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continuous positive airway pressure (CPAP)

Indications: 1) maintenance of humidified respiratory pressure above ambient pressure 2) treatment of choice for most patients with obstructive sleep apnea (OSA)* 3) hypoxia due to postoperative atelectasis (obesity) [5,11] 4) excessive daytime sleepiness 5) may improve depression in patients with cardiovascular disease [17] * The level of CPAP should be optimized in a controlled monitored setting. Advantages: 1) symptomatic improvement in patients with sleep apnea 2) may improve glycemic control in patients with sleep apnea & diabetes mellitus type 2* [3] 3) improves LVEF in patients with OSA & CHF 4) elimination of apneas 5) elimination of snoring 6) normalization of oxygen saturation 7) improvement in sleep quality [5] 8) may lower blood pressure in hypertensive patients with obstructive sleep apnea [6,12] 9) improves daytime sleepiness [5] * decrease in HgbA1c of < 0.5% [3] Contraindications: - mechanical issues: unable to fit mask, large air leak a) recent facial trauma or surgery b) facial deformity c) edentulous patients [7] d) sinus or nasal congestion e) septal deviation - does not provide ventilatory support [5] - does not reduce cardiovascular risk in patients with cardiovascular disease & obstructive sleep apnea [15] Benefit/risk: - see non-invasive positive pressure ventilation Physiology: - increases lung volumes at end-expiration - tidal volume is determined by patient effort without ventilatory assistance or with pressure support from a ventilator - the expiratory support of CPAP improves gas exchange by preventing alveolar collapse Adverse effects: 1) nasal complaints 2) eye complaints 3) discomfort 4) intolerance to noise of device itself Management: - eszopiclone (Lunesta) 3 mg QHS with the first 2 weeks of CPAP improves compliance long after discontinuation [5] - heat humidification may relieve nasal congestion [5,10] - use of motivational interviewing techniques improves compliance [13] Notes: - CPAP per se does not provide any ventilatory support, but can be added to mechanical ventilation or used in combination with non-invasive ventilatory support - see non-invasive positive pressure ventilation

Related

auto-adjusting positive airway pressure (APAP) mechanical ventilation (assisted ventilation)

General

non-invasive positive pressure ventilation (NPPV)

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 257
  2. Journal Watch 24(14):115, 2004 Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguia C, Gonzalez M, Epstein SK, Hill NS, Nava S, Soares MA, D'Empaire G, Alia I, Anzueto A. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004 Jun 10;350(24):2452-60. PMID: 15190137
  3. Journal Watch 25(7):54, 2005 Babu AR, Herdegen J, Fogelfeld L, Shott S, Mazzone T. Type 2 diabetes, glycemic control, and continuous positive airway pressure in obstructive sleep apnea. Arch Intern Med. 2005 Feb 28;165(4):447-52. PMID: 15738376
  4. Lettieri CJ et al Effects of a short course of eszopiclone on continuous positive airway pressure adherence: A randomized trial. Ann Intern Med 2009 Nov 17; 151:696. PMID: 19920270
  5. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 18. American College of Physicians, Philadelphia 2009, 2012, 2018,
  6. Duran-Cantolla J et al. Continuous positive airway pressure as treatment for systemic hypertension in people with obstructive sleep apnoea: Randomised controlled trial. BMJ 2010 Nov 24; 341:c5991 PMID: 21106625
  7. Russell T, Duntley S. Sleep-disordered breathing in the elderly. Am J Med 2011; 124:1123-1126 PMID: 21906711
  8. Jon D. Hirasuna, M.D. Clinical Professor of Medicine, UC Davis, Associate Clinical Professor of Medicine, UCSF, Sept 1997
  9. Weng CL, Zhao YT, Liu QH, Fu CJ, Sun F, Ma YL, Chen YW, He QY. Meta-analysis: Noninvasive ventilation in acute cardiogenic pulmonary edema. Ann Intern Med. 2010 May 4;152(9):590-600 PMID: 20439577
  10. Neill AM, Wai HS, Bannan SP et al Humidified nasal continuous positive airway pressure in obstructive sleep apnoea. Eur Respir J. 2003 Aug;22(2):258-62. PMID: 12952257
  11. Squadrone V, Coha M, Cerutti E et al Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial. JAMA. 2005 Feb 2;293(5):589-95. PMID: 15687314
  12. Martinez-Garcia MA et al Effect of CPAP on Blood Pressure in Patients With Obstructive Sleep Apnea and Resistant Hypertension. The HIPARCO Randomized Clinical Trial. JAMA. 2013;310(22):2407-2415 PMID: 24327037 http://jama.jamanetwork.com/article.aspx?articleid=1788459
  13. Lai AYK et al. The efficacy of a brief motivational enhancement education program on CPAP adherence in OSA: A randomized controlled trial. Chest 2014 Sep; 146:600 PMID: 24810282
  14. Keenan SP, Sinuff T, Burns KE et al Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ. 2011 Feb 22;183(3):E195-214. PMID: 21324867 Free PMC Article
  15. McEvoy RD et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med 2016 Aug 28; PMID: 27571048 http://www.nejm.org/doi/10.1056/NEJMoa1606599
  16. Sommer JU, Kraus M, Birk R et al Functional short- and long-term effects of nasal CPAP with and without humidification on the ciliary function of the nasal respiratory epithelium. Sleep Breath. 2014 Mar;18(1):85-93. PMID: 23657665
  17. Zheng D, Xu Y, You S et al. Effects of continuous positive airway pressure on depression and anxiety symptoms in patients with obstructive sleep apnoea: Results from the Sleep Apnoea Cardiovascular Endpoint randomised trial and meta-analysis. EClinicalMedicine 2019 May/Jun; 11:89 PMID: 31312807 Free PMC Article https://www.sciencedirect.com/science/article/pii/S2589537019300902
  18. FDA Safety Communication. Feb 27, 2020 Potential Risks Associated With The Use of Ozone and Ultraviolet (UV) Light Products for Cleaning CPAP Machines and Accessories. https://www.fda.gov/medical-devices/safety-communications/potential-risks-associated-use-ozone-and-ultraviolet-uv-light-products-cleaning-cpap-machines-and