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Bironneau V, Ingrand P, Pontier S, Iamandi C, Portel L, Martin F, Mallart A, Lerousseau L, Alfandary D, Levrat V, Portier F, Tamisier R, Goutorbe F, Rabec C, Codron F, Auregan G, Mercy M, Attali V, Soyez F, Launois C, Recart D, Vecchierini MF, Gagnadoux F, Meurice JC. Auto-adjusted versus fixed positive airway pressure in patients with severe OSA: A large randomized controlled trial. Respirology 2023; 28:1069-1077. [PMID: 37587548 DOI: 10.1111/resp.14569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND AND OBJECTIVE Continuous positive airway pressure (CPAP) in the treatment of severe obstructive sleep apnoea (OSA) can be used in fixed CPAP or auto-adjusted (APAP) mode. The aim of this prospective randomized controlled clinical study was to evaluate the 3 month-efficacy of CPAP used either in fixed CPAP or APAP mode. METHODS Eight hundred one patients with severe OSA were included in twenty-two French centres. After 7 days during which all patients were treated with APAP to determine the effective pressure level and its variability, 353 and 351 patients were respectively randomized in the fixed CPAP group and APAP group. After 3 months of treatment, 308 patients in each group were analysed. RESULTS There was no difference between the two groups in terms of efficacy whatever the level of efficient pressure and pressure variability (p = 0.41). Exactly, 219 of 308 patients (71.1%) in the fixed CPAP group and 212 of 308 (68.8%) in the APAP group (p = 0.49) demonstrated residual apnoea hypopnoea index (AHI) <10/h and Epworth Score <11. Tolerance and adherence were also identical with a similar effect on quality of life and blood pressure evaluation. CONCLUSION The two CPAP modes, fixed CPAP and APAP, were equally effective and tolerated in severe OSA patients.
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Affiliation(s)
- Vanessa Bironneau
- INSERM CIC 1402, IS-ALIVE Research Group, University of Poitiers, Poitiers, France
- Pneumologie, CHU de Poitiers, Poitiers, France
| | | | | | | | | | | | | | | | | | | | | | - Renaud Tamisier
- Université Grenoble Alpes, Inserm U1300, CHU Grenoble Alpes, Grenoble, France
| | | | | | | | - Guy Auregan
- Pneumologie, Polyclinique de Poitiers, Poitiers, France
| | | | - Valérie Attali
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Département R3S, Service des Pathologies du Sommeil, AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | | | | | - Didier Recart
- Pneumologie, Cabinet Médical Arnasa, Biarritz, France
| | | | - Frédéric Gagnadoux
- Département de Pneumologie et Médecine du sommeil, CHU d'Angers, Angers, France
| | - Jean-Claude Meurice
- INSERM CIC 1402, IS-ALIVE Research Group, University of Poitiers, Poitiers, France
- Pneumologie, CHU de Poitiers, Poitiers, France
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Kennedy B, Lasserson TJ, Wozniak DR, Smith I. Pressure modification or humidification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev 2019; 12:CD003531. [PMID: 31792939 PMCID: PMC6888022 DOI: 10.1002/14651858.cd003531.pub4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is the repetitive closure of the upper airway during sleep. This results in disturbed sleep and excessive daytime sleepiness. It is a risk factor for long-term cardiovascular morbidity. Continuous positive airway pressure (CPAP) machines can be applied during sleep. They deliver air pressure by a nasal or oronasal mask to prevent the airway from closing, reducing sleep disturbance and improving sleep quality. Some people find them difficult to tolerate because of high pressure levels and other symptoms such as a dry mouth. Switching to machines that vary the level of air pressure required to reduce sleep disturbance could increase comfort and promote more regular use. Humidification devices humidify the air that is delivered to the upper airway through the CPAP circuit. Humidification may reduce dryness of the throat and mouth and thus improve CPAP tolerability. This updated Cochrane Review looks at modifying the delivery of positive pressure and humidification on machine usage and other clinical outcomes in OSA. OBJECTIVES To determine the effects of positive pressure modification or humidification on increasing CPAP machine usage in adults with OSA. SEARCH METHODS We searched Cochrane Airways Specialised Register and clinical trials registries on 15 October 2018. SELECTION CRITERIA Randomised parallel group or cross-over trials in adults with OSA. We included studies that compared automatically adjusting CPAP (auto-CPAP), bilevel positive airway pressure (bi-PAP), CPAP with expiratory pressure relief (CPAPexp), heated humidification plus fixed CPAP, automatically adjusting CPAP with expiratory pressure relief, Bi-PAP with expiratory pressure relief, auto bi-PAP and CPAPexp with wakefulness detection with fixed pressure setting. DATA COLLECTION AND ANALYSIS We used standard methods expected by Cochrane. We assessed the certainty of evidence using GRADE for the outcomes of machine usage, symptoms (measured by the Epworth Sleepiness Scale (ESS)), Apnoea Hypopnoea Index (AHI), quality of life measured by Functional Outcomes of Sleep Questionnaire (FOSQ), blood pressure, withdrawals and adverse events (e.g. nasal blockage or mask intolerance). The main comparison of interest in the review is auto-CPAP versus fixed CPAP. MAIN RESULTS We included 64 studies (3922 participants, 75% male). The main comparison of auto-CPAP with fixed CPAP is based on 36 studies with 2135 participants from Europe, USA, Hong Kong and Australia. The majority of studies recruited participants who were recently diagnosed with OSA and had not used CPAP previously. They had excessive sleepiness (ESS: 13), severe sleep disturbance (AHI ranged from 22 to 59), and average body mass index (BMI) of 35 kg/m2. Interventions were delivered at home and the duration of most studies was 12 weeks or less. We judged that studies at high or unclear risk of bias likely influenced the effect of auto-CPAP on machine usage, symptoms, quality of life and tolerability, but not for other outcomes. Primary outcome Compared with average usage of about five hours per night with fixed CPAP, people probably use auto-CPAP for 13 minutes longer per night at about six weeks (mean difference (MD) 0.21 hours/night, 95% confidence interval (CI) 0.11 to 0.31; 31 studies, 1452 participants; moderate-certainty evidence). We do not have enough data to determine whether auto-CPAP increases the number of people who use machines for more than four hours per night compared with fixed CPAP (odds ratio (OR) 1.16, 95% CI 0.75 to 1.81; 2 studies, 346 participants; low-certainty evidence). Secondary outcomes Auto-CPAP probably reduces daytime sleepiness compared with fixed CPAP at about six weeks by a small amount (MD -0.44 ESS units, 95% CI -0.72 to -0.16; 25 studies, 1285 participants; moderate-certainty evidence). AHI is slightly higher with auto-CPAP than with fixed CPAP (MD 0.48 events per hour, 95% CI 0.16 to 0.80; 26 studies, 1256 participants; high-certainty evidence), although it fell with both machine types from baseline values in the studies. Ten per cent of people in auto-CPAP and 11% in the fixed CPAP arms withdrew from the studies (OR 0.90, 95% CI 0.64 to 1.27; moderate-certainty evidence). Auto-CPAP and fixed CPAP may have similar effects on quality of life, as measured by the FOSQ but more evidence is needed to be confident in this result (MD 0.12, 95% CI -0.21 to 0.46; 3 studies, 352 participants; low-certainty evidence). Two studies (353 participants) provided data on clinic-measured blood pressure. Auto-CPAP may be slightly less effective at reducing diastolic blood pressure compared to fixed CPAP (MD 2.92 mmHg, 95% CI 1.06 to 4.77 mmHg; low-certainty evidence). The two modalities of CPAP probably do not differ in their effects on systolic blood pressure (MD 1.87 mmHg, 95% CI -1.08 to 4.82; moderate-certainty evidence). Nine studies (574 participants) provided information on adverse events such as nasal blockage, dry mouth, tolerance of treatment pressure and mask leak. They used different scales to capture these outcomes and due to variation in the direction and size of effect between the studies, the comparative effects on tolerability outcomes are uncertain (very low-certainty evidence). The evidence base for other interventions is smaller, and does not provide sufficient information to determine whether there are important differences between pressure modification strategies and fixed CPAP on machine usage outcomes, symptoms and quality of life. As with the evidence for the auto-CPAP, adverse events are measured disparately. AUTHORS' CONCLUSIONS In adults with moderate to severe sleep apnoea starting positive airway pressure therapy, auto-CPAP probably increases machine usage by about 13 minutes per night. The effects on daytime sleepiness scores with auto-CPAP are not clinically meaningful. AHI values are slightly lower with fixed CPAP. Use of validated quality of life instruments in the studies to date has been limited, although where they have been used the effect sizes have not exceeded proposed clinically important differences. The adoption of a standardised approach to measuring tolerability would help decision-makers to balance benefits with harms from the different treatment options available. The evidence available for other pressure modification strategies does not provide a reliable basis on which to draw firm conclusions. Future studies should look at the effects of pressure modification devices and humidification in people who have already used CPAP but are unable to persist with treatment.
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Affiliation(s)
- Barry Kennedy
- St. James's HospitalDepartment of Sleep MedicineDublinIreland
| | - Toby J Lasserson
- Cochrane Central ExecutiveEditorial & Methods DepartmentSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Dariusz R Wozniak
- Royal Papworth HospitalRespiratory Support and Sleep CentrePapworth EverardCambridgeUKCB23 3RE
| | - Ian Smith
- Royal Papworth HospitalRespiratory Support and Sleep CentrePapworth EverardCambridgeUKCB23 3RE
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Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment. J Clin Sleep Med 2019; 15:301-334. [PMID: 30736888 DOI: 10.5664/jcsm.7638] [Citation(s) in RCA: 303] [Impact Index Per Article: 60.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/14/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The purpose of this systematic review is to provide supporting evidence for the clinical practice guideline for the treatment of obstructive sleep apnea (OSA) in adults using positive airway pressure (PAP). METHODS The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of PAP with no treatment as well as studies that compared different PAP modalities. Meta-analyses were performed to determine the clinical significance of using PAP in several modalities (ie, continuous PAP, auto-adjusting PAP, and bilevel PAP), to treat OSA in adults. In addition, meta-analyses were performed to determine the clinical significance of using an in-laboratory versus ambulatory strategy for the initiation of PAP, educational and behavioral interventions, telemonitoring, humidification, different mask interfaces, and flexible or modified pressure profile PAP in conjunction with PAP to treat OSA in adults. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations. RESULTS The literature search resulted in 336 studies that met inclusion criteria; 184 studies provided data suitable for meta-analyses. The data demonstrated that PAP compared to no treatment results in a clinically significant reduction in disease severity, sleepiness, blood pressure, and motor vehicle accidents, and improvement in sleep-related quality of life in adults with OSA. In addition, the initiation of PAP in the home demonstrated equivalent effects on patient outcomes when compared to an in-laboratory titration approach. The data also demonstrated that the use of auto-adjusting or bilevel PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP. Furthermore, data demonstrated a clinically significant improvement in PAP adherence with the use of educational, behavioral, troubleshooting, and telemonitoring interventions. Systematic reviews for specific PAP delivery method were also performed and suggested that nasal interfaces compared to oronasal interfaces have improved adherence and slightly greater reductions in OSA severity, heated humidification compared to no humidification reduces some continuous PAP-related side effects, and pressure profile PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP.
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Affiliation(s)
| | - Indu A Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - R Joh Kimoff
- McGill University Health Centre, Montreal, Quebec, Canada
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Meurice JC, Antone E, Gilbert M, Watrin A, Bironneau V. [Continuous positive airway pressure in obstructive sleep apnea]. Presse Med 2017; 46:423-431. [PMID: 28434626 DOI: 10.1016/j.lpm.2017.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 02/25/2017] [Indexed: 12/18/2022] Open
Abstract
Continuous positive airway pressure (CPAP) is currently the most used and efficient therapy in OSAS. Efficiency of CPAP on sleep respiratory disorders is the same whether in fixed or automatic mode. Larger studies are required to evaluate their respective beneficial impact on cardiovascular or metabolic complications of OSAS. Close medical monitoring is necessary during the first weeks of CPAP therapy. Compliance to CPAP therapy is crucial for efficacy in preventing cardiovascular or metabolic complications of OSAS. As beneficial effects of CPAP in obese patients are modest, on blood pressure levels and metabolic disorders, its use has to be part of a comprehensive care of OSAS and related comorbidities.
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Affiliation(s)
- Jean Claude Meurice
- CHU de Poitiers, université de Poitiers, service de pneumologie, 86000 Poitiers, France; Groupe ALIVE, CIC Inserm 1402, 86000 Poitiers, France.
| | - Elise Antone
- CHU de Poitiers, université de Poitiers, service de pneumologie, 86000 Poitiers, France
| | - Mylene Gilbert
- CHU de Poitiers, université de Poitiers, service de pneumologie, 86000 Poitiers, France
| | - Audrey Watrin
- CHU de Poitiers, université de Poitiers, service de pneumologie, 86000 Poitiers, France
| | - Vanessa Bironneau
- CHU de Poitiers, université de Poitiers, service de pneumologie, 86000 Poitiers, France; Groupe ALIVE, CIC Inserm 1402, 86000 Poitiers, France
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Phenotypes in obstructive sleep apnea: A definition, examples and evolution of approaches. Sleep Med Rev 2016; 35:113-123. [PMID: 27815038 DOI: 10.1016/j.smrv.2016.10.002] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 07/23/2016] [Accepted: 10/05/2016] [Indexed: 01/02/2023]
Abstract
Obstructive sleep apnea (OSA) is a complex and heterogeneous disorder and the apnea hypopnea index alone can not capture the diverse spectrum of the condition. Enhanced phenotyping can improve prognostication, patient selection for clinical trials, understanding of mechanisms, and personalized treatments. In OSA, multiple condition characteristics have been termed "phenotypes." To help classify patients into relevant prognostic and therapeutic categories, an OSA phenotype can be operationally defined as: "A category of patients with OSA distinguished from others by a single or combination of disease features, in relation to clinically meaningful attributes (symptoms, response to therapy, health outcomes, quality of life)." We review approaches to clinical phenotyping in OSA, citing examples of increasing analytic complexity. Although clinical feature based OSA phenotypes with significant prognostic and treatment implications have been identified (e.g., excessive daytime sleepiness OSA), many current categorizations lack association with meaningful outcomes. Recent work focused on pathophysiologic risk factors for OSA (e.g., arousal threshold, craniofacial morphology, chemoreflex sensitivity) appears to capture heterogeneity in OSA, but requires clinical validation. Lastly, we discuss the use of machine learning as a promising phenotyping strategy that can integrate multiple types of data (genomic, molecular, cellular, clinical) to identify unique, meaningful OSA phenotypes.
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Isetta V, Montserrat JM, Santano R, Wimms AJ, Ramanan D, Woehrle H, Navajas D, Farré R. Novel Approach to Simulate Sleep Apnea Patients for Evaluating Positive Pressure Therapy Devices. PLoS One 2016; 11:e0151530. [PMID: 26978077 PMCID: PMC4792477 DOI: 10.1371/journal.pone.0151530] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 02/28/2016] [Indexed: 11/29/2022] Open
Abstract
Bench testing is a useful method to characterize the response of different automatic positive airway pressure (APAP) devices under well-controlled conditions. However, previous models did not consider the diversity of obstructive sleep apnea (OSA) patients’ characteristics and phenotypes. The objective of this proof-of-concept study was to design a new bench test for realistically simulating an OSA patient’s night, and to implement a one-night example of a typical female phenotype for comparing responses to several currently-available APAP devices. We developed a novel approach aimed at replicating a typical night of sleep which includes different disturbed breathing events, disease severities, sleep/wake phases, body postures and respiratory artefacts. The simulated female OSA patient example that we implemented included periods of wake, light sleep and deep sleep with positional changes and was connected to ten different APAP devices. Flow and pressure readings were recorded; each device was tested twice. The new approach for simulating female OSA patients effectively combined a wide variety of disturbed breathing patterns to mimic the response of a predefined patient type. There were marked differences in response between devices; only three were able to overcome flow limitation to normalize breathing, and only five devices were associated with a residual apnea-hypopnea index of <5/h. In conclusion, bench tests can be designed to simulate specific patient characteristics, and typical stages of sleep, body position, and wake. Each APAP device behaved differently when exposed to this controlled model of a female OSA patient, and should lead to further understanding of OSA treatment.
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Affiliation(s)
- Valentina Isetta
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
- CIBERES, Madrid, Spain
| | - Josep M. Montserrat
- CIBERES, Madrid, Spain
- Sleep Laboratory, Pneumology Department, Hospital Clinic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain
| | - Raquel Santano
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| | | | | | | | - Daniel Navajas
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
- CIBERES, Madrid, Spain
- Institute for Bioengineering of Catalonia, IBEC, Barcelona, Spain
| | - Ramon Farré
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
- CIBERES, Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain
- * E-mail:
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Farré R, Navajas D, Montserrat JM. Technology for noninvasive mechanical ventilation: looking into the black box. ERJ Open Res 2016; 2:00004-2016. [PMID: 27730162 PMCID: PMC5005145 DOI: 10.1183/23120541.00004-2016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 01/17/2016] [Indexed: 11/21/2022] Open
Abstract
Current devices for providing noninvasive respiratory support contain sensors and built-in intelligence for automatically modifying ventilation according to the patient's needs. These devices, including automatic continuous positive airway pressure devices and noninvasive ventilators, are technologically complex and offer a considerable number of different modes of ventilation and setting options, the details of which are sometimes difficult to capture by the user. Therefore, better predicting and interpreting the actual performance of these ventilation devices in clinical application requires understanding their functioning principles and assessing their performance under well controlled bench test conditions with simulated patients. This concise review presents an updated perspective of the theoretical basis of intelligent continuous positive airway pressure and noninvasive ventilation devices, and of the tools available for assessing how these devices respond under specific ventilation phenotypes in patients requiring breathing support. Current devices for intelligent noninvasive ventilation should be tested to better understand clinical performance http://ow.ly/XAS6Z
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Affiliation(s)
- Ramon Farré
- Unitat Biofísica i Bioenginyeria, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain; CIBER Enfermedades Respiratorias, Madrid, Spain; Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, Spain
| | - Daniel Navajas
- Unitat Biofísica i Bioenginyeria, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain; CIBER Enfermedades Respiratorias, Madrid, Spain; Institut de Bioenginyeria de Catalunya, Barcelona, Spain
| | - Josep M Montserrat
- CIBER Enfermedades Respiratorias, Madrid, Spain; Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, Spain; Sleep Lab, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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Donovan LM, Boeder S, Malhotra A, Patel SR. New developments in the use of positive airway pressure for obstructive sleep apnea. J Thorac Dis 2015; 7:1323-42. [PMID: 26380760 DOI: 10.3978/j.issn.2072-1439.2015.07.30] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 07/03/2015] [Indexed: 12/14/2022]
Abstract
Obstructive sleep apnea (OSA) is a disorder which afflicts a large number of individuals around the world. OSA causes sleepiness and is a major cardiovascular risk factor. Since its inception in the early 1980's, continuous positive airway pressure (CPAP) has emerged as the major treatment of OSA, and it has been shown to improve sleepiness, hypertension, and a number of cardiovascular indices. Despite its successes, adherence with treatment remains a major limitation. Herein we will review the evidence behind the use of positive airway pressure (PAP) therapy, its various modes, and the methods employed to improve adherence. We will also discuss the future of PAP therapy in OSA and personalization of care.
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Affiliation(s)
- Lucas M Donovan
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Schafer Boeder
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Atul Malhotra
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sanjay R Patel
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Isetta V, Navajas D, Montserrat JM, Farré R. Comparative assessment of several automatic CPAP devices' responses: a bench test study. ERJ Open Res 2015; 1:00031-2015. [PMID: 27730142 PMCID: PMC5005142 DOI: 10.1183/23120541.00031-2015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 07/26/2015] [Indexed: 11/05/2022] Open
Abstract
Automatic continuous positive airway pressure (APAP) devices adjust the delivered pressure based on the breathing patterns of the patient and, accordingly, they may be more suitable for patients who have a variety of pressure demands during sleep based on factors such as body posture, sleep stage or variability between nights. Devices from different manufacturers incorporate distinct algorithms and may therefore respond differently when subjected to the same disturbed breathing pattern. Our objective was to assess the response of several currently available APAP devices in a bench test. A computer-controlled model mimicking the breathing pattern of a patient with obstructive sleep apnoea (OSA) was connected to different APAP devices for 2-h tests during which flow and pressure readings were recorded. Devices tested were AirSense 10 (ResMed), Dreamstar (Sefam), Icon (Fisher & Paykel), Resmart (BMC), Somnobalance (Weinmann), System One (Respironics) and XT-Auto (Apex). Each device was tested twice. The response of each device was considerably different. Whereas some devices were able to normalise breathing, in some cases exceeding the required pressure, other devices did not eliminate disturbed breathing events (mainly prolonged flow limitation). Mean and maximum pressures ranged 7.3-14.6 cmH2O and 10.4-17.9 cmH2O, respectively, and the time to reach maximum pressure varied from 4.4 to 96.0 min. Each APAP device uses a proprietary algorithm and, therefore, the response to a bench simulation of OSA varied significantly. This must be taken into account for nasal pressure treatment of OSA patients and when comparing results from clinical trials.
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Affiliation(s)
- Valentina Isetta
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain; CIBERES, Madrid, Spain
| | - Daniel Navajas
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain; CIBERES, Madrid, Spain; Institute for Bioengineering of Catalonia (IBEC), Barcelona, Spain
| | - Josep M Montserrat
- CIBERES, Madrid, Spain; Sleep Lab, Pneumology Department, Hospital Clinic, Barcelona, Spain; IDIBAPS (Institut d'investigacions Biomèdiques August Pi i Sunyer), Barcelona, Spain
| | - Ramon Farré
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain; CIBERES, Madrid, Spain; IDIBAPS (Institut d'investigacions Biomèdiques August Pi i Sunyer), Barcelona, Spain
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Álvarez D, Gutiérrez-Tobal GC, Del Campo F, Hornero R. Positive airway pressure and electrical stimulation methods for obstructive sleep apnea treatment: a patent review (2005 - 2014). Expert Opin Ther Pat 2015; 25:971-89. [PMID: 26077527 DOI: 10.1517/13543776.2015.1054094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a major health problem with significant negative effects on the health and quality of life. Continuous positive airway pressure (CPAP) is currently the primary treatment option and it is considered the most effective therapy for OSAHS. Nevertheless, comfort issues due to improper fit to patient's changing needs and breathing gas leakage limit the patient's adherence to treatment. AREAS COVERED The present patent review describes recent innovations in the treatment of OSAHS related to optimization of the positive pressure delivered to the patient, methods and systems for continuous self-adjusting pressure during inspiration and expiration phases, and techniques for electrical stimulation of nerves and muscles responsible for the airway patency. EXPERT OPINION In the last few years, CPAP-related inventions have mainly focused on obtaining an optimal self-adjusting pressure according to patient's needs. Despite intensive research carried out, treatment compliance is still a major issue. Hypoglossal electrical nerve stimulation could be an effective secondary treatment option when CPAP primary therapy fails. Several patents have been granted focused on selective stimulation techniques and parameter optimization of the stimulating pulse waveform. Nevertheless, there remain important issues to address, like effectiveness and adverse events due to improper stimulation.
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Affiliation(s)
- Daniel Álvarez
- a 1 Universidad de Valladolid, Biomedical Engineering Group, E.T.S.I. Telecomunicación , Paseo de Belén 15, 47011 Valladolid, Spain +34 983185570 ; +34 983 423667 ;
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11
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Antone E, Gilbert M, Bironneau V, Meurice JC. [Continuous positive airways pressure treatment for obstructive sleep apnoea]. Rev Mal Respir 2015; 32:447-60. [PMID: 25823935 DOI: 10.1016/j.rmr.2014.11.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 11/07/2014] [Indexed: 11/16/2022]
Abstract
Continuous positive airway pressure (CPAP) still remains the most frequently used and the most efficient treatment for obstructive sleep apnea syndrome. However, its efficiency is conditioned by healthcare quality depending on many factors such as medical specificities of the patients as well as the severity of sleep-related breathing disorders. In order to optimize CPAP efficiency, it is necessary to be aware of the functional abilities of the different devices, and to perform a close monitoring of the patients, particularly during the first weeks of treatment, by maximally using the data provided by the CPAP apparatus. Some questions remain unsolved, such as the impact of nasal CPAP on glucose metabolism or cardiovascular prognosis. Furthermore, the strategy of CPAP use should be improved according to future results of studies dedicated to the interest of home telemonitoring and taking into account the validated mode of CPAP initiation.
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Affiliation(s)
- E Antone
- Service de pneumologie, CHU de Poitiers, université de Poitiers, 2, rue de la Miletrie, 86000 Poitiers, France.
| | - M Gilbert
- Service de pneumologie, CHU de Poitiers, université de Poitiers, 2, rue de la Miletrie, 86000 Poitiers, France
| | - V Bironneau
- Service de pneumologie, CHU de Poitiers, université de Poitiers, 2, rue de la Miletrie, 86000 Poitiers, France
| | - J C Meurice
- Service de pneumologie, CHU de Poitiers, université de Poitiers, 2, rue de la Miletrie, 86000 Poitiers, France
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Joosten SA, O'Driscoll DM, Berger PJ, Hamilton GS. Supine position related obstructive sleep apnea in adults: pathogenesis and treatment. Sleep Med Rev 2013; 18:7-17. [PMID: 23669094 DOI: 10.1016/j.smrv.2013.01.005] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 01/21/2013] [Accepted: 01/21/2013] [Indexed: 11/26/2022]
Abstract
The most striking feature of obstructive respiratory events is that they are at their most severe and frequent in the supine sleeping position: indeed, more than half of all obstructive sleep apnea (OSA) patients can be classified as supine related OSA. Existing evidence points to supine related OSA being attributable to unfavorable airway geometry, reduced lung volume, and an inability of airway dilator muscles to adequately compensate as the airway collapses. The role of arousal threshold and ventilatory control instability in the supine position has however yet to be defined. Crucially, few physiological studies have examined patients in the lateral and supine positions, so there is little information to elucidate how breathing stability is affected by sleep posture. The mechanisms of supine related OSA can be overcome by the use of continuous positive airway pressure. There are conflicting data on the utility of oral appliances, while the effectiveness of weight loss and nasal expiratory resistance remains unclear. Avoidance of the supine posture is efficacious, but long term compliance data and well powered randomized controlled trials are lacking. The treatment of supine related OSA remains largely ignored in major clinical guidelines. Supine OSA is the dominant phenotype of the OSA syndrome. This review explains why the supine position so favors upper airway collapse and presents the available data on the management of patients with supine related OSA.
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Affiliation(s)
- Simon A Joosten
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Australia; The Ritchie Centre, Monash Institute of Medical Research, Monash University, Clayton, Australia.
| | - Denise M O'Driscoll
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Australia; Department of Medicine, Southern Clinical School, Monash University, Clayton, Australia
| | - Philip J Berger
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Clayton, Australia
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Australia; The Ritchie Centre, Monash Institute of Medical Research, Monash University, Clayton, Australia
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13
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The undervalued potential of positional therapy in position-dependent snoring and obstructive sleep apnea-a review of the literature. Sleep Breath 2012; 17:39-49. [PMID: 22441662 PMCID: PMC3575552 DOI: 10.1007/s11325-012-0683-5] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 01/20/2012] [Accepted: 03/05/2012] [Indexed: 11/15/2022]
Abstract
Purpose Research during the past 10–20 years shows that positional therapy (PT) has a significant influence on the apnea–hypopnea index. These studies are predominantly performed as case series on a comparably small number of patients. Still, results have not found their way into the daily diagnostic and treatment routine. An average of 56 % of patients with obstructive sleep apnea (OSA) have position-dependent OSA (POSA), commonly defined as a difference of 50 % or more in apnea index between supine and non-supine positions. A great deal could be gained in treating patients with POSA with PT. The aim of this paper was to perform a thorough review of the literature on positional sleep apnea and its therapy. Methods A broad search strategy was run electronically in the MEDLINE and EMBASE databases using synonyms for position and sleep apnea. Results Sixteen studies were found which examined the effect of PT on OSA. In this literature review, we discuss the various techniques, results, and compliance rates. Conclusion Long-term compliance for PT remains an issue, and although remarkable results have been shown using innovative treatment concepts for PT, there is room for both technical improvement of the devices and for further research.
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Portier F, Orvoen Frija E, Chavaillon JM, Lerousseau L, Reybet Degat O, Léger D, Meurice JC. Traitement du SAHOS par ventilation en pression positive continue (PPC). Rev Mal Respir 2010; 27 Suppl 3:S137-45. [DOI: 10.1016/s0761-8425(10)70019-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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15
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Abstract
Several treatment options are available for obstructive sleep apnea syndrome (OSAS), including various types of positive airway pressure (PAP) therapy, oral appliances, surgery, and conservative approaches including weight loss and positional therapy. This article focuses on continuous positive airway pressure treatment and technological advancements in the delivery of PAP therapy for OSAS, reviews indications for treatment, treatment outcomes, and methods of improving compliance, and discusses the other non-PAP treatment options.
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16
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The value of auto-adjustable CPAP devices in pressure titration and treatment of patients with obstructive sleep apnea syndrome. Sleep Med Rev 2010; 14:115-9. [DOI: 10.1016/j.smrv.2009.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 07/04/2009] [Accepted: 07/06/2009] [Indexed: 01/08/2023]
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17
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Smith I, Lasserson TJ. Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev 2009:CD003531. [PMID: 19821310 DOI: 10.1002/14651858.cd003531.pub3] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Continuous Positive Airways Pressure (CPAP) is considered to be the cornerstone of therapy for obstructive sleep apnoea (OSA). However, compliance with this treatment is frequently poor, which may lead to ongoing symptoms of sleep disruption, daytime sleepiness and poor waking cognitive function. Mechanical interventions which involve changing the way that positive pressure is delivered, and the addition of humidification, might improve compliance. OBJECTIVES To determine the efficacy of pressure level modifications and additional humidification in increasing CPAP machine usage. SEARCH STRATEGY We searched the Cochrane Airways Group Specialised Register (September 2008). SELECTION CRITERIA Randomised controlled trials (RCTs) assessing interventions to improve compliance with CPAP usage. Control groups received fixed pressure CPAP. DATA COLLECTION AND ANALYSIS Two authors assessed articles for inclusion in the review and extracted data. We made attempts to obtain additional unpublished data from the trialists. MAIN RESULTS Forty-five studies met the inclusion criteria (1874 participants). Auto-CPAP (30 studies, 1136 participants): a statistically significant difference in machine usage of 0.21 hours/night (0.08 to 0.35) was observed in favour of auto-CPAP from cross-over studies. This difference is of questionable clinical significance. Pooled effect estimates from parallel group trials detected a similar sized difference for average nightly machine usage, but this was not statistically significant. Evidence from parallel group studies did not identify a statistically significant difference between pressure modes in Epworth Sleepiness Scores, but there was an overall reduction of 0.64 units with cross-over studies (-0.12 to -1.16) in favour of auto-CPAP. Parallel group studies did not identify a significant difference. More participants preferred auto-CPAP to fixed CPAP where this was measured. Bi-level PAP (six studies, 285 participants): no significant differences were observed in machine usage. One small study found no difference in preference. C-Flex (six studies, 318 participants): no significant difference was observed in machine usage. Humidification (three studies, 135 participants): there were conflicting findings between the studies. Two parallel group trials found no significant difference in machine usage, whereas a cross-over study found a significant difference. AUTHORS' CONCLUSIONS Improvement in average machine use of auto-CPAP was superior in studies with a cross-over design; the point estimate in parallel group trials was similar, but did not reach statistical significance. It is uncertain how use of machines in study settings relates to 'real world' use. Where preference was measured participants preferred auto-CPAP to fixed pressure CPAP. Further studies are required to assess the evidence for Bi-PAP, C-Flex(TM) and humidification. The studies assembled were characterised by high machine usage in the control groups, and low withdrawal rates. Future studies need to consider the effects of treatment in participants with more mild disease, and those who struggle to accept therapy despite persistent symptoms.
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Affiliation(s)
- Ian Smith
- Respiratory Support and Sleep Centre, Papworth Hospital, Papworth Everard, Cambridge, UK, CB3 8RE
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To KW, Chan WC, Choo KL, Lam WK, Wong KK, Hui DS. A randomized cross-over study of auto-continuous positive airway pressure versus fixed-continuous positive airway pressure in patients with obstructive sleep apnoea. Respirology 2008; 13:79-86. [PMID: 18197915 DOI: 10.1111/j.1440-1843.2007.01138.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES To compare the efficacy of auto-CPAP (AutoSet Spirit, ResMed) versus fixed-CPAP (S6 Elite, ResMed) in improving daytime sleepiness, health status, objective compliance and the ultimate treatment preference in patients with severe OSA. METHODS The study recruited 43 subjects aged 18-65 years with newly diagnosed severe OSA (AHI >30/h). Patients were initially treated with either auto-CPAP or fixed-CPAP for 2 months and then crossed over after a washout period of 1 week for another 2 months. RESULTS The study was completed by 41 patients. Results are presented as mean (SE). Use of auto-CPAP in the first and the second month was significantly higher than that of fixed-CPAP [129.7 (9.9) and 130.5 (10.7) h vs 115.2 (9.5) and 113.2 (9.4) h, P = 0.04 and 0.01], whereas mean hourly use per night was 4.3 and 4.4 h versus 3.8 and 3.7 h, respectively. The Epworth sleepiness scores improved after 1 month in both treatments (13.4 to 8.5 and 8.2, P < 0.01 for both). The Sleep apnoea quality of life index improved in the first month in both compared with baseline [4.6 (0.2) to 5.0 (0.2) for auto-CPAP and 4.9 (0.2) for fixed-CPAP, P = 0.01 and 0.04, respectively], with no difference between the two treatments. Nine and 30 patients preferred auto-CPAP and fixed-CPAP, respectively, at the end of the trial, whereas 14 and 25 patients would have chosen the same treatments if cost had not been a consideration. CONCLUSIONS Auto-CPAP and fixed-CPAP were equally effective in improving symptoms and health status in patients with severe OSA. Usage was higher with auto-CPAP, but more patients ultimately chose fixed-CPAP.
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Affiliation(s)
- Kin W To
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong, China
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Meurice JC, Cornette A, Philip-Joet F, Pepin JL, Escourrou P, Ingrand P, Veale D. Evaluation of autoCPAP devices in home treatment of sleep apnea/hypopnea syndrome. Sleep Med 2007; 8:695-703. [PMID: 17638595 DOI: 10.1016/j.sleep.2007.03.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 03/14/2007] [Accepted: 03/15/2007] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND PURPOSE Quality of life (QOL) and sleepiness for patients with sleep apnea/hypopnea syndrome (SAHS) might improve with continuous positive airway pressure devices working in auto-adjust mode (autoCPAP) by allowing pressure modulations following patient needs. Clinical comparisons between devices driven by different algorithms are needed. METHODS We compared the clinical effectiveness of fixed pressure CPAP and four different autoCPAP devices by assessing compliance and QOL (36-item short-form health survey [SF-36]). SAHS patients were randomly allocated to five groups. Polysomnography (PSG) was performed to titrate the effective pressure in the constant CPAP group and evaluate residual apnea/hypopnea index (AHI) under autoCPAP. Follow-up consisted of clinical visits at three and six months by homecare technicians who assessed compliance, symptom scores and SF-36 scores. A laboratory-based PSG using the same CPAP/autoCPAP device as at home was performed at six months. RESULTS Eighty-three patients (mean age 56+/-10 yrs) with mean body mass index (BMI) 30.8+/-5.3 kg/m(2) and severe SAHS (mean AHI: 52.3+/-17.8/h) were included. There were no differences in clinical symptoms or QOL scores, and similar clinical and PSG improvements were seen in all groups. CPAP use was >5 h per night, without any significant difference between groups. CONCLUSIONS AutoCPAP is equally as effective as fixed CPAP for long-term home treatment in severe SAHS patients.
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Affiliation(s)
- J C Meurice
- Service de Pneumologie, 2 Rue de la Milétrie, CHU de Poitiers, 86000 Poitiers, France.
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Bachour A, Virkkala JT, Maasilta PK. AutoCPAP initiation at home: optimal trial duration and cost-effectiveness. Sleep Med 2007; 8:704-10. [PMID: 17531533 DOI: 10.1016/j.sleep.2007.01.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2006] [Revised: 12/28/2006] [Accepted: 01/16/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND The duration of automatic computer-controlled continuous positive airway pressure device (autoCPAP) initiation at home varies largely between sleep centers. Our objectives were to evaluate the cost-effectiveness and to find the optimal trial duration. METHODS Of the 206 consecutive CPAP-naive patients with obstructive sleep apnea syndrome, who were referred to our hospital, 166 received autoCPAP for a 5-day trial at home. RESULTS Of the 166 patients, 89 (15 women) showed a successful 5-day autoCPAP trial (normalized oximetry and mask-on time exceeding 4 h/day for at least 4 days). For the first trial day, 88 (53%) patients had normalized oximetry and a mask-on time exceeding 4 h. A 1-day autoCPAP trial EUR 668 was less cost-effective than a 5-day trial EUR 653, with no differences in values of efficient CPAP pressure or residual apnea-hypopnea index (AHI). The systematic requirement of oximetry monitoring raised the cost considerably from EUR 481 to EUR 668. CONCLUSIONS In selected patients with obstructive sleep apnea, the optimal duration for initiating CPAP therapy at home by autoCPAP is 5 days. Although a 1-day trial was sufficient to determine the CPAP pressure requirement, it was not cost-effective and had a high rate of failure.
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Affiliation(s)
- Adel Bachour
- Sleep Unit, Skin and Allergy Hospital, Helsinki, Finland.
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21
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Santamaria J, Iranzo A, Ma Montserrat J, de Pablo J. Persistent sleepiness in CPAP treated obstructive sleep apnea patients: evaluation and treatment. Sleep Med Rev 2007; 11:195-207. [PMID: 17467312 DOI: 10.1016/j.smrv.2007.02.005] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Nasal continuous positive airway pressure (CPAP) is an effective treatment for most patients with obstructive sleep apnea syndrome (OSAS), improving sleepiness, cognitive function and mood. A number of patients, however, complain about persistent sleepiness after CPAP. In these cases another clinical history should be carried out to confirm the diagnosis of OSAS, to check CPAP compliance and to exclude associated conditions such as poor sleep hygiene, depression, narcolepsy or idiopathic hypersomnia. If necessary, a full polysomnography (PSG) followed by a multiple sleep latency test or even a full PSG with CPAP titration should be performed. Experimental data in animals suggest that long-term intermittent hypoxia related to the apneic events could deteriorate the brain structures that regulate alertness. This impairment, if present in humans, could be another reason for residual sleepiness after CPAP. Modafinil has been shown to reduce subjective sleepiness after CPAP in OSAS patients. Further studies are warranted to clarify the way in which CPAP modifies sleepiness.
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Affiliation(s)
- Joan Santamaria
- Neurology Service, Multidisciplinary Sleep Disorders Unit, Hospital Clínic de Barcelona, Faculty of Medicine, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain.
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Hartenbaum N, Collop N, Rosen IM, Phillips B, George CFP, Rowley JA, Freedman N, Weaver TE, Gurubhagavatula I, Strohl K, Leaman HM, Moffitt GL, Rosekind MR. Sleep Apnea and Commercial Motor Vehicle Operators:. J Occup Environ Med 2006; 48:S4-37. [PMID: 16985410 DOI: 10.1097/01.jom.0000236404.96857.a2] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rigau J, Montserrat JM, Wöhrle H, Plattner D, Schwaibold M, Navajas D, Farré R. Bench Model To Simulate Upper Airway Obstruction for Analyzing Automatic Continuous Positive Airway Pressure Devices. Chest 2006; 130:350-61. [PMID: 16899832 DOI: 10.1378/chest.130.2.350] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Automatic positive airway pressure (APAP) devices are increasingly being used in patients with obstructive sleep apnea. Some APAP devices present an unstable behavior when subjected to some events or artifacts. The aims were to develop a bench model capable of reproducing real flow, snoring, and obstructive patterns and to compare the response of APAP devices based on flow and snoring with other devices using, in addition, the forced oscillation technique (FOT). METHODS The bench model subjected APAP devices to apneas with and without obstruction, obstructive hypopneas with and without snoring, periods of flow limitation, and artifacts such as leaks and mouth expiration. RESULTS Almost all the devices increased the pressure when subjected to apneas with obstruction, but at different rates. The time required by each device to reach 10 cm H(2)O ranged from 2.5 to 13 min. In the presence of apneas without obstruction, all the devices based on flow and snoring increased the pressure at the same rate as during apneas with obstruction. However, the devices using FOT did not modify the pressure. Four devices did not modify the pressure in the presence of obstructive hypopneas, and all but one device increased the pressure in the presence of snoring. Mask leaks had little effect on the response of the devices, but four devices increased the pressure during mouth expiration artifacts. CONCLUSIONS When, in addition to the flow and snoring signals, the measurement of the upper airway resistance is included, the accuracy of the event detection algorithms is improved.
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Affiliation(s)
- Jordi Rigau
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina, Universitat de Barcelona, Spain
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Meurice JC. Faut-il traiter le SAS par PPC autopilotée ? Arguments contre. Rev Mal Respir 2006. [DOI: 10.1016/s0761-8425(06)72483-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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25
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Faut-il traiter le SAS par PPC autopilotée ? Arguments pour. Rev Mal Respir 2006. [DOI: 10.1016/s0761-8425(06)72503-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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d'Ortho MP. Auto-titrating continuous positive airway pressure for treating adult patients with sleep apnea syndrome. Curr Opin Pulm Med 2004; 10:495-9. [PMID: 15510056 DOI: 10.1097/01.mcp.0000144438.73152.4a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The treatment of sleep apnea syndrome (SAS) is continuous positive airway pressure (CPAP) as the first line of therapy. The current standard is for an attendant technician to titrate CPAP by means of an in-laboratory polysomnography to obtain a fixed single pressure. Over the past decade and a half, some devices able to modify the pressure delivered to the patient overnight and from night to night have become available. The efficacy of such devices to manage SAS has been demonstrated, however the question of their use either as unattended APAP to determine pressures for fixed CPAP or for self-adjusting APAP treatment on a long-term basis is still matter of debate. RECENT FINDINGS However, if cost considerations may render reluctant to APAP, off note, using APAP could allow initiation of treatment more quickly, reduce in-laboratory time, and reduce healthcare costs. SUMMARY Auto-titrating continuous positive airway pressure and CPAP are to date equivalent in terms of efficacy to treat SAS, but APAP could allow quick initiation of treatment and therefore reduce healthcare costs.
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Affiliation(s)
- M-P d'Ortho
- Service de Physiologie, Explorations Fonctionnelles Hôpital Henri Mondor Assistance Publique, Hôpitaux de Paris, Créteil, France.
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Ruhle KH, Raschke F, Fietze I, Randerath W, Wessendorf T, Hein H. Titration und Therapie mittels Positiv-Druckatmung bei schlafbezogenen Atemstorungen (SBAS). Titration and Therapy by Positive Pressure Breathing in Sleep-Related Breathing Disorders (SRBD). SOMNOLOGIE 2004. [DOI: 10.1111/j.1439-054x.2004.00024.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Noseda A, Kempenaers C, Kerkhofs M, Braun S, Linkowski P, Jann E. Constant vs Auto-Continuous Positive Airway Pressure in Patients With Sleep Apnea Hypopnea Syndrome and a High Variability in Pressure Requirement. Chest 2004; 126:31-7. [PMID: 15249439 DOI: 10.1378/chest.126.1.31] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Auto-continuous positive airway pressure (CPAP) has been reported to have no more efficacy than constant CPAP in unselected patients with sleep apnea hypopnea syndrome (SAHS). The aim of this study was to evaluate patients judged to be good candidates for auto-CPAP because of a high within-night variability in pressure requirement. DESIGN Single-blind, randomized, cross-over study (2 x 8 weeks) to compare auto-CPAP with constant CPAP. PATIENTS Outpatients with moderate-to-severe SAHS attending the chest clinic. INTERVENTIONS Patients were equipped at home in the auto-CPAP mode (model GK418A; Malinckrodt; Nancy, France), using a 4- to 14-cm H(2)O pressure range. Those individuals having a high within-night variability in pressure requirement, assessed at the end of a 14-day run-in period, were included in the cross-over study. Auto-CPAP was compared with constant CPAP (according to a titration night in the sleep laboratory) in terms of compliance, efficacy on apneas (assessed from the pressure monitor), and sleepiness (assessed on the Epworth sleepiness scale). MEASUREMENTS AND RESULTS Of 90 consecutive patients with SAHS, 27 patients were selected for a within-night variability in pressure requirement exceeding a given threshold. After completion of the cross-over, 24 patients were evaluable. The median percentage of nights the machine was used was 95.5% (range, 45 to 100%) on constant CPAP, and 96.5% (range, 40 to 100%) on auto-CPAP; the median apnea index recorded by the device was 0.40/h (range, 0 to 2.40/h) on constant CPAP, and 0.45/h (range, 0 to 5.80/h) on auto-CPAP (differences not significant). The mean Epworth sleepiness score was significantly (p < 0.01) lower on auto-CPAP (5.1; SD, 2.8) than on constant CPAP (6.1; SD, 2.8). CONCLUSIONS In patients selected for a high within-night variability in pressure requirement, auto-CPAP administered via a GK418A device was equivalent to constant CPAP based on a titration night in the sleep laboratory. Subjective ratings for sleepiness were slightly lower on auto-CPAP.
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Affiliation(s)
- André Noseda
- Chest Department and Sleep Laboratory, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.
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Senn O, Brack T, Matthews F, Russi EW, Bloch KE. Randomized Short-term Trial of Two AutoCPAP Devices versus Fixed Continuous Positive Airway Pressure for the Treatment of Sleep Apnea. Am J Respir Crit Care Med 2003; 168:1506-11. [PMID: 14525804 DOI: 10.1164/rccm.200304-542oc] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We evaluated the efficacy of two different continuous positive airway pressure devices with automatic mask pressure adjustment (autoCPAP) in comparison with fixed CPAP in treating obstructive sleep apnea syndrome in 29 patients. The mean (+/- SE) apnea-hypopnea index was 46 +/- 4 per hour and the Epworth score was 14.2 +/- 0.7. Patients were treated over three consecutive 1-month periods with three regimens in random order: an autoCPAP device responding to apnea-hypopnea and snoring, another autoCPAP device responding to snoring and changes in flow contour, and fixed CPAP at the 90th pressure percentile titrated by autoCPAP over 2 weeks. Allowed pressure in the autoCPAP mode was 4 to 15 cm H2O. At the end of each treatment period, symptoms, quality of life, vigilance, and nocturnal breathing disturbances were evaluated. All three treatment modalities improved symptoms, quality-of-life domains, and apnea-hypopnea index significantly and to a similar degree. Mean (+/- SE) maintenance-of-wakefulness time increased by 4.5 +/- 1.8, 6.0 +/- 1.5, and 6.1 +/- 1.4 minutes with DeVilbiss AutoAdjust LT, AutoSet T, and fixed-pressure CPAP, respectively (p<0.001 vs. baseline, p=not significant for comparisons among the three modalities). We conclude that both autoCPAP devices were equally effective as fixed-pressure CPAP in improving major outcomes during short-term therapy of sleep apnea.
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Affiliation(s)
- Oliver Senn
- Pulmonary Division, Universitätsspital Zürich, Zürich, Switzerland
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Abstract
Automatic positive airway pressure devices are the most technologically advanced positive airway pressure devices available for use in OSA. Although heterogeneous, they have in common the ability to detect and respond to changes in upper airway resistance. Data cannot necessarily be extrapolated from one device to another, and the field is rapidly advancing. Most studies of APAP have been performed in a supervised setting, or patients have been carefully selected to have a high likelihood of OSA uncomplicated by disorders such as alveolar hypoventilation or central apnea or technical problems such as mask leaks. Studies of APAP for the diagnosis of OSA have shown that APAP can diagnose severe OSA effectively, but the diagnosis of mild-moderate OSA is less reliable. APAP devices also can be effective therapy for selected patients with OSA, with overall similar results to conventional fixed CPAP in terms of respiratory disturbances, sleep quality, nocturnal oxygenation, and daytime sleepiness and performance, with less known or other long-term outcomes. In most studies, mean treatment pressures are lower, without change in side effect profile. Compliance and preference with APAP are similar to or somewhat better than CPAP in most studies. APAP also can be used in an attended setting to titrate an effective pressure for use in long-term conventional CPAP therapy, also with similar results to CPAP in many patients. APAP devices are more expensive than CPAP devices, but the cost may be outweighed if a group of patients who can be diagnosed, treated, or titrated safely in the unattended setting can be identified. Although diagnostic and therapeutic algorithms for APAP have been proposed, the best candidates for this modality must be defined better.
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Affiliation(s)
- Francoise J Roux
- Section of Pulmonary and Critical Care Medicine, Yale University School of Medicine, 333 Cedar Street, Post Office Box 208057, New Haven, CT 06520-8057, USA.
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31
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Abstract
Obstructive sleep apnea (OSA) is a common disorder associated with an increased risk of cardiovascular disease and stroke. As it is strongly associated with known cardiovascular risk factors, including obesity, insulin resistance, and dyslipidemia, OSA is an independent risk factor for hypertension and has also been implicated in the pathogenesis of congestive cardiac failure, pulmonary hypertension, arrhythmias, and atherosclerosis. Obesity is strongly linked to an increased risk of OSA, and weight loss can reduce the severity of OSA. The current standard treatment for OSA-nasal continuous positive airway pressure (CPAP)-eliminates apnea and the ensuing acute hemodynamic changes during sleep. Long-term CPAP treatment studies have shown a reduction in nocturnal cardiac ischemic episodes and improvements in daytime blood pressure levels and left ventricular function. Despite the availability of effective therapy, OSA remains an underdiagnosed and undertreated condition. A lack of physician awareness is one of the primary reasons for this deficit in diagnosis and treatment.
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Affiliation(s)
- Jo-Dee L Lattimore
- Department of Cardiology, Royal Prince Alfred Hospital, NSW, Sydney, Australia.
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32
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Farré R, Montserrat JM, Rigau J, Trepat X, Pinto P, Navajas D. Response of automatic continuous positive airway pressure devices to different sleep breathing patterns: a bench study. Am J Respir Crit Care Med 2002; 166:469-73. [PMID: 12186822 DOI: 10.1164/rccm.2111050] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Evaluating the usefulness of automatic continuous positive airway pressure (CPAP) in treating the sleep apnea-hypopnea syndrome (SAHS) is not easy because the algorithms for automatic CPAP implemented in the devices available are not well known and are probably dependent on the device. In addition, at present it is not possible to test the behavior of automatic CPAP devices in response to well-defined breathing patterns. Our aim was to implement a bench test to characterize the responses of automatic CPAP devices by subjecting them to breathing patterns of patients with SAHS. To this end, a variety of typical breathing patterns (normal, apneas, hypopneas, flow limitation, snoring) previously recorded in patients with SAHS during sleep were reproduced by a breathing waveform generator. Five commercially available automatic CPAP devices were tested. The responses of the devices to apneas, hypopneas, flow limitation, and snoring were considerably different. In some devices, the response was modified by air leaks similar to the ones found in patients. Consequently, the effectiveness of automatic CPAP assessed in clinical tests performed by using particular devices has no general validity. Testing automatic CPAP devices in a bench study is a useful first step in evaluating the performance of this new type of device in adjusting nasal pressure for each patient.
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Affiliation(s)
- Ramon Farré
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina Casanova 143, Universitat de Barcelona, E-08036 Barcelona, Spain.
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