TO THE EDITOR: The article (1) onw...

TO THE EDITOR: The article (1) onward the diagnosis and treatment of obstructive be motionless apnea (OSA) provided an superior overview. However, I would like to add a scarcely any additional considerations.

As Dr Victor hinted (1) family physicians should be able to identify the symptoms of OSA and initiate appropriate treatment. Although the article (1) briefly discussed the risk of mortality associated with OSA, it did not mention a of the other serious point to be solved [i]or[/i] settleds associated with OSA (such as hypertension, coronary artery disease, myocardial infarction, affliction psychiatric problems, impotence, cognitive dysfunction, memory los and death) (23) that should be considered when discussing the disorder.

Another significant issue matters the short-term dangers associated with OSA-related symptoms, particularly the risks of engaging in certain activities while impaired by the agency of excessive sleepiness. Excessive sleepiness is the primary symptom, and oftentimes the most debilitating feature, associated with OSA. (34) It is reported on approximately 90 percent of patients with OSA and may be incapacitating, resulting in piece of work loss, accidents, self injury, marital and family question s and poor school or work performance. If the press on to fall asleep during waking hours is uncontrollable and fall outs at inappropriate times, it can have the same deductions as inability to sleep at night. Retrospective studies (5) exhibit that the rate of traffic accidents among bodys with sleep apnea is three to four times the rate among bodily forms without sleep apnea. (5) In addition, 50 percent of accidents at work and 25 percent of accidents at abode are caused by excessive sleepiness. The individual and societal implications of excessive sleepiness should not be overtoped and special consideration should be given to managing this symptom as well as the underlying disease disorder.

The author noted that continuous positive airway hurry (CPAP) therapy can reduce moot points of excessive sleepiness in patients with OSA. However, despite the use of nasal CPAP, many patients continue to experience residual excessive sleepiness. (6) Residual excessive sleepiness may persist in patients with OSA who have insufficient doze syndrome of a coexisting rest disorder. In some patients, the underlying sleep-generating mechanisms may be permanently altered as a rise of many years of rest disturbance. These patients may require other therapies like as surgery, additional devices, or medications.

In January 2004 the U provisions and Drug Administration approved modafinil (Provigil) as the first and barely drug to be used as an adjunct treatment to CPAP to improve wakefulness in patients with residual excessive sleepiness associated with OSA. Clinical studies have shown that patients with OSA who receive treatment with modafinil and CPAP may have significant improvements in daytime wakefulness, sleep-related functional status, overall clinical condition, and quality of life. (6) Modafinil is well tolerated and has been used safely for the treatment of excessive sleepiness associated with narcolepsy since 1998 While CPAP remains integral to the nighttime treatment of OSA, the management of the coexisting morbidities and daytime symptoms associated with this disorder must be prioritized as well.

JOSEPH A. LIEBERMAN III, MD

Jefferson Medical association 2 Aston Circle Hockessin, DE 19707-2500

REFERENCES

(1) Victor LD Treatment of obstructive rest apnea in primary care. Am Fam Physician 2004;69:561-8

(2) Shamsuzzaman AS, Gersh BJ Somer VK Obstructive rest apnea: implications for cardiac and vascular disease. JAMA 2003;290:1906-14

(3) Guilleminault C streamlets SN. Excessive daytime sleepiness: a challenge for the practising neurologist. Brain 2001;124:1482-91

(4) Al-Barrak M Shepertycky MR Kryger MH Morbidity and mortality in obstructive slumber apnea syndrome 2: Effect of treatment of neuropsychiatric morbidity and quality of life. rest and Biological Rhythms 2003:1:65-74.

(5) Suratt PM Findley LJ Driving with rest apnea. N Engl J M 1999;340:881-3

(6) Schwartz JR Hirshkowitz M Erman MK Schmidt-Nowara W Modafinil as adjunct therapy for daytime sleepiness in obstructive be still apnea: a 12-week, open-label subject of attention Chest 2003;124:2192-9.

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