. 63.
    Hoekema A, Stegenga B, De Bont LG. Efficacy and co-morbidity of oral appliances in the treatment of obstructive sleep apnea-hypopnea: a systematic review. Crit Rev Oral Biol Med. 2004;15:137–155.PubMedGoogle Scholar
  64. 64.
    Otsuka R, Ribeiro de Almeida F, Lowe AA, Linden W, Ryan F. The effect of oral appliance therapy on blood pressure in patients with obstructive sleep apnea. Sleep Breath. 2006;10:29–36.PubMedGoogle Scholar
  65. 65.
    Verse T, Pirsig W, Stuck BA, Hormann K, Maurer JT. Recent developments in the treatment of obstructive sleep apnea. Am J Respir Med. 2003;2:157–168.PubMedGoogle Scholar
  66. 66.
    Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep. 2006;29:244–262.PubMedGoogle Scholar
  67. 67.
    Constantinidis J, Ereliadis S, Angouridakis N, Konstantinidis I, Vital V, Angouridaki C. Cytokine changes after surgical treatment of obstructive sleep apnoea syndrome. Eur Arch Otorhinolaryngol. 2008;265:1275–1279.PubMedGoogle Scholar
  68. 68.
    Eun YG, Kim SW, Kwon KH, Byun JY, Lee KH. Single-session radiofrequency tongue base reduction combined with uvulopalatopharyngoplasty for obstructive sleep apnea syndrome. Eur Arch Otorhinolaryngol. 2008;265:1495–1500.PubMedGoogle Scholar
  69. 69.
    Li HY, Lin Y, Chen NH, Lee LA, Fang TJ, Wang PC. Improvement in quality of life after nasal surgery alone for patients with obstructive sleep apnea and nasal obstruction. Arch Otolaryngol Head Neck Surg. 2008;134:429–433.PubMedGoogle Scholar
  70. 70.
    Nakata S, Noda A, Yasuma F, et al. Effects of nasal surgery on sleep quality in obstructive sleep apnea syndrome with nasal obstruction. Am J Rhinol. 2008;22:59–63.PubMedGoogle Scholar
  71. 71.
    Lye KW, Waite PD, Meara D, Wang D. Quality of life evaluation of maxillomandibular advancement surgery for treatment of obstructive sleep apnea. J Oral Maxillofac Surg. 2008;66:968–972.PubMedGoogle Scholar
  72. 72.
    Hirshkowitz M, Black J. Effect of adjunctive modafinil on wakefulness and quality of life in patients with excessive sleepiness-associated obstructive sleep apnoea/hypopnoea syndrome: a 12-month, open-label extension study. CNS Drugs. 2007;21:407–416.PubMedGoogle Scholar
  73. 73.
    Pack AI, Black JE, Schwartz JR, Matheson JK. Modafinil as adjunct therapy for daytime sleepiness in obstructive sleep apnea. Am J Respir Crit Care Med. 2001;164:1675–1681.PubMedGoogle Scholar
  74. 74.
    Dinges DF, Weaver TE. Effects of modafinil on sustained attention performance and quality of life in OSA patients with residual sleepiness while being treated with nCPAP. Sleep Med. 2003;4:393–402.PubMedGoogle Scholar
  75. 75.
    Hirshkowitz M, Black JE, Wesnes K, Niebler G, Arora S, Roth T. Adjunct armodafinil improves wakefulness and memory in obstructive sleep apnea/hypopnea syndrome. Respir Med. 2007;101:616–627.PubMedGoogle Scholar
  76. 76.
    Roth T, White D, Schmidt-Nowara W, et al. Effects of armodafinil in the treatment of residual excessive sleepiness associated with obstructive sleep apnea/hypopnea syndrome: a 12-week, multicenter, double-blind, randomized, placebo-controlled study in nCPAP adherent adults. Clin Ther. 2006;28:689–706.PubMedGoogle Scholar
  77. 77.
    Roth T, Rippon GA, Arora S. Armodafinil improves wakefulness and long-term episodic memory in nCPAP-adherent patients with excessive sleepiness associated with obstructive sleep apnea. Sleep Breath. 2008;12:53–62.PubMedGoogle Scholar
  78. 78.
    Elshaug AG, Moss JR, Southcott AM, Hiller JE. An analysis of the evidence-practice continuum: is surgery for obstructive sleep apnoea contraindicated? J Eval Clin Pract. 2007;13:3–9.PubMedGoogle Scholar
  79. 79.
    Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge of effective treatment. Proc Am Thorac Soc. 2008;5:173–178.PubMedGoogle Scholar
  80. 80.
    Means MK, Edinger JD. Graded exposure therapy for addressing claustrophobic reactions to continuous positive airway pressure: a case series report. Behav Sleep Med. 2007;5:105–116.PubMedGoogle Scholar
  81. 81.
    Yetkin O, Kunter E, Gunen H. CPAP compliance in patients with obstructive sleep apnea syndrome. Sleep Breath. 2008;12:365–367.PubMedGoogle Scholar
  82. 82.
    McArdle N, Devereux G, Heidarnejad H, Engleman HM, Mackay TW, Douglas NJ. Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med. 1999;159:1108–1114.PubMedGoogle Scholar
  83. 83.
    Olsen S, Smith S, Oei T, Douglas J. Health beliefs model predicts adherence to CPAP before experience with CPAP. Eur Respir J. 2008;32:710–717.PubMedGoogle Scholar
  84. 84.
    To KW, Chan WC, Choo KL, Lam WK, Wong KK, Hui DS. A randomized cross-over study of auto-continuous positive airway pressure versus fixed-continuous positive airway pressure in patients with obstructive sleep apnoea. Respirology. 2008;13:79–86.PubMedGoogle Scholar
  85. 85.
    Ballard RD, Gay PC, Strollo PJ. Interventions to improve compliance in sleep apnea patients previously non-compliant with continuous positive airway pressure. J Clin Sleep Med. 2007;3:706–712.PubMedGoogle Scholar
  86. 86.
    Cartwright R. Sleeping together: a pilot study of the effects of shared sleeping on adherence to CPAP treatment in obstructive sleep apnea. J Clin Sleep Med. 2008;4:123–127.PubMedGoogle Scholar
  87. 87.
    Kiekens S, De Groot V, Coeckelbergh T, et al. Continuous positive airway pressure therapy is associated with an increase in intraocular pressure in obstructive sleep apnea. Invest Ophthalmol Vis Sci. 2008;49:934–940.PubMedGoogle Scholar
  88. 88.
    Flammer J, Orgül S, Costa VP, et al. The impact of ocular blood flow in glaucoma. Prog Retin Eye Res. 2002;21:359–393.PubMedGoogle Scholar
  89. 89.
    Mojon DS, Hess CW, Goldblum D, et al. High prevalence of glaucoma in patients with sleep apnea syndrome. Ophthalmology. 1999;106:1009–1012.PubMedGoogle Scholar
  90. 90.
    Devulapally K, Pongonis R Jr, Khayat R. OSA: the new cardiovascular disease. Part II: overview of cardiovascular disease associated with obstructive sleep apnea. Heart Fail Rev. 2008;[Epub ahead of print].Google Scholar
  91. 91.
    Kushida CA, Morgenthaler TI, Littner MR, et al. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep. 2006;29:240–243.PubMedGoogle Scholar
  92. 92.
    Padma A, Ramakrishnan N, Narayanan V. Management of obstructive sleep apnea: a dental perspective. Indian J Dent Res. 2007;18:201–209.PubMedGoogle Scholar
  93. 93.
    Barnes M, McEvoy RD, Banks S, et al. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med. 2004;170:656–664.PubMedGoogle Scholar
  94. 94.
    Engleman HM, McDonald JP, Graham D, et al. Randomized crossover trial of two treatments for sleep apnea/hypopnea syndrome: continuous positive airway pressure and mandibular repositioning splint. Am J Respir Crit Care Med. 2002;166:855–859.PubMedGoogle Scholar
  95. 95.
    Tan YK, L’Estrange PR, Luo YM, et al. Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: a randomized crossover trial. Eur J Orthod. 2002;24:239–249.PubMedGoogle Scholar
  96. 96.
    Walker-Engström ML, Wilhelmsson B, Tegelberg A, Dimenas E, Ringgvist I. Quality of life assessment of treatment with dental appliance or UPPP in patients with mild to moderate obstructive sleep apnoea. A prospective randomized 1-year follow-up study. J Sleep Res. 2000;9:303–308.PubMedGoogle Scholar
  97. 97.
    Lindman R, Bondemark L. A review of oral devices in the treatment of habitual snoring and obstructive sleep apnoea. Swed Dent J. 2001;25:39–51.PubMedGoogle Scholar
  98. 98.
    Walker-Engström ML, Tegelberg A, Wilhelmsson B, Ringqvist I. 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: a randomized study. Chest. 2002;121:739–746.PubMedGoogle Scholar
  99. 99.
    Koutsourelakis I, Georgoulopoulos G, Perraki E, Vagiakis E, Roussas C, Zakynthinos SG. Randomized trial of nasal surgery for fixed nasal obstruction in obstructive sleep apnoea. Eur Respir J. 2008;31:110–117.PubMedGoogle Scholar
  100. 100.
    Sundaram S, Lim J, Lasserson TJ. Surgery for obstructive sleep apnoea. Cochrane Database Syst Rev. 2005;(4):CD001004.Google Scholar
  101. 101.
    Won CHJ, Li KK, Guilleminault C. Surgical treatment of obstructive sleep apnea: upper airway and maxillomandibular surgery. Proc Am Thorac Soc. 2008;5:193–199.PubMedGoogle Scholar
  102. 102.
    Kezirian EJ, Goldberg AN. Hypopharyngeal surgery in obstructive sleep apnoea: an evidence-based medicine review. Arch Otolaryngol Head Neck Surg. 2006;132:206–213.PubMedGoogle Scholar
  103. 103.
    Jones TM, Earis JE, Calverley PM, Swift AC. Snoring surgery: a retrospective review. Laryngoscope. 2005;115:2010–2015.PubMedGoogle Scholar
  104. 104.
    Hicklin LA, Tostevin P, Dasan S. Retrospective survey of long-term results and patient satisfaction with uvulopalatopharyngoplasty for snoring. J Laryngol Otol. 2000;114:675–681.PubMedGoogle Scholar
  105. 105.
    Berry RB, Yamaura EM, Gill K, Reist C. Acute effects of paroxetine on genioglossus activity in obstructive sleep apnea. Sleep. 1999;22:1087–1092.PubMedGoogle Scholar
  106. 106.
    Kraiczi H, Hedner J, Dahlöf P, Ejnell H, Carlson J. Effect of serotonin uptake inhibition on breathing during sleep and daytime symptoms in obstructive sleep apnea. Sleep. 1999;22:61–67.PubMedGoogle Scholar
  107. 107.
    Veasey SC. Serotonin agonists and antagonists in obstructive sleep apnea: therapeutic potential. Am J Respir Med. 2003;2:21–29.PubMedGoogle Scholar
  108. 108.
    Marshall NS, Yee BJ, Desai AV, et al. Two randomized placebo-controlled trials to evaluate the efficacy and tolerability of mirtazapine for the treatment of obstructive sleep apnea. Sleep. 2008;31:824–831.PubMedGoogle Scholar
  109. 109.
    Peppard PE, Young T, Palta M, Dempsey J, Skatrud J. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA. 2000;284:3015–3021.PubMedGoogle Scholar
  110. 110.
    Morgenthaler TI, Kapen S, Lee-Chiong T, et al. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep. 2006;29:1031–1035.PubMedGoogle Scholar
  111. 111.
    Smith I, Lasserson TJ, Wright JJ. Drug therapy for obstructive sleep apnoea in adults. Cochrane Database Syst Rev. 2006;(2):CD003002.Google Scholar
  112. 112.
    Rosenberg R, Roach JM, Scharf M, Amato DA. A pilot study evaluating acute use of eszopiclone in patients with mild to moderate obstructive sleep apnea syndrome. Sleep Med. 2007;8:464–470.PubMedGoogle Scholar
  113. 113.
    Weaver TE, Maislin G, Dinges DF, et al. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep. 2007;30:711–719.PubMedGoogle Scholar
  114. 114.
    Engleman HM, Cheshire KE, Deary IJ, Douglas NJ. Daytime sleepiness, cognitive performance and mood after continuous positive airway pressure for the sleep apnoea/hypopnoea syndrome. Thorax. 1993;48:911–914.PubMedGoogle Scholar
  115. 115.
    Santamaria J, Iranzo A, Montserrat MJ, de Pablo J. Persistent sleepiness in CPAP treated obstructive sleep apnea patients: evaluation and treatment. Sleep Med Rev. 2007;11:195–207.PubMedGoogle Scholar
  116. 116.
    Antczak J, Popp R, Hajak G, Zulley J, Marienhagen J, Geisler G. Positron emission tomography findings in obstructive sleep apnea patients with residual sleepiness treated with continuous positive airway pressure. J Physiol Pharmacol. 2007;58(suppl. 5):25–35.PubMedGoogle Scholar
  117. 117.
    Veasey SC, Guilleminault C, Strohl KP, Sanders MH, Ballard MD, Magalang UJ. Medical therapy for obstructive sleep apnea: a review by the Medical Therapy for Obstructive Sleep Apnea Task Force of the Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 2006;29:1036–1044.PubMedGoogle Scholar
  118. 118.
    Beck P, Odle A, Wallace-Huitt T, Skinner RD, Garcia-Rill E. Modafinil increases arousal determined by P13 potential amplitude: an effect blocked by gap junction agonists. Sleep. 2008;31:1647–1654.PubMedGoogle Scholar
  119. 119.
    de Saint Hilaire Z, Orosco M, Rouch C, Blanc G, Nicolaidis S. Variation in extracellular monoamines in the prefrontal cortex and medial hypothalamus after modafinil administration: a microdialysis study in rats. Neuroreport. 2001;12:3533–3537.Google Scholar

Copyright information

© Springer Healthcare Communications 2009

Authors and Affiliations

  1. 1.Atlanta School of Sleep Medicine and TechnologyAtlantaUSA
  2. 2.Collegeville Family PracticeCollegevilleUSA

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