How to manage residual sleepiness in patients with Obstructive Sleep Apnea (OSA) despite Continuous Positive Airway Pressure (CPAP) therapy?

Management of Residual Sleepiness in OSA Patients Despite CPAP Therapy

For patients experiencing residual sleepiness despite CPAP therapy for OSA, a systematic approach should be implemented that includes optimizing CPAP adherence, evaluating for comorbidities, and considering FDA-approved wakefulness-promoting medications when appropriate.

Initial Assessment of Residual Sleepiness

• Verify CPAP adherence, aiming for use during all sleep periods, with a minimum target of >4 hours/night 1

• Evaluate CPAP efficacy through tracking systems to assess:

  • Residual sleep-disordered breathing events 1
  • Mask leak (manufacturer-specific thresholds range from 24-95 L/min) 1
  • Hours of actual CPAP use 1

• Assess sleepiness using validated tools:

  • Subjective measures: Epworth Sleepiness Scale (ESS) 1
  • Objective measures when needed: Psychomotor Vigilance Test (PVT), Maintenance of Wakefulness Test (MWT) 1

Common Causes of Residual Sleepiness

• Inadequate CPAP adherence - even one night off therapy can cause return of sleepiness 2
• Suboptimal CPAP settings or significant mask leak 1
• Comorbid sleep disorders:
  • Periodic limb movement disorder 3
  • Insufficient sleep syndrome (behavioral sleep deprivation) 3
• Medical and psychiatric comorbidities:
  • Depression 3
  • Medication side effects 4
  • Metabolic disorders affecting sleep quality 4

Management Algorithm

1. Optimize CPAP therapy:

   • Address early adherence issues within 7-90 days of initiation 1, 2
   • Ensure proper mask fit and comfort 1
   • Adjust pressure settings if residual events are detected 1
   • Minimize mask leak 1

2. Rule out and treat comorbidities:

   • Evaluate for other sleep disorders 3
   • Assess for depression and other psychiatric conditions 3
   • Review medications that may cause sedation 4
   • Address insufficient sleep habits 3

3. Consider pharmacologic therapy when residual sleepiness persists despite optimized CPAP and management of comorbidities:

   • Solriamfetol (Sunosi) is FDA-approved for excessive daytime sleepiness in OSA patients on continued primary OSA therapy 5
   • Important limitation: Solriamfetol is not a substitute for primary OSA therapy; underlying airway obstruction treatment must be continued 5
   • Modafinil and armodafinil are also indicated for residual sleepiness in OSA patients on CPAP 4

Important Clinical Considerations

• True residual sleepiness after excluding all possible causes affects approximately 6% of CPAP-treated OSA patients 3

• Some research suggests the prevalence of sleepiness (ESS >10) in optimally treated CPAP patients is similar to the general population (16.1% vs. 14.3%) 6

• Untreated residual sleepiness carries significant risks:

  • Impaired driving ability comparable to being over the legal blood alcohol limit 2
  • Increased risk of motor vehicle accidents 2
  • Cognitive impairment affecting memory, attention, and executive function 2

• Long-term monitoring of CPAP adherence and efficacy is essential for optimal outcomes 1, 2

• Early intervention for non-adherence significantly improves long-term treatment success 1

Treatment Effectiveness

• CPAP remains the reference standard treatment for OSA, with demonstrated improvements in:

  • Objective and subjective sleepiness measures 7
  • Quality of life 7
  • Cognitive function 7
  • Blood pressure 7

• However, CPAP efficacy depends on patient adherence, with ≥4 hours of therapy per night required for significant clinical benefits 8