Medical Sedation and Sleep Apnea

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Key points

  • Although there is continued caution about the use of benzodiazepines in patients with obstructive sleep apnea (OSA), there is scant clinical evidence supporting significant worsening of sleep-related breathing.

  • Nonbenzodiazepine receptor agonists seem to be relatively well tolerated by most patients with OSA and, in selected cases, may show promise as a component of therapy for OSA.

  • Opioids exert their effects on respiration by reducing the ventilatory rate and tidal volume, decreasing

Pathophysiologic mechanisms of OSA

OSA is characterized by a repetitive intermittent reduction of airflow associated with collapse at the level of the pharynx and ongoing ventilatory effort during sleep. This action results in either complete (apnea) and/or partial (hypopnea) cessation of airflow. Occasional obstructive apneas and hypopneas during sleep are common, but when the frequency of such events increases beyond 5 per hour of sleep, both symptoms and pathologic consequences of OSA begin to manifest. The pathophysiology

Relevant Pharmacology

The varied therapeutic indications for BDZ result from exploiting their hypnotic, anxiolytic, anticonvulsant, antispasmodic, and amnestic effects. These effects are mediated by the agonistic action of BDZ on various GABAA receptor subtypes. Which effects predominate with a given BDZ depend in large part on which subunits are most affected and in which part of the nervous system the receptors are located. The pharmacology of GABAA receptors and their subtypes is well worked out. In brief, the

Relevant Pharmacology

Several agents have been developed that selectively bind to the α1 subtype GABAA subunit. These non–BDZ-RA preferentially cause sedation and less prominent muscle relaxation and anxiolysis promoted by nonselective BDZ (see Fig. 2). These agents include zolpidem, zaleplon, zopiclone, and eszopiclone. Because of the selectivity of their pharmacologic targets, non–BDZ-RA have generally been associated with a more favorable side-effect profile than the nonselective BDZ. However, because they do not

Opioids

The quantity of opioid prescriptions in the United States has grown exceedingly in recent years. In 1990, it is estimated that more than 2.2 million grams of morphine, 3273 g of fentanyl, and 118 455 g of hydromorphone were used medically. Subsequent follow-up measures suggested that the use of morphine had increased by 59%, fentanyl by more than 1000%, and hydromorphone by 19%.57 Only meperidine use declined over this interval.58 In the authors’ sleep practice, they see clear increases in the

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  • Disclosures: nil.

    Conflicts of interest: nil.

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