Excessive Daytime Sleepiness in Obstructive Sleep Apnea Patients Treated With Continuous Positive Airway Pressure: Data From the European Sleep Apnea Database

Abstract

Excessive daytime sleepiness (EDS) is a symptom of obstructive sleep apnea (OSA) that resolves under treatment with continuous positive airway pressure (CPAP). In some patients, sleepiness persists despite CPAP treatment. We retrospectively analyzed data on subjective residual EDS, assessed as an Epworth Sleepiness Scale score (ESS) >10, in patients from the European Sleep Apnea Database (n = 4,853, mean age ± SD 54.8 ± 11.8 years, 26.1% females), at baseline and at the first visit (median follow-up: 5 months, interquartile range 3–13). An ESS > 10 occurred in 56% of patients at baseline and in 28.2% of patients at follow-up. Residual EDS was analyzed in 2,190 patients (age: 55.1 ± 12.0 years, 26.1% females) with sleep monitoring data (median follow-up: 3 months, interquartile range 1–15). Sleep studies during CPAP use were obtained in 58% of these patients; EDS was reported by 47.2% of patients at baseline and by 30.3% at follow-up. Residual OSA, defined as an apnea–hypopnea index >10/h, and insufficient CPAP adherence, defined as nightly use <4 h, occurred with similar frequency in patients with and without EDS at follow-up. Prevalence of residual EDS was highest (40%) in patients with a first follow-up visit at 0–3 months, then it was 13–19% in patients with a first follow-up visit after 4 months to 2 years. The change in ESS (n = 2,190) was weakly correlated with CPAP use (R2 = 0.023, p < 0.0001). Logistic regression showed that an ESS score >10 at the first follow-up visit was associated directly with ESS at baseline and inversely with duration of follow-up, and CPAP use (R2 of the model: 0.417). EDS showed heterogeneity in different European countries both at baseline and at the first follow-up visit, suggesting modulation by cultural and lifestyle factors. In conclusion, residual EDS in CPAP-treated OSA occurred in approximately one in four patients at follow-up; its prevalence was highest (40%) in the first 3 months of treatment and subsequently decreased. The finding of residual EDS in a significant percentage of optimally treated OSA patients suggests that wake-promoting agents may be useful, but their indication should be evaluated after at least 3 months of treatment.

Different components of excessive daytime sleepiness and the change with positive airway pressure treatment in patients with obstructive sleep apnea: Results from the Icelandic Sleep Apnea Cohort (ISAC)

“…Using our expanded sleepiness characterisations, nearly 43% of patients’ adherent to PAP therapy had persistent sleepiness symptoms. In contrast, 26% of participants had persistent sleepiness based solely on an ESS score of >10, which is in agreement with results from a recent multicentre study on 4,852 PAP‐treated patients with OSA reporting 28.2% of the population had persistent sleepiness (Bonsignore et al, 2021). Two other recent prospective studies on persistent sleepiness found a lower proportion, with only 12%–13% of the study populations having an ESS score of >10 (Gasa et al, 2013; Pépin et al, 2009).…”

“…We found that the non-sleepy phenotype had the highest pro- (Bonsignore et al, 2021). Two other recent prospective studiesonpersistentsleepinessfoundalowerproportion,withonly 12%-13%ofthestudypopulationshavinganESSscoreof>10 (Gasa et al, 2013;Pépin et al, 2009).…”

Risk Factors for Sleepiness at the Wheel and Sleep-Related Car Accidents Among Patients with Obstructive Sleep Apnea: Data from the French Pays de la Loire Sleep Cohort

“…[10][11][12] Obstructive sleep apnea is highly prevalent, with recent general population studies indicating that 20% to 30% in men and 10% to 15% in women have moderate or severe sleep-disordered breathing. 13,14 Excessive daytime sleepiness (EDS), a major symptom of OSA, is reported in approximately 25% to 50% of OSA patients 15 and studies have shown that EDS while driving is an important factor in road accidents or work-related accidents. 13,16 While OSA has been recognized by the European Respiratory Society (ERS) as a risk factor for road accidents, 13 there is still uncertainty about the relative importance of OSA severity indices of OSA, and the degree of sleepiness as a risk factor for accidents.…”

Investigation and management of residual sleepiness in CPAP-treated patients with obstructive sleep apnoea: the European view

“…Results in patients using mandibular advancement devices were similar to those in patients using CPAP [60]. Studies agree that a high ESS at baseline increases the risk of remaining sleepy on CPAP treatment [47,54,57,60,62]. As for the impact of OSA severity assessed as AHI, mild-moderate rather than severe OSA was more often associated with RES [47,56,57].…”

“…One multicentre randomised controlled trial assessed EDS monthly for the first 3 months of CPAP use, and showed a progressive decrease in its prevalence from 60% to 17%, together with significant sleep disruption during CPAP treatment documented by actigraphy [53]. The majority of studies were observational, either multicentre [5,[54][55][56][57] or single-centre [47,53,[58][59][60]. These studies reported a variable prevalence of EDS in treated OSA patients, and follow-up duration varied from 3 to 24 months.…”