What is the treatment for REM (Rapid Eye Movement) obstructive sleep apnea (OSA)?

Treatment of REM Obstructive Sleep Apnea (OSA)

Continuous positive airway pressure (CPAP) therapy is the first-line treatment for REM OSA, with treatment duration needing to exceed the standard 4 hours to effectively cover REM sleep periods that predominantly occur in the second half of the night. 1

Understanding REM OSA

REM OSA is characterized by obstructive events that occur predominantly or exclusively during REM sleep. Key features include:

• Higher prevalence in women than men
• Usually occurs in the context of mild-moderate OSA
• Respiratory events are typically longer and cause more significant oxygen desaturation than in NREM sleep 1
• Associated with systemic hypertension and excessive daytime sleepiness similar to non-stage-dependent OSA 1
• May increase cardiometabolic risk 1, 2

Treatment Options

First-Line Treatment: CPAP Therapy

CPAP remains the gold standard treatment for REM OSA:

• Effectively prevents upper airway collapse during REM sleep when the airway is most prone to collapse due to REM sleep atonia 1
• Typical therapeutic pressures range from 8-12 cm H₂O 3
• Important consideration: Since REM sleep occurs predominantly during the second half of the night, CPAP usage should exceed the standard 4 hours of use to effectively treat REM OSA 1, 2

Challenges with CPAP for REM OSA

• Patients with REM OSA often show poor adherence to CPAP therapy 1
• Standard CPAP usage of 3-4 hours from the beginning of sleep would leave 60-75% of REM-related obstructive events untreated 2
• Adherence to CPAP decreases over time, potentially limiting long-term benefits 3

Alternative Treatments

For patients who cannot tolerate CPAP or have poor adherence:

1. Mandibular Advancement Devices (MADs):

   • Recommended by the American College of Physicians as an alternative therapy for patients who prefer MADs or experience adverse effects with CPAP 4
   • Can be considered in patients with adverse effects or those who do not tolerate or adhere to CPAP 4

2. Positional Therapy:

   • Vibratory positional therapy may be used for patients with mild to moderate position-dependent OSA 4
   • Limited specific data for REM OSA

3. BiPAP Therapy:

   • Provides higher pressure during inspiration and lower pressure during expiration
   • May be more comfortable for some patients who do not tolerate CPAP 3
   • Typically started with pressures of 10/5 or 8/3 (inspiratory/expiratory) 3

4. Emerging Therapies:

   • Hypoglossal nerve stimulation
   • Oropharyngeal exercises
   • Note: Evidence for these approaches specifically for REM OSA is limited 3

Optimizing CPAP Adherence

Given the importance of CPAP therapy and the challenges with adherence in REM OSA patients, consider:

• Telemonitoring to improve adherence 3
• Heated humidification for patients experiencing nasal congestion or dryness 5
• Early intervention for side effects 5
• Systematic approach including education, objective adherence monitoring, and clinic support 5
• Desensitization therapy with a behavioral specialist for patients willing to try CPAP with support 3

Treatment Algorithm for REM OSA

1. Initial Assessment:

   • Confirm diagnosis of REM OSA through polysomnography
   • Evaluate severity and symptom burden

2. First-Line Treatment:

   • Initiate CPAP therapy with appropriate pressure settings
   • Emphasize the importance of using CPAP for >4 hours and throughout the entire night
   • Implement adherence strategies from the beginning

3. If CPAP Adherence Issues:

   • Address specific barriers (mask fit, pressure discomfort, nasal symptoms)
   • Consider heated humidification
   • Implement telemonitoring and support systems

4. If CPAP Failure:

   • Consider MADs as the primary alternative, especially for mild-moderate OSA
   • Evaluate for positional therapy if applicable
   • Consider BiPAP if pressure intolerance is the main issue

Monitoring and Follow-up

• Regular follow-up is essential to monitor treatment efficacy
• Objective monitoring of CPAP usage is crucial as self-reported use may be inaccurate 3
• Early adherence predicts long-term adherence, making initial support critical 3

Important Caveats

• Pharmacologic therapy is not currently supported by evidence for OSA treatment 4
• Surgical treatments carry risks and serious adverse effects; evidence is limited and insufficient to show benefits as initial treatment 4
• Weight loss should be encouraged in obese patients as it may reduce OSA symptoms 4