Can Nighttime Oxygen Use Replace CPAP for Treatment of Sleep Apnea?

Over the years, my colleagues and I have had requests to prescribe oxygen for treating sleep apnea in patients who do not tolerate CPAP. This made some sense since some of the complications of sleep apnea are driven by a lack of oxygen during periods of apnea. However, there has been little research addressing the role of oxygen as a sleep apnea treatment. We therefore designed the Heart Biomarker Evaluation in Apnea Treatment (HeartBEAT) study. With funding from the American Recovery and Reinvestment Act, we conducted a clinical trial at four U.S. medical centers comparing the health outcomes of patients randomized to receive either healthy lifestyle and sleep education alone (the control group), or that in addition to either CPAP or nocturnal supplemental oxygen. The main study outcome was 24 hour blood pressure level, measured using a cuff that records blood pressure during the day and night. (24 hour blood pressure is often elevated in patients with sleep apnea and contributes to risk of stroke and heart attack.)

The results of the trial were published in the New England Journal of Medicine in June, 2014 (N Engl J Med. 2014 Jun 12;370(24):2276-85.PMID:24918372). A total of 318 patients with sleep apnea and risk factors for heart disease were enrolled in the study and followed for 3 months. CPAP performed significantly better than either control or supplemental oxygen in terms of reducing blood pressure levels. The effect of CPAP on blood pressure was greatest at night, the time when sleep apnea often prevents the expected fall in blood pressure. Moreover, the decrease in blood pressure was seen despite generally well-controlled blood pressure measured during routine clinic visits.

What does this research mean to you? The study was designed to most directly address the role of oxygen and CPAP as a means for reducing heart disease risk factors, such as improving blood pressure control. It focused on patients who had risk factors for heart disease, had moderate or more severe sleep apnea, and were not very sleepy. The study supports a beneficial effect of CPAP on blood pressure and does not support supplemental oxygen for helping with blood pressure control. The average improvement in blood pressure levels- by 2 to 4 mm mercury- is small, but occurred over and beyond the effects of routine hypertension medications. The improvement in blood pressure is estimated to reduce, on average, the risk of death from stroke by 10%. Because sleep apnea commonly elevates nighttime blood pressure levels, and many people are unaware of this, the findings suggest that CPAP may benefit many patients with sleep apnea.

More about the study's background can be found: http://tune.pk/video/5868591/sleep-apnea-research-the-heartbeat-study-susan-redline

We are still analyzing data from this study and also examining whether oxygen helps with fatigue, mood and quality of life. It would be of interest to better understand our members experience with oxygen and whether we should think about new questions to ask of the data in this trial.

It makes perfect sense. Simply using O2 without CPAP won't work. The patient is still having events which won't allow the O2 into the airway. There are however many patients with severe OSA that are on 02 with CPAP to bring their oxygen saturation up to a safe level.

Joe

Thanks Joe for clarifying this. Absolutely correct- this study did not address the role of using supplemental oxygen along with CPAP, which is often needed in patients with lung disease or what is called "hypoventilation" disorders. Thanks for the clarification.

Absolutely, Arch!
Susan, what about oxygen supplementation w/PAP and cognitive function? We have all this dementia burgeoning in our population, we know OSA can cause brain damage via at least the hypo-oxygenation, and there is a ton of "anecdotal" evidence. Would love to see that study.

Great question! The results from the study on oxygen vs CPAP (HeartBEAT Study) suggest that some quality of life measures improve more with oxygen--especially those related to physical functioning. Mood seemed to improve more with CPAP. We did not have measures of cognitive function in this study--its really too bad, as you are correct that drops in oxygen can adversely affect the brain. We know from work in patients with chronic lung disease and daytime hypoxemia that use of supplemental oxygen can improve their cognitive function. Had the "HeartBEAT" study been designed with patient input from the beginning, we likely would not have missed the chance to include a good cognition test. We need patients to help design the research from the beginning!

You're also pulmonology trained -- what about apnea not being simply a night-time issue? What if apnea is apnea, and we only notice it during the day? I have observed patients... Any info on that in your work?

My apologies -- what if we only notice the apneas at night?

In COPD, even those with nighttime drops in oxygen benefited from oxygen.

Anybody else have personal experience using o2 at night. Either with cpap or just o2?

I just know that I pray for something else that is better than cpap to be used. A machine that goes along with someones breathing. Like I am a sleep talker so every time I tried using cpap I would start talking in my sleep. Then I can't breathe so I would knock it off of me while half awake. It would be so much better if there was a machine that went with a persons breathing. If a person would do something like talk in their sleep the machine would stop working while that was happening and then start working again after that. I tried every kind of mask there is, even the nose pads. I tried cpap and bipap without any success with it. Now I have one of those mouth pieces I just got not too long ago. I'm so afraid of it failing that I have been too scared to use it. I just know one thing, I'm so tired of being tired.

Hi @AffableCobaltBlueJellyfish7400. Is the mouth piece you mention something you purchased over the counter without a prescription? Or have you seen a dentist who specializes in sleep medicine? There are oral appliances that can be adjusted that are designed specifically for patient who have sleep apnea, but they must be prescribed by a dentist and properly fitted and adjusted. Those types of oral appliances are generally most effective for patients with sleep apnea, depending on severity. There is CPAP technology available that senses wake and lowers the pressure until you return to sleep. If you Google "awake sensing cpap" there should be some results that talk about this. Some APAP machines will lower the pressure when they sense coughing, talking, etc. If you are willing to try CPAP or APAP again, this might be something worth mentioning to your home care provider or sleep physician. Good luck, and I hope you are able to get some rest and feel less tired!

I am hoping to find an acceptable alternative to CPAP for my so called OSA. Having spent 3 years now trying to get my drivers license back in BC Canada without success. I've tried all the CPAP masks, machines, settings adjustments, and the simple fact is I get less sleep, am more exhausted and deeply frustrated by the whole experience. This is not helped by the Salesman who deflect all input and seemed over focused on one objective, to make me buy the device, even if it doesn't help me. The Sleep Specialist seems of the same mindset, almost as if their interests were coordinated. In my case, I drifted off after closing my eyes briefly while stopped in traffic, the day after having undergone Dental Surgery, with some post surgery Tylenol 3 and antibiotics in my system. Concurrently I have high Iron Levels, and until recently stage 3 HepC, both of which have now been successfully treated. All of which may have previously impacted my hemoglobin O2 uptake Levels, as well as generate depression and fatigue. But none of this matters to the Sleep Specialist who continues to dig in with, "Either I buy and use this machine for the rest of my life, or he wont sign off on you getting my license back. And there is NO Appeal process or even a face to face Meeting process with the BC Drivers Licensing Agency. It take 3 months to submit even a request or letter, and another 2 months for them to reply. They have refused to consider all the letters submitted on my behalf by the dentist, my doctors and even our Local BC Member of Parliament. Something is very wrong with this whole process. By the way, my first test 3 years ago indicated a low to moderate level of Sleep Apnea. Then a follow up overnight Hospital Test suddenly and surprisingly insisted I in fact now had SEVERE Sleep Apnea! And ever since that test, they promoters of the CPAP Machines have Owned Me. So my next hope is perhaps an Oxygen Therapy at night, combined with a daytime medication like Modafinil and Armodafinil might satisfy the powers that be and get my license reinstated. I have a meeting Nov. 30th with the Sleep Specialist again, (which took 6 months to get) and I want to present a request fro some alternative solutions. Meanwhile I am fit, active and alert during the day. Although at 63 less maybe so then I used to be, but certainly not in danger of falling asleep or being unable to operate Machinery etc. I Don't smoke, drink, or Use drugs of any kind or rarely even stay up late. If the CPAP machine had somehow improved my life or rest I would be all for it. But the fact is it made it worse, much worse, and I have learned to resent the whole "System" that seems programmed just to sell more machines, even if they don't help. so ~ PLEASE HELP!!

Hello @EnthusiasticRaspberryMandrill3407. I'm very sorry to hear you have been through such a process, and I hope things begin to improve for you. While I don't know much about the Canadian process you are attempting to navigate, I can attempt to provide some information that might be helpful. It sounds like your first test might have been performed in the home. Is that correct? If so, home tests are known to underestimate the severity of sleep apnea. This is because the reporting is usually based on the recording time (start to end) instead of actual time spent asleep. When there is EEG present that allows wake to be removed from the equation, the severity of sleep apnea usually does increase. Sometimes the increase is minor, but other times the increase in severity can be significant. Also, sleep apnea can change with age and other factors (medications, other health conditions, etc.). That might help explain why your diagnosis was worse with the in-lab hospital test. As for treatment, I am sure you know by now that CPAP is considered the "gold standard" for treating sleep apnea. However, there are options you might discuss with your physician such as oral appliance (dental devices) and surgical options. I am not sure what is available to you in Canada, but the Inspire implant has also been approved here in the U.S. and has been a successful treatment for patients with moderate to severe sleep apnea. Are there any other members who might have suggestions? Best wishes, and please do keep us posted on your progress.

Hello, I have ben diagnosed with mild sleep apena AHI-14 and this was the sleep test. The home test gave me negative results. Ive been fighting for two years the sleep apnea. I've been using the C-Pap for over a year but my condition is getteing eorse. I have no relief from Chronic and I mean chronic fatigue. I camt sit down in public seting without falling asleep even if my eyes are open. I wear the nasal pillow mask and even tried using a sleep strap with it. I now wake up with palpitations all the time. The sad part is, I love the mask because I breathe better with it than without it. However, it has not help me cognitevly, I have been told Im sleep walking. Snoring while performing regular during work. But of course groggy and now anxious through the whole day. Its very embarrassing and fustrating. Ive lost 20lbs, I eat healthy and exercise regularly. Ive even used the nuvigil day alertness med with no beneficial relief. Should I be on oxygen all day? That is what it seems like. How would you use O2 and a CPAP, I thought the CPAP provided O2 I am so confused the difference. If there is anything else that would help, I'd be more than glad to try it out.

Hello, @Mimi. I'm sorry to hear you are still having such fatigue. While CPAP often improves alertness and helps fatigue issues for some patients, there are often other causes for fatigue. Those causes can be related to other health conditions, to medications, or to other issues not related to sleep apnea. I encourage you to speak with your physician about your continued symptoms. Regarding O2 and CPAP, the two are very different. CPAP uses only room air to provide positive pressure that helps keep your airway open during sleep. It can help improve blood oxygen levels because it helps keep breathing regular during sleep. Oxygen does not prevent airway collapse and is generally not used to treat sleep apnea. Patients with other conditions that cause their blood oxygen level to drop at night, but who do night have sleep apnea, may be prescribed oxygen to help maintain blood oxygen levels while the sleep. There are patients who use oxygen and CPAP together, and this requires a prescription for both treatments. A home care company usually provides the appropriate equipment to allow the oxygen machine to work with the CPAP machine. The two may be prescribed together when sleep apnea has been treated but blood oxygen levels remain low. Your physician should be able to test you to make sure your blood oxygen levels are as they should be both during wake and during sleep. I hope this information is helpful, and please keep us posted on your progress!

Mimi, I got on PAP therapy due to falling asleep while driving and using power tools while working not to mention dozing off constantly anytime at rest. I am not a medical person but my understanding is that the issue is caused by two main factors. One, when sleeping or dozing with sleep apnea, you don't go into deep sleep needed for real rest for as long or at all. Second, with sleep apnea, your blood doesn't get the oxygen it needs because you airway is shut for periods of time. It is my understanding that normal is mid-90s and if you drop significantly lower your organs and brain starve for oxygen and real damage can occur.

I am not sure how you can self-test for the level of sleep you get when using PAP therapy but you can buy an inexpensive Pulse Oximeter and record your blood O2 level while sleeping. I bought one on eBay for well under $100 and it comes with software to allow you to download a nights results of your pulse rate as well as O2 level. I have used it while napping without my BIPAP in place and have found that my O2 levels are all over the place but with the BIPAP on during the night, my O2 levels are pretty much perfect. Since using PAP therapy, my sleepiness is gone and I feel a bit more perky at all times.

Suggest you self test your O2 levels while sleeping and see where your O2 is using therapy. If they are not where they should be, then perhaps your therapy prescription needs evaluation. If your O2 level is satisfactory, then you have issues beyond my understanding and should consult a pro for the help you need. Best of luck and do follow up and let us know how you fare.

DecisiveChampagneQuail3429 - I am not a medical professional and was diagnosed with OSA about a year ago. I joined this forum to get information, just as you are and have found that there are situations where O2 and CPAP therapies are combined as there are specific machines with this capability. It is often difficult to get good information on this whole subject as many primary care physicians, who are the medical professionals we often come in contact with, don't really recognize ALL the various implications of sleep apnea. This thread discussed only one; blood pressure and there are many others and they often overlap. One way to learn about any issue, especially one so complex is to do some self research on the internet while being wary of sources. Look up ANY health issue on youtube, for instance and you will see a lot of snake oil and diversity of opinions and some outright dangerous and poor medical advice; same with some sleep apnea forums. Be discerning while looking and once you have more specific issues regarding O2 & CPAP therapies used in concert with each other, ask more specific questions as I suspect the subject could fill volumes and the answers will be aimed at specific medical issues related the need for such therapy and there are probably more tha a couple. Good luck in your search.

I am a patient with sever OSA, When I was first diagnosed I had over 50 AHI and my SpO2 that went well below 88% I also had high blood pressure that was barely controlled with a complex cocktail of medications. During the fit test segment of the study I was unable to tolerate CPAP/BiPAB and accompanying masks. My Doctor I was tested with nocturnal O2 with the results that the SpO2 remained above 88%. After being on the O2 therapy for a year or so I was able to reduce the number of daily medications and the BP is well with in the normal range. I am now using APAP/O2 therapy with the DreamWear mask with no issues. I will be seeing both my PCP and Pulmonologist this month. I will update this then.

I didn't notice any replies mentioning that extra oxygen reduces your body's breathing reflex.

One of the factors in sleep apnea incidents is your breathing reflex. It's hypercapnia (the buildup of CO2) that eventually forces your body to overcome whatever is causing the apnea/hypopnea in the first place.

For example, If it's a simple breathing obstruction, for example your palate collapsing when you relax during sleep, then the CO2 buildup can eventually either stress you enough to un-relax it, or cause your body to try hard enough to overcome it. If it's a neurological or other factor causing you to simply stop trying to breathe (for example, unobstructed apnea, happens in a smaller proportion but still many people), the CO2 buildup can overcome this and cause you to resume breathing.

When you stop or slow breathing for whatever reason, you don't instantly run out of oxygen. The left-over oxygen in your lungs is known as your FRC, Functional Residual Capacity. With normal lungs full of air, you are thought to have something like two minutes' worth, normally, though the CO2 buildup happens gradually during that time and your breathing reflex increases pretty quickly. If you have the usual end-expiratory apnea (you breath out, then stop breathing) it's worse, of course, because you have less air in your lungs, but my point is the same:

Supplementing oxygen increases your FRC by increasing the extra oxygen in your lungs. This, once it reaches a significant amount, reduces your body's breathing reflex, and/or retards the timing of its response.

I suppose one could argue that this may render oxygen use (at least by some) irrelevant or worse. They will have more FRC, which will protect them from the harm of the apnea, but may also make the apnea incidents last longer, the CO2 buildup triggering forced breathing being delayed. But perhaps prolonged incidents from oxygen use, themselves, would be worse. The cortisol buildup from stress may be increased simply because of the longer timespan, for example.

I am not offering a conclusion either way, regarding O2 supplementation. But its impact on the breathing is a factor worth considering.

Oxygen is a big issue with sleep apnea. My blood pressure is fine, because it starts at a very low level. I would like supplemental O2 to help with my oxygen levels, but some people confuse a test NOT DESIGNED TO TEST FOR THIS as indicating that is does not work. Please be clear that this was designed to test BP, and does not have helpful information about 02.