Resp Care
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Over the past few decades, continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea has evolved into more and more sophisticated modes of therapy for various forms of sleep-disordered breathing. While the principles of splinting the airway and delivering assisted ventilation underpin the basics of this therapy, the introduction of newer technologies and miniaturization are revolutionizing the former conventions of the field. The purpose of this review is to improve our understanding of various forms of PAP therapy by providing the rationale for such modalities, gaining a basic working knowledge of device technology, and critically assessing the clinical research evidence while identifying barriers to implementation. Dissemination of such information is vital in order to prevent knowledge gaps in healthcare providers and systems.
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Clinicians are becoming more aware of the risks of sleep deprivation and unrecognized sleep-disordered breathing in hospitalized patients, most importantly in those patients planning to undergo surgical procedures. Polysomnography is difficult to perform in the hospital setting, such that actigraphy or urinary metabolites of melatonin are often used as surrogate measures, and show that sleep is markedly impaired. Patients in the medical intensive care unit with sepsis or requiring mechanical ventilation may show complete absence of the normal circadian rhythm pattern, and many centers have initiated sleep-enhancement protocols. ⋯ Protocols to evaluate patients that determine the need and process for positive-airway-pressure treatment in the hospital patient with OSA are being developed. An obstructive apnea systematic intervention strategy protocol to deal with patients with suspected OSA can help guide diagnostic and therapeutic decision making. Hospitals that are proactive in the development of protocols for identification and management of patients with sleep-disordered breathing are likely to be rewarded with reduced complications and costs, and the issue is sure to be incorporated in future pay-for-performance evaluations.
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Obstructive sleep apnea (OSA) is a chronic disease treated effectively with the use of continuous positive airway pressure (CPAP) therapy. Patient adherence to prescribed CPAP is variable, however, leaving the undertreated OSA patient at risk of development or worsening of comorbid medical conditions, including hypertension and cardiovascular disease. The severity of disease and the presence of daytime sleepiness appear to have some predictive quality for subsequent adherence, though a search for consistent predictive factors related to CPAP adherence has proven elusive. ⋯ The use of sophisticated therapy modalities such as auto-titration or bi-level PAP units has been shown to improve adherence in certain subsets of OSA patients. Adverse effects such as nasal congestion, dry mouth, or skin irritation occur in approximately 50% of CPAP users, and addressing these adverse effects may improve adherence in some patients. More encouraging, studies on the use of intensive patient education and behavioral interventions have shown more positive effects on adherence, leading to the conclusion that improvement in patient adherence to CPAP therapy requires a multi-layered approach, using combined technological, behavioral, and adverse-effect interventions.
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Portable-monitor testing is being used increasingly in ambulatory management pathways for the diagnosis and treatment of patients with obstructive sleep apnea. Wide varieties of portable monitors are commercially available and they range from single-channel recorders to units that record a full polysomnogram. Recent comparative effectiveness research studies have shown that clinical outcomes of patients with a high pretest probability for obstructive sleep apnea who receive ambulatory management using portable-monitor testing have similar functional outcomes and adherence to continuous positive airway pressure treatment, compared to patients managed with in-laboratory polysomnography. The cost-effectiveness of portable-monitor testing and its potential to improve patient access to diagnosis and treatment requires further investigation.