MKSAP: 52-year-old man with severe obstructive sleep apnea

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 52-year-old man is evaluated in follow-up after being diagnosed with severe obstructive sleep apnea 8 weeks ago. Continuous positive airway pressure (CPAP) was prescribed based on a titration during in-laboratory polysomnography. He notes some improvement in his sleep with CPAP, but he still feels drowsy during the day. He does not have problems with nasal congestion. Medical history is otherwise negative and he takes no medications.

On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure is 138/86 mm Hg, pulse rate is 72/min, and respiration rate is 12/min; BMI is 32. A low-lying soft palate and patent nasal airways are noted. The cardiopulmonary examination is unremarkable, and the neurologic examination is normal.

Which of the following is the most appropriate next step in management to address this patient’s continued drowsiness?

A. Prescribe eszopiclone
B. Prescribe modafinil
C. Review data from the patient’s continuous positive airway pressure device
D. Switch to a bilevel positive airway pressure device

MKSAP Answer and Critique

The correct answer is C. Review data from the patient’s continuous positive airway pressure device.

The most appropriate next step in management is to review data from the patient’s continuous positive airway pressure (CPAP) device to assess adherence to therapy. This patient has severe, symptomatic obstructive sleep apnea (OSA), for which positive airway pressure (PAP) is the preferred therapy. The response to treatment is dependent on adherence, and a substantial proportion of patients, particularly early in the course of therapy, do not wear the PAP device as intended (all night, every night). Downloading and reviewing data from the PAP device yields important information about usage that can be discussed with the patient to explore barriers and formulate a plan to promote compliance.

Despite some limited evidence that the use of hypnotic agents such as eszopiclone may be helpful in promoting CPAP adherence early in therapy, the role of hypnotic agents in promoting CPAP compliance remains controversial. Their use later in the course of PAP, as in this patient, is not established, and the risk of side effects may outweigh the benefit.

Modafinil is a stimulant medication that is approved for use in patients with OSA who are using CPAP optimally and continue to have residual excessive sleepiness. Compliance with CPAP therapy should be established in this patient before prescribing modafinil.

There are few data to support the superiority of a bilevel positive airway pressure (BPAP) device in promoting treatment compliance for OSA. BPAP, which promotes ventilation by delivery of pressure support derived from the gradient between inspiratory and expiratory pressure, is the preferred therapy for hypoventilation syndromes, such as those associated with neuromuscular disease or obesity.

Key Point

  • The response to obstructive sleep apnea treatment is dependent on adherence to continuous positive airway pressure (CPAP) therapy; the level of adherence to therapy can be established by downloading and reviewing data from the CPAP device.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 17 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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