When continuous positive airway pressure (CPAP) fails

Abstract

Obstructive sleep apnoea (OSA) is increasingly prevalent, particularly in the context of the obesity epidemic, and is associated with a significant social, health and economic impact. The gold standard of treatment for moderate to severe OSA is continuous positive airway pressure (CPAP). However compliance rates can be low. Methodology to improve patient tolerance to CPAP alongside with alternative, non-surgical and surgical, management strategies are discussed. All patients that fail CPAP therapy would benefit from formal upper airway evaluation by the otolaryngologist to identify any obvious causes and consider site-specific surgical therapies. Patient selection is integral to ensuring successful outcomes. A multidisciplinary team is needed to manage these patients.

Keywords: Obstructive sleep apnoea (OSA); compliance; continuous positive airway pressure (CPAP); failure; surgery.

Figure 1

Computed tomography images of two obstructive sleep apnoea (OSA) patients requiring continuous positive airway pressure (CPAP) with nasal pathology. (A,B) Coronal and axial slices of the first patient demonstrating a left sided polyp occluding part of the post nasal space, maxillary sinus disease and a slightly deviated septum to the left; (C,D) coronal and axial images of a second patient demonstrating extensive sinonasal polyposis, which ultimately failed medical management and required endoscopic sinus surgery.

Figure 2

Rigid endoscope image of right sided nasal cavity with a deviated nasal septum (DNS) with a large spur opposing the right middle turbinate (MT) and part of the inferior turbinate (IT).

Figure 3

Rigid endoscope image of nasal polyposis (NP); note the differing texture, colour and position of the polyp in comparison to the normal nasal mucosa; polyps are also insensate.

Figure 4

Rigid endoscope image of adenoidal hypertrophy in adult, occluding post nasal space.

Figure 5

Clinical photograph demonstrating right nasal valve collapse on gentle inspiration; nasal valve can be primary or secondary to other pathology (e.g., deviated septum).

Figure 6

Clinical image of an overcrowded oropharynx secondary to tonsillar hypertrophy, lax palate and redundant pharyngeal mucosa.