Treatment Modalities and Therapy Management
Matching therapy to diagnosis
Positive airway pressure is the mainstay for obstructive sleep apnea, delivered as fixed CPAP, auto-titrating PAP, or bilevel therapy when higher pressures or hypoventilation are issues. Therapeutic goals are a residual AHI below 5, leak controlled (roughly under 24 L/min), and consistent use - commonly defined as at least 4 hours per night on 70% of nights. Alternatives include mandibular advancement devices for mild to moderate disease, positional therapy, hypoglossal nerve stimulation for selected patients, weight management, and surgical options such as maxillomandibular advancement.
Chronic insomnia is treated first line with cognitive behavioral therapy for insomnia, whose active ingredients are stimulus control, sleep restriction, cognitive restructuring, relaxation training, and relapse prevention; sleep hygiene education alone is not CBT-I. Pharmacologic options carry risks of tolerance, falls, and next-day impairment, and newer orexin-receptor antagonists have a different profile.
Restless legs syndrome responds to iron repletion when ferritin is low, alpha-2-delta ligands, and dopamine agonists with careful monitoring for augmentation; aggravating drugs such as antihistamines and dopamine antagonists should be reviewed. Circadian disorders rely on timed light exposure and correctly timed melatonin - for delayed sleep phase, melatonin is given several hours before the habitual bedtime, not at bedtime. Narcolepsy management combines scheduled naps with stimulants, wake-promoting agents, and sodium oxybate.
Traps
Pressure changes require an order; a single good night does not establish adherence; higher pressure does not imply more severe disease; and congestion is often a humidification or interface problem rather than a pressure problem.
Rule of thumb: when PAP adherence falters, troubleshoot in order - interface and leak first, then nasal symptoms and humidification, then expectations and claustrophobia.