The minimal disease severity at which patients with the sleep apnea/hypopnea syndrome (SAHS) gain benefit from treatment is not well characterized, although a pilot study of continuous positive airway pressure (CPAP) therapy showed daytime improvements in patients with 5 to 15 apneas + hypopneas per hour slept (AHI). We have thus performed a second, larger, randomized, placebo- controlled study in a prospective series of 34 patients (13 female) with mild SAHS (AHI 5 to 15) and daytime sleepiness. Patients spent 4 wk on CPAP treatment and 4 wk on an oral placebo, with randomization of treatment order, and daytime assessments on the last day of each treatment. Effective CPAP use averaged 2.8 +/- 2.1 h (mean +/- SD) per night. Compared with placebo, CPAP improved symptom score (p< 0.01), subjective (Epworth; p < 0.01) but not objective (maintenance of wakefulness test; p > 0.2) sleepiness, performances on 2 of 7 cognitive tasks (p < 0.02), depression score (p < 0.01), and five subscales of the SF-36 health/functional status questionnaire (p

Continuous positive airway pressure (CPAP) therapy is widely prescribed for patients with the sleep apnea/hypopnea syndrome (SAHS), but the use of CPAP for such patients is disappointingly low. We postulated that providing intensive educational programs and nursing support to SAHS patients might improve CPAP use and outcomes. We also examined the hypothesis that CPAP use would be greater among patients who had initiated their own referral than among those asked to seek help by a partner. We randomized 80 consecutive, new patients with SAHS to receive either usual support or additional nursing input including CPAP education at home and involving their partners, a 3-night trial of CPAP in our institution's sleep center, and additional home visits once they had begun CPAP. The primary outcome variable was objective CPAP use; symptoms, mood, and cognitive function were also assessed after 6 mo. CPAP use over 6 mo was greater (p = 0.003) among patients receiving intensive than among those receiving standard support (5.4 +/- 0.3 versus 3.9 +/- 0. 4 h/night [mean +/- SEM]), with greater improvements (p < 0.05) in SAHS symptoms, mood, and reaction time in the intensively supported group. CPAP use was greater (p = 0.002) among patients who initiated their own referrals. CPAP use and outcomes of therapy can be improved by provision of a nurse-led intensive CPAP education and support program. CPAP use is lower among patients whose partners ask them to seek treatment.

Background-Patients with the sleep apnoea/hypopnoea syndrome (SAHS) report improved sleepiness, cognitive function, and psychological well being after continuous positive airway pressure (CPAP) therapy, and it is for these daytime features that CPAP is usually given. However, few randomised or controlled studies exist on the eVects of CPAP on daytime function. Methods-A prospective, randomised, single blind, placebo controlled, crossover trial of daytime function after CPAP was conducted in 23 patients with SAHS, all with >15 apnoeas+hypopnoeas/hour and >2 symptoms of SAHS. All patients spent four weeks on CPAP therapy and four weeks on oral placebo treatment, following randomisation to treatment order. With ethics committee approval, patients were told the placebo tablet might improve upper airway function. Average eVective CPAP use was monitored using hidden time clocks. Assessments of objective and subjective sleepiness, symptoms, cognitive performance, and psychological well being were performed on the last day of each treatment and compared. Results-Objective sleepiness measured by sleep onset latency on the multiple sleep latency test improved with CPAP (mean diVerence from placebo +2.4 min, 95% CI 0.8 to 4.0; p<0.001) as did subjective sleepiness on the Epworth scale (mean diVerence -6, 95% CI -3 to -9; p = 0.001). Symptom total score also fell with CPAP (mean diVerence -1.6, 95% CI -2.2 to -1.0; p<0.001). No determinants of these changes with active treatment were identified, and no significant enhancements to cognitive function or psychosocial well being were found in this small sample. Conclusions-These findings provide further evidence for clinically significant benefits to daytime function from CPAP.(Thorax 1998;53:341-345) Keywords: sleep apnoea/hypopnoea syndrome; continuous positive airway pressure; sleepiness; psychomotor performance; aVective disorders Excessive daytime sleepiness, cognitive deficits, and impaired psychosocial function [1][2][3][4][5] are major features of the sleep apnoea/hypopnoea syndrome (SAHS), and provide the greatest incentive to seek treatment. The current treatment of choice is continuous positive airway pressure (CPAP) but the evidence for the eYcacy of CPAP has recently been challenged by Wright et al 6 who concluded from a systematic review of the benefits of CPAP in SAHS that "the results . . . do not . . . provide suYciently robust evidence for the eVectiveness of continuous positive airway pressure".Randomised controlled trials of daytime function after intervention with CPAP are few.7 8 In one recent report of 32 patients with a wide range of severity of SAHS 7 we observed significant enhancements for objective and subjective sleepiness, cognitive function, psychological well being, and functional status following CPAP therapy. A smaller study in 16 patients with mild SAHS 8 showed no changes in sleepiness but improved symptoms, cognitive performance, and psychosocial well being with CPAP.We report here a further prospective, randomised, placebo controlle...

Moderate to severe OSA is common in very young children with DS. Examination of tonsillar size did not predict OSA severity. Population-based screening for OSA is recommended in these children, and domiciliary cardiorespiratory polygraphy is an acceptable screening approach. Further research is required to understand the natural history, associated morbidity, optimal screening methodology and treatment modality for OSA in these children.

Patients with the sleep apnoea/hypopnoea syndrome (SAHS) suffer from excessive daytime sleepiness [1,2], cognitive decrements [3,4] and decreased psychological well-being [5]. These daytime effects lead to an increased risk of vehicle accidents [6], work inefficiency [7] and poor social relationships [7]. Previous correlational studies [3,5,8,9] have looked at possible causative relationships between the nocturnal features of SAHS and daytime function. However, there is still controversy as to what extent these daytime deficits are due to sleep fragmentation, caused by brief microarousals from sleep [9], or to intermittent nocturnal hypoxaemia associated with the sleep disordered breathing [4]. Studies by GUILLEMINAULT et al. [8] and found measures of sleep disturbance and sleep fragmentation, respectively, to be the best predictors of excessive daytime sleepiness. In contrast, BEDARD et al. [4] found hypoxaemia best predicted daytime sleepiness and CHESHIRE et al. [5] found no nocturnal correlates of daytime sleepiness, but did find that hypoxaemia and sleep fragmentation significantly correlated with measures of cognitive function.These conflicting results have tended to be based on older definitions of arousal [1,4,8,9] and/or relatively small numbers of subjects [1,4,5]. It has recently been shown that brief arousals from sleep produce sleepiness [10][11][12] and impair daytime function [10]. The primary aim of the current study was to investigate the hypothesis that brief arousals from sleep cause the sleepiness and impaired daytime function found in SAHS. The secondary aim of this study was to determine whether the multiple sleep latency test (MSLT) [13] or maintenance of wakefulness test (MWT) [14] is better related to daytime function in SAHS patients. Methods SubjectsA prospective study on consecutive patients clinically referred to the sleep centre with possible SAHS was performed. All study patients had either self-reported sleepiness (defined as Epworth sleepiness scale (ESS)Š8) or two other major symptoms of SAHS [2] (table 1). Patients were aged between 18 and 75 yrs old and living within 50 miles of the sleep centre. Patients who had coexisting causes of daytime sleepiness (e.g. night or rotating shiftworkers; self-reported average sleep duration <5 h), major psychiatric and neurological disorders, and coexisting causes of hypoxaemia were excluded. Following scoring of the diagnostic polysomnography, patients with an apnoea/hypopnoea index (AHI)<5 or with evidence of coexisting sleep disorders were also excluded. One hundred and sixty-seven consecutive patients were eligible for the study and 150 One hundred and fifty patients with sleep disordered breathing were studied prospectively, comparing overnight polysomnography with daytime measures of objective sleepiness, psychological well-being and cognitive performance.Significant, but weak (r 2 <0.1), relationships were seen between several nocturnal measures (apnoea/hypopnoea index, arousals and desaturation variables) and daytime measures of ...

Continuous positive airway pressure (CPAP) therapy improves daytime function in the sleep apnea/ hypopnea syndrome (SAHS) but it is unclear which patients benefit and what factors predict this improvement. To test the hypothesis that brief arousals from sleep predict improvements in daytime functioning with CPAP therapy, we prospectively studied 62 patients with polysomnography-defined SAHS. Each underwent daytime function assessments at baseline and after 6 mo of CPAP therapy to measure objective sleepiness, psychological well-being, quality of life, and cognitive performance. The microarousal frequency and AHI were poor predictors of improvements in daytime function with CPAP. Measures of hypoxemia predicted improvements in the mean sleep latency on the maintenance of wakefulness test, SAHS symptoms, quality of life, and reaction time, but such correlations were weak or moderate only explaining between 7% and 22% of variance. Significant relationships were found between CPAP use and improvements in self-ratings of daytime function. Results suggest that standard polysomnographic baseline variables are poor predictors of the response to CPAP therapy.

Background-Thesleep apnoea/ hypopnoea syndrome (SAHS) causes snoring, apnoeas, and restlessness during sleep which partners frequently complain about. A study was undertaken to determine the impact on partners of SAHS and of treatment of the patient with continuous positive airway pressure (CPAP). Methods-Forty nine partners and patients with SAHS booked for CPAP treatment completed in house and validated questionnaires (Pittsburgh sleep quality index, Short Form 36 self-reported health status) before the patient started treatment. Twenty three couples in whom the index SAHS patient had no driving problems were recruited to a randomised crossover trial with 1 month limbs of CPAP and placebo capsule. At the end of each limb the partners' sleep was monitored by home polysomnography (PSG) and questionnaires were completed. Results-Before treatment partners frequently reported moderate to severe disturbance from patient snoring/apnoeas/ restlessness and had poor sleep quality and self-reported health status. In the crossover study (22 completed) the partners' objective sleep quality did not diVer between CPAP and placebo, but they reported benefit from treatment of the patients with CPAP in subjective sleep quality (p=0.05) and disturbance to sleep (p=0.03). The reported change in partners' sleep quality between pre-study and following CPAP treatment correlated positively with CPAP use (r=0.5, p=0.01). Conclusions-Partners of patients with SAHS have poor sleep quality and selfreported health status but only subjective sleep quality benefits from treatment of the patient with CPAP. (Thorax 2001;56:513-518)

Some patients with the sleep apnea/hypopnea syndrome (SAHS) remain subjectively and objectively sleepy despite using effective continuous positive airway pressure (CPAP) therapy. The aim of this single center study was to determine the efficacy and safety of the novel wake-promoting medication modafinil in the treatment of CPAP-resistant daytime sleepiness. Thirty sleep apneics receiving effective CPAP therapy (objective use, 6.5 +/- 1.1 h/night) received daily single doses of 400 mg modafinil or placebo for 2 wk in a double-blind randomized crossover design. Outcome measures were assessed at baseline and at the end of both 2-wk treatment periods. Treatment periods were separated by a 1-wk washout. Modafinil had no effect on sleepiness as measured by the Epworth Sleepiness Scale or the Multiple Sleep Latency Test (p > 0.1); however, significant improvements in alertness were found with the Maintenance of Wakefulness Test (modafinil 18.3 +/- 3.9 min; placebo, 16.6 +/- 5.0 min; p < 0.02). No significant treatment-related improvements in cognitive performance or quality of life were found with modafinil (all p > 0.05). There was a significant reduction in CPAP use on modafinil compared to placebo (6.3 +/- 1 h/ night; 6.5 +/- 1, p = 0.03). This study suggests that modafinil may improve some aspects of alertness in patients with SAHS who remain sleepy during CPAP therapy, but further studies are required to assess the significance of the reduction in CPAP use.