Residual excessive daytime sleepiness in patients with obstructive sleep apnea treated with positive airway pressure therapy

  • Shannon N. FosterEmail author
  • Shana L. Hansen
  • Nicholas J. Scalzitti
  • Panagiotis Matsangas
  • Brian A. Moore
  • Vincent Mysliwiec
Sleep Breathing Physiology and Disorders • Original Article



Patients with obstructive sleep apnea (OSA) commonly report residual excessive daytime sleepiness (EDS) despite treatment with positive airway pressure (PAP). The present study aimed to determine whether patients presenting with subjective sleepiness after treatment with PAP therapy had objective evidence of residual sleepiness.


We conducted a retrospective analysis of 29 adults with OSA on PAP therapy who underwent a standardized evaluation for EDS. Patients were evaluated with the Epworth Sleepiness Scale (ESS) and attend an in-lab polysomnogram (PSG) with PAP followed by a multiple sleep latency test (MSLT).


Our cohort consisted of 23 men (79%) and 6 women (21%) with a mean age of 40.7 years. All patients were subjectively sleepy with an ESS score of > 10 and met minimal PAP usage of 4 h a night for at least 70% of nights with a residual apnea-hypopnea index (AHI) ≤ 10. On MSLT, 31% of patients had an average sleep onset latency (SOL) < 8 min, 35% had a SOL between 8 and 11 min, and 35% had SOL > 11 min.


After optimizing PAP therapy and sleep in patients with OSA and residual EDS, the majority were found to have objective findings of an abnormally short SOL on MSLT. This is further evidence that there is a distinct OSA phenotype that will have persistent EDS despite appropriate treatment of their sleep-disordered breathing. Objective testing to quantify the degree of sleepiness is recommended for OSA patients with residual EDS.


Hypersomnolence Excessive daytime sleepiness Obstructive sleep apnea Positive airway pressure therapy Multiple sleep latency test 


Compliance with ethical standards

All procedures performed in this study as it pertains to the utilization of personally identifiable information (involving human participants) were in accordance with the ethical standards of the San Antonio Military Health Systems Institutional Review Board and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Conflict of interest

The authors declare that they have not conflict of interest.


All work was performed at the Wilford Hall Ambulatory Surgical Center, JBSA Lackland, TX 78236. The opinions and assertions in this manuscript are those of the authors and do not represent those of the Department of the Air Force, Department of the Army, Department of Defense, or the U.S. government.


  1. 1.
    Kushida CA, Littner MR, Hirshkowitz M, Morgenthaler TI, Alessi CA, Bailey D, Boehlecke B, Brown TM, Coleman J Jr, Friedman L, Kapen S, Kapur VK, Kramer M, Lee-Chiong T, Owens J, Pancer JP, Swick TJ, Wise MS (2006) Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders. SLEEP. 29(3):375–380CrossRefGoogle Scholar
  2. 2.
    Campos-Rodriguez F, Queipo-Corona C, Carmona-Bernal C, Jurado-Gamez B, Cordero-Guevara J, Reyes-Nuñez N, Troncoso-Acevedo F, Abad-Fernandez A, Teran-Santos J, Caballero-Rodriguez J, Martin-Romero M, Encabo-Motiño A, Sacristan-Bou L, Navarro-Esteva J, Somoza-Gonzalez M, Masa JF, Sanchez-Quiroga MA, Jara-Chinarro B, Orosa-Bertol B, Martinez-Garcia MA (2016) Continuous positive airway pressure improves quality of life in women with OSA. A randomized-controlled trial. Am J Respir Crit Care Med 194:1286–1294. CrossRefGoogle Scholar
  3. 3.
    Weaver TE, Maislin G, Dinges DF, Bloxham T, George CFP, Greenberg H, Kader G, Mahowald M, Younger J, Pack AI (2007) Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. SLEEP. 30(6):711–719CrossRefGoogle Scholar
  4. 4.
    Antic NA, Catcheside P, Buchan C, Hensley M, Naughton MT, Rowland S, Williamson B, Windler S, McEvoy RD (2011) The effect of CPAP in normalizing daytime sleepiness, quality of life, and neurocognitive function in patients with moderate to severe OSA. SLEEP. 34(1):111–119CrossRefGoogle Scholar
  5. 5.
    Launois SH, Ramisier R, Levy P, Pepin J (2013) On treatment but still sleepy: cause and management of residual sleepiness in obstructive sleep apnea. Curr Opin Pulm Med 19:601–608CrossRefGoogle Scholar
  6. 6.
    Laranjeira CM, Barbosa ERF, Rabahi MF (2018) Is subjective sleep evaluation a good predictor for obstructive sleep apnea? Clinics (Sao Paulo) 73:e355CrossRefGoogle Scholar
  7. 7.
    Johns MW (2000) Sensitivity and specificity of the multiple sleep latency test (MSLT), the maintenance of wakefulness test and the Epworth sleepiness scale: failure of the MSLT as a gold standard. J Sleep Res 9(1):5–11CrossRefGoogle Scholar
  8. 8.
    Garbarino S, Scoditti E, Lanteri P, Conte L, Magnavita N, Toraldo DM (2018) Obstructive sleep apnea with or without excessive daytime sleepiness: clinical and experimental data-driven phenotyping. Front Neurol 9:505. CrossRefGoogle Scholar
  9. 9.
    Nam H, Lim J, Kim J et al (2016) Sleep perception in obstructive sleep apnea: a study using polysomnography and the multiple sleep latency test. J Clin Neurol 12(2):230–235CrossRefGoogle Scholar
  10. 10.
    Li Y, Vgontzas AN, Fernandez-Mendoza J, Kritikou I, Basta M, Pejovic S, Gaines J, Bixler E (2017) Objective, but not subjective, sleepiness is associated with inflammation in sleep apnea. SLEEP. 40(2)Google Scholar
  11. 11.
    Littner MR, Kushida C, Wise M, Davila DG, Morgenthaler T, Lee-Chiong T et al (2005) Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test. SLEEP. 28(1):113–121CrossRefGoogle Scholar
  12. 12.
    Sunwoo BY, Jackson N, Maislin G, Gurubhagavatula I, George C, Pack AI (2012) Reliability of a single objective measure in assessing sleepiness. SLEEP. 35(1):149–158CrossRefGoogle Scholar
  13. 13.
    American Academy of Sleep Medicine (2014) International classification of sleep disorders, 3rd edn. American Academy of Sleep Medicine, Darien, ILGoogle Scholar
  14. 14.
    Berry RB, Brooks R, Gamaldo CE, Hardling SM, Marcus CL, Vaughn BV (2012) The AASM manual for the scoring of sleep and associated events. Rules, terminology and technical specifications. American Academy of Sleep Medicine, IllinoisGoogle Scholar
  15. 15.
    O'donoghue FJ, Briellmann RS, Rochford PD et al (2005) Cerebral structural changes in severe obstructive sleep apnea. Am J Respir Crit Care Med 171(10):1185–1190CrossRefGoogle Scholar
  16. 16.
    Robbins J, Redline S, Ervin A, Walsleben JA, Ding J, Nieto FJ (2005) Associations of sleep-disordered breathing and cerebral changes on MRI. J Clin Sleep Med 1(2):159–165Google Scholar
  17. 17.
    Vernet C, Redolfi S, Attali V, Konofal E, Brion A, Frija-Orvoen E, Pottier M, Similowski T, Arnulf I (2011) Residual sleepiness in obstructive sleep apnoea: phenotype and related symptoms. Eur Respir J 38(1):98–105CrossRefGoogle Scholar
  18. 18.
    Philip P, Stoohs R, Guilleminault C (1994) Sleep fragmentation in normals: a model for sleepiness associated with upper airway resistance syndrome. Sleep. 17(3):242–247Google Scholar
  19. 19.
    Calero G, Farre R, Ballester E, Hernandez L, Daniel N, Montserrat canal JM (2006) Physiological consequences of prolonged periods of flow limitation in patients with sleep apnea hypopnea syndrome. Respir Med 100(5):813–817CrossRefGoogle Scholar
  20. 20.
    Mansour KF, Rowley JA, Meshenish AA, Shkoukani MA, Badr MS (2002) A mathematical model to detect inspiratory flow limitation during sleep. J Appl Physiol 93(3):1084–1092CrossRefGoogle Scholar
  21. 21.
    Kapur VK, Baldwin CM, Resnick HE, Gottlieb DJ, Nieto FJ (2005) Sleepiness in patients with moderate to severe sleep-disordered breathing. Sleep. 28(4):472–477CrossRefGoogle Scholar
  22. 22.
    Li Y, Vgontzas AN, Fernandex-Mendoza J et al (2017) Objective, but not subjective, sleepiness is associated with inflammation in sleep apnea. Sleep. 40(2):1–6CrossRefGoogle Scholar
  23. 23.
    He K, Kapur V (2017) Sleep-disordered breathing and excessive daytime sleepiness. Sleep Med Clin 12:369–382CrossRefGoogle Scholar
  24. 24.
    Gottlieb DJ, Ellenbogen JM, Bianchi MT, Czeisler CA (2018) Sleep deficiency and motor vehicle crash risk in the general population: a prospective cohort study. BMC Med 16(1):44CrossRefGoogle Scholar
  25. 25.
    Korkmaz S, Bilecenoglu NT, Aksu M, Yoldas TK (2018) Cyclic alternating pattern in obstructive sleep apnea patients with versus without excessive sleepiness. Sleep Disord 2018:8713409–8713407. eCollection 2018CrossRefGoogle Scholar
  26. 26.
    Maugeri A, Medina-Inojosa JR, Kunzova S, Agodi A, Barchitta M, Sochor O, Lopez-Jimenez F, Geda Y, Vinciguerra M (2018) Sleep duration and excessive daytime sleepiness are associated with obesity independent of diet and physical activity. Nutrients. 10(9):pii: E1219. CrossRefGoogle Scholar
  27. 27.
    Fu Y, Xu H, Xia Y et al (2017) Excessive daytime sleepiness and metabolic syndrome in men with obstructive sleep apnea: a large cross-sectional study. Oncotarget. 8(45):79693–79702CrossRefGoogle Scholar

Copyright information

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2019

Authors and Affiliations

  • Shannon N. Foster
    • 1
    Email author
  • Shana L. Hansen
    • 1
  • Nicholas J. Scalzitti
    • 1
  • Panagiotis Matsangas
    • 2
  • Brian A. Moore
    • 3
    • 4
  • Vincent Mysliwiec
    • 1
  1. 1.Department of Sleep MedicineSan Antonio Military Medical CenterSan AntonioUSA
  2. 2.Operations Research DepartmentNaval Postgraduate SchoolMontereyUSA
  3. 3.University of Texas Health Science Center at San AntonioSan AntonioUSA
  4. 4.University of Texas at San AntonioSan AntonioUSA

Personalised recommendations