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Background —There is increasing evidence that obstructive sleep apnea ( OSA ) is an independent risk factor for arterial hypertension . Because there are no controlled studies showing a substantial effect of nasal continuous positive airway pressure ( nCPAP ) therapy on hypertension in OSA , the impact of treatment on cardiovascular sequelae has been question ed altogether . Therefore , we studied the effect of nCPAP on arterial hypertension in patients with OSA . Methods and Results —Sixty consecutive patients with moderate to severe OSA were r and omly assigned to either effective or subtherapeutic nCPAP for 9 weeks on average . Nocturnal polysomnography and continuous noninvasive blood pressure recording  for 19 hours was performed before and with treatment . Thirty two patients , 16 in each group , completed the study . Apneas and hypopneas were reduced by ≈95 % and 50 % in the therapeutic and subtherapeutic groups , respectively . Mean arterial blood pressure decreased by 9.9±11.4 mm Hg with effective nCPAP treatment , whereas no relevant change occurred with subtherapeutic nCPAP ( P = 0.01 ) . Mean , diastolic , and systolic blood pressures all decreased significantly by ≈10 mm Hg , both at night and during the day . Conclusions —Effective nCPAP treatment in patients with moderate to severe OSA leads to a substantial reduction in both day and night arterial blood pressure . The fact that a 50 % reduction in the apnea-hypopnea index did not result in a decrease in blood pressure emphasizes the importance of highly effective treatment . The drop in mean blood pressure by 10 mm Hg would be predicted to reduce coronary heart disease event risk by 37 % and stroke risk by 56 % RATIONALE Twenty-eight percent of people with mild to moderate obstructive sleep apnea experience daytime sleepiness , which interferes with daily functioning . It remains unclear whether treatment with continuous positive airway pressure improves daytime function in these patients . OBJECTIVES To evaluate the efficacy of continuous positive airway pressure treatment to improve functional status in sleepy patients with mild and moderate obstructive sleep apnea . METHODS Patients with self-reported daytime sleepiness ( Epworth Sleepiness Scale score > 10 ) and an apnea-hypopnea index with 3 % desaturation and from 5 to 30 events per hour were r and omized to 8 weeks of active or sham continuous positive airway pressure treatment .  After the 8-week intervention , participants in the sham arm received 8 weeks of active continuous positive airway pressure treatment . MEASUREMENTS AND MAIN RESULTS The Total score on the Functional Outcomes of Sleep Question naire was the primary outcome measure . The adjusted mean change in the Total score after the first 8-week intervention was 0.89 for the active group ( n = 113 ) and -0.06 for the placebo group ( n = 110 ) ( P = 0.006 ) . The group difference in mean change corresponded to an effect size of 0.41 ( 95 % confidence interval , 0.14 - 0.67 ) . The mean ( SD ) improvement in Functional Outcomes of Sleep Question naire Total score from the beginning to the end of the crossover phase ( n = 91 ) was 1.73 ± 2.50 ( t[90 ] = 6.59 ; P < 0.00001 ) with an effect size of 0.69 . CONCLUSIONS Continuous positive airway pressure treatment improves the functional outcome of sleepy patients with mild and moderate obstructive sleep apnea BACKGROUND Obstructive sleep apnea subjects the failing heart to adverse hemodynamic and adrenergic loads and may thereby contribute to the progression of heart failure . We hypothesized that treatment of obstructive sleep apnea by continuous positive airway pressure in patients with heart failure would improve left ventricular systolic function . METHODS Twenty-four patients with a depressed left ventricular ejection fraction ( 45 percent or less ) and obstructive sleep apnea who were receiving optimal medical treatment for heart failure underwent polysomnography .  On the following morning , their blood pressure and heart rate were measured by digital photoplethysmography , and left ventricular dimensions and left ventricular ejection fraction were assessed by echocardiography . The subjects were then r and omly assigned to receive medical therapy either alone ( 12 patients ) or with the addition of continuous positive airway pressure ( 12 patients ) for one month . The assessment protocol was then repeated . RESULTS In the control group of patients who received only medical therapy , there were no significant changes in the severity of obstructive sleep apnea , daytime blood pressure , heart rate , left ventricular end-systolic dimension , or left ventricular ejection fraction during the study . In contrast , continuous positive airway pressure markedly reduced obstructive sleep apnea , reduced the daytime systolic blood pressure from a mean ( + /-SE ) of 126+/-6 mm Hg to 116+/-5 mm Hg ( P=0.02 ) , reduced the heart rate from 68+/-3 to 64+/-3 beats per minute ( P=0.007 ) , reduced the left ventricular end-systolic dimension from 54.5+/-1.8 to 51.7+/-1.2 mm ( P=0.009 ) , and improved the left ventricular ejection fraction from 25.0+/-2.8 to 33.8+/-2.4 percent ( P<0.001 ) . CONCLUSION In medically treated patients with heart failure , treatment of coexisting obstructive sleep apnea by continuous positive airway pressure reduces systolic blood pressure and improves left ventricular systolic function . Obstructive sleep apnea may thus have an adverse effect in heart failure that can be addressed by targeted therapy RATIONALE Continuous positive airway pressure ( CPAP ) and m and ibular advancement device ( MAD ) therapy are commonly used to treat obstructive sleep apnea ( OSA ) . Differences in efficacy and compliance of these treatments are likely to influence improvements in health outcomes . OBJECTIVES To compare health effects after 1 month of optimal CPAP and MAD therapy in OSA . METHODS In this r and omized crossover trial , we compared the effects of 1 month each of CPAP and MAD treatment on cardiovascular and neurobehavioral outcomes . MEASUREMENTS AND MAIN RESULTS Cardiovascular ( 24-h blood pressure , arterial stiffness ) , neurobehavioral ( subjective sleepiness , driving simulator performance ) , and quality of life ( Functional Outcomes of Sleep Question naire , Short Form-36 ) were compared between treatments . Our primary outcome was 24-hour mean arterial pressure .  A total of 126 patients with moderate-severe OSA ( apnea hypopnea index [ AHI ] , 25.6 [ SD 12.3 ] ) were r and omly assigned to a treatment order and 108 completed the trial with both devices . CPAP was more efficacious than MAD in reducing AHI ( CPAP AHI , 4.5 ± 6.6/h ; MAD AHI , 11.1 ± 12.1/h ; P < 0.01 ) but reported compliance was higher on MAD ( MAD , 6.50 ± 1.3 h per night vs. CPAP , 5.20 ± 2 h per night ; P < 0.00001 ) . The 24-hour mean arterial pressure was not inferior on treatment with MAD compared with CPAP ( CPAP-MAD difference , 0.2 mm Hg [ 95 % confidence interval , -0.7 to 1.1 ] ) ; however , overall , neither treatment improved blood pressure . In contrast , sleepiness , driving simulator performance , and disease-specific quality of life improved on both treatments by similar amounts , although MAD was superior to CPAP for improving four general quality -of-life domains . CONCLUSIONS Important health outcomes were similar after 1 month of optimal MAD and CPAP treatment in patients with moderate-severe OSA . The results may be explained by greater efficacy of CPAP being offset by inferior compliance relative to MAD , result ing in similar effectiveness . Clinical trial registered with https://www.anzctr.org.au ( ACTRN 12607000289415 ) Background : The effects of continuous positive airway pressure ( CPAP ) for obstructive sleep apnoea ( OSA ) on insulin resistance are not clear . Trials have found conflicting results and no appropriate control groups have been used . Methods : Forty-two men with known type 2 diabetes and newly diagnosed OSA ( > 10 dips/h in oxygen saturation of > 4 % ) were r and omised to receive therapeutic ( n = 20 ) or placebo CPAP ( n = 22 ) for 3 months . Baseline tests were performed and repeated after 3 months . The study was double blind . Results : Results are expressed as mean ( SD ) . CPAP  improved the Epworth sleepiness score significantly more in the therapeutic group than in the placebo group ( −6.6 ( 4.5 ) vs −2.6 ( 4.9 ) , p = 0.01 ) . The maintenance of wakefulness test improved significantly in the therapeutic group but not in the placebo group ( + 10.6 ( 13.9 ) vs −4.7 ( 11.8 ) min , p = 0.001 ) . Glycaemic control and insulin resistance did not significantly change in either the therapeutic or placebo groups : HbA1c ( −0.02 ( 1.5 ) vs + 0.1 ( 0.7 ) , p = 0.7 , 95 % CI −0.6 % to + 0.9 % ) , euglycaemic clamp ( M/I : + 1.7 ( 14.1 ) vs −5.7 ( 14.8 ) , p = 0.2 , 95 % CI −1.8 to + 0.3 l/kg/min1000 ) , HOMA-%S ( −1.5 ( 2.3 ) vs −1.1 ( 1.8 ) , p = 0.2 , 95 % CI −0.3 % to + 0.08 % ) and adiponectin ( −1.1 ( 1.2 ) vs −1.1 ( 1.3 ) , p = 0.2 , 95 % CI −0.7 to + 0.6 & mgr;g/ml ) . Body mass index , bioimpedance and anthropometric measurements were unchanged . Hours of CPAP use per night were 3.6 ( 2.8 ) in the treatment group and 3.3 ( 3.0 ) in the placebo group ( p = 0.8 ) . There was no correlation between CPAP use and the measures of glycaemic control or insulin resistance . Conclusion : Therapeutic CPAP does not significantly improve measures of glycaemic control or insulin resistance in men with type 2 diabetes and OSA The aim of this study was to evaluate the effect of a m and ibular advancement splint ( MAS ) on daytime sleepiness and a range of other symptoms in obstructive sleep apnea ( OSA ) .  Using a r and omized crossover design , patients received 4 weeks of treatment with MAS and a control device ( inactive oral appliance ) , with an intervening 1-week washout . At the end of each treatment period , patients were reassessed by question naire , polysomnography , and multiple sleep latency test .  Fifty-nine men and 14 women with a mean ( + /- SD ) age of 48 + /- 11 years and proven OSA experienced a significantly improved mean ( + /- SEM ) sleep latency on the multiple sleep latency test ( 10.3 + /- 0.5 versus 9.1 + /- 0.5 minutes , p = 0.01 ) and Epworth sleepiness scale score ( 7 + /- 1 versus 9 + /- 1 , p < 0.0001 ) with the MAS compared with the control device after 4 weeks . The proportion of patients with normal subjective sleepiness was significantly higher with the MAS than with the control device ( 82 versus 62 % , p < 0.01 ) , but this was not so for objective sleepiness ( 48 versus 34 % , p = 0.08 ) . Other OSA symptoms were controlled in significantly more patients with the MAS than with the control device . MAS therapy improves a range of symptoms associated with OSA Objective To assess the effect of continuous positive airway pressure ( CPAP ) on 24 hour ambulatory blood pressure monitoring values in a large number of patients with untreated systemic hypertension of new onset and obstructive sleep apnoea . Design Multicentre , double blind , r and omised , placebo controlled trial . Setting Eleven general hospitals in Spain between 2004 and 2007 . Participants 340 patients recently diagnosed as having systemic hypertension by a general practitioner ( systolic blood pressure ≥140 mm Hg , diastolic blood pressure ≥90 mm Hg , or both ) and an apnoea-hypopnoea index per hour of sleep of > 15 events/hour . Intervention Patients were assigned to CPAP ( n=169 ) or sham CPAP ( n=171 ) for three months . Main outcome measurements Net changes in the different 24 hour ambulatory blood pressure monitoring values from baseline to three months of optimal or sham CPAP . Results 277 ( 81 % ) of the 340 patients r and omised were men ; the patients had a mean age of 52.4 ( SD 10.5 ) years , a body mass index of 31.9 ( 5.7 ) , an Epworth sleepiness scale score of 10.1 ( 4.3 ) , an apnoea-hypopnoea index of 43.5 ( 24.5 ) . No differences between groups were seen at baseline . Compared with placebo and analysed by intention to treat , the mean 24 hour ambulatory blood pressure of the CPAP group decreased by 1.5 ( 95 % confidence interval : 0.4 to 2.7 ) mm Hg ( P=0.01 ) . The mean 24 hour ambulatory blood pressure monitoring measures decreased by 2.1 mm Hg ( 0.4 to 3.7 ) mm Hg ( P=0.01 ) for systolic pressure and 1.3 ( 0.2 to 2.3 ) mm Hg ( P=0.02 ) for diastolic blood pressure . Mean nocturnal blood pressure decreased by 2.1 ( 0.5 to 3.6 ) mm Hg ( P=0.01 ) . Conclusions CPAP produced a statistically significant reduction in blood pressure in patients with systemic hypertension and obstructive sleep apnoea . This reduction is small and did not achieve the 3 mm Hg drop in mean 24 hour ambulatory blood pressure that the trial was powered to detect . Consequently , these results may have uncertain clinical relevance . However , taking into account the prevalence of hypertension and the likelihood of comorbidities , the decrease in blood pressure , although minimal , may be beneficial . Trial registration Clinical trials NCT00202527 BACKGROUND The increase in peripheral chemoreflex sensitivity in patients with obstructive sleep apnea ( OSA ) is associated with activation of autonomic nervous system and hemodynamic responses . Nasal CPAP ( nCPAP ) is an effective treatment for OSA , but little is known on its effect on chemoreflex sensitivity . OBJECTIVES To assess the effect of nCPAP treatment or placebo ( sham nCPAP ) on ventilatory control in patients with OSA . SETTING Sleep laboratory of Azienda Ospedaliera Garibaldi . PATIENTS Twenty-five patients with moderate-to-severe OSA . DESIGN AND MEASUREMENTS Patients were r and omly assigned to either therapeutic nCPAP ( use of optimal pressure , n = 15 ) or sham nCPAP ( suboptimal pressure of 1 to 2 cm H2O , n = 10 ) in a double-blind fashion and treated for 1 month . A rebreathing test to assess ventilatory response to normocapnic hypoxia and normoxic hypercapnia was performed at basal condition and after 1 month of treatment . RESULTS The use of therapeutic nCPAP or sham nCPAP did not affect daytime percentage of arterial oxygen saturation ( SaO2 % ) or end-tidal P(CO2 ) . The normocapnic hypoxic ventilatory response was reduced after 1 month of treatment with nCPAP ( the slope was 1.08 + /- 0.02 L/min/SaO2 % at basal condition and 0.53 + /- 0.07 L/min/SaO2 % after 1 month of treatment , p = 0.008 ) [ mean + /- SD ] , but not in patients treated with sham nCPAP ( slope , 0.83 + /- 0.09 L/min/SaO2 % and 0.85 + /- 0.19 L/min/SaO2 % at basal condition and after 1 month , respectively ) . The normoxic hypercapnic ventilatory response remained unchanged after 1 month in both groups . No changes in ventilatory response to either hypoxia or hypercapnia were observed after a single night of nCPAP treatment . CONCLUSION The ventilatory response to hypoxia is reduced during regular treatment , but not after short-term treatment , with nCPAP . Readjusted peripheral oxygen chemosensitivity during nCPAP treatment may be a side effect of both reduced sympathetic activity and increased baroreflex activity , or a possible continuous positive airway pressure-related mechanism leading to a reduced activation of autonomic nervous system per se OBJECTIVES Complaints of fatigue are frequent in patients with obstructive sleep apnea ( OSA ) ; however , the impact of continuous positive airway pressure ( CPAP ) on fatigue remains unclear . METHODS Fifty-nine men and women with OSA were r and omly assigned to therapeutic or placebo CPAP in a double-blind fashion for a 3-week intervention period . Four outcome measures were assessed : ( 1 ) fatigue/vigor measured with the Multidimensional Fatigue Symptom Inventory -- Short Form ( MFSI-sf ) , the ( 2 ) fatigue and ( 3 ) vigor subscales of the Profile of Mood States -- Short Form ( POMS ) , and ( 4 ) the Epworth Sleepiness Scale ( ESS ) . Data were analyzed using repeated- measures analysis of variance . RESULTS Compared with patients receiving placebo CPAP , those patients treated with therapeutic CPAP showed significant reductions in the apnea-hypopnea index , as well as decreases in both measures of fatigue and increases in vigor ( P values < 0.05 ) . The beneficial effect of therapeutic treatment was most pronounced in patients with high levels of fatigue at study onset . Significant treatment effects in sleepiness scores were not observed in the entire sample ( P > 0.05 ) ; however , in a subset of patients with excessive sleepiness at the onset of treatment , ESS scores were significantly reduced with use of therapeutic CPAP ( P < 0.05 ) . CONCLUSIONS Results suggest that 3 weeks of therapeutic CPAP significantly reduced fatigue and increased energy in patients with OSA . Therapeutic CPAP significantly reduced daytime sleepiness in patients who reported excessive sleepiness at the onset of treatment Background —The purpose of this study was to determine the role of obstructive sleep apnea syndrome ( OSAS ) as an independent risk factor for the development of left ventricular diastolic abnormalities . Moreover , we tested the hypothesis that nasal continuous positive airway pressure ( nCPAP ) improves such alterations in OSAS patients by eliminating apneic events . Methods and Results —In this prospect i ve , r and omized , placebo-controlled , double-blind crossover study , 27 consecutive newly diagnosed middle-aged OSAS men with neither controllable factors nor conditions affecting left ventricular diastolic function and 15 healthy control subjects were selected . OSAS patients were r and omized to 12 weeks on sham nCPAP and 12 weeks on effective nCPAP application .  Echocardiographic parameters , blood pressure recordings , and urinary catecholamine levels were obtained at baseline and after both treatment modalities . At baseline , an abnormal left ventricular filling pattern was present in 15 of the 27 OSAS patients and only in 3 of the 15 control subjects ( P=0.020 ) . Impaired relaxation was by far the most common abnormal pattern in both groups ( 11 and 3 patients , respectively ) . In OSAS patients , 12 weeks on effective nCPAP induced a significant increase in E/A ratio ( P<0.01 ) , as well as reductions in mitral deceleration ( P<0.01 ) and isovolumic relaxation ( P<0.05 ) times . Conclusions —OSAS can affect left ventricular diastolic function independently of other possible factors . Chronic application of nCPAP could avoid the progression of diastolic abnormalities , and indeed , it might reverse these alterations , at least in the initial stages before severe structural changes can be developed Background : Previous r and omized controlled trials have addressed the efficacy of m and ibular advancement devices ( MADs ) in the treatment of obstructive sleep apnea ( OSA ) . Their common control condition , nasal continuous positive airway pressure ( nCPAP ) , was frequently found to be superior to MAD therapy . However , in most of these studies , only nCPAP was titrated objective ly but not MAD . To enable an unbiased comparison between both treatment modalities , the MAD should be titrated objective ly as well . Objective : The aim of the present study was to compare the treatment effects of a titrated MAD with those of nCPAP and an intra-oral placebo device . Methods : Sixty-four mild/moderate patients with obstructive sleep apnea ( OSA ; 52.0 ± 9.6 years ) were r and omly assigned to three parallel groups : MAD , nCPAP and placebo device . From all patients , two polysomnographic recordings were obtained at the hospital : one before treatment and one after approximately 6 months of treatment . Results : The change in the apnea-hypopnea index ( ΔAHI ) between baseline and therapy evaluation differed significantly between the three therapy groups ( ANCOVA ; p = 0.000 ) . No differences in the ΔAHI were found between the MAD and nCPAP therapy ( p = 0.092 ) , whereas the changes in AHI in these groups were significantly larger than those in the placebo group ( p = 0.000 and 0.002 , respectively ) . Conclusion : There is no clinical ly relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objective ly The aim of this trial was to evaluate the efficacy of a m and ibular advancement appliance ( MAA ) for obstructive sleep apnoea ( OSA ) . Ninety-three patients with OSA and a mean apnoea-hypopnoea index ( AHI ) of 34.7 were central ly r and omised into three , parallel groups : ( a ) MAA ; ( b ) m and ibular non-advancement appliance ( MNA ) ; and ( c ) no intervention . The appliances were custom made , in one piece . The MAAs had a mean protrusion of the m and ible of 74 % ( range 64 - 85 % ) . Outcome measures , assessed after continuous use for 4 weeks , were AHI ( polysomnography ) , daytime sleepiness ( Epworth ) and quality of life ( SF-36 ) . Eighty-one patients ( 87 % ) completed the trial . The MAA group achieved mean AHI and Epworth scores significantly lower ( P < 0.001 and P < 0.05 ) than the MNA group and the no-intervention group . No significant differences were found between the MNA group and the no-intervention group . The MAA group had a mean AHI reduction of 14.1 ( 95 % CI 7.4 - 20.8 ) , and a mean Epworth score reduction of 3.3 ( 95 % CI 1.8 - 4.8 ) . Eight MAA patients ( 30 % ) achieved a reduction in AHI > or = 75 % ending with an AHI < 5 , half of them having baseline AHI > 30 . Sensitivity analyses confirmed these results . MAA had a significant beneficial effect on the vitality domain of SF-36 . Four MAA patients ( 14.8 % ) and two MNA patients ( 8 % ) discontinued interventions because of adverse effects . Our conclusion is that MAA has significant beneficial effects on OSA , including cure in some cases of severe OSA . Protrusion of the m and ible is essential for the effect . MNA has no placebo effect . MAA may be a good alternative to CPAP in subsets of OSA patients M and ibular repositioning splints ( MRSs ) and continuous positive airway pressure ( CPAP ) are used to treat the sleep apnea/hypopnea syndrome ( SAHS ) . There are some data suggesting that patients with milder symptoms prefer MRS , but there are few comparative data on outcomes . Therefore , we performed a r and omized crossover trial of 8 weeks of CPAP and 8 weeks of MRS treatment in consecutive new out patients diagnosed with SAHS ( apnea/hypopnea index [ AHI ] > or= 5/hour , and > or= 2 symptoms including sleepiness ) . Assessment s at the end of both limbs comprised home sleep study , subjective ratings of treatment value , sleepiness , symptoms , and well-being , and objective tests of sleepiness and cognition .  Forty-eight of 51 recruited patients completed the trial ( 12 women ; age [ mean + /- SD ] , 46 + /- 9 years ; Epworth 14 + /- 4 ; median AHI , 22/hour ; interquartile ratio [ IQR ] , 11 - 43/hour ) . Significant ( p < or= 0.01 ) differences between MRS and CPAP were observed for 7 of 21 variables ( effect sizes , 0.3 - 0.6 SDs ) , all favoring CPAP , including AHI ( 15 + /- 16 and 8 + /- 6/hour , respectively ) , effectiveness rating , symptoms , Epworth ( 12 + /- 5 and 8 + /- 5 , respectively ) , functional outcomes of sleepiness question naire , short-form 36 health survey mental component , and health transition scores . Objective sleepiness , cognitive performance , and preference for treatments were not different . In patients experiencing a mild form of the syndrome ( AHI < 15 , n = 18 ) , symptoms , treatment efficacy and satisfaction , and subjective sleepiness were also better with CPAP than with MRS ( effect sizes , 0.7 - 1.1 SDs ) . These results do not support these MRS devices as first-line treatment for sleepy patients with SAHS Application of continuous positive airway pressure ( CPAP ) as the st and ard treatment for  sleep apnea/hypopnea syndrome ( SAHS )  is a moot point . Studies on the effectiveness of this treatment have been challenged because of the lack of a suitable placebo . The recent description of a true placebo ( sham CPAP ) prompted us to conduct a r and omized trial of CPAP or placebo to assess the effectiveness of CPAP in improving SAHS-related symptoms and daytime function in patients with moderate to severe SAHS . Forty-eight patients , stratified in four groups according to severity , were r and omly allocated into two treatment groups ( optimal and sham CPAP ) for a 6-wk period . Of these , 45 completed follow-up ( 91 % males ; age : 54 + /- 10 yr ; body mass index [ BMI ] : 32 + /- 6 kg/m(2 ) ; apnea-hypopnea index [ AHI ] : 54 + /- 19 events/h ; and Epworth Sleepiness Scale [ ESS ] : 16 + /- 5 ) . The ESS , a question naire on SAHS-related symptoms , Functional Outcomes Sleep Question naire ( FOSQ ) , and the Short Form Health Survey ( SF-36 ) were completed at inclusion and after treatment . After 10 d of washout , the placebo group was treated with optimal CPAP and reassessed before and after optimal CPAP . The group receiving optimal CPAP when compared with the group with sham CPAP showed considerably greater improvement in the relief of sleepiness ( -9.5 versus -2.3 , p < 0.001 ) , other SAHS-related symptoms ( -18.5 versus -4.5 , p < 0.001 ) , vigilance ( + 8.5 versus + 3.4 , p = 0.009 ) , and general productivity ( + 4.0 versus + 0.5 , p = 0.04 ) FOSQ scales . Both groups used a similar number of hours for the optimal and the sham CPAP ( 4.3 versus 4.5 , ( p = NS ) . The patients initially treated with placebo CPAP improved significantly more when optimal CPAP was applied for ESS ( -2.3 versus -6.7 , p < 0.001 ) and other sleep apnea syndrome (SAS)-related symptoms ( -4.5 versus -11.2 , p = 0.02 ) . Our study provides strong evidence of the effectiveness of CPAP treatment in improving symptoms and perceived health status in moderate to severe SAHS Obstructive sleep apnea ( OSA ) is associated with recurrent episodes of nocturnal hypoxia and increased risk for development of systemic hypertension . Prior studies have been limited , however , in their ability to show reduction in blood pressure after continuous positive airway pressure ( CPAP ) therapy , and the effect of supplemental oxygen alone on blood pressure in OSA has not been evaluated . We performed a r and omized , double-blind , placebo-controlled study comparing the effects of 2 weeks of CPAP versus sham-CPAP versus supplemental nocturnal oxygen on 24-hour ambulatory blood pressure in 46 patients with moderate-severe OSA . We found that 2 weeks of CPAP therapy result ed in a significant reduction in daytime mean arterial and diastolic blood pressure and nighttime systolic , mean , and diastolic blood pressure ( all Ps < 0.05 ) . Although nocturnal supplemental oxygen therapy improved oxyhemoglobin saturation , it did not affect blood pressure . We conclude that CPAP therapy reduces both daytime and nighttime blood pressure in patients with OSA , perhaps through mechanisms other than improvement of nocturnal oxyhemoglobin saturation BACKGROUND Patients with the sleep apnoea/hypopnoea syndrome ( SAHS ) report improved sleepiness , cognitive function , and psychological well being after continuous positive airway pressure ( CPAP ) therapy , and it is for these daytime features that CPAP is usually given . However , few r and omised or controlled studies exist on the effects of CPAP on daytime function . METHODS A prospect i ve , r and omised , single blind , placebo controlled , crossover trial of daytime function after CPAP was conducted in 23 patients with SAHS , all with ⩾15 apnoeas+hypopnoeas/hour and ⩾2 symptoms of SAHS . All patients spent four weeks on CPAP therapy and four weeks on oral placebo treatment , following r and omisation to treatment order . With ethics committee approval , patients were told the placebo tablet might improve upper airway function . Average effective CPAP use was monitored using hidden time clocks . Assessment s of objective and subjective sleepiness , symptoms , cognitive performance , and psychological well being were performed on the last day of each treatment and compared . RESULTS Objective sleepiness measured by sleep onset latency on the multiple sleep latency test improved with CPAP ( mean difference from placebo + 2.4 min , 95 % CI 0.8 to 4.0 ; p<0.001 ) as did subjective sleepiness on the Epworth scale ( mean difference –6 , 95 % CI –3 to –9 ; p = 0.001 ) . Symptom total score also fell with CPAP ( mean difference –1.6 , 95 % CI –2.2 to –1.0 ; p<0.001 ) . No determinants of these changes with active treatment were identified , and no significant enhancements to cognitive function or psychosocial well being were found in this small sample . CONCLUSIONS These findings provide further evidence for clinical ly significant benefits to daytime function  from CPAP Background : Patients with mild to moderate obstructive sleep apnoea ( OSA ) may be managed with different treatment options . This study compared the effectiveness of three commonly used non-surgical treatment modalities . Methods : Subjects with mild to moderate OSA were r and omised to one of three treatment groups for 10 weeks : conservative measures ( sleep hygiene ) only , continuous positive airways pressure ( CPAP ) in addition to conservative measures or an oral appliance in addition to conservative measures .  All overweight subjects were referred to a weight-reduction class . OSA  was assessed by polysomnography .  Blood pressure was recorded in the morning and evening in the sleep laboratory . Daytime sleepiness was assessed with the Epworth Sleepiness Scale . Health-related quality of life ( HRQOL ) was assessed with the 36-Item Short-Form Health Survey ( SF-36 ) and Sleep Apnoea Quality of Life Index ( SAQLI ) . Results : 101 subjects with a mean ( SEM ) apnoea – hypopnoea index ( AHI ) of 21.4 ( 1.1 ) were r and omised to one of the three groups . The severity of sleep-disordered breathing was decreased in the CPAP and oral appliance groups compared with the conservative measures group , and the CPAP group was significantly better than the oral appliance group . Relief from sleepiness was significantly better in the CPAP group . CPAP was also better than the oral appliance or conservative measures in improving the “ bodily pain ” domain , and better than conservative measures in improving the “ physical function ” domain of SF-36 . Both CPAP and the oral appliance were more effective than conservative measures in improving the SAQLI , although no difference was detected between the CPAP and oral appliance groups . CPAP and the oral appliance significantly lowered the morning diastolic blood pressure compared with baseline values , but there was no difference in the changes in blood pressure between the groups . There was also a linear relationship between the changes in AHI and body weight . Conclusion : CPAP produced the best improvement in terms of physiological , symptomatic and HRQOL measures , while the oral appliance was slightly less effective . Weight loss , if achieved , result ed in an improvement in sleep parameters , but weight control alone was not uniformly effective BACKGROUND Limited data have suggested that sleep-disordered breathing , a condition of repeated episodes of apnea and hypopnea during sleep , is prevalent among adults . Data from the Wisconsin Sleep Cohort Study , a longitudinal study of the natural history of cardiopulmonary disorders of sleep , were used to estimate the prevalence of undiagnosed sleep-disordered breathing among adults and address its importance to the public health . METHODS A r and om sample of 602 employed men and women 30 to 60 years old were studied by overnight polysomnography to determine the frequency of episodes of apnea and hypopnea per hour of sleep ( the apnea-hypopnea score ) . We measured the age- and sex-specific prevalence of sleep-disordered breathing in this group using three cutoff points for the apnea-hypopnea score ( > or = 5 , > or = 10 , and > or = 15 ) ; we used logistic regression to investigate risk factors . RESULTS The estimated prevalence of sleep-disordered breathing , defined as an apnea-hypopnea score of 5 or higher , was 9 percent for women and 24 percent for men . We estimated that 2 percent of women and 4 percent of men in the middle-aged work force meet the minimal diagnostic criteria for the sleep apnea syndrome ( an apnea-hypopnea score of 5 or higher and daytime hypersomnolence ) . Male sex and obesity were strongly associated with the presence of sleep-disordered breathing . Habitual snorers , both men and women , tended to have a higher prevalence of apnea-hypopnea scores of 15 or higher . CONCLUSIONS The prevalence of undiagnosed sleep-disordered breathing is high among men and is much higher than previously suspected among women . Undiagnosed sleep-disordered breathing is associated with daytime hypersomnolence The purpose of this study was to investigate the effects of an oral appliance ( OA ) , with and without m and ible advance , in the treatment of  obstructive sleep apnea syndrome ( OSA ) . Twenty-four patients diagnosed with OSA agreed to participate in this study . The patients were treated for 3 months ( with a removable soft elastic silicone positioner customized with thermoplastic silicone and with a 5-mm opening ) . Patients were selected , using a r and omized design , to receive an OA model either with ( 12 patients ) or without advance ( 12 patients ) . Before treatment , a snoring question naire , the Medical Outcomes Study 36-Item Short-Form Health Survey ( SF-36 ) , the Functional Outcomes of Sleep Question naire ( FOSQ ) , the Epworth Sleepiness Scale ( ESS ) , and polysomnography  were completed . Fifteen subjects completed the protocol ( 13 men , two women ) . With respect to basal values , the m and ible-advanced OA group presented a decrease in the mean apnea – hypopnea index ( AHI ) ( 33.8±4.7 versus 9.6±2.1 ; p<0.01 ) , number of arousals per hour ( 33.8±13.9 versus 16.0±1.5 ; p<0.05 ) , ESS score ( 14.7±5.1 versus 5.1±1.9 ; p<0.05 ) , snoring score ( 15.4±1.9 versus 10.1±3.2 ; p<0.05 ) , and total FOSQ score ( 78.1±22.6 versus 99.3±14.4 ; p<0.05 ) . After treatment , the non-advanced group presented a decrease in the mean AHI ( 24.0±12.2 versus . 11.7±7.9 ; p<0.05 ) . However , no significant differences were found in the number of arousals per hour , ESS score , snoring , and total FOSQ score in the non-advanced group . Neither study group showed significant difference in mean SF36 scores . Oral appliances , especially those that advance the m and ible , offer an effective treatment for OSA Formulating a rational health policy necessitates the ability to compare between different healthcare interventions and disease scenarios . Continuous positive airway pressure ( CPAP ) therapy with a conservative lifestyle strategy in sleep apnoea/hypopnoea syndrome ( SAHS ) was evaluated using health utility and quality -adjusted life years ( QALYs ) as outcome measures . A total 71 SAHS ( apnoea/hypopnoea index ≥15 h−1 ) patients completed a r and omised , parallel group study over 3 months using utilities derived by the st and ard gamble approach ( Usg ) and European quality of life question naire ( Euroqol ) ( Ueq ) . The severely impaired health status at baseline improved by 23 % ( Usg 0.32 to 0.55 ) adding 8 QALYs in the CPAP group , compared to a 4 % improvement with 4.7 QALYs added in the lifestyle group ( Usg 0.31 to 0.35 ) . The Ueq showed a marginal change with CPAP ( 0.73 to 0.77 ) but did not demonstrate any improvement with lifestyle intervention . The health status impairment in sleep apnoea/hypopnoea syndrome patients is markedly improved by continuous positive airway pressure compared to a modest improvement with conservative lifestyle strategies using the st and ard gamble utility , which may be incorporated in effectiveness and economic analyses . The European quality of life question naire did not reflect a similar degree of impact and is probably not useful in this population CONTEXT Continuous positive airway pressure ( CPAP ) is the first-line treatment for patients with symptomatic obstructive sleep apnea ( OSA ) . However , its indication for all patients with sleep-disordered breathing , regardless of daytime symptoms , is unclear . OBJECTIVE To evaluate the effect of CPAP treatment on the incidence of hypertension or cardiovascular events in a cohort of nonsleepy patients with OSA . DESIGN , SETTING , AND PATIENTS Multicenter , parallel-group , r and omized controlled trial in 14 teaching hospitals in Spain . Between May 2004 and May 2006 , 725 consecutive patients were enrolled who had an apnea-hypopnea index of 20 h(-1 ) or greater and an Epworth Sleepiness Scale score of 10 or less ( scores range from 0 - 24 , with values < 10 suggesting no daytime sleepiness ) . Exclusion criteria were previous cardiovascular event , physical or psychological incapacity , chronic disease , or drug or alcohol addiction . Follow-up ended in May 2009 . INTERVENTION Patients were allocated to receive CPAP treatment or no active intervention . All participants received dietary counseling and sleep hygiene advice . MAIN OUTCOME MEASURES Incidence of either systemic hypertension ( taking antihypertensive medication or blood pressure greater than 140/90 mm Hg ) or cardiovascular event ( nonfatal myocardial infa rct ion , nonfatal stroke , transient ischemic attack , hospitalization for unstable angina or arrhythmia , heart failure , or cardiovascular death ) . RESULTS Seven hundred twenty-three patients underwent follow-up for a median of 4 ( interquartile range , 2.7 - 4.4 ) years ( 1 patient from each group did not receive allocated treatment ) ; 357 in the CPAP group and 366 in the control group were included in the analysis . In the CPAP group there were 68 patients with new hypertension  and 28 cardiovascular events ( 17 unstable angina or arrhythmia , 3 nonfatal stroke , 3 heart failure , 2 nonfatal myocardial infa rct ion , 2 transient ischemic attack , 1 cardiovascular death ) . In the control group there were 79 patients with new hypertension and 31 cardiovascular events ( 11 unstable angina or arrhythmia , 8 nonfatal myocardial infa rct ion , 5 transient ischemic attack , 5 heart failure , 2 nonfatal stroke ) . The hypertension or cardiovascular event incidence density rate was 9.20 per 100 person-years ( 95 % CI , 7.36 - 11.04 ) in the CPAP group and 11.02 per 100 person-years ( 95 % CI , 8.96 - 13.08 ) in the control group . The incidence density ratio was 0.83 ( 95 % CI , 0.63 - 1.1 ; P = .20 ) . CONCLUSIONS In patients with OSA without daytime sleepiness , the prescription of CPAP compared with usual care did not result in a statistically significant reduction in the incidence of hypertension or cardiovascular events . However , the study may have had limited power to detect a significant difference . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00127348 RATIONALE  Obstructive sleep apnea ( OSA ) is associated with adverse cardiovascular outcomes , including myocardial infa rct ion and stroke . Atherosclerosis is a key mechanism for these cardiovascular events . Recent cross-sectional studies showed the presence of early signs of atherosclerosis in patients with OSA who were free of comorbidities . OBJECTIVES To determine the impact of treatment with continuous positive airway pressure ( CPAP ) on atherosclerosis . METHODS We r and omly assigned 24 patients with severe OSA ( age , 46 + /- 6 yr ) who were free of comorbidities to receive no treatment ( control , n = 12 ) or CPAP ( n = 12 ) for 4 months . Carotid intima-media thickness , arterial stiffness ( evaluated by pulse-wave velocity ) , carotid diameter , 24-hour blood pressure monitoring , C-reactive protein , and catecholamines were determined at baseline and after 4 months . MEASUREMENTS AND MAIN RESULTS At baseline , all measurements were similar in both groups and did not change in the control group after 4 months . In contrast , a significant decrease occurred in carotid intima-media thickness ( 707 + /- 105 vs. 645 + /- 95 microm , P = 0.04 ) , pulse-wave velocity ( 10.4 + /- 1.0 vs. 9.3 + /- 0.9 m/s , P < 0.001 ) , C-reactive protein ( 3.7 + /- 1.8 vs. 2.0 + /- 1.2 mg/L , P = 0.001 ) , and catecholamines ( 365 + /- 125 vs. 205 + /- 51 ng/ml , P < 0.001 ) after 4 months of CPAP . Carotid diameter did not change significantly . Regarding the whole group , changes in carotid intima-media thickness were correlated with changes in catecholamines ( r = 0.41 , P < 0.05 ) . Changes in pulse-wave velocity were correlated with changes in C-reactive protein ( r = 0.58 , P < 0.01 ) and catecholamines ( r = 0.54 , P < 0.01 ) . CONCLUSIONS The treatment of OSA significantly improves early signs of atherosclerosis , supporting the concept that OSA is an independent risk factor for atherosclerosis . Clinical trial registered with www . clinical trials.gov ( NCT 00400543 ) Although there is increasing interest in the use of oral appliances to treat obstructive sleep apnea ( OSA ) , the evidence base for this is weak . Furthermore , the precise mechanisms of action are uncertain . We aim ed to systematic ally investigate the efficacy of a novel m and ibular advancement splint ( MAS ) in patients with OSA . The sample consisted of 28 patients with proven OSA . A r and omized , controlled three-period ( ABB/BAA ) crossover study design was used . After an acclimatization period , patients underwent three polysomnographs with either a control oral plate , which did not advance the m and ible ( A ) , or MAS ( B ) , 1 wk apart , in either the ABB or BAA sequence . Complete response ( CR ) was defined as a resolution of symptoms and a reduction in Apnea/Hypopnea Index ( AHI ) to < 5/h , and partial response ( PR ) as a > or = 50 % reduction in AHI , but remaining > or = 5/h . Twenty-four patients ( 19 men , 5 women ) completed the protocol . Subjective improvements with the  MAS  were reported by the majority of patients ( 96 % ) . There were significant improvements in AHI ( 30 + /- 2/h versus 14 + /- 2/h , p < 0.0001 ) , MinSa(O(2 ) ) ( 87 + /- 1 % versus 91 + /- 1 % , p < 0.0001 ) , and arousal index ( 41 + /- 2/h versus 27 + /- 2/h , p < 0.0001 ) with MAS , compared with the control . The control plate had no significant effect on AHI and MinSa(O(2 ) ) . CR ( n = 9 ) or PR ( n = 6 ) was achieved in 62.5 % of patients . The MAS is an effective treatment in some patients with OSA , including those patients with moderate or severe OSA BACKGROUND Nasal continuous positive airway pressure ( NCPAP ) is widely used as a treatment for obstructive sleep apnoea . However , to date there are no r and omised controlled trials of this therapy against a well-matched control . We undertook a r and omised prospect i ve parallel trial of therapeutic NCPAP for obstructive sleep apnoea compared with a control group on subtherapeutic NCPAP . METHODS Men with obstructive sleep apnoea , defined as an Epworth sleepiness score of 10 or more and ten or more dips per h of more than 4 % SaO2 caused by obstructive sleep apnoea on overnight sleep study , were r and omly assigned therapeutic NCPAP or subtherapeutic NCPAP ( about 1 cm H2O ) for 1 month . Primary outcomes were subjective sleepiness ( Epworth sleepiness score ) , objective sleepiness ( maintenance of wakefulness test ) , and SF-36 question naire measurements of self-reported functioning and well-being . FINDINGS 107 men entered the study : 53 received subtherapeutic NCPAP and 54 therapeutic NCPAP . Use of NCPAP by the two treatment groups was similar : 5.4 h ( therapeutic ) and 4.6 h ( subtherapeutic ) per night . Subtherapeutic NCPAP did not alter the overnight number of SaO2 dips per h compared with baseline , and thus acted as a control . Therapeutic NCPAP was superior to subtherapeutic NCPAP in all primary outcome measures . The Epworth score was decreased from a median of 15.5 to 7.0 on therapeutic NCPAP , and from 15.0 to 13.0 on subtherapeutic NCPAP ( between treatments , p<0.0001 ) . Mean maintenance-of-wakefulness time increased from 22.5 to 32.9 min on therapeutic NCPAP and , not significantly , from 20.0 to 23.5 min on subtherapeutic NCPAP ( between treatments p<0.005 ) . Effect sizes for SF-36 measures of energy and vitality were 1.68 ( therapeutic ) and 0.97 ( subtherapeutic ) NCPAP ( between treatments p<0.0001 ) . For mental summary score , the corresponding values were 1.02 and 0.4 ( between treatments p=0.002 ) . INTERPRETATION Therapeutic NCPAP reduces excessive daytime sleepiness and improves self-reported health status compared with a subtherapeutic control . Compared with controls , the effects of therapeutic NCPAP are large and confirm previous uncontrolled clinical observations and the results of controlled trials that used an oral placebo Background Oral appliance ( OA ) therapy is increasingly prescribed as a non-continuous positive airway pressure treatment modality for sleep-disordered breathing ( SDB ) . Although OA therapy is reported to be efficacious for the treatment of SDB , data on compliance remain limited to self-report . Methods In this 3-month prospect i ve clinical trial , the main outcome was to assess the safety and feasibility of an objective measurement of compliance during OA therapy using an embedded microsensor thermometer with on-chip integrated readout electronics in 51 consecutive patients with an established diagnosis of SDB ( AHI 18.0±11.9/h ; age 47±10 y ; BMI 26.6±4.0 kg/m2 ; men/women : 31/20 ) . Patients were unaware of the purpose of the study . Results No microsensor-related adverse events were recorded . In addition , no problems were encountered during the readout of the compliance data . Out of 51 microsensors , one had a technical defect and was lost to follow-up . In this study , the overall objective mean rate of OA use was 6.6±1.3 h per day with a regular OA users ’ rate of 82 % at the 3-month follow-up . Statistical analysis revealed no significant differences between objective and self-reported OA compliance data in this study . Measurement of the objective OA compliance allowed us to calculate the mean disease alleviation ( MDA ) as the product of objective compliance and therapeutic efficacy . MDA serves as a measure of the overall therapeutic effectiveness , and turned out to be 51.1 % . Conclusions The results illustrate the safety and feasibility of objective measurement of OA compliance . The objective measurement of OA compliance allows for calculation of the MDA Arterial blood pressure rises at apnea termination , and there is increasing evidence that the sleep apnea-hypopnea syndrome ( SAHS ) is associated with daytime hypertension but no r and omized controlled trial evidence of whether SAHS treatment reduces blood pressure exists . We , therefore , conducted a r and omized placebo-controlled cross-over study of the effects of 4 wk of continuous positive airway pressure ( CPAP ) or oral placebo on 24-h blood pressure in 68 patients ( 55 males , 13 females ; median apnea-hypopnea index [ AHI ] , 35 ) not receiving hypotensive medication .  Ambulatory blood pressure was recorded for the last 48 h of each treatment . Epworth Sleepiness Score ( ESS ) and Functional Outcomes of Sleep Question naire ( FOSQ ) were also recorded . All patients were normotensive . There was a small decrease in 24-h diastolic blood pressure ( placebo , 79.2 [ SE 0.9 ] mm Hg ; CPAP , 77.8 [ SE 1.0 ] mm Hg ; p = 0.04 ) with the greatest fall occurring between 2:00 A.M. and 9:59 A.M. The observed decrease in 24-h diastolic blood pressure was greater in two a priori groups , CPAP use > or = 3.5 h per night ( 81.5 [ SE 1.2 ] mm Hg ; 79.6 [ SE 1.2 ] mm Hg ; p = 0.03 ) and those with more than twenty 4 % desaturations per hour ( 82.4 [ SE 2.1 ] mm Hg ; 77.4 [ SE 2.1 ] mm Hg ; p = 0.002 ) . Systolic pressure also fell in the latter group ( 133.1 [ SE 2.8 ] mm Hg ; 129.1 [ SE 2.1 ] mm Hg ; p = 0.009 ) . Desaturation frequency was the best predictor of diastolic blood pressure fall with CPAP ( r = 0.38 ; p = 0.002 ) . Both ESS and FOSQ domains improved . Thus , CPAP can reduce blood pressure in patients with SAHS , particularly in those with nocturnal oxygen desaturation , but the decrease is small Background : A r and omised controlled study was undertaken to examine the effect of nasal continuous positive airway pressure ( CPAP ) on 24 hour systemic blood pressure ( BP ) in patients with obstructive sleep apnoea ( OSA ) . Methods : Patients were fitted with an ambulatory BP measuring device as out patients during normal activities and recorded for 24 hours before starting therapeutic or subtherapeutic ( 4 cm H2O ) CPAP treatment . BP monitoring was repeated before completion of 12 weeks of treatment . The primary end point was the change in 24 hour mean BP . Results : Twenty three of 28 participants in each treatment arm completed the study . There was no significant difference between the two groups in age , body mass index , Epworth Sleepiness Score , apnoea-hypopnoea index , arousal index , and minimum Sao2 . Twenty four patients were hypertensive . The pressure in the therapeutic CPAP group was 10.7 ( 0.4 ) cm H2O . CPAP usage was 5.1 ( 0.4 ) and 2.6 ( 0.4 ) hours/night for the therapeutic and subtherapeutic CPAP groups , respectively ( p<0.001 ) . After 12 weeks of treatment there were significant differences between the two CPAP groups in mean ( SE ) changes in 24 hour diastolic BP ( −2.4 ( 1.2 ) v 1.1 ( 1.0 ) mm Hg ( 95 % CI −6.6 to −0.5 ) , p = 0.025 ) ; 24 hour mean BP ( −2.5 ( 1.3 ) v 1.3 ( 1.1 ) mm Hg ( 95 % CI −7.2 to −0.2 ) , p = 0.037 ) ; sleep time systolic BP ( −4.1 ( 2.1 ) v 2.2 ( 1.8 ) mm Hg ( 95 % CI −11.8 to −0.7 ) , p = 0.028 ) ; and sleep time mean BP ( −3.6 ( 1.7 ) v 1.3 ( 1.4 ) mm Hg ( 95 % CI −9.2 to −0.4 ) , p = 0.033 ) . Conclusions : Compared with subtherapeutic CPAP , 12 weeks of treatment with therapeutic CPAP leads to reductions in 24 hour mean and diastolic BP by 3.8 mm Hg and 3.5 mm Hg , respectively , in mildly sleepy patients with OSA Patients with the sleep apnea/hypopnea syndrome ( SAHS ) treated by nasal continuous positive airway pressure ( CPAP )  need to use CPAP long-term to prevent recurrence of symptoms . It is thus important to clarify the level of long-term CPAP use and the factors influencing long-term use . We examined determinants of objective CPAP use in 1 , 211 consecutive patients with SAHS who were prescribed a CPAP trial between 1986 and 1997 . Prospect i ve CPAP use data were available in 1 , 155 ( 95.4 % ) , with a median follow-up of 22 mo ( interquartile range [ IQR ] , 12 to 36 mo ) . Fifty-two ( 4.5 % ) patients refused CPAP treatment ( these were more often female and current smokers ) ; 1,103 patients took CPAP home , and during follow-up 20 % stopped treatment , primarily because of a lack of benefit . Methods of survival analysis showed that 68 % of patients continued treatment at 5 yr . Independent predictors of long-term CPAP use were snoring history , apnea/hypopnea index ( AHI ) , and Epworth score ; 86 % of patients with Epworth > 10 and an AHI > /= 30 were still using CPAP at 3 yr . Average nightly CPAP use within the first 3 mo was strongly predictive of long-term use . We conclude that long-term CPAP use is related to disease severity and subjective sleepiness and can be predicted within 3 mo Obstructive sleep apnoea ( OSA ) is associated with high cardiovascular morbidity and mortality . Several r and omised controlled trials have shown that continuous positive airway pressure ( CPAP ) treatment of OSA reduces blood pressure ( BP ) . This r and omised , sham-placebo controlled crossover trial assesses whether CPAP produces a similar clinical ly significant fall in BP in hypertensive OSA patients , but without hypersomnolence . Thirty-five , nonsleepy , hypertensive patients with OSA were treated with CPAP for 1 month , r and omised first to either therapeutic or sham-placebo ( subtherapeutic CPAP , about 1 cmH2O pressure ) . The second months ' alternative treatment followed a 2-week washout period .  BP was measured over 24 h , before and at the end of the two treatment periods : mean 24-h BP was the primary outcome variable . There was no overall significant difference in mean 24-h BP : the change in mean 24-h BP on therapeutic CPAP was -2.1 mmHg ( sd 8.1 ) , and -1.1 mmHg ( sd 8.1 ) on subtherapeutic CPAP , with a difference of 0.7 mmHg ( 95 % confidence interval ( CI ) + 2.9– -4.4 ) . There was a small significant fall in Epworth Sleepiness Score , therapeutic ( -1.4 ) versus sham ( -0.3 ) , and difference -1.2 ( 95 % CI -2.0– -0.4 ) , but no change in objective sleepiness . In nonhypersomnolent hypertensive patients with obstructive sleep apnoea , there is no significant fall in mean 24-h blood pressure with continuous positive airway pressure , in contrast to the fall seen in hypersomnolent patients with obstructive sleep apnoea BACKGROUND Although oral appliances are effective in some patients with obstructive sleep apnoea ( OSA ) , they are not universally effective . A novel anterior m and ibular positioner ( AMP ) has been developed with an adjustable hinge that allows progressive advancement of the m and ible . The objective of this prospect i ve crossover study was to compare efficacy , side effects , patient compliance , and preference between AMP and nasal continuous positive airway pressure ( nCPAP ) in patients with symptomatic mild to moderate OSA . METHODS Twenty four patients of mean ( SD ) age 44.0 ( 10.6 ) years were recruited with a mean ( SD ) body mass index of 32.0 ( 8.2 ) kg/m2 , Epworth sleepiness score 10.7 ( 3.4 ) , and apnoea/hypopnoea index 26.8 (11.9)/hour . There was a two week wash-in and a two week wash-out period and two treatment periods ( AMP and nCPAP ) each of four months . Efficacy , side effects , compliance , and preference were evaluated by a question naire and home sleep monitoring . RESULTS One patient dropped out early in the study and three refused to cross over so treatment results are presented on the remaining 20 patients . The apnoea/hypopnoea index ( AHI ) was lower with nasal CPAP 4.2 (2.2)/hour than with the AMP 13.6 (14.5)/hour ( p < 0.01 ) . Eleven of the 20 patients ( 55 % ) who used the AMP were treatment successes ( reduction of AHI to < 10/hour and relief of symptoms ) , one ( 5 % ) was a compliance failure ( unable or unwilling to use the treatment ) , and eight ( 40 % ) were treatment failures ( failure to reduce AHI to < 10/hour and /or failure to relieve symptoms ) . Fourteen of the 20 patients ( 70 % ) who used nCPAP were treatment successes , six ( 30 % ) were compliance failures , and there were no treatment failures . There was greater patient satisfaction with the AMP ( p < 0.01 ) than with nCPAP but no difference in reported side effects or compliance . CONCLUSIONS AMP is an effective treatment in some patients with mild to moderate OSA and is associated with greater patient satisfaction than nCPAP This r and omized placebo-controlled cross-over trial assessed the effectiveness of a m and ibular advancement appliance ( MAA ) in managing  obstructive sleep apnoea ( OSA ) . Twenty-one adults , with confirmed OSA , were provided with a maxillary placebo appliance and a MAA for 4 - 6 weeks each , in a r and omized order . Question naires at baseline and after each appliance assessed bed-partners ' reports of snoring severity ( loudness and number of nights per week ) , and patients ' daytime sleepiness ( Epworth Sleepiness Score , ESS ) . The Apnoea Hypopnoea Index ( AHI ) and Oxygen Desaturation Index ( ODI ) were measured at baseline and with each appliance during single night sleep studies . Seventy-nine per cent of subjects wore their MAA for at least 4 hours at night . Sixty-eight per cent of subjects wore their MAA for 6 - 7 nights per week . Excessive salivation was the most commonly reported complication . One subject was unable to tolerate the MAA and withdrew from the study . Among the remaining 20 subjects , the MAA produced significantly lower AHI and ODI values than the placebo . However , although the reported frequency and loudness of snoring and the ESS values were lower with the MAA than the placebo , these differences were not statistically significant . When wearing the MAA , 35 per cent of the OSA subjects had a reduction in the pre-treatment ODI to 10 or less , while 33 per cent had an AHI of 10 or less . The MAA was less effective in the subjects with the most severe OSA ( pre-treatment ODI > 50 and /or pre-treatment AHI > 50 ) Background Continuous positive airway pressure ( CPAP ) for symptomatic obstructive sleep apnoea ( OSA ) improves sleepiness and reduces vascular risk , but such treatment for the more prevalent , minimally symptomatic disease is contentious . Methods This multicentre , r and omised controlled , parallel , hospital-based trial across the UK and Canada , recruited 391 patients with confirmed OSA ( oxygen desaturation index > 7.5/h ) but insufficient symptoms to warrant CPAP therapy .  Patients were r and omised to 6 months of auto-adjusting CPAP therapy , or st and ard care . Co primary endpoints were change in Epworth Sleepiness Score ( ESS ) and predicted 5-year mortality using a cardiovascular risk score ( components : age , sex , height , systolic blood pressure , smoking , diabetes , cholesterol , creatinine , left ventricular hypertrophy , previous myocardial infa rct ion or stroke ) . Secondary endpoints included some of the individual components of the vascular risk score , objective ly measured sleepiness and self-assessed health status . Results Of 391 patients r and omised , 14 withdrew , 347 attended for their follow-up visit at 6 months within the predefined time window , of which 341 had complete ESS data ( baseline mean 8.0 , SD 4.3 ) and 310 had complete risk score data . 22 % of patients in the CPAP group reported stopping treatment and overall median CPAP use was 2 : 39 h per night . CPAP significantly improved subjective daytime sleepiness ( adjusted treatment effect on ESS −2.0 ( 95 % CI −2.6 to −1.4 ) , p<0.0001 ) , objective ly measured sleepiness and self-assessed health status . CPAP did not improve the 5-year calculated vascular risk or any of its components . Conclusions In patients with minimally symptomatic OSA  , CPAP can reduce subjective and objective daytime sleepiness , and improve self-assessed health status , but does not appear to improve calculated vascular risk BACKGROUND Patients with obstructive sleep apnoea ( OSA ) commonly have mood symptoms such as depression and anxiety . However , the results of r and omized controlled trials on the therapeutic effect of CPAP on mood symptoms have been inconsistent . The present study examined whether three weeks of CPAP treatment had specific therapeutic effects on mood symptoms in patients with OSA compared with placebo . METHODS A double-blind , parallel , r and omized controlled trial using therapeutic and placebo CPAP was performed in 71 patients newly diagnosed with OSA ( apnoea-hypopnoea index [AHI]⩾10 ) . Mood was assessed by the Center for Epidemiologic Studies -Depression ( CES-D ) Scale , the Profile of Mood States ( POMS ) , and the Brief Symptom Inventory ( BSI ) before and after three weeks of treatment . AHI was used to assess the severity of apnoea . The two groups were compared using a simple comparison of the changes within each arm and repeated measures analysis of variance . RESULTS Fifty-six subjects completed the study : 26 in the CPAP group and 30 in the placebo group . The two groups were well matched at baseline , with no significant differences in demographic , mood and apnoea variables . Both groups had severe apnoea , mild depression , and anxiety at baseline . After three weeks of treatment , AHI decreased significantly in the CPAP group . The mean change in AHI was -30.7 ( st and ard deviation [ SD ] 23.1 ) in the CPAP group and -5.8 ( SD 18.3 ) in the placebo group ( difference between groups P<0.001 ) . However , after three weeks of treatment , there were no significant time by treatment effects in relation to mood , as assessed by the CES-D , POMS Depression , POMS Tension , BSI Depression , or BSI Anxiety ( all P>0.05 ) . CONCLUSION In conclusion , three weeks of CPAP treatment did not show a specific therapeutic effect on mood symptoms in patients with OSA A placebo-controlled , partial cross-over , double-blind , r and omized study was performed with 46 adults with sleep apnea-hypopnea syndrome ( SAHS ) to determine the effect of therapeutic and subtherapeutic ( 0 - 1  cm H(2)O ) nasal continuous positive airway pressure ( CPAP ) treatment on polysomnographic and neuropsychological testing . The following neuropsychological tests were administered : Geriatric Depression Scale , Trail Making A and B , Digit Span Test Forward and Backward , Epworth Sleepiness Scale , SteerClear , Digit Symbol , Controlled Oral Word Association , and Complex Figure Recall . Compared with results without CPAP , subtherapeutic CPAP did not affect any measured polysomnographic parameter . Comparison of neuropsychological test results obtained between the initial periods of effective treatment ( Group 1 , 16.1 d ; Group 2 , 19.6 d ; p = NS ) in all subjects showed significant improvements in Digit Symbol , Digit Span Backward , and Complex Figure tests . However , there were no group differences in changes in test results during the period when one group was on effective CPAP and the other on ineffective CPAP ( Group 1 , 16.1 d ; Group 2 , 13.9 d ; p = NS ) . The results indicate the feasibility and importance of using ineffective CPAP as a placebo treatment and the importance of including a placebo control in studies evaluating the effect of treatment on neuropsychological function in SAHS Background : It is unclear whether continuous positive airway pressure ( CPAP ) , the treatment of choice for severe obstructive sleep apnoea ( OSA ) , is effective at improving outcomes in mild OSA . Methods : To help define the role of humidified CPAP in mild OSA , a r and omised crossover study was undertaken of patients with an apnoea hypopnoea index ( AHI ) of 5–30/hour .  Subjective sleepiness , objective wakefulness , mood , reaction time , and quality of life were measured at baseline , after 3 weeks treatment with humidified CPAP and 3 weeks sham CPAP ( 2 week washout ) . Results : Twenty nine of 31 enrolled patients ( age 25–67 years , seven women , mean ( SD ) body mass index 31.5 ( 6 ) kg/m2 ) completed the protocol .  Humidified CPAP  improved polysomnographic indices of OSA and Epworth Sleepiness Scale ( 2.4 points ( 95 % CI 0.6 to 4.2 ) ) . Objective wakefulness ( modified maintenance of wakefulness test ) showed a trend towards improvement ( 5.2 minutes ( 95 % CI −0.6 to 11 ) ) . Mood ( Hospital Anxiety and Depression Scale ) , quality of life ( SF 36 , Functional Outcomes of Sleep Question naire ) , and reaction times ( Psychomotor Vigilance Task ) were not improved more than sham CPAP . Compliance with humidified and sham CPAP both averaged 4.9 hours/night . Placebo effects were evident in many outcomes and there was no clear treatment preference . Conclusions : Humidified CPAP  improves subjective sleepiness and possibly objective wakefulness but not reaction times , quality of life , or mood . These results do not support the routine use of CPAP in all patients with mild OSA , but offers some support for the trialling of CPAP in those with severe sleepiness A common clinical dilemma faced by sleep physicians is in deciding the level of severity at which patients with obstructive sleep apnea ( OSA ) should be treated . There is particular uncertainty about the need for , and the effectiveness of , treatment in mild cases . To help define the role of nasal continuous positive airway pressure ( CPAP ) treatment in mild OSA we undertook a r and omized controlled cross-over trial of CPAP in patients with an apnea- hypopnea index ( AHI ) of 5 - 30 ( mean , 12.9 + /- 6.3 SD ) . Twenty-four-hour blood pressure and neurobehavioral function were measured at baseline , after 8 wk of treatment with CPAP , and after 8 wk of treatment with an oral placebo tablet .  Twenty-eight of 42 patients enrolled in the study completed both treatment arms . Baseline characteristics were not different between those who completed the study and those who did not complete the study . Patients used CPAP  for a mean ( SD ) of 3.53 ( 2.13 ) h per night and the mean AHI on the night of CPAP implementation was 4.24 ( 2.9 ) . Nasal CPAP improved self-reported symptoms of OSA , including snoring , restless sleep , daytime sleepiness , and irritability ( in-house question naire ) , more than did placebo , but did not improve objective ( Multiple Sleep Latency Test ) or subjective ( Epworth Sleepiness Scale ) measures of daytime sleepiness . We found no benefit of CPAP over placebo in any tests of neurobehavioral function , generic SF-36 ( 36-item Short Form Medical Outcomes Survey ) or sleep-specific ( Functional Outcomes of Sleep Question naire ) quality of life question naires , mood score ( Profile of Moods States and Beck Depression Index ) , or 24-h blood pressure . However , the placebo tablet result ed in a significant improvement in a wide range of functional variables compared with baseline . This placebo effect may account for some of the treatment responses to CPAP observed previously in patients with mild OSA Ambulatory blood pressure ( BP ) monitoring was performed in 13 patients with the sleep apnea/ hypopnea syndrome ( SAHS ) during a r and omized , placebo controlled crossover trial of the effects of continuous positive airway pressure ( CPAP ) therapy .  BP was monitored at half-hourly intervals for a 24-hour period both on CPAP and on an oral placebo , each given for a minimum of 3 weeks . Objective effective CPAP use averaged 4.3 hours per night . Weight and anti-hypertensive medications remained stable over the study period . Systolic , diastolic and mean arterial BP for 24-hour , daytime and nighttime periods were not significantly different on placebo compared to CPAP . Those patients with no significant overnight fall in BP on placebo ( " non-dippers " ) showed a significant improvement in daytime mean arterial BP on CPAP ( 98 + /- 4 mm Hg ) compared to placebo ( 102 + /- 4 mm Hg ; p = 0.01 ) . These findings , in a well-controlled trial , suggest that BP is not reduced by CPAP in a heterogeneous group of SAHS patients , but it may be selectively improved in those patients most at risk for cardiovascular morbidity and mortality The sleep apneahypopnea syndrome is currently defined by the presence of a pathologic number of episodes of cessation ( apnea ) or reduction ( hypopnea ) of respiratory flow during sleep ( the apneahypopnea index , defined as the number of apnea and hypopnea episodes per hour ) . This syndrome is normally associated with arterial desaturation , sleep disruption ( arousals ) , severe snoring , and excessive daytime sleepiness ( 1 ) . Nasal continuous positive airway pressure ( CPAP ) is the treatment of choice for the sleep apneahypopnea syndrome ( 2 , 3 ) . Several r and omized , placebo-controlled studies have shown that CPAP improves subjective and objective daytime sleepiness , quality of life , cognitive performance , and psychological well-being in patients with this syndrome ( 4 - 9 ) . The effects of CPAP on other clinical ly relevant variables , such as prognosis and incidence of cardiovascular events or traffic accidents , are unclear ( 10 ) . The available evidence therefore supports the notion that CPAP is an effective symptomatic treatment for patients with the sleep apneahypopnea syndrome . Epidemiologic studies report that many persons with an apneahypopnea index of at least 5 do not experience daytime sleepiness ( 11 ) . In clinical practice , these patients are commonly referred to consultation by their partner ( who observed apneas during sleep ) or by an otorhinolaryngologist ( who ordered a polysomnographic study before surgery for snoring ) . Whether these nonsleepy patients with a pathologic apneahypopnea index require treatment with CPAP is unclear ( 12 , 13 ) . On the one h and , it may be argued that they do not need treatment because they do not have symptoms ; moreover , the available evidence relates only to the efficacy of CPAP treatment on such symptoms . On the other h and , because the sleep apneahypopnea syndrome is a chronic , slowly progressing disease , patients with this syndrome may perceive their symptoms poorly . If this is the case , treatment with CPAP may substantially improve their well-being and quality of life . In addition , CPAP treatment of nonsleepy patients may have other potentially relevant biological effects , such as control of arterial hypertension , which is common in the sleep apneahypopnea syndrome ( 14 ) but often goes unnoticed . We design ed a multicenter r and omized , placebo-controlled , parallel-group study to evaluate the short-term ( 6 weeks ) effects of CPAP on quality of life , objective sleepiness , cognitive function , and arterial blood pressure in nonsleepy patients with a pathologic apneahypopnea index . Methods Patients Participants were recruited prospect ively from patients attending the sleep units of six teaching hospitals in Spain from August 1999 to March 2000 . All participants had an apneahypopnea index of 30 or greater , as determined during a full , supervised , st and ard polysomnographic study ; had Epworth Sleepiness Scale scores of 10 or less ( 15 ) ; and had no or mild daytime sleepiness , according to the International Classification of Sleep Disorders ( 16 ) . Patients were excluded if they had cognitive deterioration of any cause , a chronic underlying disease that may affect their quality of life , or severe cardiac disease ; had less than 8 years of formal education ; or used illicit drugs or drank excessive alcohol . The ethics committee of all participating institutions approved the study protocol , and all participants gave written consent after they were informed of the characteristics of the investigation . However , participants remained blinded to the hypothesis of the study . Design We design ed a multicenter r and omized , placebo-controlled , parallel-group study . A computer-generated r and om-number list generated with SPSS software [ SPSS , Inc. , Chicago , Illinois ] was used to assign patients to receive CPAP or sham CPAP . In all participants , we measured the following variables at baseline and after 6 weeks of treatment with CPAP or sham CPAP : 1 ) quality of life ; 2 ) degree of sleepiness ; 3 ) different psychological variables , such as attention , vigilance , visual memory , coordination , and mental control ; 4 ) arterial blood pressure on ambulatory monitoring ; and 5 ) drug intake and alcohol consumption , as potential confounding variables . Patients assigned to the CPAP group received treatment with optimal nasal CPAP at home for 6 weeks ( Respironics , Inc. , Murrisville , Pennsylvania ) . The optimal nasal CPAP pressure was determined during a full-night polysomnographic study as the pressure necessary to abolish all respiratory events and snoring , secondary arousals , and episodes of oxyhemoglobin desaturation during rapid eye movement sleep and in the supine position . Patients assigned to sham CPAP received this treatment at home during 6 weeks , using the method described by Farr and colleagues ( 17 ) . These patients also underwent a sham titration polysomnographic study in which no pressure was added . According to the r and omization schedule , the morning after the CPAP trial , patients were sent home with a CPAP or sham CPAP device . During the study , all participants had telephone access to research ers for advice if required . Measurements Polysomnographic studies included recording of oronasal flow and thoracoabdominal movements , electrocardiography , submental and pretibial  electromyography  , electroculography , electroencephalography ( C4A1 and C3A2 ) , and transcutaneous measurement of arterial oxygen saturation . A polysomnographic study was considered valid for scoring if the total sleep time was longer than 240 minutes . Sleep scoring was st and ardized according to international criteria ( 18 ) . Respiratory events ( apneas and hypopneas ) were scored according to criteria proposed by the Spanish Respiratory Society ( 19 ) , which defined apneas as cessation of respiratory flow for more than 10 seconds and hypopneas as a significant reduction in respiratory flow followed by an arousal ( as defined by Collard and associates [ 20 ] ) or an episode of arterial oxygen desaturation greater than 4 % . The apneahypopnea index was defined as the sum of the number of apneas plus hypopneas per hour of sleep . The arousal index indicates the number of arousals per hour of sleep . Quality of life was quantified by using the Medical Outcomes Study 36-Item Short-Form Health Survey ( SF-36 ) ( 21 ) and the Functional Outcomes of Sleep Question naire ( FOSQ ) ( 22 ) . The degree of sleepiness was assessed by using the  Multiple Sleep Latency Test ( 1 ) ( MSLT ) and the Epworth Sleepiness Scale ( 15 ) . The technicians who scored the MSLT were blinded to the patients ' treatment assignments . Patients filled out the Epworth Sleepiness Scale themselves , without input from family or friends . Attention , vigilance , visual memory , and coordination were assessed by using the following psychological tests : digit span , block design , and digit symbols from the Wechsler Adult Intelligence Scale ( 23 ) ; mental control and verbal paired associates from the Wechsler Memory Scale ( 24 ) ; the Paced Auditory Serial Addition Test ( PASAT ) ; and the trail making test ( 25 ) . A psychologist administered or supervised ( in the case of the SF-36 , the FOSQ , and the Epworth Sleepiness Scale ) these tests between 9 a.m. and noon and in the absence of family or friends . Psychologists were aware of the study hypothesis but were blinded to patient treatment assignments . Ambulatory blood pressure ( Spacelabs Medical , Redmond , Washington ) was recorded 3 days before the MSLT was administered . Systolic and diastolic blood pressure values were measured for 24 hours . At least 60 data points were recorded in each patient . The average daytime ( 8:00 to 22:00 ) and nighttime ( 22:00 to 8:00 ) values were calculated . Patients were classified as nondippers if the systolic or diastolic blood pressure at night did not decrease by more than 10 % of diurnal values ( 26 ) . Adherence  to CPAP or sham CPAP was assessed by using the timer built into each CPAP device . At the end of the study period , we recorded the presence or absence of several potential side effects of therapy , such as claustrophobia , morning headache , insomnia , nose or ear pain , skin lesions , bleeding , and dryness of the oropharyngeal mucosa . Statistical Analysis The study was powered according to the findings of Jenkinson and colleagues ( 8) . In brief , quality of life ( assessed by the SF-36 question naire ) was the main outcome variable . We expected a mean difference of 9 in the change in the SF-36 question naire score after treatment between the CPAP and the sham CPAP group . Accordingly , we calculated that for a two-sided test , 25 patients in each group had to complete the study if a st and ard deviation of 9.5 , an error of 0.5 , and a error of 0.1 were assumed . Results are given as the mean ( SE ) . For the main outcome variables , the 95 % CI is also given . A two-tailed t-test for independent sample s or a chi-square test was used to compare anthropometric and clinical variables at baseline in the two groups . The effects of treatment were analyzed on an intention-to-treat basis by using a two-sided t-test for independent sample s to compare the change over time in different variables between the two groups . A P value less than 0.05 was considered significant . Results Baseline Data Figure 1 shows the trial design . During the study , 69 patients who fulfilled all inclusion criteria were recruited from the six participating institutions . Fourteen patients declined to participate in the study . The remaining 55 patients underwent r and omization . One patient initially assigned to the sham CPAP group was lost to follow-up after his first evaluation owing to a change in residence ( Figure 1 ) . Thus , the final study sample comprised 54 patients ( 29 in the CPAP group and 25 in the sham CPAP group ) . Figure 1 . Trial design . Table 1 shows the patients ' main anthropometric and clinical characteristics at the start of the study . The  CPAP  and  sham CPAP  groups did not differ significantly for any variable ( Table 1 ) . By design , all patients had an apneahypopnea index of 30 or greater ( ranging from 30 to 91 ) Background Continuous positive airway pressure treatment has been shown to lower blood pressure ( BP ) in patients with obstructive sleep apnea ( OSA ) . The aims of the present pilot study were to evaluate the potential effects of oral appliance ( OA ) therapy on BP , to assess various outcome BP measures , and to inform sample size calculation . Methods Seventy-two patients with OSA and hypertension were r and omly assigned to intervention with either an OA with m and ibular advancement ( active group ) or an OA without advancement ( control group ) . Before and after 3 months of treatment , the patients underwent  nocturnal somnographic registration and  24-h ambulatory BP monitoring  . Results Among the various BP measures , the largest trend toward effect of OA treatment was seen in 24-h mean systolic BP with a 1.8 mmHg stronger BP reduction in the active group compared with controls . A stronger trend toward effect was seen in a subgroup with baseline ambulatory daytime mean systolic BP > 135/85 mmHg where the mean systolic BP fell , on average , 2.6 mmHg . Additional exclusion of patients with baseline apnea hypopnea index ( AHI ) ≤15 gave a significant reduction in mean systolic BP of 4.4 mmHg ( P = 0.044 ) in the active group compared with controls . Conclusions In patients with OSA and hypertension  , OA treatment had a modest trend toward effect on reducing BP . A stronger trend toward treatment effect was seen after excluding patients with normal baseline ambulatory BP . Additional exclusion of patients with baseline AHI ≤15 showed a significant treatment effect . Data to inform sample size for an adequately powered r and omized study are provided This prospect i ve , r and omized , cross-over trial was design ed to compare the efficacy of a m and ibular advancement splint ( MAS ) with that of nasal continuous positive airway pressure ( nCPAP ) in patients with obstructive sleep apnoea ( OSA ) . Twenty-four patients ( 20 males and four females ) with mild to moderate OSA ( AHI between 10 and 49 events per hour ) were enrolled in the study . Each patient used both MAS and nCPAP , with the initial therapy being allocated at r and om . Treatment periods lasted for two months with a two-week wash-out interval between .  Polysomnography  was performed prior to the study and after each clinical intervention . Patient and partner question naires were used to assess changes in general health and daytime somnolence . The AHI decreased from 22.2 to 3.1 using nCPAP , and to 8.0 using the MAS ( P < 0.001 for both devices ) and there was no statistically significant difference between the two treatments . The Epworth Sleepiness Score ( ESS ) fell from 13.4 to 8.1 with nCPAP , and to 9.2 with MAS ( P < 0.001 ) , again with no differences between the use of MAS or nCPAP . The question naire data showed an improvement in general health scores ( P < 0.001 ) after both treatments , but daytime sleepiness only improved significantly using nCPAP ( P < 0.001 ) . Despite this , 17 out of the 21 subjects who completed both arms of the study preferred the MAS . The splints were well tolerated and their efficacy suggests that the MAS may be a suitable alternative to nCPAP in the management of patients with mild or moderate OSA BACKGROUND Obstructive sleep apnoea is associated with raised blood pressure . If blood pressure can be reduced by nasal continuous positive airway pressure ( nCPAP ) , such treatment could reduce risk of cardiovascular disease in patients with obstructive sleep apnoea . Our aim was to see whether nCPAP for sleep apnoea reduces blood pressure compared with the most robust control intervention subtherapeutic nCPAP . METHODS We did a r and omised parallel trial to compare change in blood pressure in 118 men with obstructive sleep apnoea ( Epworth score > 9 , and a > 4 % oxygen desaturation index of > 10 per h ) who were assigned to either therapeutic ( n=59 ) or subtherapeutic ( 59 ) nCPAP ( about 1 cm H(2)O pressure ) for 1 month . The primary outcome was the change in 24-h mean blood pressure . Secondary outcomes were changes in systolic , diastolic , sleep , and wake blood pressure , and relations between blood pressure changes , baseline blood pressure , and severity of sleep apnoea . FINDINGS Therapeutic nCPAP reduced mean arterial ambulatory blood pressure by 2.5 mm Hg ( SE 0.8 ) , whereas subtherapeutic nCPAP increased blood pressure by 0.8 mm Hg ( 0.7 ) ( difference -3.3 [ 95 % CI -5.3 to -1.3 ] ; p=0.0013 , unpaired t test ) . This benefit was seen in both systolic and diastolic blood pressure , and during both sleep and wake . The benefit was larger in patients with more severe sleep apnoea than those who had less severe apnoea , but was independent of the baseline blood pressure . The benefit was especially large in patients taking drug treatment for blood pressure .  INTERPRETATION In patients with most severe sleep apnoea , nCPAP reduces blood pressure , providing significant vascular risk benefits , and substantially improving excessive daytime sleepiness and quality of life AIMS We tested the hypothesis that : ( i ) obstructive sleep apnoea ( OSA ) by itself originates pulmonary hypertension ( PH ) ; and ( ii ) the application of continuous positive airway pressure ( CPAP ) can reduce pulmonary pressure . METHODS AND RESULTS In this r and omized and cross-over trial , 23 middle-aged OSA ( apnoea-hypopnoea index , 44.1 + /- 29.3 h(-1 ) ) and otherwise healthy patients and 10 control subjects were included . OSA patients r and omly received either sham or effective CPAP for 12 weeks . Echocardiographic parameters , blood pressure recordings , and urinary catecholamine levels were obtained at baseline and after both treatment modalities . At baseline , OSA patients had higher pulmonary artery systolic pressure than control subjects ( 29.8 + /- 8.8 vs. 23.4 + /- 4.1 mmHg , respectively , P = 0.036 ) . Ten out of 23 patients [ 43 % , ( 95 % CI : 23 - 64 % ) ] and none of the control subjects had PH at baseline ( P = 0.012 ) . Two patients were removed from the study because of inadequate CPAP compliance . Effective CPAP induced a significant reduction in the values for pulmonary systolic pressure ( from 28.9 + /- 8.6 to 24.0 + /- 5.8 mmHg , P < 0.0001 ) . The reduction was greatest in patients with either PH or left ventricular diastolic dysfunction at baseline . CONCLUSION Severe OSA is independently associated with PH in direct relationship with disease severity and presence of diastolic dysfunction . Application of CPAP reduces pulmonary systolic pressure levels A prothrombotic state may contribute to the elevated cardiovascular risk in patients with obstructive sleep apnea ( OSA ) . We investigated the relationship between apnea severity and hemostasis factors and effect of continuous positive airway pressure ( CPAP ) treatment on hemostatic activity . We performed full overnight polysomnography in 44 OSA patients ( mean age 47±10 years ) , yielding  apnea – hypopnea index ( AHI ) and mean nighttime oxyhemoglobin saturation ( SpO2 ) as indices of apnea severity . For treatment , subjects were double-blind r and omized to 2 weeks of either therapeutic CPAP ( n=18 ) , 3 l/min supplemental nocturnal oxygen ( n=16 ) or placebo – CPAP ( < 1 cm H2O ) ( n=10 ) . Levels of von Willebr and factor antigen ( VWF : Ag ) , soluble tissue factor ( sTF ) , D-dimer , and plasminogen activator inhibitor (PAI)-1 antigen were measured in plasma pre- and posttreatment . Before treatment , PAI-1 was significantly correlated with AHI ( r=0.47 , p=0.001 ) and mean nighttime SpO2 ( r=−0.32 , p=0.035 ) , but these OSA measures were not significantly related with VWF : Ag , sTF , and D-dimer . AHI was a significant predictor of PAI-1 ( R2=0.219 , st and ardized β=0.47 , p=0.001 ) , independent of mean nighttime SpO2 , body mass index ( BMI ) , and age . A weak time-by-treatment interaction for PAI-1 was observed ( p=0.041 ) , even after adjusting for age , BMI , pre-treatment AHI , and mean SpO2 ( p=0.046 ) . Post hoc analyses suggested that only CPAP treatment was associated with a decrease in PAI-1 ( p=0.039 ) ; there were no changes in VWF : Ag , sTF , and D-dimer associated with treatment with placebo – CPAP or with nocturnal oxygen . Apnea severity may be associated with impairment in the fibrinolytic capacity . To the extent that our sample size was limited , the observation that CPAP treatment led to a decrease in PAI-1 in OSA must be regarded as tentative The minimal disease severity at which patients with the sleep apnea/hypopnea syndrome ( SAHS ) gain benefit from treatment is not well characterized , although a pilot study of continuous positive airway pressure ( CPAP ) therapy showed daytime improvements in patients with 5 to 15 apneas + hypopneas per hour slept ( AHI ) . We have thus performed a second , larger , r and omized , placebo- controlled study in a prospect i ve series of 34 patients ( 13 female ) with mild SAHS ( AHI 5 to 15 ) and daytime sleepiness . Patients spent 4 wk on CPAP treatment and 4 wk on an oral placebo , with r and omization of treatment order , and daytime assessment s on the last day of each treatment . Effective  CPAP  use averaged 2.8 + /- 2.1 h ( mean + /- SD ) per night . Compared with placebo , CPAP improved symptom score ( p < 0.01 ) , subjective ( Epworth ; p < 0.01 ) but not objective ( maintenance of wakefulness test ; p > 0.2 ) sleepiness , performances on 2 of 7 cognitive tasks ( p < 0.02 ) , depression score ( p < 0.01 ) , and five subscales of the SF-36 health/functional status question naire ( p < /= 0.03 ) . Fourteen of 34 patients preferred CPAP . In 14 patients with AHI in the range 5 to 10 , symptoms , cognitive function , psychological well-being and quality of life were improved . These results confirm benefits for daytime function after CPAP treatment for mild SAHS , but highlight unacceptability of CPAP in many such patients Rationale M and ibular advancement devices ( MADs ) are used to treat obstructive sleep apnoea-hypopnoea syndrome ( OSAHS ) but evidence is lacking regarding their clinical and cost-effectiveness in less severe disease . Objectives To compare clinical - and cost-effectiveness of a range of MADs against no treatment in mild to moderate OSAHS . Measurements and methods This open-label , r and omised , controlled , crossover trial was undertaken at a UK sleep centre . Adults with Apnoea-Hypopnoea Index ( AHI ) 5–<30/h and Epworth Sleepiness Scale ( ESS ) score ≥9 underwent 6 weeks of treatment with three non-adjustable MADs : self-moulded ( SleepPro 1 ; SP1 ) ; semi-bespoke ( SleepPro 2 ; SP2 ) ; fully-bespoke MAD ( bMAD ) ; and 4 weeks no treatment . Primary outcome was AHI scored by a polysomnographer blinded to treatment . Secondary outcomes included ESS , quality of life , re source use and cost . Main results 90 patients were r and omised and 83 were analysed . All devices reduced AHI compared with no treatment by 26 % ( 95 % CI 11 % to 38 % , p=0.001 ) for SP1 , 33 % ( 95 % CI 24 % to 41 % ) for SP2 and 36 % ( 95 % CI 24 % to 45 % , p<0.001 ) for bMAD . ESS was 1.51 ( 95 % CI 0.73 to 2.29 , p<0.001 , SP1 ) to 2.37 ( 95 % CI 1.53 to 3.22 , p<0.001 , bMAD ) lower than no treatment ( p<0.001 for all ) . Compliance was lower for SP1 , which was the least preferred treatment at trial exit . All devices were cost-effective compared with no treatment at a £ 20 000/ quality -adjusted life year ( QALY ) threshold . SP2 was the most cost-effective up to £ 39 800/QALY . Conclusions Non-adjustable MADs achieve clinical ly important improvements in mild to moderate OSAHS and are cost-effective . Of those trialled , the semi-bespoke MAD is an appropriate first choice . Trial registration number IS RCT N02309506 STUDY OBJECTIVES The effect of therapy using a cervicom and ibular support collar ( CMSC ) to manage obstructive sleep apnea ( OSA ) was compared with st and ard therapy , nasal continuous positive airway pressure ( nCPAP ) . DESIGN Subjects received treatment with CMSC or nCPAP each for 1 month in r and om order . The study was analyzed on an intention-to-treat basis . SETTING Tom McKendrick Sleep Laboratory , Dunedin Hospital . PARTICIPANTS Ten adult subjects with mild-to-moderate OSA ( apnea-hypopnea index [ AHI ] , 24 + /- 13/h slept [ mean + /- SD ] ) completed the study . INTERVENTIONS The CMSC was design ed to prevent m and ibular movement and hold the head in slight extension , thus preventing the postural changes that might contribute to OSA . Positioning of the CMSC was confirmed by an externally applied cervical range of motion ( CROM ) instrument and by cephalometry . Subjects were carefully instructed in the use of each device and completed a symptom diary . After 1 month , subjects underwent  polysomnography  with each of the allocated devices in situ , and symptom question naires were administered . MEASUREMENTS AND RESULTS Treatment success ( AHI < /= 10/h slept ) with CMSC was achieved in only 2 of 10 subjects , partial success ( AHI > 10/h to < /= 15/h slept ) was achieved in 2 subjects , and in 6 of 10 subjects there was no benefit . In contrast , treatment success was achieved in 7 of 10 subjects receiving nCPAP .  Mean AHI was 29.4 + /- 13.4/h at baseline , 26.9 + /- 17.2/h slept with CMSC , and 9.9 + /- 8.0/h slept with nCPAP ( p = 0.001 ) . No significant differences in sleep architecture or sleep efficiency were achieved using nCPAP compared to CMSC . The efficacy of the CMSC in maintaining the desired head position was confirmed by cephalometry and the CROM instrument . CONCLUSIONS Our results , although negative , provide important evidence that control of head and neck posture , perhaps adopted as a second-line treatment , is not helpful in the management of OSA . It appears that other anatomic and physiologic factors have a dynamic overriding influence on upper airway closure compared to simple skeletal relationships The aim of this r and omized controlled trial was to assess the effects of treatment with continuous positive airway pressure versus conservative therapy ( CT ) on well-being , mood , and functional status in subjects with mild sleep-disordered breathing ( SDB ) . One hundred and eleven subjects , aged 25 to 65 yr , with a respiratory disturbance index ( RDI ) of 5 to 30 and without subjective pathologic sleepiness , were r and omized to nasal CPAP or to CT . Ninety-seven subjects were followed-up after 8 wk . Treatment response was assessed from changes between baseline and follow-up measures of mood , energy/fatigue , and functional status/general health . Of the 51 subjects r and omized to CPAP , 25 ( 49 % ) experienced an improved outcome , as compared with 12 of 46 of subjects ( 26 % ) r and omized to CT ( p < 0.05 ) . The odds of experiencing a treatment response in the CPAP as compared with the CT group were 2.72 ( OR : 1.18 to 6.58 , 95 % CI ) . A beneficial effect of CPAP over CT was most evident among individuals without sinus problems and among subjects with hypertension or diabetes . Differential treatment responses were not related to degree of baseline sleepiness or SDB . This suggests that middle-aged snorers with relatively low levels of SDB ( RDI < 30 ) may benefit more from nasal CPAP than from less specific therapy directed at improving breathing during sleep .  CPAP therapy may be beneficial to a broader group of subjects than previously appreciated RATIONALE Dyslipidemia is common in Obstructive Sleep Apnea ( OSA ) . Postpr and ial lipidemia ( PPL ) is a strong marker of cardiovascular risk . Evidence that OSA treatment improves PPL is lacking . OBJECTIVES To investigate the effect of continuous positive airway pressure ( CPAP ) treatment on postpr and ial lipidemia ( PPL ) in patients with obstructive sleep apnea ( OSA ) in the upper moderate or severe range . METHODS In this r and omized , placebo-controlled crossover trial , we compared the effects of 2 months each of therapeutic and placebo CPAP on PPL . MEASUREMENTS AND MAIN RESULTS PPL was determined from the area under the 24-hour triglyceride concentration curve ( TAG-AUC(24 ) ) using seven blood sample s drawn across both the wake and sleep periods . Secondary outcomes were the difference in other 24-hour lipid profiles .  Thirty-eight eligible patients were r and omly assigned to a treatment order and 29 patients completed the trial .  CPAP reduced PPL compared with placebo with a mean TAG-AUC(24 ) difference of -357 mmol/L/d ( 95 % confidence interval [ CI ] , -687.3 to -26.8 ; P = 0.035 ) . During both the CPAP and placebo studies , TAG levels peaked during both wakefulness ( 2:00 p.m. ) and sleep ( 3:00 a.m. ) . Both peaks were lower during CPAP than placebo : 2:00 p.m. , -0.49 mmol/L ( 95 % CI , -0.74 to -0.24 ; P < 0.0005 ) and 3:00 a.m. , -0.40 mmol/L ( 95 % CI , -0.65 to -0.15 ; P = 0.002 ) . Moreover , mean 24-hour total cholesterol was -0.19 mmol/L lower on CPAP ( 95 % CI , -0.27 to -0.11 ; P < 0.00001 ) . CONCLUSIONS This r and omized trial demonstrated that treatment of severe OSA with CPAP improves postpr and ial TAG and total cholesterol levels . These effects may reduce the risk for cardiovascular events . The results imply that the association between OSA and cardiovascular disease may , in part , be caused by direct effects on dyslipidemia . Clinical trial registered with the Australian and New Zeal and Clinical Trials Registry at www.anzctr.org.au ( ACTRN 12605000066684 ) The aim of this trial was to evaluate the effectiveness of continuous positive airway pressure ( CPAP ) in patients with mild sleep apnea- hypopnea syndrome ( SAHS ) . One hundred forty-two consecutive patients with mild SAHS ( apnea-hypopnea index 10 - 30 , without severe sleepiness ) were r and omly assigned to receive conservative treatment (CT)-sleep hygiene and weight loss-(65 patients ) or CT plus CPAP ( 77 patients ) , and 125 patients ( 86 % males , age : 54 + /- 9 yr , BMI : 29 + /- 4 kg/m(2 ) , AHI : 20 + /- 6 , ESS : 12 + /- 4 ) completed the follow-up . The following outcomes were assessed at inclusion and after 3 and 6 mo of treatment : sleepiness ( Epworth scale , multiple sleep latency test [ MSLT ] ) , other symptoms related to SAHS , cognitive function , and perceived health status ( Functional Outcomes of Sleep Question naire [ FOSQ ] , Nottingham Health profile ) . The relief of SAHS-related clinical symptoms was significantly greater in the CPAP group than in the CT group ; the Epworth scale and FOSQ also showed more improvement in the CPAP group but did not reach significance . There were no significant differences in the other tests performed probably because the baseline values were normal . CPAP compliance was 4.8 + /- 2.2 h and treatment continuation was accepted by 62 % of the patients at the end of the study . These results suggest that CPAP can be considered in treating patients with mild SAHS  on the basis of an improvement in symptoms STUDY OBJECTIVES Previous studies have shown that CPAP has a substantial impact on daytime symptoms and quality of life ( QOL ) . It remains unclear which outcome measures best identify real CPAP effects and carry independent information . METHODS One hundred-two men with moderate-severe obstructive sleep apnea were r and omized to either " real " or " sham " CPAP for one month . Outcome measures were subjective sleepiness ( Epworth Sleepiness Scale [ ESS ] ) and QOL measures includiig SF-36/SF-12 and Calgary Sleep Apnea Quality of Life Index ( SAQLI ) . The bed partner 's  QOL and rating of patient 's response to CPAP were assessed with the Dublin question naire . All data were st and ardized using effect sizes and expressed as real minus sham to remove the nonspecific effects of placebo . RESULTS Real CPAP was superior to sham CPAP in almost all outcome measures . ESS , patient 's component from Dublin , and social interactions from SAQLI showed the largest differences in effect sizes between real and sham ( 1.33 , 0.98 , and 0.92 respectively ) . ESS carried the highest predictive power of real CPAP response ( P < 0.0001 , r2 = 0.21 ) . Question number 5 from Dublin ( partner assessed patient 's sleep quality ) and question 6 from ESS ( dozing while talking ) were the best single item predictors of real CPAP response . CONCLUSIONS Real CPAP reduces subjective sleepiness and improves  QOL  of both patients and bed partners . ESS is the best score ; question number 5 from Dublin and question number 6 from ESS are the best single item predictors of real CPAP response . This information should allow the selection of appropriate questions in clinical practice and research protocol STUDY OBJECTIVES Oral appliance therapy has emerged as an important alternative to continuous positive airway pressure ( CPAP ) in treating patients with obstructive sleep apnea syndrome ( OSAS ) . In this study we report about the subjective and objective treatment outcome of oral appliance therapy and CPAP in patients with OSAS . DESIGN Cohort study of a previously conducted r and omized clinical trial . SETTING University Medical Center , Groningen , The Netherl and s. PATIENTS OR PARTICIPANTS One hundred three patients with OSAS . INTERVENTIONS CPAP and oral appliance therapy ( Thornton Adjustable Positioner type-1 , Airway Management , Inc. , Dallas , TX , USA ) . MEASUREMENTS AND RESULTS Objective ( polysomnography ) and subjective ( Epworth Sleepiness Scale , Functional Outcomes of Sleep Question naire , Medical Outcomes Study 36-item Short Form Health Survey [ SF-36 ] ) parameters were assessed after 1 and 2 years of treatment . Treatment was considered successful when the apnea-hypopnea index ( AHI ) was < 5 or showed substantial reduction , defined as reduction in the index of at least 50 % from the baseline value to a value of < 20 in a patient without OSAS symptoms while undergoing therapy . Regarding the proportions of successful treatments , no significant difference was found between oral appliance therapy and CPAP in treating mild to severe OSAS in a 2-year follow-up . More patients ( not significant ) dropped out under oral appliance therapy ( 47 % ) compared with CPAP ( 33 % ) . Both therapies showed substantial improvements in polysomnographic and neurobehavioral outcomes . However , CPAP was more effective in lowering the AHI and showed higher oxyhemoglobin saturation levels compared to oral appliance therapy ( P < 0.05 ) . CONCLUSIONS Oral appliance therapy should be considered as a viable treatment alternative to continuous positive airway pressure ( CPAP ) in patients with mild to moderate obstructive sleep apnea syndrome ( OSAS ) . In patients with severe OSAS , CPAP remains the treatment of first choice . CLINICAL TRIAL INFORMATION The original r and omized clinical trial , of which this study is a 2-year follow-up , is registered at IS RCT N.org ; identifier : IS RCT N18174167 ; trial name : Management of the obstructive sleep apnea-hypopnea syndrome : oral appliance versus continuous positive airway pressure therapy ; URL : http://www.controlled-trials.com/IS RCT N18174167 OBJECTIVE The m and ibular advancement appliance ( MAA ) is now recognized as a first-line therapy option for mild to moderate obstructive sleep apnea syndrome ( OSAS ) . The aim of this follow-up study was to re-assess the long-term efficacy of MAAs provided to patients in a previous comparative study . METHODS Sixteen subjects had participated in a previous comparative study in which the efficacy and compliance of two MAAs ( Klearway - K and Silencer - S ) were compared in a r and omized cross-over design . At the end of the previous comparative study , subjects selected the MAA they preferred . Nine chose the K and seven the S. Fifteen subjects were available for a follow-up interview and 14 ( 4 women and 10 men ; mean ± SEM : 51.9 ± 1.7 y.o . ) agreed to participate in an overnight sleep recording at a hospital sleep laboratory from January to February 2009 . The mean time lag between the end of the previous comparative study and the follow-up was 40.9 ± 2.1 months ( range of 2.5 - 4.5 years ) . Comparisons were made across the three polysomnographic evaluations ( PSGE ) : baseline , the night with the appliance of their choice at the end of the previous comparative study , and the follow-up night . Subjects completed the Epworth sleepiness scale ( ESS ) , the fatigue severity scale ( FSS ) , and a quality of life question naire ( FOSQ ) . RESULTS At the follow-up , the respiratory disturbance index ( RDI ) remained significantly lower than baseline ( p<0.001 ) . Question naire responses revealed that ESS , FSS , and FOSQ remained improved at follow-up ( p<0.02 ) . Body mass index ( BMI ) increased slightly from baseline to follow-up ( p<0.05 ) . Diastolic and systolic blood pressure and cardiac rhythm decreased significantly from baseline to follow-up . CONCLUSIONS The MAAs remained effective in improving RDI , sleepiness , blood pressure , cardiac rhythm , fatigue , sleep quality , and quality of life over a period of 2.5 - 4.5 years . The rise in BMI is a concern that merits further examination STUDY OBJECTIVE To compare efficacy , side effects , patient compliance , and preference between oral appliance ( OA ) therapy and nasal-continuous positive airway pressure ( N-CPAP ) therapy . DESIGN R and omized , prospect i ve , crossover study . SETTING University hospital and tertiary sleep referral center . PATIENTS Twenty-seven unselected patients with mild-moderate obstructive sleep apnea ( OSA ) . INTERVENTIONS There was a 2-week wash-in and a 2-week wash-out period , and 2 x 4-month treatment periods ( OA and N-CPAP ) . Efficacy , side effects , compliance , and preference were evaluated by a question naire and home sleep monitoring . MEASUREMENTS AND RESULTS Two patients dropped out early in the study and treatment results are presented on the remaining 25 patients . The apnea/hypopnea index was lower with N-CPAP ( 3.5 + /- 1.6 ) ( mean + /- SD ) than with the OA ( 9.7 + /- 7.3 ) ( p < 0.05 ) . Twelve of the 25 patients who used the OA ( 48 % ) were treatment successes ( reduction of apnea/hypopnea to < 10/h and relief of symptoms ) , 6 ( 24 % ) were compliance failures ( unable or unwilling to use the treatment ) , and 7 ( 28 % ) were treatment failures ( failure to reduce apnea/hypopnea index to < 10/h and /or failure to relieve symptoms ) . Four people refused to use N-CPAP after using the OA . Thirteen of the 21 patients who used N-CPAP were overall treatment successes ( 62 % ) , 8 were compliance failures ( 38 % ) , and there were no treatment failures . Side effects were more common and the patients were less satisfied with N-CPAP ( p < 0.005 ) . Seven patients were treatment successes with both treatments , six of these patients preferred OA , and one preferred N-CPAP as a long-term treatment . CONCLUSIONS We conclude that OA is an effective treatment in some patients with mild-moderate OSA and is associated with fewer side effects and greater patient satisfaction than N-CPAP Objectives This controlled trial assessed the effect of continuous positive airway pressure ( CPAP ) on blood pressure ( BP ) in patients with obstructive sleep apnea ( OSA ) and resistant hypertension ( RH ) . Methods We evaluated 96 patients with resistant hypertension , defined as clinic BP at least 140/90 mmHg despite treatment with at least three drugs at adequate doses , including a diuretic . Patients underwent a polysomnography and a 24-h ambulatory BP monitoring ( ABPM ) . They were classified as consulting room or ABPM-confirmed resistant hypertension , according to 24-h BP lower or higher than 125/80 mmHg . Patients with an apnea-hypopnea index at least 15 events/h ( n = 75 ) were r and omized to receive either CPAP added to conventional treatment ( n = 38 ) or conventional medical treatment alone ( n = 37 ) . ABPM was repeated at 3 months . The main outcome was the change in systolic and diastolic BP .  Results Sixty-four patients completed the follow-up . Patients with ABPM-confirmed resistant hypertension treated with CPAP ( n = 20 ) , unlike those treated with conventional treatment ( n = 21 ) , showed a decrease in 24-h diastolic BP ( −4.9 ± 6.4 vs. 0.1 ± 7.3 mmHg , P = 0.027 ) . Patients who used CPAP > 5.8 h showed a greater reduction in daytime diastolic BP { −6.12 mmHg [ confidence interval ( CI ) −1.45 ; −10.82 ] , P = 0.004 } , 24-h diastolic BP ( −6.98 mmHg [ CI −1.86 ; −12.1 ] , P = 0.009 ) and 24-h systolic BP ( −9.71 mmHg [ CI −0.20 ; −19.22 ] , P = 0.046 ) . The number of patients with a dipping pattern significantly increased in the CPAP group ( 51.7 % vs. 24.1 % , P = 0.008 ) . Conclusion In patients with resistant hypertension and OSA , CPAP treatment for 3 months achieves reductions in 24-h BP . This effect is seen in patients with ABPM-confirmed resistant hypertension who use CPAP more than 5.8 BACKGROUND Patients with obstructive sleep apnea ( OSA ) exhibit reduced quality of life ( QoL ) due to their daytime symptoms that restricted their social activities . The available data for QoL after treatment with continuous positive airway pressure ( CPAP ) are inconclusive , and few studies have assessed QoL after treatment with speech therapy or other methods that increase the tonus of the upper airway muscles or with a combination of these therapies . The aim of our study was to assess the effect of speech therapy alone or combined with CPAP on QoL in patients with OSA using three different question naires . METHODS Men with OSA were r and omly allocated to four treatment groups : placebo , 24 patients had sham speech therapy ; speech therapy , 27 patients had speech therapy ; CPAP , 27 patients had treatment with CPAP ; and combination , 22 patients had treatment with CPAP and speech therapy . All patients were treated for 3 months . Participants were assessed before and after treatment and after 3 weeks of a washout period using QoL question naires ( Functional Outcomes of Sleep Question naire [ FOSQ ] , World Health Organization Quality of Life [ WHOQoL-Bref ] , and Medical Outcomes Study 36-Item Short-Form Health Survey [ SF-36 ] ) . Additional testing measures included an excessive sleepiness scale ( Epworth sleepiness scale [ ESS ] ) , polysomnography ( PSG ) , and speech therapy assessment . RESULTS A total of 100 men aged 48.1±11.2 ( mean±st and ard deviation ) years had a body mass index ( BMI ) of 27.4±4.9 kg/m(2 ) , an ESS score of 12.7±3.0 , and apnea-hypopnea index ( AHI ) of 30.9±20.6 . After treatment , speech therapy and combination groups showed improvement in the physical domain score of the WHOQoL-Bref and in the functional capacity domain score of the SF-36 . CONCLUSIONS Our results suggest that speech therapy alone as well as in association with CPAP might be an alternative treatment for the improvement of  QoL  in patients with OSA Previous case reports have indicated dental devices can be an effective nonsurgical treatment for  snoring and obstructive sleep apnea .  This pilot study evaluated the effectiveness of two intraoral devices in reducing the Respiratory Disturbance Index ( RDI ) and Epworth Sleepiness Scale ( ESS ) scores in a group of 24 adult volunteers with a history of loud snoring . Subjects were r and omly assigned to two groups . Twelve subjects were fitted with a dental device design ed to increase vertical dimension and protrude the m and ible ( device A ) . The other 12 subjects received a different device design ed to minimally increase vertical opening without protruding the m and ible ( device B ) .  Unattended home sleep monitoring ( Edentrace II Digital Recorder , Edentech Corp. ) was used to compute RDI at two time periods : ( T0 ) before using any dental device and ( T1 ) while using a dental device 2 weeks after the initial delivery date . The mean RDI and ESS scores at T0 for subjects in the device A group were 35.6 + /- 28.4 and 12.0 + /- 3.9 , respectively . Means for the same measures at T1 were 21.1 + /- 21.4 and 8.2 + /- 4.0 . For subjects in the device B group , means for RDI and ESS scores at T0 were 36.5 + /- 43.7 and 13.0 + /- 4.5 , the means at T1 were 46.8 + /- 47.0 and 12.5 + /- 5.7 . The effectiveness of the two devices was estimated by comparing the difference in RDI scores from T0 to T1 for the 10 subjects who were using device A and completed the study and the 8 subjects who were using device B and completed the study . Six subjects withdrew for various reasons . From T0 to T1 , device A reduced RDI scores in 9 of 10 subjects , with a mean reduction in RDI of 14.5 ( p < or = 0.05 ) and in ESS score of 3.8 ( p < or = 0.005 ) . Device B showed no change or an increased RDI score in 8 of 8 subjects . Seven of the eight subjects who showed no improvement in RDI with device B were then fitted with device A. Four of these seven subjects showed a reduction in RDI and five showed a reduction in ESS after using device A for 2 weeks . The mean reduction in RDI and ESS was 2.4 + /- 19.8 and 2.4 + /- 3.0 , respectively . Hence , we conclude that a dental device that advances the m and ible and increases the vertical dimension to open the upper airway is more effective in reducing the number of apneic and snoring events during sleep than one which does not STUDY OBJECTIVE To determine the neurocognitive effects of continuous positive airway pressure ( CPAP ) therapy on patients with obstructive sleep apnea ( OSA ) . DESIGN , SETTING , AND PARTICIPANTS The Apnea Positive Pressure Long-term Efficacy Study ( APPLES ) was a 6-month , r and omized , double-blind , 2-arm , sham-controlled , multicenter trial conducted at 5 U.S. university , hospital , or private practice s. Of 1,516 participants enrolled , 1,105 were r and omized , and 1,098 participants diagnosed with OSA contributed to the analysis of the primary outcome measures . INTERVENTION Active or sham CPAP MEASUREMENTS : THREE NEUROCOGNITIVE VARIABLES , EACH REPRESENTING A NEUROCOGNITIVE DOMAIN : Pathfinder Number Test-Total Time ( attention and psychomotor function [ A/P ] ) , Buschke Selective Reminding Test-Sum Recall ( learning and memory [ L/M ] ) , and Sustained Working Memory Test-Overall Mid-Day Score ( executive and frontal-lobe function [ E/F ] ) RESULTS The primary neurocognitive analyses showed a difference between groups for only the E/F variable at the 2 month CPAP visit , but no difference at the 6 month CPAP visit or for the A/P or L/M variables at either the 2 or 6 month visits . When stratified by measures of OSA severity ( AHI or oxygen saturation parameters ) , the primary E/F variable and one secondary E/F neurocognitive variable revealed transient differences between study arms for those with the most severe OSA . Participants in the active CPAP group had a significantly greater ability to remain awake whether measured subjectively by the Epworth Sleepiness Scale or objective ly by the maintenance of wakefulness test . CONCLUSIONS CPAP treatment improved both subjectively and objective ly measured sleepiness , especially in individuals with severe OSA ( AHI > 30 ) . CPAP use result ed in mild , transient improvement in the most sensitive measures of executive and frontal-lobe function for those with severe disease , which suggests the existence of a complex OSA-neurocognitive relationship . CLINICAL TRIAL INFORMATION Registered at clinical trials.gov . Identifier : NCT00051363 . CITATION Kushida CA ; Nichols DA ; Holmes TH ; Quan SF ; Walsh JK ; Gottlieb DJ ; Simon RD ; Guilleminault C ; White DP ; Goodwin JL ; Schweitzer PK ; Leary EB ; Hyde PR ; Hirshkowitz M ; Green S ; McEvoy LK ; Chan C ; Gevins A ; Kay GG ; Bloch DA ; Crabtree T ; Demen WC . Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients : the Apnea Positive Pressure Long-term Efficacy Study ( APPLES ) . SLEEP 2012;35(12):1593 - 1602 Obstructive sleep apnea ( OSA ) is a common disease with significant medical and psychiatric comorbidities . The literature documenting the effects of continuous positive airway pressure ( CPAP ) treatment on mood in OSA patients is mixed . We previously observed that 1 week of CPAP treatment did not result in improvements in mood beyond those observed in a group treated with placebo – CPAP . This study examined the effect of a 2 week CPAP treatment on mood in a placebo-controlled design in OSA patients . Fifty patients with untreated sleep apnea were evaluated by  polysomnography  and completed the Profile of Mood States ( POMS ) pre-/post-treatment . The patients were r and omized for 2 weeks to either therapeutic CPAP or placebo – CPAP ( at insufficient pressure ) . Both the therapeutic CPAP and the placebo – CPAP groups showed significant improvements in POMS total score , tension , fatigue , and confusion . No significant time × treatment effect was observed for either group . We could not show a specific beneficial impact of CPAP treatment on mood in OSA patients BACKGROUND Continuous positive airway pressure ( CPAP ) is an effective treatment in patients with moderate and severe sleep apnoea/hypopnoea syndrome ( SAHS ) , but the minimum illness severity at which patients obtain benefit from CPAP is unclear . A study was therefore undertaken to investigate whether CPAP improves symptoms and daytime function in patients with mild SAHS . METHODS Sixteen consecutively recruited patients with mild SAHS ( 5.0 - 14.9 apnoeas + hypopnoeas per hour slept and two or more symptoms of SAHS ) participated in a prospect i ve placebo controlled r and omised crossover trial to assess the effects of CPAP on symptoms and daytime function . Patients spent four weeks on placebo and four weeks on CPAP , undergoing assessment s of sleepiness , symptoms , cognitive performance , and well being on the last day of each treatment . Data from the placebo and CPAP assessment s were compared . RESULTS The mean ( SE ) objective effective use of CPAP was 2.8 ( 0.7 ) hours per night . Significant improvements in symptom score ( -1.7 ( 0.5 ) , p < 0.01 ) , mental flexibility ( -14 ( 5 ) seconds , p = 0.02 ) , and depression rating ( -1.6 ( 0.8 ) , p = 0.03 ) on CPAP were observed . However , no significant differences in subjective or objective sleepiness were found . Ten of the 16 patients preferred CPAP and opted to continue with this treatment , although this proportion was non-significant ( p > 0.4 ) . The eight patients with best CPAP use showed an additional CPAP related improvement in quality of life ( -4.4 ( 1.8 ) , p = 0.03 ) . Those who complied better with CPAP therapy also had a higher average microarousal frequency ( p < 0.01 ) and apnoea+hypopnoea index ( p = 0.02 ) than the poorer compliers . CONCLUSIONS The results of this study provide evidence for improvements in symptoms and daytime function for patients with mild SAHS treated with CPAP BACKGROUND Obstructive sleep apnea syndrome ( OSAS ) is an independent risk factor for arterial hypertension . Several controlled trials have investigated the effect of continuous positive airway pressure ( CPAP ) on BP in patients with OSAS , but its effect on hypertensive patients has not been analyzed specifically . OBJECTIVE To analyze the effect of CPAP on ambulatory BP in patients with OSAS and hypertension who were undergoing antihypertensive treatment . DESIGN AND PATIENTS We conducted a parallel , r and omized , placebo-controlled trial in 68 patients with OSAS and hypertension , who were receiving treatment with antihypertensive medication .  Patients were r and omly allocated to either therapeutic or subtherapeutic CPAP for 4 weeks . Ambulatory BP was registered at baseline and after treatment . Antihypertensive treatment was not changed during the study . Changes in BP were assessed on an intention-to-treat basis . RESULTS There were no baseline differences in the apnea-hypopnea index , comorbidities , or ambulatory BP between groups . Objective compliance with CPAP was similar in both the therapeutic and subtherapeutic groups ( 5.0 + /- 1.4 h/d vs 4.4 + /- 1.9 h/d , respectively ; p = 0.13 [ mean + /- SD ] ) . There was a small and statistically nonsignificant decrease ( - 0.3 + /- 6.3 mm Hg vs - 1.1 + /- 7.9 mm Hg ; difference , - 0.8 mm Hg [ 95 % confidence interval , - 2.7 to 4.3 ] ; p = 0.65 ) in 24-h mean BP ( 24hMBP ) in both subtherapeutic and therapeutic groups after 4 weeks of treatment . No significant changes in systolic , diastolic , daytime , or nighttime BP were observed . The normal circadian dipper pattern was restored in a higher proportion of patients in the therapeutic group compared to the subtherapeutic CPAP group , although differences were not significant ( 11 of 32 patients vs 3 of 25 patients ; odds ratio , 3.84 ; 95 % confidence interval , 0.82 to 20.30 ; p = 0.10 ) . There was no correlation between the magnitude of change in 24hMBP and CPAP compliance , OSAS severity , or number of antihypertensive drugs used . CONCLUSION Four weeks of CPAP did not reduce BP in patients with OSAS and hypertension who were treated with antihypertensive medication , compared to placebo group Obstructive sleep apnea ( OSA ) is highly prevalent among patients with congestive heart failure ( CHF ) and may contribute to progression of cardiac dysfunction via hypoxia , elevated sympathetic nervous system activity , and systemic hypertension . Our aim was to assess the long-term effect of OSA treatment with nocturnal continuous positive airway pressure ( CPAP ) on systolic heart function , sympathetic activity , blood pressure , and quality of life in patients with CHF . Fifty-five patients with CHF and OSA were r and omized to 3 months of CPAP or control groups . End points were changes in left ventricular ejection fraction , overnight urinary norepinephrine excretion , blood pressure , and quality of life .  Nineteen patients in the CPAP group and 21 control subjects completed the study . Compared with the control group , CPAP treatment was associated with significant improvements in left ventricular ejection fraction ( delta 1.5 + /- 1.4 % vs. 5.0 + /- 1.0 % , respectively , p = 0.04 ) , reductions in overnight urinary norepinephrine excretion ( delta 1.6 + /- 3.7 vs. -9.9 + /- 3.6 nmol/mmol creatinine , p = 0.036 ) , and improvements in quality of life . There were no significant changes in systemic blood pressure . In conclusion , treatment of OSA among patients with CHF leads to improvement in cardiac function , sympathetic activity , and quality of life Continuous positive airway pressure ( CPAP ) is worldwide considered as the st and ard treatment of sleep apnea/hypopnea syndrome ( SAHS ) although studies on the effectiveness of this treatment are limited . The aim of our study was to evaluate the effectiveness of CPAP in improving SAHS-related symptoms , daytime function , perceived health status , and quality of life in patients with moderate to severe SAHS . The effect of conservative treatment ( CT ) measures -sleep hygiene and weight loss- was compared with CT + CPAP . We included 105 consecutive patients ( 13 females , age 53 + /- 10 yr , body mass index [ BMI ] = 32 + /- 6 kg/m2 , apnea/hypopnea index [ AHI ] = 56 + /- 20 , Epworth sleepiness scale [ ESS ] = 12 + /- 5 ) who met our criteria for CPAP treatment . Patients were r and omly allocated in two groups of similar characteristics . Group 1 ( n = 37 ) was asked to improve sleep hygiene and started a weight loss program . Group 2 ( n = 68 ) received , in addition , treatment with CPAP . Both groups were followed through weekly telephone calls and appointments . Sleepiness , other symptoms related to SAHS , daytime function , perceived health status , and quality of life were assessed through question naires at inclusion and after 3 mo of treatment . The relief of sleepiness and other SAHS-related clinical symptoms and improvement in perceived health status was much greater in Group 2 receiving CT + CPAP compared with Group 1 , only receiving CT . The odds of experiencing a treatment response with CPAP + CT compared with CT alone was 6.52 ( odds ratio [ OR ] = 2.51 to 17.6 , 95 % confidence interval [ 95 % CI ] ) . CPAP is currently the treatment of choice . At this time , the indication of CPAP treatment in moderate to severe SAHS is adequately supported BACKGROUND For the treatment of nonsevere obstructive sleep apnea syndrome ( OSAS ) , m and ibular advancement devices ( MADs ) are employed as an alternative to nasal continuous positive airway pressure ( CPAP ) therapy . However , very few specific data on the effectiveness of MADs in this group of patients are available . We therefore compared an individually adjustable intraoral sleep apnea device ( ISAD ) that permits movements of the lower jaw in three dimensions , with CPAP in the treatment of patients with an apnea/hypopnea index ( AHI ) < or = 30/h . METHODS In a r and omized crossover study , 16 men and 4 women ( mean + /- SD age , 56.5 + /- 10.2 years ; body mass index , 31.2 + /- 6.4 ; AHI , 17.5 + /- 7.7/h ) were treated for 6 weeks with each modality . RESULTS In the initial phase , a significant improvement in AHI ( baseline , 17.5 + /- 7.7/h ; ISAD , 10.5 + /- 7.5/h [ p < 0.05 ] ; CPAP , 3.5 + /- 2.9/h [ p < 0.01 ] ) and in breathing-related arousals ( baseline , 8.9 + /- 6.1/h ; ISAD , 3.7 + /- 3.3/h [ p < 0.01 ] ; CPAP , 1.4 + /- 1.6/h [ p < 0.01 ] ) was achieved with both modalities . Considering all 20 subjects , after 6 weeks of treatment , normalization of the respiratory parameters was seen only with CPAP . However , 30 % of the patients had a lasting reduction in AHI to < 10/h with the ISAD also . The patients considered the ISAD to be easier to use ( scale of 1 to 6 : ISAD , 1.8 + /- 1.1 ; CPAP , 3.1 + /- 1.5 [ p < 0.05 ] ) , and indicated greater utilization of the device in comparison with CPAP . CONCLUSION Even in patients with mild-to-moderate OSAS , CPAP is the more effective long-term treatment modality . In the individual case , the better compliance seen with the ISAD may be advantageous The efficacy of currently recommended treatments is uncertain in patients with mild to moderate obstructive sleep apnea ( apnea-hypopnea index [ AHI ] , 5 - 30 ) . A group of 114 sleep clinic patients with an AHI of 5 - 30 have participated in a r and omized controlled crossover trial of 3 months of treatment with each of nasal continuous positive airway pressure ( CPAP ) , a m and ibular advancement splint , and a placebo tablet . Outcomes were sleep fragmentation and hypoxemia , daytime sleepiness , quality of life , neurobehavioral function , and blood pressure . Both active treatments improved sleep outcomes , but positive airway pressure had a greater effect . The quality of life , symptoms , and subjective but not objective sleepiness improved to a similar degree with both treatments ; however , many of the improvements seen in neuropsychologic function and mood were not better than the placebo effect . Some aspects of nocturnal blood pressure were improved with the splint but not with CPAP . This study has shown that although both CPAP and m and ibular advancement splint effectively treated sleep-disordered breathing and sleepiness , the expected response in neurobehavioral function was incomplete . This may be due to the splint having a lesser therapeutic effect and CPAP being poorly tolerated and therefore used less in this patient group BACKGROUND AND OBJECTIVE Avoidance of sleep in the supine position is recommended in the management of position-dependent OSA hypopnoea syndrome ( OSAHS ) . Our aim was to evaluate the efficacy of a thoracic anti-supine b and ( TASB ) , design ed to mimic the so-called ' tennis ball technique ' , compared with nasal CPAP ( nCPAP ) . METHODS Twenty adults with mild to moderately severe position-dependent OSAHS ( mean AHI + /- SD ) 22.7 + /- 12.0/H ( range 6.0 - 51.2 ) ; AHI supine , 59.6 + /- 27.5/H , were included in a r and omized cross-over trial . Portable sleep studies were undertaken at baseline and after 1 month on each treatment . A successful treatment outcome was defined as AHI < or= 10/H. RESULTS Mean AHI was 12.0 + /- 14.5/H with the TASB and 4.9 + /- 3.9/H with nCPAP ( P = 0.02 ; 95 % confidence interval for the difference : -13.1 to -1.0 ) . With the TASB , treatment ' success ' was achieved in 13/18 subjects , whereas ' success ' was achieved in 16/18 subjects using nCPAP ( P = 0.004 ) . In the two subjects with baseline AHI < 10/H , AHI remained below 10 for both therapies . The TASB successfully reduced time spent in the supine position . Mean percentage supine sleep time was 6.3 + /- 5.9 % with the TASB , and 35.4 + /- 34.1 % with nCPAP ( P < 0.001 ) . No significant differences in sleep efficiency or subjective responses were observed between treatments . CONCLUSIONS Control of body position during sleep using an anti-supine device mimicking the so-called ' tennis ball technique ' provides benefit in the management of position-dependent OSAHS in subjects who meet strict inclusion criteria . The overall improvement is , however , less than for nCPAP
Summary Obstructive sleep apnoea-hypopnoea ( OSAH ) causes excessive daytime sleepiness , impairs quality -of-life , and increases cardiovascular disease and road traffic accident risks .
Continuous positive airway pressure ( CPAP ) treatment and m and ibular advancement devices ( MAD ) have been shown to be effective in individual trials but their effectiveness particularly relative to disease severity is unclear .