Understanding adherence to continuous positive airway pressure in patients with obstructive sleep apnea post-stroke: A prospective study based on the Andersen model

Adherence to continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) post-stroke is often problematic, despite potential benefits. This study aimed to evaluate CPAP adherence in patients with OSA post-stroke based on the Andersen behavioral model of health services utilization. A total of 227 eligible participants were recruited from a Chinese hospital. After baseline assessment, participants were followed for 6 months to determine short-term CPAP adherence. Those with good short-term adherence were followed for an additional 6 months to explore long-term adherence and influencing factors. Short-term CPAP adherence rate was 33%. Being married or living with a partner, having an associate degree or baccalaureate degree or higher, and stronger health beliefs independently predicted short-term CPAP adherence. Only 25% of participants from the adherent group showed good long-term adherence. The factor associated with long-term CPAP adherence was participants not using alcohol. Adherence to CPAP is suboptimal among patients having OSA post-stroke. Addressing unfavorable predisposing factors and modifying health beliefs are suggested.

Assessment and management of continuous positive airway pressure therapy in patient with obstructive sleep apnea

Obstructive sleep apnea (OSA) causes excessive daytime sleepiness, impaired daytime functioning, and an increased risk of cardiovascular diseases. Continuous positive airway pressure (CPAP) is a highly effective therapy for moderate to severe OSA. Although CPAP adherence is commonly assessed using a 4-hthreshold, determining the optimal usage time based on clinical outcomes is crucial. While subjective sleepiness often improves with ≥4 h of CPAP usage, an extended duration (≥6 h) may be necessary to impact objective sleepiness. CPAP demonstrated a modest yet clinically meaningful dose-dependent effect on lowering blood pressure. For patients seeking antihypertensive benefits from CPAP therapy, the goal should extend beyond 4 h of use to maximize the therapeutic impact. Recognizing individual variations in sleep duration and responses to CPAP therapy is essential. The adoption of 'individualized goals for CPAP use,' outlining target times for specific outcomes, should also consider an individual's total sleep duration, including periods without CPAP. The impact of CPAP on clinical outcomes may vary, even with the same duration of CPAP use, depending on the period without CPAP use, particularly during the first or second half of sleep. Patients who remove or initiate CPAP midway or have a low CPAP usage frequency may require different forms of guidance. Tailoring patient education to address CPAP usage patterns may be necessary to enhanced satisfaction, self-efficacy, and adherence to therapy. Management of CPAP treatment should be personalized to meet individual needs and adapted based on specific response patterns for achieving treatment efficacy.

Objectively measured adherence may affect side effects of mandibular advancement therapy in subjects with obstructive sleep apnea

PURPOSE

The purpose of this study was to determine if objectively measured adherence to oral appliance (OA) treatment may affect dental changes and temporomandibular disorders (TMD) in patients with obstructive sleep apnea (OSA).

METHODS

The original study group consisted of adults with OSA who were referred for OA therapy. Eight indicators of subjective side effects of using OA (temporomandibular joint (TMJ) and muscle pain, pain in teeth, jaw stiffness in the morning, clicking, dry mouth, hypersalivation, gingival irritation) were evaluated by a questionnaire. Three occlusal indicators (overjet, overbite, molar occlusion) and clinical TMD signs (TMJ pain, muscle pain, clicking, jaw deviation on opening) were evaluated at baseline and at the 3-, 6-, and 12-month follow-up. In addition, objective adherence monitoring for OA was registered. Statistical analyses included the chi-square test, Fisher's exact test, paired sample t-test, and linear regression analyses.

RESULTS

A total of 58 adults with OSA were referred for OA therapy. Mean (SD) age was 50.7 (11.7) and mean apnea-hypopnea index (AHI) was 19.5 (10.0). At 1-year follow-up, the study group consisted of 28 men and 12 women. Overjet but not overbite reduced significantly after 1-year OA therapy. The average nightly wear of OA was related to overjet and overbite reduction, and to TMD signs. Hypersalivation, dry mouth, and tooth discomfort were the most common subjective side effects of OA therapy.

CONCLUSION

There was a time-dependent relationship with the nightly wear of OA and reduction in overjet and overbite, and clinical TMD signs. With 60% of mandibular advancement, dental changes and TM-disorders were considered mild/minor in the 1-year study period.

Comparative analysis of sleep parameters and structures derived from wearable flexible electrode sleep patches and polysomnography in young adults

Polysomnography (PSG) is the gold standard for clinical sleep monitoring, but its cost, discomfort, and limited suitability for continuous use present challenges. The flexible electrode sleep patch (FESP) emerges as an economically viable and patient-friendly solution, offering lightweight, simple operation, and self-applicable. Nevertheless, its utilization in young individuals remains uncertain. The objective of this study was to compare sleep data obtained by FESP and PSG in healthy young individuals and analyze agreement for sleep parameters and structure classification. Overnight monitoring with FESP and PSG recordings in 48 participants (mean age: 23 yr) was done. Correlation analysis, Bland-Altman plots, and Cohen's kappa coefficient assessed consistency. Sensitivity, specificity, and predictive values compared classification against PSG. FESP showed strong correlation and consistency with PSG for sleep monitoring. Bland-Altman plots indicated small errors and high consistency. Kappa values (0.70-0.84) suggested substantial agreement for sleep stage classification. Pearson correlation coefficient values for sleep stages (0.75-0.88) and sleep parameters (0.80-0.96) confirm that FESP has a strong application. Intraclass correlation coefficient yielded values between 0.65 and 0.97. In addition, FESP demonstrated an impressive accuracy range of 84.12-93.47% for sleep stage classification. The FESP also features a wearable self-test program with an error rate of no more than 8% for both deep sleep and wake. In young adults, FESP demonstrated reliable monitoring capabilities comparable to PSG. With its low cost and user-friendly design, FESP is a potential alternative for portable sleep assessment in clinical and research applications. Further studies involving larger populations are needed to validate its diagnostic potential.NEW & NOTEWORTHY By comparison with PSG, this study confirmed the reliability of an efficient, objective, low-cost, and noninvasive portable automatic sleep-monitoring device FESP, which provides effective information for long-term family sleep disorder diagnosis and sleep quality monitoring.

Effect of a digital patient motivation and support tool on CPAP/APAP adherence and daytime sleepiness: a randomized controlled trial

The purpose of this study was to assess the effect of a digital patient support (DPS) tool, complementary to standard care on continuous or automatic positive airway pressure (auto)CPAP adherence and daytime sleepiness after 12 weeks in patients diagnosed with severe obstructive sleep apnea (OSA). All patients with apnea-hypopnea index (AHI) ≥ 30 per hour were prospectively included and randomized to receive standard care (SC) or standard care with personalized DPS via a mobile app prototype version (SC + DPS). Patients in the SC + DPS arm received additionally automated feedback on their therapy, motivational messages and therapy recommendations. 100 patients completed the study (SC: 50, SC + DPS: 50). No differences were found in characteristics of SC vs. SC + DPS (mean ± SD) for age (53.9 ± 10.8 vs. 51.7 ± 12.3 years), initial diagnostic apnea-hypopnea index (51.1 ± 15.5 vs. 50.9 ± 17.7 events/h), BMI (33.8 ± 6.7 vs. 33.5 ± 4.5 kg/m), and Epworth Sleepiness Scale (ESS) baseline score (9.5 ± 4.2 vs. 9.1 ± 5.2). After 12 weeks, mean ESS score was significantly lower (SC: 7.6 ± 4.1 vs. SC + DPS: 5.5 ± 3.9; p = 0.006) in the SC + DPS group vs. standard care group. Therapy adherence was significantly higher (SC: 268.7 ± 122.1 vs. SC + DPS: 338.8 ± 106.8 min; p = 0.002) in the SC + DPS group compared to standard care group. No difference was found in the residual AHI between both groups. However, SC + DPS group showed a trend towards fewer phases with increased leakage compared to SC group. Intention-to-treat analysis (112 (56/56) patients) showed similar results. After 12 weeks, (auto)CPAP adherence and daytime sleepiness improved significantly in patients with severe OSA using the digital patient support tool. Clinical Trial Registration (retrospectively registered): Registry: NCT05440279; Title: Effects of Telemedical Support on Therapeutic Results of CPAP Patients; URL: https://clinicaltrials.gov/ct2/show/NCT05440279; Date of registration: June 30, 2022.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41105-023-00479-9.

Effects of chlorthalidone plus amiloride compared with amlodipine on short-term blood pressure variability in individuals with hypertension and obstructive sleep apnea: a randomized controlled trial

OBJECTIVE

To compare the effects of chlortalidone plus amiloride and amlodipine on blood pressure (BP) variability in patients with hypertension and obstructive sleep apnea syndrome (OSA).

METHODS

A randomized, controlled, double-blind trial enrolled men and women aged 40 years or older with a diagnosis of OSA (apnea-hypopnea index 10-40 apneas/h of sleep) confirmed by overnight laboratory polysomnography and systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg. Participants were randomized to receive chlortalidone 25 mg plus amiloride 5 mg daily or amlodipine 10 mg daily for 8 weeks. BP variability was calculated from 24-hour ambulatory BP monitoring at baseline and follow-up using the following indices: SD, coefficient of variation, average real variability (ARV), time-rate index, and variability independent of the mean (VIM).

RESULTS

The study included 65 patients, with 33 assigned to the chlortalidone plus amiloride group and 32 to the amlodipine group. Participants in both groups had similar baseline characteristics. Short-term BP variability decreased within groups for SD and ARV indexes for 24-hour systolic BP and daytime systolic BP, but statistically significant time*group interactions were found for sleep systolic SD and VIM, with greater reduction in patients treated with amlodipine.

CONCLUSION

In brief, our study has shown that the use of chlorthalidone in combination with amiloride and amlodipine produces comparable effects on short-term BP variability in patients with hypertension and OSA. Therefore, our findings suggest that BP variability may not be a significant factor when choosing between these medications for the treatment of hypertension and OSA.

Treatment of obstructive sleep apnea with a simple CPAP device

PURPOSE

CPAP is the "gold standard" treatment for obstructive sleep apnea (OSA). Current CPAP models have developed additional functions including automatic CPAP and pressure relief. However, CPAP adherence has not improved over the last three decades. Many patients in low-income countries cannot afford these CPAP devices. A novel simple CPAP device with a fixed pressure without pressure controller was developed.

METHODS

Manual CPAP pressure titration was performed in 127 patients with OSA. Six patients with a titration pressure higher than 11 cmH2O and 14 patients who could not tolerate CPAP were excluded, leaving 107 participating in the following 2 studies. In study one, 54 of 107 patients were treated by both conventional fixed CPAP and simple CPAP in random order. In the second study, another 53 patients were treated by both autoCPAP in automatic function and simple CPAP in random order. Simple CPAP was fixed at 10 cmH2O, 8 cmH2O, and 6 cmH2O for patients whose titration pressure was between 9-10, 7-8, and ≤ 6 cmH2O, respectively. Conventional fixed CPAP device was set exactly the same as manual titration pressure.

RESULTS

All patients whose manual titration pressure ≤ 10 cmH2O were effectively treated by simple CPAP (AHI 40.7 ± 2.3 events/h before vs 2.5 ± 0.3 events/h after, p < 0.001). Patients expressed similar preferences for simple CPAP, autoCPAP, and conventional fixed CPAP (p > 0.05).

CONCLUSIONS

We conclude that a novel simple CPAP is an alternative treatment for most patients with OSA, which may widen access to CPAP therapy in the developing countries because of its low cost.

Veterans' Experiences of Support in Managing Comorbid Sleep Apnea and Type 2 Diabetes

BACKGROUND

Obstructive sleep apnea (OSA) is highly prevalent in patients with Type 2 diabetes, more so in veterans compared with nonveterans. Positive airway pressure is the recommended first-line treatment for OSA. However, adherence to both positive airway pressure and diabetes management regimens can be challenging for older adults. Support from family or friends may improve glucose control or sleep-apnea-related symptoms, yet the evidence is limited when both conditions coexist.

OBJECTIVES

This study aimed to describe veterans' experiences of support from family and friends with managing comorbid sleep apnea and Type 2 diabetes.

METHODS

We conducted a postal survey of older veterans with OSA and Type 2 diabetes from one healthcare system. Questions include demographic and health-related information, information about sleep apnea and diabetes treatment and education received, related support from family or a friend, perceived benefits of regular positive airway pressure device use on improving sleep health, and perceived benefits of education for family or a friend on sleep apnea and diabetes. Descriptive and bivariate analyses were performed.

RESULTS

Of 145 respondents (mean age = 72 years), 43% reported receiving help for Type 2 diabetes from family or a friend. Almost two thirds of the respondents were currently using a positive airway pressure device, of whom 27% received support with device use from family or friends. About one third of veterans perceived family and friends receiving education on treating sleep apnea and diabetes to be very or extremely helpful. Such perceived benefit was higher among those who were married or identified as non-White. Veterans using a positive airway pressure device had lower hemoglobin A1c levels than nonusers.

DISCUSSION

Veterans perceived that additional education for the individuals providing support would be beneficial. Future studies could address interventions to increase sleep apnea and Type 2 diabetes knowledge among families and friends of veterans with these comorbid conditions. In addition, patients' adherence to positive airway pressure may be enhanced by support from family and friends.

The firstly visited department affects the acceptance of CPAP in patients with obstructive sleep apnea: a cohort study

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is the first-line treatment for obstructive sleep apnea (OSA). However, the low acceptance rate of CPAP remains a challenging clinical issue. This study aimed to determine the factors that influence the acceptance rate of CPAP.

METHODS

This retrospective cohort study was conducted at the sleep center of Shuang-Ho Hospital. Initially, 1186 OSA patients who received CPAP therapy between December 2013 and December 2017 were selected, and finally, 1016 patients were analyzed. All patients with OSA received CPAP therapy for at least 1 week, and their acceptance to treatment was subsequently recorded. Outcome measures included patients' demographic and clinical characteristics (sex, age, BMI, comorbidities, history of smoking, and the medical specialist who prescribed CPAP treatment), polysomnography (PSG) results, and OSA surgical records.

RESULTS

Patients with a lower CPAP acceptance rate were referred from otolaryngologists (acceptance rate of otolaryngology vs. others: 49.6% vs. 56.6%, p = .015), in addition to having a lower apnea-hypopnea index (AHI) (acceptance vs. non-acceptance: 55.83 vs. 40.79, p = .003), rapid eye movement AHI (REM-AHI) (acceptance vs. non-acceptance: 51.21 vs. 44.92, p = .014), and arousal index (acceptance vs. non-acceptance: 36.80 vs. 28.75, p = .011). The multiple logistic regression model showed that patients referred from otolaryngology had a lower CPAP acceptance rate (odds ratio 0.707, p = .0216) even after adjusting for age, sex, BMI, AHI, REM-AHI, arousal index, comorbidities, and smoking status.

CONCLUSIONS

Before their initial consultation, patients may already have their preferred treatment of choice, which is strongly linked to the type of medical specialists they visit, and consequently, affects their rate of acceptance to CPAP therapy. Therefore, physicians should provide personalized care to patients by exploring and abiding by their preferred treatment choices.

Adherence to CPAP Treatment and the Risk of Recurrent Cardiovascular Events: A Meta-Analysis

Importance

The effect of continuous positive airway pressure (CPAP) on secondary cardiovascular disease prevention is highly debated.

Objective

To assess the effect of CPAP treatment for obstructive sleep apnea (OSA) on the risk of adverse cardiovascular events in randomized clinical trials.

Data Sources

PubMed (MEDLINE), EMBASE, Current Controlled Trials: metaRegister of Controlled Trials, ISRCTN Registry, European Union clinical trials database, CENTRAL (Cochrane Central Register of Controlled Trials), and ClinicalTrials.gov databases were systematically searched through June 22, 2023.

Study Selection

For qualitative and individual participant data (IPD) meta-analysis, randomized clinical trials addressing the therapeutic effect of CPAP on cardiovascular outcomes and mortality in adults with cardiovascular disease and OSA were included.

Data Extraction and Synthesis

Two reviewers independently screened records, evaluated potentially eligible primary studies in full text, extracted data, and cross-checked errors. IPD were requested from authors of the selected studies (SAVE [NCT00738179], ISAACC [NCT01335087], and RICCADSA [NCT00519597]).

Main Outcomes and Measures

One-stage and 2-stage IPD meta-analyses were completed to estimate the effect of CPAP treatment on risk of recurrent major adverse cardiac and cerebrovascular events (MACCEs) using mixed-effect Cox regression models. Additionally, an on-treatment analysis with marginal structural Cox models using inverse probability of treatment weighting was fitted to assess the effect of good adherence to CPAP (≥4 hours per day).

Results

A total of 4186 individual participants were evaluated (82.1% men; mean [SD] body mass index, 28.9 [4.5]; mean [SD] age, 61.2 [8.7] years; mean [SD] apnea-hypopnea index, 31.2 [17] events per hour; 71% with hypertension; 50.1% receiving CPAP [mean {SD} adherence, 3.1 {2.4} hours per day]; 49.9% not receiving CPAP [usual care], mean [SD] follow-up, 3.25 [1.8] years). The main outcome was defined as the first MACCE, which was similar for the CPAP and no CPAP groups (hazard ratio, 1.01 [95% CI, 0.87-1.17]). However, an on-treatment analysis by marginal structural model revealed a reduced risk of MACCEs associated with good adherence to CPAP (hazard ratio, 0.69 [95% CI, 0.52-0.92]).

Conclusions and Relevance

Adherence to CPAP was associated with a reduced MACCE recurrence risk, suggesting that treatment adherence is a key factor in secondary cardiovascular prevention in patients with OSA.

The Beginning of the AI-Enabled Preventative PAP Therapy Era: A First-in-Human Proof of Concept Interventional Study

Positive Airway Pressure (PAP) therapy is the most common and efficacious treatment for Obstructive Sleep Apnea (OSA). However, it suffers from poor patient adherence due to discomfort and may not fully alleviate all adverse consequences of OSA. Identifying abnormal respiratory events before they have occurred may allow for improved management of PAP levels, leading to improved adherence and better patient outcomes. Our previous work has resulted in the successful development of a Machine-Learning (ML) algorithm for the prediction of future apneic events using existing airflow and air pressure sensors available internally to PAP devices. Although researchers have studied the use of ML for the prediction of apneas, research to date has focused primarily on using external polysomnography sensors that add to patient discomfort and has not investigated the use of internal-to-PAP sensors such as air pressure and airflow to predict and prevent respiratory events. We hypothesized that by using our predictive software, OSA events could be proactively prevented while maintaining patients' sleep quality. An intervention protocol was developed and applied to all patients to prevent OSA events. Although the protocol's cool-down period limited the number of prevention attempts, analysis of 11 participants revealed that our system improved many sleep parameters, which included a statistically significant 31.6% reduction in Apnea-Hypopnea Index, while maintaining sleep quality. Most importantly, our findings indicate the feasibility of unobtrusive identification and unique prevention of each respiratory event as well as paving the path to future truly personalized PAP therapy by further training of ML models on individual patients.

Acceptance of and adherence with long-term positive airway pressure treatment in adults with chronic obstructive pulmonary disease: A systematic review protocol

BACKGROUND

Long-term noninvasive positive airway pressure (PAP) treatment is effective treatment for sleep-related breathing disorders and chronic hypercarbic respiratory failure secondary to chronic obstructive pulmonary disease (COPD). PAP treatment may be delivered as continuous positive airway pressure or noninvasive ventilation. Success in initiating PAP treatment and barriers to its use in adult patients with COPD are largely unknown. This systematic review aims to identify the acceptance of and adherence to PAP treatment prescribed for long-term use in adult patients with COPD and to summarize variables associated with these measures.

METHODS

Seven online electronic databases will be searched by an experienced medical librarian to identify records containing the concepts "obstructive airways disease" and "noninvasive positive airway pressure" and "acceptance" or "adherence". Randomized and non-randomized studies of interventions will be included. Citation lists from relevant articles will be reviewed, and experts will be contacted regarding unpublished studies. Abstracts from key conferences between 2018-2023 and Google Scholar search results will be reviewed for inclusion. Titles, abstracts and full texts will be reviewed independently for inclusion by two reviewers. Data extraction will be completed by one author using a pre-established form and primary outcomes confirmed by a second author. Methodological quality will be evaluated. If sufficient data are available for meta-analysis, a pooled summary statistic for the primary outcome will be calculated using a random-effects generic inverse-variance meta-analysis, weighted proportion or weighted medians-based approach. Subgroup analysis will explore clinically meaningful sources of heterogeneity. Variables that are associated with acceptance and adherence will be described.

DISCUSSION

Long-term PAP treatment is a complex intervention prescribed to patients with COPD for several indications. Synthesis of the evidence on success with PAP treatment and variables associated with acceptance or adherence will inform program and policy development for supporting patients with COPD who are prescribed this therapy.

TRIAL REGISTRATION

Systematic review registration: This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on July 13, 2021 (registration number CRD42021259262), with revisions submitted on April 17, 2023.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Pilot study of positive airway pressure usage, patient journey and program engagement for users of a digital obstructive sleep apnea program

Purpose

This single-arm, decentralized pilot study assessed patient journey, positive airway pressure (PAP) usage and program satisfaction for users of an entirely virtual telemedicine program for obstructive sleep apnea (OSA) diagnosis and management. This analysis focuses specifically on the subset of participants in the program who were diagnosed with OSA and prescribed PAP therapy.

Methods

The Verily Clinical Studies Platform was used for virtual screening, consent, and enrolling eligible patients from North Carolina and Texas. After completing the virtual OSA diagnosis process, participants diagnosed with OSA and prescribed PAP therapy downloaded the program's mobile app. The app featured tools such as educational content, live coaching support, and motivational enhancement.

Results

Of the patients included in this analysis (N = 105), the majority were female (58%), and white (90%). The mean time from first televisit to PAP initiation was 29.2 (SD 12.8) days and f 68 out of the 105 patients (65%) reached 90-day adherence. On average, patients used their PAP device for 4.4 h per day, and 5.4 h on days used. Engagement with the app was associated with higher rates of PAP adherence. Adherent individuals used the mobile app 52 out of the 90 days on average, compared to non-adherent individuals who used the app on 35 out of the 90 days on average (p = 0.0003).

Conclusions

All of the 105 patients in this program diagnosed with OSA and prescribed PAP therapy were able to efficiently complete the entire OSA diagnostic pathway. The majority of these individuals also were able to adhere to their prescribed PAP therapy and had clinically meaningful PAP usage rates over the 90 days of therapy. Future studies might further evaluate the impact of this type of end-to-end virtual program on longer-term adherence and clinical outcomes over time.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT04599803?term=NCT04599803&draw=2&rank=1, identifier NCT04599803.

Factors associated with treatment outcomes after use of auto-titrating CPAP therapy in adults with obstructive sleep apnea

OBJECTIVES

To determine factors that are associated with OSA therapy outcomes with auto-titrating positive airway pressure (APAP).

METHODS

We sequentially grouped patients from a retrospective cohort based on APAP efficacy (sufficiently vs. insufficiently treated; insufficiently treatment defined as residual AHI of ≥ 5), therapy adherence (adherent vs. non-adherent, non-adherence defined as < 70% usage for ≥ 4 h/night), and therapy outcomes (optimal vs. non-optimal and non-optimal outcomes defined as non-adherent and/or insufficiently treated). We subsequently compared each group.

RESULTS

The insufficiently treated were older (68.4 ± 12.5 vs. 60.4 ± 13.1 years, p < 0.01) and had lower BMI (31.9 ± 6.3 vs. 37.9 ± 9.1 kg/m², p < 0.01). They had higher baseline central apnea indices (CAI), longer leaks, higher peak pressures, and were less compliant. The non-adherent were younger (61.1 ± 12.6 vs. 65.5 ± 13.2 years, p = 0.03) and comprised more females (56.1 vs. 43.9%, p = 0.04). The leak duration per usage hour was higher in the non-compliant (median: 1.5; IQR 7.9 vs. median: 0.3; IQR 1.9 min/h; p < 0.01). The non-optimally treated had lower BMI, longer leaks, and less nightly usage. Multivariate analyses showed that leak duration was the common factor associated with treatment effectiveness and optimal therapy outcomes.

CONCLUSIONS

Various demographic and clinical factors were associated with treatment efficacy and adherence. However, leak duration was the common factor related to treatment efficacy and overall optimal therapy outcomes.

Adherence to CPAP Treatment: Can Mindfulness Play a Role?

Obstructive sleep apnea (OSA) is considered a chronic disease that requires long-term multidisciplinary management for effective treatment. Continuous Positive Airway Pressure (CPAP) is still considered the gold standard of therapy. However, CPAP effectiveness is limited due to poor patients' adherence, as almost 50% of patients discontinue treatment after a year. Several interventions have been used in order to increase CPAP adherence. Mindfulness-based therapies have been applied in other sleep disorders such as insomnia but little evidence exists for their application on OSA patients. This review aims to focus on the current data on whether mindfulness interventions may be used in order to increase CPAP adherence and improve the sleep quality of OSA patients. Even though controlled trials of mindfulness and CPAP compliance remain to be performed, this review supports the hypothesis that mindfulness may be used as an adjunct method in order to increase CPAP adherence in OSA patients.

Therapieadhärenz drei Monate nach Einleitung einer nichtinvasiven CPAP-Therapie bei 1078 Patienten mit obstruktiver Schlafapnoe (OSA)

Einleitung Die nächtliche kontinuierliche positive Überdruckatmung (CPAP) gilt als therapeutischer Goldstandard einer obstruktiven Schlafapnoe (OSA). Die CPAP-Therapie stellt zumeist eine Dauertherapie mit geringen Nebenwirkungen dar. Trotzdem ist die Therapietreue unbefriedigend. In dieser Arbeit wurden die Therapietreue betrachtet und typische Probleme katalogisiert.

Methode 1078 OSA-Patienten wurden nach diagnostischer Polygrafie (PG) oder Polysomnografie (PSG) auf eine CPAP-Therapie eingestellt. Die Therapietreue wurde nach 3 Monaten nachverfolgt. Folgende Therapieadhärenz-Gruppen wurden festgelegt: 1. gute CPAP-Einstellung und Nutzung, 2. CPAP-Abbruch nach anfänglicher Nutzung, 3. mangelnde CPAP-Nutzung wegen Nebenwirkungen, 4. Abbruch aufgrund fehlender Motivation/geringem Leidensdruck, 5. Masken-Unverträglichkeit, 6. CPAP-Versagen aufgrund fehlenden Therapieeffekts, 7. Umstellung auf anderes Beatmungsverfahren, 8. keine Kontrolle erfolgt.

Ergebnisse Von 1078 CPAP-Patienten erschienen 830 Patienten (77 %) zur Therapiekontrolle. Hiervon waren 450 Patienten (54,2%) in Gruppe 1, 216 Patienten (26%) in Gruppe 2, 71 Patienten (8,5%) in Gruppe 3, 35 Patienten (4,2%) in Gruppe 4, 14 Patienten (1,7%) in Gruppe 5, 3 Patienten (0,4 %) in Gruppe 6 und 41 Patienten (4,9%) in Gruppe 7. Ein geringer obstruktiver Ereignisindex, niedriger CPAP-Druck und tendenziell auch ein geringer Epworth-Sleepiness-Score waren Prädiktoren für CPAP-Versagen. Für die Therapietreue konnten keine signifikanten Prädiktoren dargestellt werden.

Diskussion Eine effektive Therapienutzung von 54% nach 3 Monaten ist ein suboptimales Ergebnis. Prädiktoren für CPAP-Versagen waren Parameter, die vor Therapie auf geringen Leidensdruck der Patienten deuteten. Trotz großer Patientenkohorte konnten keine signifikanten CPAP-Adhärenz-Prädiktoren durch anthropometrische oder PSG-Daten dargestellt werden. Vielmehr könnten Erfahrungen in den ersten Therapietagen ausschlaggebend sein. CPAP-Geräte bieten Komforteinstellungen, die kenntnisgerecht auf den Patienten individualisiert werden müssen. Eine große Auswahl an unterschiedlichen Maskenformen erfordert Erfahrung und Training bei der patientenorientierten Maskenanpassung. Eine 3-monatige Wiedervorstellung erscheint zu lang, um Therapieprobleme zeitnah mit dem Patienten zu besprechen. Telemedizinische Möglichkeiten oder kurzfristige telefonische Beratungsoptionen sollten in Betracht gezogen werden.

Adherence of obstructive sleep apnoea syndrome patients to positive airway pressure therapy - 10-year follow-up

PURPOSE

Continuous positive airway pressure (CPAP) is the most effective therapy for obstructive sleep apnoea syndrome (OSAS). Long-term adherence is necessary; however, it may be widely variable based on current literature, where the predicting factors are also not well defined. The aim of this study was to assess ten-year adherence to CPAP and to define factors influencing it.

METHODS

In total, 107 patients (91 males) were enrolled in this study, with an average age of 53.5 years (SD 10.1), with CPAP therapy being indicated (Apnoea-Hypopnoea Index - AHI > 15). Anthropometric and social status data have been obtained as well as the average use of CPAP through device memory.

RESULTS

Sufficient adherence (> 4 h per night) was found in 57% of patients in the first year with no subsequent significant change during the next 9 years. Adherence correlated significantly with the severity of OSAS - AHI (r = 0.321 over 5 years) and Epworth Sleepiness Scale (r = 0.317 over ten years) but did not correlate with the pressure used or the age of the patient. No statistically significant differences have been found between the sexes, the different mask groups, or the social status groups.

CONCLUSION

Good adherence to CPAP therapy in OSAS patients is essential. According to our results, patients with more severe OSAS or more severe sleepiness seem to have better adherence.

Identifying longitudinal patterns of CPAP treatment in OSA using growth mixture modeling: Disease characteristics and psychological determinants

In this study, we aim to identify the distinct subtypes of continuous positive airway pressure (CPAP) user profiles based on the telemedicine management platform and to determine clinical and psychological predictors of various patterns of adherence. A total of 301 patients used auto-CPAP (Autoset 10, Resmed Inc.) during the treatment period. Four categories of potential predictors for CPAP adherence were examined: (1) demographic and clinical characteristics, (2) disease severity and comorbidities, (3) sleep-related health issues, and (4) psychological evaluation. Then, growth mixture modeling was conducted using Mplus 8.0 to identify the unique trajectories of adherence over time. Adherence data were collected from the telemedicine management platform (Airview, Resmed Inc.) during the treatment. Three novel subgroups were identified and labeled “adherers” (53.8% of samples, intercept = 385, slope = −51, high mean value, negative slope and moderate decline), “Improvers” (18.6%, intercept = 256, slope = 50, moderate mean value, positive slope and moderate growth) and “non-adherers” (27.6%, intercept = 176, slope = −31, low mean value, negative slope and slight decline). The comorbidities associated with OSA and the apnea–hypopnea index (AHI), which reflects the objective severity of the disease, did not differ significantly among the subgroups. However, “improvers” showed higher levels of daytime sleepiness (8.1 ± 6.0 vs. 12.1 ± 7.0 vs. 8.0 ± 6.1 in SWIFT, p = 0.01), reduced daytime function (4.6 ± 1.6 vs. 3.8 ± 1.6 vs. 4.2 ± 1.8 in QSQ daytime symptoms, p = 0.02), and characteristics of positive coping style (1.8 ± 0.5 vs. 1.9 ± 0.5 vs. 1.7 ± 0.5 in SCSQ positive coping index, p = 0.02). Negative emotion was more pronounced in patients with “non-adherers” (12.9 ± 3.8 vs. 13.7 ± 3.3 vs. 14.6 ± 3.5, p = 0.02 in the HADS depression dimension; 9.0 ± 6.1 vs. 9.8 ± 5.1 vs. 11.5 ± 6.3, p = 0.01 with Negative Affectivity in DS14, and 9.3 ± 6.1 vs. 10.3 ± 5.1 vs. 11.7 ± 6.5, p = 0.01 with Social Inhibition in DS14). Overall, our study demonstrated that CPAP therapy may present distinct trajectories of adherence over time in addition to the traditional binary classification. Self-reported sleep health issues (diurnal sleepiness and daytime dysfunction) as well as psychological characteristics (negative emotions and coping style) were predictors of different adherence subtypes in patients with OSA. Understanding CPAP use profiles and their predictors enable the identification of those who may require additional intervention to improve adherence and further enhance the therapeutic effect in OSA patients.

Telemonitoring for the Follow-Up of Obstructive Sleep Apnea Patients Treated with CPAP: Accuracy and Impact on Therapy

Continuous positive airway pressure (CPAP) telemonitoring (TMg) has become widely implemented in routine clinical care. Objective measures of CPAP compliance, residual respiratory events, and leaks can be easily monitored, but limitations exist. This review aims to assess the role of TMg in CPAP-treated obstructive sleep apnea (OSA) patients. We report recent data related to the accuracy of parameters measured by CPAP and try to determine the role of TMg in CPAP treatment follow-up, from the perspective of both healthcare professionals and patients. Measurement and accuracy of CPAP-recorded data, clinical management of these data, and impacts of TMg on therapy are reviewed in light of the current literature. Moreover, the crucial questions of who and how to monitor are discussed. TMg is a useful tool to support, fine-tune, adapt, and control both CPAP efficacy and compliance in newly-diagnosed OSA patients. However, clinicians should be aware of the limits of the accuracy of CPAP devices to measure residual respiratory events and leaks and issues such as privacy and cost-effectiveness are still a matter of concern. The best methods to focus our efforts on the patients who need TMg support should be properly defined in future long-term studies.

Long-term use of CPAP in patients with obstructive sleep apnea: a prospective longitudinal cohort study

Continuous positive airway pressure (CPAP) is an efficient treatment for obstructive sleep apnea (OSA). Reports of long-term usage vary, as do the factors that predict long-term usage. The aim of this study was to explore long-term CPAP usage and identify potential predictors. This prospective longitudinal cohort study included all patients referred to an outpatient clinic for CPAP treatment during an eight-month period. Clinical data were collected at baseline. Follow-ups were scheduled after one week, three months and two years. Use data were downloaded from the CPAP device at each follow-up. Of 163 included patients, 112 were available for long-term follow-up 2-4 years after starting CPAP, and use data were downloaded for 99 patients. Median duration of CPAP use was 6 h/night (IQR 4.2-7.1). The only significant variable predicting long-term usage was usage at three months. Nearly half (43%) of the patients needed extra consultations beyond the standard treatment plan. Most patients (69%) did not contact the clinic for their recommended two-year follow-up but were instead called into the clinic specifically for the study. There was no significant difference in long-term CPAP usage between patients who initiated contact themselves and those who were called in and would otherwise have been lost for follow-up. Most patients adhere well to CPAP in the long term, although many need extra follow-up. Patients lost for follow-up should not necessarily be considered non-adherent as their reason for not attending could be that they are managing treatment well on their own.

Impact of wait times for treatment on clinical outcomes in patients with obstructive sleep apnoea: protocol for a randomised controlled trial

Background

Obstructive sleep apnoea (OSA) is a common chronic condition that is associated with significant morbidity and economic cost. Prolonged wait times are increasingly being recognised as a barrier to diagnosis and treatment of many chronic diseases; however, no study to date has prospectively evaluated the impact of wait times on health outcomes in OSA.

Objective

The purpose of this study is to determine whether treatment outcomes for individuals with OSA differ between patients managed using an expedited versus standard pathway.

Methods

A pragmatic randomised controlled trial design will be used with a target sample size of 200 adults. Participants with clinically significant uncomplicated OSA will be recruited through referrals to a large tertiary care sleep centre (Calgary, AB, Canada) and randomised to either early management (within 1 month) or usual care (∼6 months) with a 1:1 allocation using a concealed computer-generated randomisation sequence. The primary outcome will be adherence to positive airway pressure (PAP) therapy at 3 months after treatment initiation. Secondary outcomes will include change in sleepiness, quality of life, patient satisfaction, and patient engagement with therapy from baseline to 3 months after PAP initiation, measured using validated questionnaires and qualitative methods.

Anticipated results

This study will determine whether expedited care for OSA leads to differences in PAP adherence and/or patient-reported outcomes. More broadly, the findings of this study may improve the understanding of how wait time reductions impact health outcomes for other chronic diseases.

This study will determine whether expedited care for OSA leads to differences in PAP adherence and/or patient-reported outcomeshttps://bit.ly/38TrkwS

Nasal Symptoms in Patients with Obstructive Sleep Apnoea and Their Association with Continuous Positive Airway Pressure Usage

The role of nasal symptoms in continuous positive airway pressure (CPAP) tolerance is not completely clear. This study aimed to investigate the association between CPAP usage and nasal symptoms, either prior to, or developing during, CPAP use in patients with obstructive sleep apnoea (OSA). Two hundred thirty patients were studied and divided into high-, low-, and non-CPAP users. Nasal symptoms and related quality of life parameters were evaluated prior to CPAP initiation and after three months. We also investigated predictive factors for CPAP usage. Non-CPAP users had significantly worse baseline scores for runny nose compared with high and low users (1.34 vs. 0.68 and 0.75, respectively, p = 0.006). There were no other significant differences between the groups. Runny nose was an independent predictive factor for lower CPAP usage (p = 0.036). An evaluation after three months showed worsening in runny nose score in high-CPAP users (p = 0.025) but not in low- and non-users. There were no significant changes in other nasal symptoms. Our study demonstrates that nasal symptoms were very common in this population but rhinorrhoea was the only symptom associated with poorer CPAP adherence. Moreover, rhinorrhoea worsened after a three-month trial of high-CPAP usage.

Early objective adherence to hypoglossal nerve stimulation therapy

STUDY OBJECTIVES

To assess early adherence to therapy with hypoglossal nerve stimulation therapy.

METHODS

This is a prospective study of consecutive patients with moderate to severe obstructive sleep apnea who underwent implantation of hypoglossal nerve stimulation therapy within a single academic practice and attended a follow-up appointment after greater than 30 days of therapy use. Objective adherence data were extracted from an objective monitoring database and compared to patient characteristics.

RESULTS

The study population was 79 participants who were 29.1% female with a mean age of 58.7 ± 12.8 years old, body mass index of 28.9 ± 3.4 kg/m², and baseline apnea-hypopnea index of 33.8 ± 17.6 events/h. In the first 7 days after device activation, average use was 7.8 h/night, with 91.9% of nights with greater than 4 hours of therapy use and an average of 0.2 pauses in therapy per night. These figures remained stable after 30 days of use: 7.7 h/night, 91.0% of nights longer than 4 hours, and 0.3 pauses per night. Objective evidence of difficulty with acclimatization was associated with age less than 60 years (odds ratio 2.8, 95% confidence interval 1.1-7.1, P = .03) and a history of prior upper airway surgery (3.9, 1.2-11.9, P = .015). Insomnia was present in 31 patients and was not associated with objective evidence of difficulty tolerating therapy.

CONCLUSIONS

Early adherence to hypoglossal nerve stimulation is excellent (92.4% >4 hours on >70% of nights), suggesting that the acclimatization period is straightforward in most. Younger age and a history of prior upper airway surgery appear to be associated with an increased risk of difficulty with acclimatization.

CITATION

Huyett P. Early objective adherence to hypoglossal nerve stimulation therapy. J Clin Sleep Med. 2022;18(2):631-636.

Positive Airway Pressure Usage in Youth with Obstructive Sleep Apnea Following Transition to Adult Health Care

BACKGROUND

There is increasing prevalence of moderate to severe obstructive sleep apnea (OSA) in adolescents, the majority of whom receive treatment with positive airway pressure (PAP). Adherence to PAP is sub-optimal in adolescents with OSA. Moreover, the impact of transition from pediatric to adult healthcare system on PAP adherence is unknown. This is relevant as the transition period is a time of increased stress for youth with chronic illnesses.

RESEARCH QUESTION

Does PAP adherence decrease during the 1-year transition period from pediatric to adult healthcare system in those with OSA?

STUDY DESIGN AND METHODS

Youth previously diagnosed with persistent OSA and treated with PAP in a large academic center (Toronto, Canada) between 2017 and 2019 were enrolled on transfer from the pediatric to adult sleep clinic and followed at 12 months. Mixed-effects linear regression models were used to investigate the effect of time since the transfer on objective PAP adherence with adjustment for confounders.

RESULTS

Among the 45 enrolled participants, 42.2% were female, the median age was 18 years (interquartile range [IQR]: 17-18), median BMI was 30.3 (IQR: 24.0-37.1), and the median apnea-hypopnea index (AHI) was 17.8 events/hour (11.8-30.7). In univariate analysis, we observed a significant reduction in the 12-month average PAP usage in days used at follow-up compared to PAP use at the time of enrolment: median of 5.0 hours/day (IQR: 1.3-8.0) vs 2.6 hours/day (0.0-6.4), p < 0.0001. Following adjustment for age, level of education, employment status and living arrangement, the 12-month average PAP usage in days remained significantly decreased at follow-up compared to at the time of enrolment: change in hours of -1.14; 95% CI -2.27 to -0.01.

INTERPRETATION

Among youth with OSA treated with PAP, there is a clinically significant reduction in PAP adherence over the first year during the transition from pediatric to adult health care.

Analysis of risk factors for air leakage in auto-titrating positive airway pressure users: a single-center study

STUDY OBJECTIVES

Because air leakage from masks is known as a common cause of low adherence to continuous positive airway pressure therapy, we analyzed the risk factors for air leakage related to parameters associated with auto-titrating positive airway pressure, polysomnography, InBody Test, and rhinomanometry.

METHODS

Usage data and medical records of 120 auto-titrating positive airway pressure users were reviewed retrospectively. All patients used a nasal or pillow mask and were carefully monitored at scheduled follow-ups.

RESULTS

Use of a pillow mask, sex (male), age, and abdominal fat percentage were significantly associated with high average air leakage. The higher the auto-titrating positive airway pressure average and mean pressure, the more likely patients exhibited high rates of air leakage. The percentage of patients with high average air leakage increased over time (up to 6 months of follow-up).

CONCLUSIONS

Older male patients using a pillow mask and those with a high abdominal fat percentage and high auto-titrating positive airway pressure may require close follow-up and continuous monitoring for air leakage. Because air leakage from a mask can change over time, mask-sealing capacity should be reassessed and masks should be changed regularly.

CITATION

Kang YJ, Cho J-H, Park C-S. Analysis of risk factors for air leakage in auto-titrating positive airway pressure users: a single-center study. J Clin Sleep Med. 2022;18(1):75-88.

Risk of Severe COVID-19 in Non-Adherent OSA Patients

BACKGROUND

Patients with obstructive sleep apnoea (OSA) are at increased risk of severe course of COVID-19. Vaccination remains to be the most effective prevention of complicated courses of infection. The best contemporary conservative treatment of OSA is continuous positive airway pressure (CPAP) therapy.

PURPOSE

To compare vaccination acceptance and outcomes of COVID-19 infection between OSA patients adhering to the CPAP therapy and those who rejected CPAP and surgical therapy.

PATIENTS AND METHODS

Subjects were divided into two groups: group A (N = 167) were individuals with sufficient CPAP adherence (more than 4 hours per night on average) over the last 10 years. Group B (N = 106) were individuals who did not use the CPAP therapy at all and had no indications to surgical therapy.

RESULTS

Three patients in group B died, and one had a severe course of COVID-19. None of the patients in group A died or experienced a severe course of COVID-19. Group A had a significantly higher proportion of males (77.8% compared to 66% in group B) and all parameters of OSA severity. The vaccination status was similar among both groups, with a complete triple dose vaccination rate of 69.5% and 67.9% in groups A and B, respectively.

CONCLUSION

The results show that the patients with OSA adherent to CPAP therapy were less likely to experience a severe course of COVID-19 or death than the OSA patients non-compliant with therapy, despite the former group having more severe OSA. This result underlines the importance of adherence to CPAP therapy in OSA.

Factors Affecting Long-Term Compliance of CPAP Treatment-A Single Centre Experience

Continuous positive airway pressure (CPAP) has been the standard treatment of obstructive sleep apnoea/hypopnoea syndrome (OSA) for almost four decades. Though usually effective, this treatment suffers from poor long-term compliance. Therefore, the aim of our one centre retrospective study was to assess factors responsible for treatment failure and long-term compliance. Four hundred subsequent patients diagnosed with OSA and qualified for CPAP treatment were chosen from our database and compliance data were obtained from medical charts. Many differing factors kept patients from starting CPAP or led to termination of treatment. Overall, almost half of patients ended treatment during the mean time of observation of 3.5 years. Survival analysis revealed that 25% of patients failed at a median time of 38.2 months. From several demographic and clinical covariates in Cox’s hazard model, only the presence of a mild OSA, i.e., AHI (apnoea/hypopnoea index) below 15/h was a factor strongly associated with long term CPAP failure. The compliance results of our study are in line with numerous studies addressing this issue. Contrary to them, some demographic or clinical variables that we used in our survival model were not related to CPAP adherence.

Independent Role of Nasal Congestion in Positive Airway Pressure Compliance for OSA Treatment

OBJECTIVE

To determine the independent role of nasal congestion in positive airway pressure (PAP) therapy compliance and factors associated with an unfavorable shift of PAP compliance.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care center.

METHODS

This follow-up study comprised 174 patients with newly diagnosed obstructive sleep apnea (OSA) who accepted PAP therapy from January 2017 to June 2019. Information was collected on basic demographics, comorbidities, sleep-related symptoms, nasal symptoms, and upper airway assessment. PAP adherence data were collected at the end of the first week and the third month.

RESULTS

After 3 months of follow-up, 147 participants were included for final data analysis. The proportion of nasal congestion (29.2% vs 52.0%, P = .005) and its severity (mean rank, 58.5 vs 75.1; P = .007) were significantly higher in the noncompliance group as compared with the compliance group. After adjustment for basic demographics, comorbidities, sleep-related symptoms or sleep study parameters, and Friedman clinical staging, multinomial logistic regression models showed that nasal congestion (all odds ratios >2.0, P < .05) was independently associated with a higher odds of PAP noncompliance. Patients with an unfavorable shift of PAP compliance were younger (mean ± SD, 47.5 ± 10.6 vs 53.1 ± 12.6 years; P = .021) and had a lower body mass index (27.2 ± 3.7 vs 29.3 ± 5.0, P = .027) than those who consistently complied. OSA severity was associated with PAP compliance, initially and in the long term.

CONCLUSION

Nasal congestion is an independent predictor of PAP noncompliance. Younger patients with lower BMI were more likely to have an unfavorable shift of PAP compliance. Initial and long-term adherence to PAP therapy was affected by OSA severity.

[Adherence to CPAP Three Months after Starting Therapy in 1078 Patients with Obstructive Sleep Apnea (OSA)]

INTRODUCTION

 Nocturnal Continuous Positive Airway Pressure (CPAP) is considered the gold standard treatment for obstructive sleep apnoea (OSA). The CPAP therapy is a long-term treatment but does come with few possible side effects. The adherence to the therapy is frequently suboptimal. In this paper, adherence to therapy was assessed and typical problems were classified.

METHODS

 1078 OSA patients received CPAP therapy after a diagnostic polygraphy (PG) or polysomnography (PSG). Adherence to therapy was followed up three months after treatment induction. The following therapy adherence groups were defined: 1. correctly calibrated CPAP and good adherence, 2. CPAP non-acceptance, after initial use, 3. CPAP intolerance use due to side effects, 4. discontinuation due to lack of motivation/low rates of symptoms. 5. mask intolerance, 6. CPAP failure due to a lack of perceived treatment effect, 7. Change to another non-invasive ventilation method, 8. No control carried out.

RESULTS

 Out of 1078 OSA patients a therapy control was performed in 830 patients (77 %). Of these, 450 patients (54.2 %) were placed in group 1, 216 patients (26 %) in group 2, 71 patients (8.5 %) in group 3, 35 patients (4.2 %) in group 4, 14 patients (1.7 %) in group 5, 3 patients (0.4 %) in group 6 and 41 patients (4.9 %) in group 7. A mild obstructive index, low CPAP pressure and, as a trend, a low Epworth- Sleepiness score were predictors of CPAP failure. No significant predictors could be shown for adherence to therapy.

DISCUSSION

 An effective treatment use of 54 % after 3 months is a suboptimal result. Predictors of CPAP failure were parameters that indicated that the patient was less symptomatic prior to therapy. Despite a large patient cohort, neither anthropometric nor PSG-data provided any significant CPAP adherence predictors. Rather, experiences in the first nights of use could be decisive. CPAP devices offer comfort settings that have to be personalised to patients' needs and wants. A large selection of different mask shapes requires experience and training in patient-centred mask fitting. A three-month follow-up appointment seems too long to discuss therapy problems with the patient in a timely manner. Telemedical options or short-term telephone appointments should be considered.

Treatment outcomes among rural and urban patients with obstructive sleep apnea: a prospective cohort study

STUDY OBJECTIVES

To determine whether adherence to continuous positive airway pressure (CPAP) in adults with uncomplicated OSA differs by rural versus urban residential address.

METHODS

In this prospective cohort study, we recruited adults who initiated CPAP for uncomplicated OSA that was diagnosed by a physician using sleep specialist-interpreted diagnostic testing. Participants were classified as urban (community size > 100,000) or rural by translating residential postal code into geographic census area. The primary outcome was mean daily hours of CPAP use compared between rural and urban patients. Secondary outcomes included: the proportion of patients who were adherent to CPAP; change in Epworth Sleepiness Scale (ESS) score; change in EuroQOL-5D score; and Visit-Specific Satisfaction Instrument score. All outcomes were measured three months after CPAP initiation.

RESULTS

We enrolled 242 patients (100 rural) with mean (SD) age 51 (13) years and respiratory event index 24 (18) events/hour. Mean (95% CI) CPAP use was 3.19 (2.8,3.58) hours/night and 35% were CPAP-adherent, with no difference between urban and rural patients. Among the 65% of patients who were using CPAP at three months, mean CPAP use was 4.89 (4.51,5.28) hours/night and was not different between rural and urban patients. Improvement in ESS and patient satisfaction were similar between groups, but EuroQOL-5D score improved to a greater extent in rural patients. Urban or rural residence was not associated with CPAP adherence in multivariable regression analysis.

CONCLUSIONS

Rural versus urban residence was not associated with differences in CPAP adherence when guided by specialist-interpreted diagnostic sleep testing.

Prognostic effect of sleep-disordered breathing on hospitalized patients following acute heart failure

BACKGROUND

Identifying patients at risk for poor clinical outcomes following acute heart failure (AHF) is essential. However, data regarding the prognostic effect of sleep-disordered breathing (SDB) and treatment with positive airway pressure (PAP) on clinical outcomes of hospitalized patients following AHF is lacking.

OBJECTIVES

This study investigated the prognostic effect of SDB, PAP treatment, and compliance with PAP treatment on patient clinical outcomes. Polysomnography was performed in hospitalized patients whose left ventricular ejection fraction was < 50%. Patients were divided into groups based on whether SDB was defined as an apnea-hypopnea index ≥ 15 and if they had received PAP treatment. Furthermore, patients with SDB and PAP were subdivided into more and less compliant groups. We assessed the incidences of deaths and rehospitalizations due to heart failure.

RESULTS

Overall, 241 patients were enrolled; 73% had SDB and 29% were initiated on PAP treatment. At a median follow-up of 1.7 years, 74 clinical events (32 deaths, 42 rehospitalizations) occurred. In the multivariable analysis, compared with the non-SDB group, SDB without PAP treatment was associated with an increased risk of clinical outcomes (hazard ratio [HR] 1.79, P = 0.049), whereas SDB with PAP treatment was not (HR 0.78, P = 0.582). Among patients with PAP treatment, a more compliant group was also inversely associated with clinical events (HR 0.11, P = 0.012).

CONCLUSIONS

In hospitalized patients with AHF, untreated SDB was associated with worse clinical outcomes that might be reversible by PAP treatment. However, this potential may be suppressed in less compliant patients.

Repeat self-harm among Chinese adolescents: 1-year incidence and psychosocial predictors

PURPOSE

Self-harm in adolescents is prevalent and is the most significant predictor of future self-harm and suicide. Longitudinal data on the incidence and predictors of repeat self-harm in the general population of adolescents are limited. This study investigated 1-year incidence and psychosocial predictors of repeat self-harm in Chinese adolescents.

METHODS

Shandong Adolescent Behavior and Health Cohort is a longitudinal study of behavior and health in adolescents in Shandong Province, China. Of 7072 participants who were assessed in 2015 and again 1 year later in 2016, 1879 reported a history of self-harm at the baseline survey and were included for this analysis. A self-administered structured questionnaire was used to assess behavioral and emotional problems, sleep, life stress, previous history of self-harm and suicidal thought, and family factors at baseline and self-harm at 1-year follow-up.

RESULTS

Mean age of the sample was 14.86 (SD 1.36) years and 54.6% were female. At 1-year follow-up, 22.1% participants engaged in repeat self-harm. Multiple logistic regression analyses showed that female gender (OR 1.45, 95% CI 1.11-1.89), alcohol use (OR 1.95, 95% CI 1.48-2.57), frequent nightmares (OR 1.61, 95% CI 1.14-2.28), elevated depression score (OR 1.59, 95% CI 1.05-2.42), and prior suicidal thought (OR 1.79, 95% CI 1.37-2.34) were independently and significantly associated with an increased risk of repeat self-harm.

CONCLUSION

More than one in five Chinese adolescents who had a history of self-harm engaged in self-harm at 1-year follow-up. Multiple psychosocial factors including female gender, alcohol use, frequent nightmares, depression, and prior suicidal thought appeared to be significant predictors of repeat self-harm. Our findings highlight the importance of comprehensive psychosocial assessment and intervention of repeat self-harm in adolescents.

Endorsement of: "treatment of adult obstructive sleep apnea with positive airway pressure: an American academy of Sleep Medicine Clinical Practice Guideline" by World Sleep Society

Guidelines for the evaluation and management of sleep disorders from national societies provide recommendations that may be regionally appropriate but may not always be practical or relevant in other parts of the world. A task force of experts from the World Sleep Society's (WSS) International Sleep Medicine Guidelines Committee and Sleep and Breathing Disorders Taskforce reviewed the American Academy of Sleep Medicine's Clinical Practice Guideline on the Treatment of Adult Obstructive Sleep Apnea (OSA) with Positive Airway Pressure with respect to its relevance and applicability to the practice of sleep medicine by sleep specialists in various regions of the world. To improve the evaluation of the guideline, surveys were sent by the senior author and the WSS to approximately 800 sleep doctors around the world to query the availability of OSA treatments in their respective region. The task force and the WSS guidelines committee endorsed the AASM's CPAP guidelines with respect to the indications for PAP therapy, utilization of different PAP modalities, and concurrent strategies to improve outcomes, noting appropriate caveats for universal applicability.

Telemedicine Strategy to Rescue CPAP Therapy in Sleep Apnea Patients with Low Treatment Adherence: A Pilot Study

Patients with sleep apnea are usually treated with continuous positive airway pressure (CPAP). This therapy is very effective if the patient′s adherence is satisfactory. However, although CPAP adherence is usually acceptable during the first months of therapy, it progressively decreases, with a considerable number of patients accepting average treatment duration below the effectiveness threshold (4 h/night). Herein, our aim was to describe and evaluate a novel telemedicine strategy for rescuing CPAP treatment in patients with low adherence after several months/years of treatment. This two-week intervention includes (1) patient support using a smartphone application, phone and voice recorder messages to be answered by a nurse, and (2) daily transmission and analysis of signals from the CPAP device and potential variation of nasal pressure if required. On average, at the end of the intervention, median CPAP adherence considerably increased by 2.17 h/night (from 3.07 to 5.24 h/night). Interestingly, the procedure was able to markedly rescue CPAP adherence: the number of patients with poor adherence (<4 h/night) was considerably reduced from 38 to 7. After one month, adherence improvement was maintained (median 5.09 h/night), and only 13 patients had poor adherence (<4 h/night). This telemedicine intervention (103€ per included patient) is a cost-effective tool for substantially increasing the number of patients with CPAP adherence above the minimum threshold for achieving positive therapeutic effects.

Clinical Predictors of High Blood Eosinophils in Chronic Obstructive Pulmonary Disease

Purpose

Elevated blood eosinophils have been implicated in chronic obstructive pulmonary disease (COPD) progression and exacerbation. We aim to investigate clinical predictors of high blood eosinophils in a Chinese COPD cohort.

Patients and Methods

We conducted a retrospective cohort study in Sichuan province, a Southwest province with high prevalence of COPD in China. All patients in this cohort were extracted from the Chinese Pulmonary Health study, a large cross-sectional study on COPD epidemiology in China. Demographics, personal and family history, living condition, spirometry and blood eosinophil counts were obtained. Univariate and multiple linear regression analyses were performed to determine predictors of high blood eosinophils.

Results

A total of 375 COPD patients were included in this cohort. The median absolute blood eosinophil count was 138.8 cells/μL, and the prevalence of COPD with high blood eosinophils was 66.7% and 14.7% when using the thresholds of 100 cells/μL and 300 cells/μL, respectively. Univariate analyses indicated that male gender, lower body mass index, high-density lipoprotein (HDL), lower family income, raising pets and biomass use were significantly associated with high blood eosinophils (p < 0.05). Multiple linear regression model further revealed male gender (unstandardized coefficient (B)=66.125, 95% confidence intervals (CI) 16.350 to 115.900, p=0.009), age (B=2.819, 95% CI 0.639 to 5.000, p=0.012) predicted high blood eosinophil level, whereas HDL (B=−64.682, 95% CI −123.451 to −5.914, p=0.031) was a negative predictor for high blood eosinophils.

Conclusion

This retrospective cohort study suggests male gender, oldness and lower HDL could be clinical predictors of high blood eosinophils in Chinese COPD patients.

Outcomes of Sleep Apnea Surgery in Outpatient and Inpatient Settings

BACKGROUND

Upper airway surgery is an alternative treatment for patients with severe obstructive sleep apnea (OSA). However, there is controversy regarding selection criteria for outpatient versus inpatient settings for these surgical procedures. The aim of this retrospective study was to compare postoperative outcomes of patients undergoing airway surgery in outpatient and inpatient settings based on length of stay at the facility.

METHODS

The 2011-2017 American College of Surgeons National Surgical Quality Improvement databases were used to select adult patients with a diagnosis of OSA undergoing elective airway surgery procedures. Single-level (eg, uvulopalatopharyngoplasty [UPPP]) or multilevel surgery (eg, concomitant procedures on base of tongue, maxilla, palate, nose/turbinate, or tracheotomy) was identified using appropriate current procedural terminology (CPT) codes. Surgery setting was classified as outpatient (length of hospital stay = 0 days) or inpatient (length of stay ≥1 day). Propensity scores derived from logistic regression models were used to match inpatient to outpatient cases at a ratio of 1:1. Primary outcome was a composite of 30-day readmissions, reoperations, and/or postoperative complications. Outcomes between the matched groups were compared with McNemar's tests and generalized mixed linear regression analyses.

RESULTS

A total of 3208 cases were identified (1049 [32.7%] outpatient and 2159 [67.3%] inpatient). Inpatients were older, had more comorbidities, larger body mass index, and more multilevel procedures. UPPP was performed in about 96% of both inpatients and outpatients. The overall rate of composite of readmission, reoperations, and/or complications in the whole unmatched sample was 6.4% (6.8% and 5.5% in inpatients and outpatients, respectively). The propensity-matching algorithm produced a sample of 987 patients per surgical setting well balanced on available baseline characteristics. The incidence of the composite primary outcome was not significantly different between the groups (6.2% and 5.9% in inpatients and outpatients, respectively; odds ratio [OR] [95% confidence interval {CI}], 1.06 [0.73-1.53]; P = .77).

CONCLUSIONS

This retrospective study found that the complications and 30-day readmission rates after airway surgery for OSA are low. There were no significant differences in the composite outcome of 30-day readmissions, reoperations, or complications between inpatient and outpatient settings. Adequately designed prospective studies are necessary to confirm the retrospective observations of this study.

One-Year Adherence to Continuous Positive Airway Pressure With Telemonitoring in Sleep Apnea Hypopnea Syndrome: A Randomized Controlled Trial

Study Objective: Telemedicine (TM) for continuous positive airway pressure (CPAP) treated patients may save health-care resources without compromising treatment effectiveness. We assessed the effect of TM (AirView Online System, ResMed) during the CPAP habituation phase on 3-month and 1-year treatment adherence and efficacy in patients with moderate-to-severe obstructive sleep apnea (OSA).

Methods: At CPAP initiation, 120 patients diagnosed with OSA were randomized to either usual care (UC) or TM during the habituation phase (clinical registration: ISRCTN12865936). Both groups received a first face-to-face appointment with a sleep care giver at CPAP initiation. Within the following month, 2 other physical visits were scheduled in the UC group whereas two phone consultations were planned in the TM group, in which CPAP parameters were remotely adapted. Additional physical visits were programmed at the patient's request. Face-to-face consultations were scheduled at 3 and 12 months after CPAP initiation. The primary outcome was the mean CPAP daily use over the course of 12 months.

Results: Twenty of 60 patients stopped CPAP therapy in the UC group vs. 14 of 60 in the TM group (p = 0.24). In per protocol analysis, mean [95% CI] daily CPAP use among 86 patients still using CPAP at 12 months was 279 [237; 321] min in the 38 patients on UC and 279 [247; 311] min in the 43 patients on TM, mean difference [95% CI]: 0 [−52; 52] min, P = 0.99. Total consultation time per patient was not different between groups, TM: 163 [147; 178] min, UC: 178 [159; 197] min, difference: −15 [−39; 9] min, p = 0.22.

Conclusions: Telemedicine during the CPAP habituation phase did not alter daily CPAP use or treatment adherence and did not require more healthcare time. Telemedicine may support clinic attendance for CPAP titration.

Clinical Trial Registration: [ISRCTN], identifier [ISRCTN12865936].

Pressure adjustment is the most useful intervention for improving compliance in telemonitored patients treated with CPAP in the first 6 months of treatment

PURPOSE

Telemonitoring (TMg) for patients treated with continuous positive airway pressure (CPAP) is now routine care in some sleep labs. The purpose of the present study was to identify technical interventions associated with improved CPAP compliance in a real-life cohort of newly telemonitored patients with obstructive sleep apnea (OSA) during the first 6 months of treatment.

METHODS

All patients with moderate-to-severe OSA (apnea-hypopnea index (AHI) ≥ 15/h) who were newly treated with CPAP were included in the study and telemonitored. A group educational session was scheduled after 1 month. Technical interventions were performed at the patient's request and during scheduled visits and the impact of each intervention on CPAP therapy compliance was collected.

RESULTS

Between May 2018 and Dec 2019, 349 patients newly diagnosed with OSA were hospitalized in the sleep lab for CPAP titration and 212 patients were included (mean age 54.6 ± 13.1 years, mean BMI 31.7 ± 5.8 kg/m², mean AHI 42.8 ± 22.0). TMg acceptance rate was 87%. Mean 6-month compliance was 275 ± 154 min, 13% stopped CPAP, and 17% were non-compliant. Correlations were observed between BMI (r = 0.15, p = 0.029), median and 95th percentile leaks (r = -0.23 and -0.18, p = 0.016 and 0.002), and CPAP compliance. During follow-up, 92 interventions were required, mainly for mask change (n = 80). Pressure modification (n = 16) was the only intervention that increased CPAP use > 30 min/night, p = 0.021.

CONCLUSION

Pressure modification was the only adaptation that significantly increased CPAP compliance during the first 6 months. Remote TMg allows providing daily, accurate, and immediate feedback that could help clinicians to confirm that the CPAP treatment is effective.

Treatment usage patterns of oral appliances for obstructive sleep apnea over the first 60 days: a cluster analysis

STUDY OBJECTIVES

Oral appliance (OA) therapy usage can be objectively measured through temperature-sensing data chips embedded in the appliance. Initial reports of group data for short-term treatment usage suggest good nightly hours of usage. However, individual variability in treatment usage patterns has not been assessed. We aimed to identify OA treatment usage subtypes in the first 60 days and the earliest predictors of these usage patterns.

METHODS

OSA patients were recruited for a study of OA therapy with an embedded compliance chip (DentiTrac, Braebon, Canada). Fifty-eight participants with 60 days of downloadable treatment usage data (5-minute readings) were analyzed. A hierarchical cluster analysis was used to group participants with similar usage patterns. A random forest classification model was used to identify the minimum number of days to predict usage subtype.

RESULTS

Three user groups were identified and named "consistent users" (48.3%), "inconsistent users" (32.8%) and "non-users" (19.0%). The first twenty days provided optimal data to predict which treatment usage group a patient would belong to at 60-days (90% accuracy). The strongest predictors of user group were downloaded usage data; average wear time and number of days missed.

CONCLUSIONS

Granular analysis of OA usage data suggests the existence of treatment user subtypes (consistent, inconsistent and non-users). Our data suggest that 60-day usage patterns can be identified in the first twenty days of treatment using downloaded treatment usage data. Understanding initial treatment usage patterns provide an opportunity for early intervention to improve long-term usage and outcomes.

Impact of bariatric surgery on obstructive sleep apnea severity and continuous positive airway pressure therapy compliance-prospective observational study

To evaluate association between bariatric surgery and changes in obstructive sleep apnea (OSA) severity and sleep architecture was as well as to asses continuous positive airway pressure (CPAP) effectiveness and compliance. We enrolled patients undergoing bariatric surgery. Polysomnography was performed in each patient preoperatively and 12 months after the procedure in a subgroup of patients diagnosed with OSA. STOP-BANG, Epworth Sleepiness Scale (ESS) and Berlin questionnaire scores were obtained pre- and postoperatively. CPAP compliance data was recorded during follow-up hospitalization. Among 44 patients with median age of 49.5 years, predominantly women (68.2%) pre- and postoperative polysomnography was performed. We observed significant improvement in STOP-BANG (6.0 vs. 3.0, p < 0.001) and ESS (12.0 vs. 5.0, p < 0.001) scores, apnea–hypopnea index (44.9 vs. 29.2, p < 0.001), oxygen desaturation index (43.6 vs. 18.3, p < 0.001) and sleep architecture parameters. CPAP compliance was poor with a median percentage of days with CPAP use accounting to 49.3%. Bariatric surgery is associated with a significant decrease in the number of sleep-related respiratory disturbances, as well as improvement of sleep efficiency. Postoperative CPAP therapy compliance was poor despite low rate of OSA resolution. This study suggests that patients with OSA undergoing bariatric surgery require postoperative reassessment.

The impact of national health insurance on the compliance of positive airway pressure therapy in patients with obstructive sleep apnea

Objectives

Compliance with positive airway pressure (PAP) in patients with obstructive sleep apnea (OSA) directly affects its treatment efficacy. Since July 2018, polysomnography and PAP therapy have been covered by the national health insurance (NHI), which has reduced the price barrier and promoted PAP therapy in Korea. This study aimed to compare changes in PAP compliance before and after NHI implementation.

Methods

This study is a retrospective analysis in a tertiary hospital setting in Korea. From 2011 to 2019, patients with OSA (apnea-hypopnea index≥5) treated using a PAP device for ≥ 1 month were included. They were allocated to the pre-insurance (PI) (having started PAP before July 2018) and NHI groups (having received a PAP reimbursement by the NHI service). We collected and analyzed medical records and PAP use information for between-group comparisons of compliance. We defined compliance as (A) percentage of usage days, (B) percentage of days with usage for ≥ 4 night hours, and (C) average daily usage hours.

Results

We included 146 and 100 patients in the PI and NHI groups, respectively. Automatic positive airway pressure (APAP) mode and NHI were independent predictors of compliance B at the 3- and 9-month follow-up points. The NHI group showed significantly higher compliance A at 3, but not 9 months. For compliance B, the NHI group showed significantly higher compliance than the PI group at 1 month and 3 months, but not at 9 months. Compared with the PI group, the NHI group showed significantly higher compliance C only at 3 months.

Conclusion

The NHI has positively affected PAP therapy in patients with OSA. Insurance policy may affect compliance within the first 3 months.

Adherence to oral appliance treatment and its determinants in obstructive sleep apnoea patients

BACKGROUND AND OBJECTIVES

Treatment effectiveness, in terms of health benefits, is a composite of efficacy and adherence. Oral appliance (OA) usage is mainly based on self-reports, but nowadays, objective adherence monitoring for OAs is available. This study investigated the objective OA adherence and its determinants in obstructive sleep apnoea (OSA) patients.

MATERIALS AND METHODS

There were 29 subjects who were treated with OA; mean [SD] age 51.4 [11.1]; mean apnoea-hypopnoea index (AHI) [SD] 19.5 [10.0]. Anthropometric and sociodemographic parameters, AHI, daytime sleepiness, snoring, and adverse effects of OA as potential determinants were evaluated. Patients were classified as regular users if they wore OA at least 4 hours nightly 5-7 nights a week. Statistical analyses included the chi-square test, t-test, Mann-Whitney U-test, and linear regression analyses.

RESULTS

At the 3-month follow-up, 68% of subjects were regular users and at 12-month follow-up, 64%. AHI, sociodemographic parameters, or adverse effects were not associated with OA adherence. Snoring seemed to improve weakly adherence, whereas mandibular retrusion reduced the weekly use, and smoking the nightly use of OAs.

LIMITATIONS

The follow-up time was short, and there were a relatively small number of patients with obtainable adherence data, therefore it is difficult to establish if OA therapy alone is a successful long-term treatment option for OSA patients.

CONCLUSIONS/IMPLICATIONS

Adherence to OA therapy is mainly the outcome of patients' subjective comfort in everyday life through eliminating social disturbance of snoring. To best meet a subject's individual treatment need and to prevent suboptimal use of OA, a patient-tailored therapy including digital wear-time documentation is recommended.

What is a Clinically Meaningful Target for Positive Airway Pressure Adherence?

Although good adherence to continuous positive airway pressure (PAP) traditionally is defined as greater than or equal to 4 hours/night, the origins and rationale for this remain unclear. Research studies report variation in optimal duration of PAP adherence, depending on outcome of interest. Evidence demonstrates benefit with PAP for daytime sleepiness, quality of life, neurocognitive outcomes, depression, and hypertension, predominantly in symptomatic, moderate-severe obstructive sleep apnea. Recent randomized controlled trials, however, have failed to demonstrate a reduction in cardiovascular and mortality risks. This review explores the question of what can be considered a clinically meaningful outcome for PAP adherence.

Mask side-effects in long-term CPAP-patients impact adherence and sleepiness: the InterfaceVent real-life study

Background

For some patients, Continuous Positive Airway Pressure (CPAP) remains an uncomfortable therapy despite the constant development of technological innovations. To date, no real life study has investigated the relationship between mask related side-effects (MRSEs) and CPAP-non-adherence (defined as < 4 h/day) or residual-excessive-sleepiness (RES, Epworth-Sleepiness-Scale (ESS) score ≥ 11) in the long-term.

Methods

The InterfaceVent-CPAP study is a prospective real-life cross-sectional study conducted in an apneic adult cohort undergoing at least 3 months of CPAP with unrestricted mask-access (34 different masks). MRSEs were evaluated using visual-analogue-scales, CPAP-data using CPAP-software, sleepiness using ESS.

Results

1484 patients were included in the analysis (72.2% male, median age 67 years (IQ_25–75: 60–74), initial Apnea–Hypopnea-Index (AHI) of 39 (31–56)/h, residual AHI_flow was 1.9 (0.9–4) events/h), CPAP-treatment lasted 4.4 (2.0–9.7) years, CPAP-usage was 6.8 (5.5–7.8) h/day, the prevalence of CPAP-non-adherence was 8.6%, and the prevalence of RES was 16.17%. Leak-related side-effects were the most prevalent side-effects (patient-reported leaks concerned 75.4% of responders and had no correlation with CPAP-reported-leaks). Multivariable logistic regression analyses evaluating explanatory-variable (demographic data, device/mask data and MRSEs) effects on variables-of-interest (CPAP-non-adherence and RES), indicated for patient-MRSEs significant associations between: (i) CPAP-non-adherence and dry-mouth (p = 0.004); (ii) RES and patient-reported leaks (p = 0.007), noisy mask (p < 0.001), dry nose (p < 0.001) and harness pain (p = 0.043).

Conclusion

In long-term CPAP-treated patients, leak-related side-effects remain the most prevalent side-effects, but patient-reported leaks cannot be predicted by CPAP-reported-leaks. Patient-MRSEs can be independently associated with CPAP-non-adherence and RES, thus implying a complementary role for MRSE questionnaires alongside CPAP-device-reported-data for patient monitoring.

Trial registration InterfaceVent is registered with ClinicalTrials.gov (NCT03013283).

Personalized and Patient-Centered Strategies to Improve Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), a common sleep disorder characterized by repeated pauses in breathing during sleep, is effectively treated with positive airway pressure (PAP) therapy. The magnitude of improvements in daily functioning and reduced negative health risks are dependent on maintaining PAP adherence, which is a significant challenge. Evidence-based interventions to improve PAP use are not easily translated to clinical practice because they are labor-intensive and require specialty expertise. Further, to date, individualized care, inclusive of personalized medicine and patient- and person-centered care have been marginally incorporated in the field's understanding of OSA and PAP adherence. This integrative review describes current PAP adherence assessment processes, interventions to improve adherence, and outlines future opportunities to advance the field, particularly as it relates to individualizing care and the use of implementation science to apply evidence to practice.

Alternative Care Pathways for Obstructive Sleep Apnea and the Impact on Positive Airway Pressure Adherence: Unraveling the Puzzle of Adherence

The high burden of obstructive sleep apnea (OSA), combined with inadequate supply of sleep specialists and constraints on polysomnography resources, has prompted interest in alternative models of care to improve access and treatment effectiveness. In appropriately selected patients, ambulatory clinical pathways and use of nonphysicians or primary care providers to manage OSA can improve timely access and costs without compromising adherence or other clinical outcomes. Although initial studies show promising results, there are several potential barriers that must be considered before broad implementation, and further implementation research and economic evaluation studies are required.

CPAP adherence reduces cardiovascular risk among older adults with obstructive sleep apnea

STUDY OBJECTIVES

To examine (1) the impact of adherence to continuous positive airway pressure (CPAP) therapy on risk for cardiovascular (CVD) events among a nationally representative sample of older adults with obstructive sleep apnea (OSA), and (2) the heterogeneity of this effect across subgroups defined by race, sex, and socioeconomic status.

METHODS

We conducted a retrospective cohort study among Medicare beneficiaries aged ≥ 65 years with OSA (2009-2013). Monthly indicators of CPAP adherence (charges for machines, masks, or supplies) were summed over 25 months to create a CPAP adherence variable. New CVD events (ischemic heart disease, cardiac and peripheral procedures) were modeled as a function of CPAP adherence using generalized estimating equations. Heterogeneity of the effect of CPAP on new CVD events was evaluated based on race, sex, and socioeconomic status.

RESULTS

Among 5024 beneficiaries diagnosed with OSA who initiated CPAP, 1678 (33%) demonstrated new CVD events. Following adjustment for demographic and clinical characteristics, CPAP adherence was associated with reduced risk of new CVD events (hazard ratio 0.95; 95% confidence interval 0.94, 0.96) over 25 months. When analyses were stratified by time since the first CPAP charge, the protective effect remained significant for the 12- and 6-month, but not 3-month, outcome models. No significant differences were observed in the protective effect of CPAP based on race, sex, or socioeconomic status.

CONCLUSIONS

In this national study of older adult Medicare beneficiaries with OSA, CPAP adherence was associated with greatly reduced risk for CVD events. This risk reduction was consistent across race, sex, and socioeconomic subgroups.