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Bhattacharjee R, Winck JC, Gozal D. The future of big data: Remote monitoring of positive airway pressure treatment for obstructive sleep apnea - insights from adults and implications for pediatric care. Pediatr Pulmonol 2025; 60:e27334. [PMID: 39620375 DOI: 10.1002/ppul.27334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 10/04/2024] [Accepted: 10/07/2024] [Indexed: 01/16/2025]
Abstract
The advent of large expansive datasets has generated substantial interest as a means of developing and implementing unique algorithms that facilitate more precise and personalized interventions. This methodology has permeated the realm of sleep medicine and in the care of patients with sleep disorders. One of the large repositories of information consists of adherence and physiological datasets across long periods of time as derived from patients undergoing positive airway pressure (PAP) treatment for sleep-disordered breathing. Here, we evaluate the extant and yet scarce findings derived from big data in both adults and children receiving PAP for obstructive sleep apnea and suggest future directions towards more expansive utilization of such valuable approaches to improve therapeutic decisions and outcomes.
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Affiliation(s)
- Rakesh Bhattacharjee
- Division of Respiratory Medicine Department of Pediatrics University of California San Diego La Jolla California USA
| | | | - David Gozal
- Office of the Dean, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
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2
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Ee JS, Pham CK, Shaha DP, Mounts CW, Dogbey GY, Pogorzelski N. Behavioral KSA Intervention Class to Boost Positive Airway Pressure Adherence Among Active Duty Military Personnel With Obstructive Sleep Apnea. Mil Med 2024; 189:350-356. [PMID: 39160792 DOI: 10.1093/milmed/usae126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/24/2024] [Accepted: 03/08/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a treatable cause of daytime sleepiness and associated medical problems that can negatively impact soldier readiness and performance. This study examined adherence to positive airway pressure (PAP) by soldiers who were newly diagnosed with OSA and prescribed PAP therapy and participated in a Knowledge, Skills, and Attitudes (KSA) behavioral intervention class. MATERIALS AND METHODS The KSA was a one-time, interactive 90-minute class attended by up to 10 patients per class. PAP adherence was examined using Medicare standard at 30-, 60-, 90-, and 180 days post class. The analytic sample comprised 379 active duty patients (93% men; mean age 40.21 ± 8.06) categorized into 3 groups: KSA (n = 235), did not show (DNS; n = 61), and mandatory education class (MEC; n = 83). The MEC group comprised patients from an education class in a previous year. RESULTS Baseline scores on the apnea hypopnea index, body mass index, sleepiness, insomnia severity, and age were non-significant among the 3 groups. At 30 days, significantly more patients in KSA (48%) and MEC (51%) were adherent than the DNS group (16%). At 60 days, the adherence rates for the KSA, DNS, and MEC were significantly different at 39%, 22%, and 27%, respectively. At 90- and 180 days, the adherence rates among the KSA, DNS, and MEC groups did not differ significantly at 34%, 17%, and 26% (90 days) and 34%, 27%, and 25% (180 days), respectively. Consistently, more patients in KSA were adherent than those in DNS and MEC, except at 30 days. Additionally, adherence rates for KSA intervention declined more gradually over the 6 month period. The mean PAP usage on nights used was 4.6 hours that computed to a 34% non-use rate based on an optimal 7-hour/night sleep time. CONCLUSION KSA could be a behavioral intervention that enhances PAP adherence with a booster session implemented at the 90 days mark.
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Affiliation(s)
- Juliana S Ee
- Department of Family Medicine, Womack Army Medical Center, Fort Liberty, NC 28310, USA
| | - Christopher K Pham
- Department of Family, Community, and Preventive Medicine, Drexel University College of Medicine, Philadelphia, PA 19104, USA
| | - David P Shaha
- Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Charles W Mounts
- Department of Sleep and Family Medicine, Martin Army Community Hospital, Fort Moore, GA 31905, USA
| | - Godwin Y Dogbey
- Department of Research and Medical Education, Campbell University, Jerry M. Wallace School of Osteopathic Medicine, Lillington, NC 27546, USA
| | - Nina Pogorzelski
- Department of Allergy and Immunizations, Lackland Air Force Base, San Antonio, TX 78236, USA
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3
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Ingram DG, Cranford TA, Al-Shawwa B. Sleep Technology. Sleep Med Clin 2023; 18:235-244. [PMID: 37120166 DOI: 10.1016/j.jsmc.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Pediatric sleep providers frequently encounter issues related to sleep technology in clinical settings. In this review article, we discuss technical issues related to standard polysomnography, research on putative complementary novel metrics derived from polysomnographic signals as well as research on home sleep apnea testing in children and consumer sleep devices. Although developments across several of these domains are exciting, it remains a rapidly evolving area. When evaluating innovative devices and home sleep testing approaches, clinicians should be mindful of accurately interpreting diagnostic agreement statistics to apply these technologies appropriately.
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Thong BKS, Loh GXY, Lim JJ, Lee CJL, Ting SN, Li HP, Li QY. Telehealth Technology Application in Enhancing Continuous Positive Airway Pressure Adherence in Obstructive Sleep Apnea Patients: A Review of Current Evidence. Front Med (Lausanne) 2022; 9:877765. [PMID: 35592853 PMCID: PMC9110793 DOI: 10.3389/fmed.2022.877765] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a common type of sleep-disordered breathing associated with multiple comorbidities. Continuous positive airway pressure (CPAP) is the first choice for moderate-severe OSA but poor compliance brings a great challenge to its effectiveness. Telehealth interventions ease the follow-up process and allow healthcare facilities to provide consistent care. Fifth-generation wireless transmission technology has also greatly rationalized the wide use of telemedicine. Herein, we review the efficacy of the telehealth system in enhancing CPAP adherence. We recommend applying telemonitoring in clinical practice and advocate the development of a biopsychosocial telemedicine model with the integration of several interventions. Big databases and promising artificial intelligent technologies make clinical decision support systems and predictive models based on these databases possible.
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Affiliation(s)
- Benjamin Ka Seng Thong
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Grace Xin Yun Loh
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia Jan Lim
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Christina Jia Liang Lee
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shu Ning Ting
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong Peng Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing Yun Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Abstract
Interest in telemedicine has increased exponentially. There is a growing body of published evidence on the use of telemedicine for patients using continuous positive airway pressure. Telemedicine-ready devices can support the transmission on use time, apnea-hypopnea index, and leakage. This approach enables early activation of troubleshooting. Automated, personalized feedback for patients and patient access to their own data provide unprecedented opportunities for integrating comanagement approaches, multiactor interactions, and patient empowerment. Telemedicine is likely cost effective, but requires better evidence. Notwithstanding barriers for implementation that remain, telemedicine has to be embraced, leaving the physician and patient to accept it or not.
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Affiliation(s)
- Johan Verbraecken
- Department of Pulmonary Medicine and Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, University of Antwerp, Drie Eikenstraat 655, Edegem, Antwerp 2650, Belgium.
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Berry RB, Beck E, Jasko JG. Effect of cloud-based sleep coaches on positive airway pressure adherence. J Clin Sleep Med 2021; 16:553-562. [PMID: 32022679 DOI: 10.5664/jcsm.8276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Decreased early positive airway pressure (PAP) adherence is predictive of poor long-term adherence. We hypothesized that cloud-based sleep coaches (CBSC) providing protocol-driven live telephone contact with patients starting treatment would improve early adherence. METHODS At PAP set-up patients were randomized to: (1) standard care (SC) including respiratory therapist PAP setup, wireless adherence monitoring, and elective use of a mobile adherence feedback application (PAPapp); or (2) SC+CBSC. Primary 3-month endpoints were adherence (all nights, nights used, % of nights ≥ 4 hours use, and % participants with ≥ 4 hours use on ≥ 70% of nights [% ≥ 4 ≥ 70%]) and secondary endpoints were change in Epworth sleepiness scale (ESS) and satisfaction with treatment and PAPapp use. RESULTS Two hundred fifty participants were randomized (SC 126, SC+CBSC 124). Characteristics SC versus SC+CBSC (mean ± SD) for age (55.2 ± 13.4 versus 54.9 ± 11.5 years), diagnostic apnea-hypopnea index (36.7 ± 21.1 versus 36.6 ± 20.6 events/h), and ESS (10.8 ± 6.1 versus 11.2 ± 6.0) did not differ. At 3 months, the % of days with ≥ 4 hours of PAP use (SC: 48.1 ± 36.8% versus SC+CBSC: 57.9 ± 35.4%, P = 0.032), use all nights (SC:3.7 ± 2.7 hours versus SC + CBSC: 4.4 ± 2.6 hours, P=0.027), and PAPapp use satisfaction were greater with SC+CBSC (intention to treat analysis). The [% ≥ 4 ≥ 70%] did not differ between groups in the intention to treat analysis but was higher in those completing CBSC interventions. The ESS improvement and patient satisfaction did not differ between groups. CONCLUSIONS The CBSC system improved PAP adherence at 3 months. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: ThErapy Adherence Management in Veterans; Identifier: NCT03243487; URL: https://clinicaltrials.gov/ct2/show/NCT03243487.
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Affiliation(s)
- Richard B Berry
- Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, Florida
| | - Emily Beck
- Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, Florida
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Hu Y, Su Y, Hu S, Ma J, Zhang Z, Fang F, Guan J. Effects of telemedicine interventions in improving continuous positive airway pressure adherence in patients with obstructive sleep apnoea: a meta-analysis of randomised controlled trials. Sleep Breath 2021; 25:1761-1771. [PMID: 33694034 DOI: 10.1007/s11325-021-02292-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/03/2021] [Accepted: 01/05/2021] [Indexed: 01/25/2023]
Abstract
PURPOSE This meta-analysis was conducted to assess the effects of telemedicine interventions on continuous positive airway pressure (CPAP) adherence in patients with obstructive sleep apnoea (OSA). METHODS The PubMed, Cochrane Library, OVID, Web of Science and EBSCO host databases were searched from January 2004 to February 2020 for randomised controlled trials (RCTs) that assessed the effects of telemedicine interventions on CPAP adherence in patients with OSA. The study inclusion criteria were RCTs that compared patients who received telemedicine interventions with a control group and reported a change in CPAP adherence. The primary outcome was the improvement in CPAP adherence. RESULTS In total, there were 11 RCTs (n = 1358) with quantitative analyses. Intervention times ranged from 1 to 6 months. Compared to controls, the telemedicine group exhibited better adherence to CPAP therapy (pooled mean difference (MD) = 0.57, 95% CI = 0.33 to 0.80, I2 = 7%, p < 0.00001). We performed sensitivity analyses by the type of telemedicine intervention, comorbidity burden, and OSA severity to explore whether or not their effect sizes may have affected the time of CPAP application. We performed subgroup analyses by follow-up duration, age, and OSA Epworth sleepiness scale (ESS) symptoms to determine if their effect sizes may have affected the time of CPAP application. However, these analyses did not change the statistical significance of the pooled estimate. CONCLUSIONS The use of telemedicine for up to 6 months may enhance CPAP adherence in patients with OSA, when compared to no intervention. Our study was searched from January 2004 to February 2020 for randomised controlled trials (RCTs) that assessed the effects of telemedicine interventions on CPAP adherence in patients with OSA. Future studies can continue to search for articles after February 2020.
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Affiliation(s)
- Yuli Hu
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Department of Otolaryngology Head and Neck Surgery & Center of Sle-ep Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai, 200233, China.,Otolaryngological Institute of Shanghai Jiao Tong University, Yishan Road 600, Shanghai, 200233, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Yishan Road 600, Shanghai, 200233, China
| | - Yijia Su
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sanlian Hu
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Jun Ma
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zuoyan Zhang
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Fang Fang
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China. .,Department of Otolaryngology Head and Neck Surgery & Center of Sle-ep Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai, 200233, China. .,Otolaryngological Institute of Shanghai Jiao Tong University, Yishan Road 600, Shanghai, 200233, China. .,Shanghai Key Laboratory of Sleep Disordered Breathing, Yishan Road 600, Shanghai, 200233, China.
| | - Jian Guan
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Department of Otolaryngology Head and Neck Surgery & Center of Sle-ep Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai, 200233, China.,Otolaryngological Institute of Shanghai Jiao Tong University, Yishan Road 600, Shanghai, 200233, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Yishan Road 600, Shanghai, 200233, China
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8
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Keenan BT, Schwab RJ. Using the Remote Monitoring Framework to Promote Adherence to Continuous Positive Airway Pressure. Sleep Med Clin 2020; 16:85-99. [PMID: 33485534 DOI: 10.1016/j.jsmc.2020.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The ability to remotely monitor positive airway pressure therapy adherence and efficacy provides a unique opportunity for the field of sleep medicine to quickly and efficiently improve patient adherence. Smaller randomized studies and larger-scale retrospective evaluations show that telemedicine interventions leveraging these data can increase average usage and efficiency of care. However, more evidence on the impact of these programs on longer-term adherence and improving patient-reported outcomes is needed. Combining data from remote monitoring with clinical information in electronic health records may prove to be invaluable to the future of clinical sleep medicine practice and research.
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Affiliation(s)
- Brendan T Keenan
- Biostatistics Core, Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Translational Research Laboratories, 125 South 31st Street, Suite 2100, Office 2121, Philadelphia, PA 19104, USA
| | - Richard J Schwab
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, University of Pennsylvania Medical Center, 3624 Market Street, Suite 205, Philadelphia, PA 19104, USA.
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Wearn J, Akpa B, Mokhlesi B. Adherence to Positive Airway Pressure Therapy in Obesity Hypoventilation Syndrome. Sleep Med Clin 2020; 16:43-59. [PMID: 33485531 DOI: 10.1016/j.jsmc.2020.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Because of the prevalence of extreme obesity in the United States, there has been an increase in prevalence of obesity hypoventilation syndrome (OHS). There is limited information on the characteristics and pattern of positive airway pressure (PAP) adherence in patients with OHS compared with eucapnic patients with obstructive sleep apnea (OSA). This article discusses in detail the impact of PAP therapy on outcomes in patients with OHS, compares adherence between continuous PAP and noninvasive ventilation in OHS, and compares PAP adherence in patients with OHS to patients with moderate to severe OSA enrolled in clinical trials designed to improve CPAP adherence.
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Affiliation(s)
- Jeremy Wearn
- Sleep Medicine and Internal Medicine, Oregon Health & Science University and Portland VAMC, 3710 SW US Veterans Hospital Rd, PULM3/Sleep, Portland OR 97239, USA
| | - Bimaje Akpa
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, 420 Delaware Street SE, MMC 276, Minneapolis, MN 55455, USA
| | - Babak Mokhlesi
- Sleep Disorders Center, University of Chicago, 5841 South Maryland Avenue, MC6076/Room M630, Chicago, IL 60637, USA.
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10
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Abstract
Obstructive sleep apnea (OSA) telehealth management may improve initial and chronic care access, time to diagnosis and treatment, between-visit care, e-communications and e-education, workflows, costs, and therapy outcomes. OSA telehealth options may be used to replace or supplement none, some, or all steps in the evaluation, testing, treatments, and management of OSA. All telehealth steps must adhere to OSA guidelines. OSA telehealth may be adapted for continuous positive airway pressure (CPAP) and non-CPAP treatments. E-data collection enhances uses for individual and group analytics, phenotyping, testing and treatment selections, high-risk identification and targeted support, and comparative and multispecialty therapy studies.
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11
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Askland K, Wright L, Wozniak DR, Emmanuel T, Caston J, Smith I, Cochrane Airways Group. Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev 2020; 4:CD007736. [PMID: 32255210 PMCID: PMC7137251 DOI: 10.1002/14651858.cd007736.pub3] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although highly effective in the treatment of obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) is not universally accepted by users. Educational, supportive and behavioural interventions may help people with OSA initiate and maintain regular and continued use of CPAP. OBJECTIVES To assess the effectiveness of educational, supportive, behavioural, or mixed (combination of two or more intervention types) strategies that aim to encourage adults who have been prescribed CPAP to use their devices. SEARCH METHODS Searches were conducted on the Cochrane Airways Group Specialised Register of trials. Searches are current to 29 April 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs) that assessed intervention(s) designed to inform participants about CPAP/OSA, to support them in using CPAP, or to modify their behaviour to increase use of CPAP devices. DATA COLLECTION AND ANALYSIS We assessed studies to determine their suitability for inclusion in the review. Data were extracted independently and were entered into RevMan for analysis. 'Risk of bias' assessments were performed, using the updated 'Risk of bias 2' tool, for the primary outcome, CPAP usage. Study-level 'Risk of bias' assessments were performed using the original 'Risk of bias' tool. GRADE assessment was performed using GRADEpro. MAIN RESULTS Forty-one studies (9005 participants) are included in this review; 16 of these studies are newly identified with updated searches. Baseline Epworth Sleepiness Scale (ESS) scores indicate that most participants suffered from excessive daytime sleepiness. The majority of recruited participants had not used CPAP previously. When examining risk of bias for the primary outcome of hourly machine usage/night, 58.3% studies have high overall risk (24/41 studies), 39.0% have some concerns (16/41 studies), and 2.4% have low overall risk (1/41 studies). We are uncertain whether educational interventions improve device usage, as the certainty of evidence was assessed as very low. We were unable to perform meta-analyses for number of withdrawals and symptom scores due to high study heterogeneity. Supportive interventions probably increase device usage by 0.70 hours/night (95% confidence interval (CI) 0.36 to 1.05, N = 1426, 13 studies, moderate-certainty evidence), and low-certainty evidence indicates that the number of participants who used their devices ≥ 4 hours/night may increase from 601 to 717 per 1000 (odds ratio (OR), 1.68, 95% CI 1.08 to 2.60, N = 376, 2 studies). However, the number of withdrawals may also increase from 136 to 167 per 1000 (OR 1.27, 95% CI 0.97 to 1.66, N = 1702, 11 studies, low-certainty evidence). Participants may experience small improvements in symptoms (ESS score -0.32 points, 95% CI -1.19 to 0.56, N = 470, 5 studies, low-certainty evidence), and we are uncertain whether quality of life improves with supportive interventions, as the certainty of evidence was assessed as very low. When compared with usual care, behavioural interventions produce a clinically-meaningful increase in device usage by 1.31 hours/night (95% CI 0.95 to 1.66, N = 578, 8 studies, high-certainty evidence), probably increase the number of participants who used their machines ≥ 4 hours/night from 371 to 501 per 1000 (OR 1.70, 95% CI 1.20 to 2.41, N = 549, 6 studies, high-certainty evidence), and reduce the number of study withdrawals from 146 to 101 per 1000 (OR 0.66, 95% CI 0.44 to 0.98, N = 939, 10 studies, high-certainty evidence). Behavioural interventions may reduce symptoms (ESS score -2.42 points, 95% CI -4.27 to -0.57, N = 272, 5 studies, low-certainty evidence), but probably have no effect on quality of life (Functional Outcomes of Sleep Questionnaire (FOSQ), standardised mean difference (SMD) 0.00, 0.95% CI -0.26 to 0.26, N = 228, 3 studies, moderate-certainty evidence). We are uncertain whether behavioural interventions improve apnoea hypopnoea index (AHI), as the certainty of evidence was assessed as very low. We are uncertain if mixed interventions improve device usage, increase the number of participants using their machines ≥ 4 hours/night, reduce study withdrawals, improve quality of life, or reduce anxiety symptoms, as the certainty of evidence for these outcomes was assessed to be very low. Symptom scores via the ESS could not be measured due to considerable heterogeneity between studies. AUTHORS' CONCLUSIONS In CPAP-naïve people with OSA, high-certainty evidence indicates that behavioural interventions yield a clinically-significant increase in hourly device usage when compared with usual care. Moderate certainty evidence shows that supportive interventions increase usage modestly. Very low-certainty evidence shows that educational and mixed interventions may modestly increase CPAP usage. The impact of improved CPAP usage on daytime sleepiness, quality of life, and mood and anxiety scores remains unclear since these outcomes were not assessed in the majority of included studies. Studies addressing the choice of interventions that best match individual patient needs and therefore result in the most successful and cost-effective therapy are needed.
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Affiliation(s)
- Kathleen Askland
- Waypoint Centre for Mental Health CareWaypoint Research InstitutePenetanguisheneCanada
| | - Lauren Wright
- Waypoint Centre for Mental Health CareWaypoint Research InstitutePenetanguisheneCanada
- AstraZeneca Canada Inc.MississaugaOntarioCanada
| | - Dariusz R Wozniak
- Royal Papworth HospitalRespiratory Support and Sleep CentrePapworth EverardCambridgeUKCB23 3RE
| | - Talia Emmanuel
- Waypoint Centre for Mental Health CareWaypoint Research InstitutePenetanguisheneCanada
| | - Jessica Caston
- Waypoint Centre for Mental Health CareWaypoint Research InstitutePenetanguisheneCanada
| | - Ian Smith
- Royal Papworth HospitalRespiratory Support and Sleep CentrePapworth EverardCambridgeUKCB23 3RE
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12
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Morrone E, Giordano A, Carli S, Visca D, Rossato F, Godio M, Paracchini E, Rossi S, Balbi B, Sacco C, Braghiroli A. Something is changing in adherence to CPAP therapy: real world data after 1 year of treatment in patients with obstructive sleep apnoea. Eur Respir J 2020; 55:13993003.01419-2019. [PMID: 31806711 DOI: 10.1183/13993003.01419-2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/10/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Elisa Morrone
- Sleep Laboratory, Dept Pulmonary Rehabilitation, ICS Maugeri Spa SB, Scientific Institute of Veruno, Veruno, Italy
| | - Andrea Giordano
- Bioengineering Dept, ICS Maugeri Spa SB, Scientific Institute of Veruno, Veruno, Italy
| | - Sonia Carli
- Sleep Laboratory, Dept Pulmonary Rehabilitation, ICS Maugeri Spa SB, Scientific Institute of Veruno, Veruno, Italy
| | - Dina Visca
- Dept Pulmonary Rehabilitation, ICS Maugeri Spa SB, Scientific Institute of Tradate, Tradate, Italy
| | - Fabio Rossato
- Sleep Laboratory, Dept Pulmonary Rehabilitation, ICS Maugeri Spa SB, Scientific Institute of Veruno, Veruno, Italy
| | - Massimo Godio
- Sleep Laboratory, Dept Pulmonary Rehabilitation, ICS Maugeri Spa SB, Scientific Institute of Veruno, Veruno, Italy
| | - Elena Paracchini
- Sleep Laboratory, Dept Pulmonary Rehabilitation, ICS Maugeri Spa SB, Scientific Institute of Veruno, Veruno, Italy
| | - Sabrina Rossi
- Sleep Laboratory, Dept Pulmonary Rehabilitation, ICS Maugeri Spa SB, Scientific Institute of Veruno, Veruno, Italy
| | - Bruno Balbi
- Sleep Laboratory, Dept Pulmonary Rehabilitation, ICS Maugeri Spa SB, Scientific Institute of Veruno, Veruno, Italy
| | - Carlo Sacco
- Sleep Laboratory, Dept Pulmonary Rehabilitation, ICS Maugeri Spa SB, Scientific Institute of Veruno, Veruno, Italy
| | - Alberto Braghiroli
- Sleep Laboratory, Dept Pulmonary Rehabilitation, ICS Maugeri Spa SB, Scientific Institute of Veruno, Veruno, Italy
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13
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Khan SU, Duran CA, Rahman H, Lekkala M, Saleem MA, Kaluski E. A meta-analysis of continuous positive airway pressure therapy in prevention of cardiovascular events in patients with obstructive sleep apnoea. Eur Heart J 2019; 39:2291-2297. [PMID: 29069399 DOI: 10.1093/eurheartj/ehx597] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 09/29/2017] [Indexed: 01/24/2023] Open
Abstract
Aims To assess whether continuous positive airway pressure (CPAP) therapy reduces major adverse cardiovascular events (MACE) in patients with moderate-to-severe obstructive sleep apnoea (OSA). Methods and results A total of 235 articles were recovered using MEDLINE, EMBASE and Cochrane library (inception-December 2016) and references contained in the identified articles. Seven randomized controlled trials (RCTs) were selected for final analysis. Analysis of 4268 patients demonstrated non-significant 26% relative risk reduction in MACE with CPAP [risk ratio (RR) 0.74; 95% confidence interval (CI) 0.47-1.17; P = 0.19, I2 = 48%]. A series of sensitivity analyses suggested that increased CPAP usage time yielded significant risk reduction in MACE. and stroke. Subgroup analysis revealed that CPAP adherence time ≥4 hours (h)/night reduced the risk of MACE by 57% (RR 0.43; 95% CI 0.23-0.80; P = 0.01, I2 = 0%). CPAP therapy showed no beneficial effect on myocardial infarction (MI), all-cause mortality, atrial fibrillation/flutter (AF), or heart failure (HF) (P > 0.05). CPAP had positive effect on mood and reduced the daytime sleepiness [Epworth Sleepiness Scale (ESS): mean difference (MD) -2.50, 95% CI - 3.62, -1.39; P < 0.001, I2 = 81%]. Conclusion CPAP therapy might reduce MACE and stroke among subjects with CPAP time exceeding 4 h/night. Additional randomized trials mandating adequate CPAP time adherence are required to confirm this impression.
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Affiliation(s)
- Safi U Khan
- Department of Medicine, Guthrie Clinic/Robert Packer Hospital, Sayre, 18840?PA, USA
| | - Crystal A Duran
- Department of Medicine, Guthrie Clinic/Robert Packer Hospital, Sayre, 18840?PA, USA
| | - Hammad Rahman
- Department of Medicine, Guthrie Clinic/Robert Packer Hospital, Sayre, 18840?PA, USA
| | - Manidhar Lekkala
- Department of Medicine, Guthrie Clinic/Robert Packer Hospital, Sayre, 18840?PA, USA
| | | | - Edo Kaluski
- Department of Cardiology, Guthrie Clinic/Robert Packer Hospital, Sayre, PA, USA.,Rutgers New Jersey Medical School, Newark, NJ, USA.,Geisinger Commonwealth School of Medicine, Scranton, PA, USA
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14
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A randomized, placebo-controlled trial using a novel PAP delivery platform to treat patients with OSA and comorbid PTSD. Sleep Breath 2019; 24:1001-1009. [PMID: 31691105 DOI: 10.1007/s11325-019-01936-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/16/2019] [Accepted: 09/07/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Positive airway pressure (PAP) adherence is poor in comorbid OSA/PTSD. SensAwake™ (SA) is a wake-sensing PAP algorithm that lowers pressure when wake is detected. We compared auto-PAP (aPAP) with and without SA for comorbid OSA/PTSD. METHODS Prospective, randomized crossover study comparing aPAP to aPAP + SA. We enrolled patients with OSA/PTSD who were PAP naïve. Four weeks after randomization, the patients were crossed over to the alternate treatment group, with final follow-up at eight weeks. Sleep questionnaires (ESS, ISI, FSS, and FOSQ-10) were assessed at baseline and follow-up. RESULTS We enrolled 85 patients with OSA/PTSD. aPAP reduced AHI to < 5/h in both groups. Our primary endpoint, average hours of aPAP adherence (total) after 4 weeks, was significantly increased in the SA group in our intention-to-treat (ITT) analysis (ß = 1.13 (95% CI 0.16-2.1); p = 0.02), after adjustment for ESS differences at baseline. After adjustment for ESS, SA (ITT analysis) also showed significant improvement in percentage of nights used for ≥ 4 h (ß = 14.9 (95% CI 1.02-28.9); p = 0.04). There were trends toward an increase in percentage nights used total (ß = 17.4 (95% CI - 0.1 to 34.9); p = 0.05), average hours of aPAP adherence (nights used) (ß = 1.04 (95% CI - 0.07 to 2.1); p = 0.07), and regular use (OR = 7.5 (95% CI 0.9-64.7); p = 0.07) after adjustment for ESS at baseline. After adjustment for ESS and days to cross over, SA by actual assignment did not show any effect on adherence variables. The ESS, ISI, FSS, and FOSQ-10 all showed significant improvements with PAP, but there were no differences in the magnitude of improvement in any score between groups. CONCLUSIONS Adherence to aPAP may be improved with the addition of SA and deserves further study. SA is as effective as standard aPAP for normalizing the AHI and improving sleep-related symptoms. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT02549508 https://clinicaltrials.gov/ct2/show/NCT02549508?term=NCT02549508&rank=1 "Comparison Study Using APAP With and Without SensAwake in Patients With OSA and PTSD".
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15
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Holley AB. OSA, Exercise, and the Military. J Clin Sleep Med 2019; 15:819-820. [PMID: 31138394 DOI: 10.5664/jcsm.7824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/13/2019] [Indexed: 11/13/2022]
Affiliation(s)
- Aaron B Holley
- Pulmonary/Sleep and Critical Care Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland
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16
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Bakker JP, Weaver TE, Parthasarathy S, Aloia MS. Adherence to CPAP. Chest 2019; 155:1272-1287. [DOI: 10.1016/j.chest.2019.01.012] [Citation(s) in RCA: 147] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 12/24/2018] [Accepted: 01/08/2019] [Indexed: 01/17/2023] Open
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17
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Shaughnessy GF, Morgenthaler TI. The Effect of Patient-Facing Applications on Positive Airway Pressure Therapy Adherence: A Systematic Review. J Clin Sleep Med 2019; 15:769-777. [PMID: 31053207 DOI: 10.5664/jcsm.7772] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/09/2019] [Indexed: 01/11/2023]
Abstract
STUDY OBJECTIVES Many patients struggle with adherence to positive airway pressure (PAP) therapy for sleep apnea. In this systematic review we examined the effect that patient-facing applications (PFA)-web-based applications that interact directly with the patient-have on PAP adherence. METHODS A comprehensive search of PubMed, CINAHL, MEDLINE, and SCOPUS databases was performed. We looked for studies where: (1) patients were adults with sleep apnea initiating PAP therapy for the first time; (2) the intervention was a PFA that incorporated individual PAP use data; (3) the comparison was usual and/or telemedicine care, and (4) outcomes of objective PAP adherence data were recorded. RESULTS Seven studies were identified (two randomized trials, one prospective cohort trial, four retrospective cohort studies). Cumulatively the studies enrolled 304,328 patients, with individual enrollment ranging between 61 and 172,678 patients. Six studies showed that PFA use was associated with using PAP for significantly more hours per night (range 0.7-1.3 hours more). PFA cohorts used PAP a greater proportion of nights and had a lower rate of mask leak. There was no difference in apnea-hypopnea index and self-reported measures of symptoms between study groups. CONCLUSIONS PFA use was associated with improved adherence to PAP therapy. Although this conclusion is based on only two small trials and predominantly observational studies and therefore should be tested in large prospective trials, the PAFs are inexpensive, do not draw on health care resources, and show promise in improving PAP therapy for OSA.
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Affiliation(s)
- Gaja F Shaughnessy
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Timothy I Morgenthaler
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.,Division of Sleep Medicine, Mayo Clinic, Rochester, Minnesota
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18
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Holley AB, Londeree WA, Sheikh KL, Andrada TF, Powell TA, Khramtsov A, Hostler JM. Zolpidem and Eszopiclone Pre-medication for PSG: Effects on Staging, Titration, and Adherence. Mil Med 2019; 183:e251-e256. [PMID: 29961838 DOI: 10.1093/milmed/usx038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 10/30/2017] [Indexed: 11/13/2022] Open
Abstract
Introduction The non-benzodiazepine sedative hypnotic (NBSH) eszopiclone improves polysomnography (PSG) quality and continuous positive airway pressure (CPAP) adherence. It is unclear whether zolpidem has the same effect and neither NBSH has been studied in populations with milder forms of obstructive sleep apnea. Materials and Methods We performed a retrospective analysis on patients undergoing level I PSG at our institution. Patients are pre-medicated with NBSHs at the discretion of the sleep physician. We compared PSG/CPAP titration quality and subsequent CPAP adherence for patients receiving NBSHs or no pre-study medication. We adjusted for obstructive sleep apnea pre-test probability (PTP), arousal threshold, and other factors showing differences at baseline. Results Data on 560 patients were analyzed. Mean age and body mass index were 42.2 ± 10.1 and 28.8 ± 4.5, respectively. Median apnea hypopnea index was 12.9 (6.4-25.3), 100 (18.0%) patients had normal studies, 97 (17.3%) were split, and 457 (81.6%) had a respiratory low-arousal threshold. After adjusting for differences at baseline, neither NBSH was associated with sleep efficiency, wake after sleep onset, or total sleep time on PSG. After adjustment, patients receiving eszopiclone had a higher apnea hypopnea index at the final CPAP pressure (β = 14.2; 95% confidence intervals (CI) 7.2-21.2; p < 0.001) and were more likely to have an unacceptable titration (odds ratio (OR) = 6.6; 95% CI 2.0-21.0; p = 0.002). When only split-night studies were examined, there were no differences in any adherence variables across or between categories. Conclusions In a population with predominantly mild obstructive sleep apnea, NBSHs did not improve PSG or CPAP titration quality and did not increase CPAP adherence. There was no difference in effect between eszopiclone and zolpidem.
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Affiliation(s)
- Aaron B Holley
- Pulmonary/Sleep and Critical Care Medicine, San Antonio Military Medical Center, Roger Brooke Dr, San Antonio, TX
| | - William A Londeree
- Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, Wisconsin Ave, Bethesda, MD
| | - Karen L Sheikh
- Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, Wisconsin Ave, Bethesda, MD
| | - Teotimo F Andrada
- Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, Wisconsin Ave, Bethesda, MD
| | - Tyler A Powell
- Pulmonary/Sleep and Critical Care Medicine, San Antonio Military Medical Center, Roger Brooke Dr, San Antonio, TX
| | - Andrei Khramtsov
- Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, Wisconsin Ave, Bethesda, MD
| | - Jordanna M Hostler
- Pulmonary/Sleep and Critical Care Medicine, Tripler Army Medical Center, 1 Jarrett White Rd, Honolulu, HI
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19
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20
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Holley AB, Walter RJ. Does a Low Arousal Threshold Equal Low PAP Adherence? J Clin Sleep Med 2018; 14:713-714. [PMID: 29734998 DOI: 10.5664/jcsm.7088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 04/18/2018] [Indexed: 11/13/2022]
Affiliation(s)
- Aaron B Holley
- Pulmonary/Sleep and Critical Care Medicine Service, Brooke Army Medical Center, San Antonio, Texas
| | - Robert J Walter
- Pulmonary/Sleep and Critical Care Medicine Service, Brooke Army Medical Center, San Antonio, Texas
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