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Sleep Position Training

In some patients, obstructive sleep apnea is related to sleeping on one's back. Positional therapy for the treatment of OSA has been studied. According to some researchers the prevalence of positional OSA is between 55 and 60%. Several devices, including the Snore-Ball and Dr. Parker's Snore Relief Cushion, have been developed to encourage the patient to sleep on his/her side rather than back.

Behavior Modification

• Weight reduction is occasionally the only treatment needed for the obese patient. Long term results require behavior modification to maintain reduced weight.(Neck size is a reliable index as a predictor of OSA. In men OSA is more prevalent in those with a neck size > 17 inches; in women, neck size > 15.5 inches.)
  
• Reduction in the intake of alcoholic beverages
  
• Limitations in the use of sedatives and muscle relaxants
• Cease smoking

Nasal Congestion

At times, nasal congestion or obstruction can lead to problems with snoring and apnea. In cases where the nasal passage is obstructed such as with enlarged turbinates or nasal polyps, surgical intervention is often needed.

In cases where nasal obstruction is transient BreatheRight strips and nasal sprays may be of value.

Pharmacological Agents

Because nasal CPAP is often poorly tolerated, a search for pharmocologic treatment of sleep disordered breathing was instituted. Unfortunately, there is no universally accepted pharmacologic treatment for OSA that will take the place of CPAP or oral appliance therapy.

• Theophylline - Some evidence exists that supports the use of theophylline for central sleep apnea when the sleep disordered breathing is related to heart disease. It may also reduce obstructive events but causes rather severe sleep disruption.
  
• Progestational Agents - In some randomized controlled trials, estrogen m may be helpful in central sleep apnea and obesity-hypoventilation syndrome but not likely to be of help in obstructive sleep apnea.
  
• Opiod Antogonists and Nicotine - both agents have been shown to improve oxygenation in obstructive sleep apnea patient but are not clinically useful because they are extremely short-acting and they disrupt sleep.
  
• Thyroxine - Up to 25% of hypothyroid patients have obstructive sleep apnea. It is unsure as to whether treatment of the hypothyroidism will resolve the obstructive sleep apnea.
  
• Acetazolamide - Acetazolamide produces metaboloic acidosis and stimulates ventilatory control centrally. It seems to be very useful in patients with periodic breathing and central sleep apnea and may be helpful in some obstructive sleep apnea patients. Studies have been uncontrolled and there is a p[ossibility of worsening the obstructive sleep apnea after acetazolamide therapy is stopped.
  
• Serotonergic Active Agents - Obstructive sleep apnea patients may have a functional brain deficiency in serotonin activity possibilty sue to the presence of obesity and insulin resistance. Serotonin deficiency may contribute to the centilatory instability of upper airway muscle function that exists in OSA and to the upper airway obstruction that occurs during sleep. THe best scientific evidence reveals little beneficial usefulness in OSA.
  
• Protriptyline - Protryptyline is a nonsedating tricyclic antidepressant. Protryptyline is most effective in decreasing REM-associated OSA, however, it has significant anticholinergic side effects and interferes with bladder and penile function.

In summary, the search for a pharmacoloigc agent to treat obstructive sleep apnea has been disappointing in general although some specific subgroups of patients respond to medication. THe majority of obsturctive sleep apnea drug trials have been unsuccessful.

(References for medication section:

Lesson 23, Volume 15 - Pharmacologic Treatment of Sleep-DIsordered Breathing, David Hudgel MD
http://www.chestnet.org/education/online/pccu/vol15/lessons23_24/lesson23.php

Hudgel DW, Thanakitcharu S. Pharmacologic Treatment of Sleep Disordered Breathing. Am. J. Respir. Crit. Care Med.,Vol 158 (3). September, 1998. pp 691-699)