The most appropriate next step in management is to review data from the patient's continuous positive airway pressure (CPAP) device to assess adherence to therapy. This patient has severe, symptomatic obstructive sleep apnea (OSA), for which positive airway pressure (PAP) is the preferred therapy. The response to treatment is dependent on adherence, and a substantial proportion of patients, particularly early in the course of therapy, do not wear the PAP device as intended (all night, every night). Downloading and reviewing data from the PAP device yields important information about usage that can be discussed with the patient to explore barriers and formulate a plan to promote compliance.

Despite some limited evidence that the use of hypnotic agents such as eszopiclone may be helpful in promoting CPAP adherence early in therapy, the role of hypnotic agents in promoting CPAP compliance remains controversial. Their use later in the course of PAP, as in this patient, is not established, and the risk of side effects may outweigh the benefit.

Modafinil is a stimulant medication that is approved for use in patients with OSA who are using CPAP optimally and continue to have residual excessive sleepiness. Compliance with CPAP therapy should be established in this patient before prescribing modafinil.

There are few data to support the superiority of a bilevel positive airway pressure (BPAP) device in promoting treatment compliance for OSA. BPAP, which promotes ventilation by delivery of pressure support derived from the gradient between inspiratory and expiratory pressure, is the preferred therapy for hypoventilation syndromes, such as those associated with neuromuscular disease or obesity.