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Evaluation and management of residual sleepiness in obstructive sleep apnea

Jean Louis Pepin, MD, PhD
Section Editors
Nancy Collop, MD
Thomas E Scammell, MD
Deputy Editor
Geraldine Finlay, MD


Excessive daytime sleepiness (EDS) is one of the most common symptoms reported by patients with obstructive sleep apnea (OSA). While successful treatment of OSA with positive airway pressure (PAP) therapy or other modalities typically improves sleep quality, a small proportion of patients continue to experience EDS.

Patients with residual daytime sleepiness require careful evaluation to ensure proper functioning of positive airway pressure therapy or oral devices, adherence with primary therapy, and exclusion of alternative causes of EDS. In patients with adequately treated OSA and no additional explanations for residual sleepiness, symptomatic treatment with a wakefulness promoting drug may be beneficial.

The evaluation and management of residual sleepiness in adults with OSA is discussed here. Primary therapy for OSA (eg, PAP, oral appliances, or, occasionally, surgery) is discussed separately. (See "Management of obstructive sleep apnea in adults".)


Excessive daytime sleepiness (EDS) is defined as the inability to maintain wakefulness and alertness during the major waking episodes of the day, with sleep occurring unintentionally or at inappropriate times [1]. In practice, EDS is often measured using the Epworth Sleepiness Scale (ESS), with scores greater than 10 generally considered abnormal (table 1) (calculator 1). The ESS does not capture all facets of sleepiness, however, and some patients who are sleepy may have a normal ESS score.

Residual sleepiness in patients with OSA refers to the subjective complaint of EDS that is present even when breathing and oxygenation parameters during sleep are normalized by successful OSA therapy. Although this definition of residual sleepiness is agreed upon, the entity itself is not universally accepted, as some experts feel that the prevalence of EDS in patients with successfully treated OSA simply reflects a prevalent complaint in the general population [2-4].

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Literature review current through: Nov 2017. | This topic last updated: Dec 14, 2016.
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