Type of mask may impact on continuous positive airway pressure adherence in apneic patients

The Swedish sleep apnea registry (SESAR) cohort - "Real world data" on a national level

INTRODUCTION

The Swedish Sleep Apnea Registry (SESAR) collects clinical data from individual obstructive sleep apnea (OSA) patients since 2010. SESAR has recently been integrated with additional national healthcare data. The current analysis presents the SESAR structure and representative clinical data of a national sleep apnea cohort.

METHODS

Clinical data from unselected patients with a diagnosis of OSA are submitted to the SESAR registry. 48 sleep centers report data from diagnosis, treatment starts with Continuous Positive Airway Pressure (CPAP), oral devices (OD), and Upper Airway Surgery (UAS). Data from follow-up are included. SESAR is linked to mandatory national healthcare data (mortality, comorbidities, procedures, prescriptions) and diagnosis-specific quality registries (e.g. stroke, heart failure, diabetes) within the DISCOVERY project.

RESULTS

83,404 OSA patients have been reported during the diagnostic workup (age 55.4 ± 14.1 years, BMI 30.8 ± 6.5 kg/m2, AHI 25.8 ± 21.6n/h, respectively). At least one cardiometabolic and respiratory comorbidity is recognized in 57 % of female and 53 % of male OSA patients with a linear increase across OSA severity. In 54,468, 7,797, and 390 patients, start of CPAP, OD or UAS treatment is reported, respectively. OD patients have 4 units lower BMI and 10 units lower AHI compared to patients started on CPAP. UAS patients are characterized by 10 years lower age. The degree of daytime sleepiness is comparable between treatment groups with mean Epworth Sleepiness Scale Scores between 9 and 10.

CONCLUSION

SESAR is introduced as a large national registry of OSA patients. SESAR provides a useful tool to highlight OSA management and to perform relevant outcome research.

Mask side-effects are related to gender in long-term CPAP: results from the InterfaceVent real-life study

BACKGROUND

Over the past three decades, our understanding of sleep apnea in women has advanced, revealing disparities in pathophysiology, diagnosis, and treatment compared to men. However, no real-life study to date has explored the relationship between mask-related side effects (MRSEs) and gender in the context of long-term CPAP.

METHODS

The InterfaceVent-CPAP study is a prospective real-life cross-sectional study conducted in an apneic adult cohort undergoing at least 3 months of CPAP with unrestricted mask-access (34 different masks, no gender specific mask series). MRSE were assessed by the patient using visual analog scales (VAS). CPAP-non-adherence was defined as a mean CPAP-usage of less than 4 h per day. The primary objective of this ancillary study was to investigate the impact of gender on the prevalence of MRSEs reported by the patient. Secondary analyses assessed the impact of MRSEs on CPAP-usage and CPAP-non-adherence depending on the gender.

RESULTS

A total of 1484 patients treated for a median duration of 4.4 years (IQ25-75: 2.0-9.7) were included in the cohort, with women accounting for 27.8%. The prevalence of patient-reported mask injury, defined as a VAS score ≥ 5 (p = 0.021), was higher in women than in men (9.6% versus 5.3%). For nasal pillow masks, the median MRSE VAS score for dry mouth was higher in women (p = 0.039). For oronasal masks, the median MRSE VAS score for runny nose was higher in men (p = 0.039). Multivariable regression analyses revealed that, for both women and men, dry mouth was independently and negatively associated with CPAP-usage, and positively associated with CPAP-non-adherence.

CONCLUSION

In real-life patients treated with long-term CPAP, there are gender differences in patient reported MRSEs. In the context of personalized medicine, these results suggest that the design of future masks should consider these gender differences if masks specifically for women are developed. However, only dry mouth, a side effect not related to mask design, impacts CPAP-usage and non-adherence.

TRIAL REGISTRATION

INTERFACEVENT IS REGISTERED WITH CLINICALTRIALS.GOV (NCT03013283).FIRST REGISTRATION DATE IS 2016-12-23.

Residual upper airway obstruction during nocturnal noninvasive ventilation despite high positive expiratory pressure. Impact of oronasal mask to nasal mask switch

BACKGROUND

Nasal mask (NM) and oronasal masks (OM) can be used to provide noninvasive ventilation (NIV). Recent studies suggested that OM is the most used interface and that there is no difference in efficacy or in tolerance between OM and NM for chronic use. However, studies focusing on video laryngoscopy underlined the impact of OM in residual upper airway obstruction (UAO) under NIV. We sought to assess the real-life practice of switching from OM to NM when UAO events persist despite high EPAP levels.

METHODS

In an open-label single center prospective cohort study, data from files and full night polysomnography on NM and OM were collected for patients wearing OM and presenting an UAO index ≥15/h despite an EPAP level ≥ 10 cmH20.

RESULTS

Forty-four patients were included in the study. In 31 patients (74 %), switching to a NM reduced UAOi to ≥10/h. Interestingly, 92 % of these patients still had NM at 3 to 12 months of follow-up. Switching to a NM was also associated with a trend in paCO2 reduction and significant improvements in Epworth, sleep quality and NIV compliance. Successful interface switching was significantly associated with female gender, and a trend was observed in non-smokers.

CONCLUSION

As for CPAP, switching to a NM improved NIV efficacy in a selected group of patients presenting residual UAO events despite high EPAP levels. Additionally, this switch has an impact on compliance and subjective sleepiness. Thus, in patients with persisting UAO on OM, switching to a NM could be a first-line intervention before considering further investigation such as polygraphy or video laryngoscopy. We also derive an algorithm for mask allocation and adaptation in acute and chronic NIV use.

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

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

Supplementary Information

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

Performance of the NOSE Questionnaire in Mask Selection for Home CPAP Titration

Introduction  Many patients abandon CPAP treatment because they find the mask uncomfortable. Therefore, specialists may benefit from the predictive value of airway assessment tools. Objective  To identify nasal ventilation failure through the Nasal Obstruction Symptom Evaluation (NOSE) scale in patients with obstructive sleep apnea (OSA) who undergo home-based auto-adjusting CPAP titration and to determine whether there is a correlation between NOSE score and the type of mask selected. Materials and Methods  In this prospective correlational study, the NOSE scale was used in terms of mask selection and titration indicators. Patients were classified based on their NOSE score: > or < 50. Results  We included 303 patients; 226 men (74.5%), BMI: 33.2 ± 6.1 kg/m 2 , neck circumference (cm): 42.8 ± 3.6 and Epworth (ESS) score: 9.2 ± 5.6, mild OSA: 12 (3.9%), moderate OSA: 127 (41.9%), and severe OSA: 164 (54.1%). The mean NOSE score was 24.3 ± 22.8 and 42 patients (13.8%) had NOSE scores > 50. Indicators for both groups were: compliance (5.9 ± 1.3 vs. 5.8 ± 1.4 hours) p: 0.41, therapeutic pressure (9.1 ± 2.0 vs. 8.8 ± 1.6 cm of H 2 O) p: 0.23, residual AHI (2.3 ± 1.8 vs. 2.8 ± 2.6 events/hour) p: 0.25, and leaks (20.5 ± 10.6 vs. 21.3 ± 10.7 liters/minute) p: 0.64. According to adjusted multiple regression, a NOSE of > 50 was not a predictor of mask selection. Conclusions  A > 50 NOSE score was not a predictor of mask selection, and it was not correlated to titration performance.

Nasal pillow vs. standard nasal mask for treatment of OSA: a systematic review and meta-analysis

PURPOSE

The purpose of this study was to compare the effectiveness of nasal pillows with standard nasal masks in the treatment of patients with obstructive sleep apnea (OSA).

METHODS

A digitalized search was carried out in four different databases including PubMed, Scopus, EMBASE, and CENTRAL using relevant keywords along with a manual search in relevant journals. All comparative studies comparing outcomes of using a nasal pillow with the use of standard nasal masks for continuous positive airway pressure (CPAP) treatment in patients with OSA were included. The qualitative analysis was carried out by tabulating the demographic data. The quantitative data were subjected to meta-analysis. The quality of comparative studies (both retrospective and prospective cohorts) was evaluated using New-castle Ottawa scale (NOS).

RESULTS

A total of 14 studies (eight prospective and six retrospective) were included in the review. Of them, five studies were randomized and were of cross-over study design. No significant differences were observed in achieved CPAP and residual apnea-hypopnea index (AHI) levels between the nasal pillow and nasal mask with SMD - 0.05 95% CI [- 0.18, 0.09], p = 0.50 and SMD - 0.13 95% CI [- 0.28, 0.03], p = 0.12, respectively. However, nasal pillow usage was associated with better CPAP adherence with a difference of only + 0.29 min/night as compared to a standard nasal mask, with SMD 0.29 95% CI [0.07, 0.50], p = 0.009.

CONCLUSION

Nasal pillow and standard nasal mask were equally effective in terms of residual AHI level and achieved similar therapeutic CPAP pressures. However, the difference in CPAP adherence between groups, though statistically significant, is of questionable clinical significance.

Evaluation and Performance of a Positive Airway Pressure Device (CPAP-AirFlife™): A Randomized Crossover Non-Inferiority Clinical Study in Normal Subjects

Background and Objectives: During the COVID-19, the demand for non-invasive ventilatory support equipment significantly increased. In response, a novel non-invasive ventilatory support model called CPAP-AirFlife™ was developed utilizing existing technologies. This model offers technological advantages, including an aerosol-controlled helmet suitable for high-risk environments such as ambulances. Additionally, it is cost-effective and does not require medical air, making it accessible for implementation in low-level hospitals, particularly in rural areas. This study aimed to assess the efficacy of CPAP-AirFlife™ by conducting a non-inferiority comparison with conventional ventilation equipment used in the Intensive Care Unit. Materials and Methods: A clinical study was conducted on normal subjects in a randomized and sequential manner. Parameters such as hemoglobin oxygen saturation by pulse oximetry, exhaled PCO2 levels, vital signs, and individual tolerance were compared between the CPAP-AirFlife™ and conventional equipment. The study population was described in terms of demographic characteristics and included in the analysis. Results: It was shown that the CPAP-AirFlife™ was not inferior to conventional equipment in terms of efficacy or tolerability. Hemoglobin oxygen saturation levels, exhaled PCO2 levels, vital signs, and individual tolerance did not significantly differ between the two models. Conclusions: The findings suggest that CPAP-AirFlife™ is a practical and cost-effective alternative for non-invasive ventilatory support. Its technological advantages, including the aerosol-controlled helmet, make it suitable for high-risk environments. The device's accessibility and affordability make it a promising solution for implementation in low-level hospitals, particularly in rural areas. This study supports using CPAP-AirFlife™ as a practical option for non-invasive ventilatory support, providing a valuable contribution to respiratory care during the COVID-19 pandemic and beyond.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Monitoring Seasonal Compliance of Patients with Obstructive Sleep Apnea Using CPAP Systems via SD Card

Background

Obstructive sleep apnea (OSA) is a common disorder characterized by recurrent upper airway collapse during sleep, leading to neurological and cardiovascular adverse effects.

Objective

The present study aimed to explore seasonal compliance with Continuous Positive Airway Pressure (CPAP) therapy among OSA patients in Greece.

Methods

Data from 954 OSA patients using CPAP devices were collected during summer and winter months. Factors evaluated included the Apnea-Hypopnea Index (AHI), mask type, mask leaks, and hours of CPAP device usage.

Results

The majority of patients were male (78.2%) and aged 60 years or above (58.5%). Most patients had been using CPAP for over 2 years (82.8%), with auto CPAP devices and nasal or pillow masks being most common. Compliance was observed in 57.7% of patients, while 22.1% were non-compliant. A significant number of patients (8.2% and 12%) were compliant only in summer or winter, respectively. Compliance was influenced by duration of CPAP use, BMI up to 25, and the use of nasal/pillow masks. Higher compliance was associated with lower summer severity and both low and severe winter severity. Logistic regression analysis confirmed these findings.

Conclusion

The findings suggest that utilizing CPAP device data can provide actionable insights on seasonal compliance among OSA patients. Summer compliance is lower, and the use of nasal/pillow masks and auto CPAP devices is recommended for improved compliance.

Unexpected Resolution of Obstructive Sleep Apnea after Nasal Surgery in a Patient Nonadherent to Continuous Positive Airway Pressure Therapy

Continuous positive airway pressure (CPAP) is recommended as first-line therapy in cases of moderate-to-severe obstructive sleep apnea (OSA). Continuous positive airway pressure (CPAP) prevents upper airway obstruction and abolishes apnea or hypopnea events during sleep. But up to 50% of OSA patients may be nonadherent to CPAP due to various causes, including nasal obstruction. Nasal surgery may improve CPAP compliance in some OSA patients but is not regarded as OSA therapy. Here, I report a patient non-adherent to CPAP whose sleep apnea resolved unexpectedly after nasal surgery to increase adherence to CPAP.

Effect of switching from continuous to bilevel positive airway pressure on sleep quality in patients with obstructive sleep apnea: the prospective POP IN VAuto study

Background

Issues with tolerability and side effects can decrease continuous positive airway pressure (CPAP) device usage and the benefits of therapy. Different positive airway pressure (PAP) therapy modes providing expiratory pressure relief or using a different pressure during inspiration vs. expiration (bilevel PAP) may alleviate some of these issues. This multicenter, prospective study evaluated the effects of switching from CPAP to bilevel PAP (VAuto mode) on respiratory parameters, device usage, side effects and patient-reported outcomes in patients with obstructive sleep apnea (OSA).

Methods

Eligible OSA patients had started CPAP ≥3 months previously, had good compliance (mean 6.1±2.0 h/night) and well-controlled OSA [residual apnea-hypopnea index (AHI) 4.9±3.1/h] but had pressure tolerance issues or persistent side effects/discomfort. All were switched from CPAP to bilevel PAP (AirCurve 10 VAuto; ResMed). Effectiveness (residual AHI), sleep quality, daytime sleepiness, fatigue, therapy-related side effects, and patient satisfaction/preference were assessed after 3 months and 1 year.

Results

Forty patients were analyzed (68% male, age 64±11 years, body mass index 30.7±5.8 kg/m²). At 3 months and 1 year after switching to bilevel PAP, median [interquartile range] residual AHI was 4/h [2-5.3] and 3.7/h [1.8-5], respectively, and device usage was 7.0 [4.9-7.5] and 6.4 [4.4-7.3] h/night, respectively. Device switch was associated with significant reductions from baseline in expiratory PAP {from 12 [11-13] to 8 [7-9] cmH₂O at 3 months (P<0.001) and 9 [8-12] cmH₂O at 1 year (P=0.005)}, 95^th percentile pressure {from 14 [12-14] to 10 [9-11] and 10 [8-11] cmH2O; P<0.001 and P=0.001, respectively} and leak {from 1 [0-6] to 0 [0-1] and 0 [0-2] L/min; P=0.049 and P=0.033, respectively}. The Pittsburgh Sleep Quality Index score decreased significantly from baseline to 3 and 6 months [7.2±4.0 to 5.0±3.2 (P=0.005) and 4.5±2.7 (P<0.001), respectively]. CPAP-related mouth dryness, choking sensation and aerophagia were significantly improved one year after switching to bilevel PAP. Bilevel PAP was preferred over CPAP by 90% of patients.

Conclusions

Switching to bilevel PAP had several benefits in patients struggling with CPAP, facilitating therapy acceptance and ongoing device usage.

Factors Associated With Residual Apnea-Hypopnea Index Variability During CPAP Treatment

BACKGROUND

CPAP is the first-line therapy for OSA. A high or variable residual apnea-hypopnea index (rAHI) reflects treatment failure and potentially is triggered by exacerbation of cardiovascular comorbidities. Previous studies showed that high rAHI and large rAHI variability are associated with underlying comorbidities, OSA characteristics at diagnosis, and CPAP equipment, including mask type and settings.

RESEARCH QUESTION

What factors are associated with predefined groups with low to high rAHI variability?

STUDY DESIGN AND METHODS

This registry-based study included patients with a diagnosis of OSA who were receiving CPAP treatment with at least 90 days of CPAP remote monitoring. We applied the hidden Markov model to analyze the day-to-day trajectories of rAHI variability using telemonitoring data. An ordinal logistic regression analysis identified factors associated with a risk of having a higher and more variable rAHI with CPAP treatment.

RESULTS

The 1,126 included patients were middle-aged (median age, 66 years; interquartile range [IQR], 57-73 years), predominantly male (n = 791 [70.3%]), and obese (median BMI, 30.6 kg/m² (IQR, 26.8-35.2 kg/m²). Three distinct groups of rAHI trajectories were identified using hidden Markov modeling: low rAHI variability (n = 393 [35%]), moderate rAHI variability group (n = 420 [37%]), and high rAHI variability group (n = 313 [28%]). In multivariate analysis, factors associated with high rAHI variability were age, OSA severity at diagnosis, heart failure, opioids and alcohol consumption, mental and behavioral disorders, transient ischemic attack and stroke, an oronasal mask, and level of leaks when using CPAP.

INTERPRETATION

Identifying phenotypic traits and factors associated with high rAHI variability will allow early intervention and the development of personalized follow-up pathways for CPAP treatment.

In search of a better CPAP interface: A network meta-analysis comparing nasal masks, nasal pillows and oronasal masks

Until now, no study has directly network meta-analysed the impact of nasal masks, nasal pillows and oronasal masks on continuous positive airway pressure therapy in patients with obstructive sleep apnea. This study aimed to meta-analyse the impact of three kinds of nasal interfaces with both network meta-analysis and pairwise comparison. PubMed, EMBASE, CENTRAL and ClinicalTrials.gov were systematically searched from inception to December 2020 for studies that compared the three types of nasal interfaces for treating obstructive sleep apnea with continuous positive airway pressure. The outcomes were residual apnea-hypopnea index, continuous positive airway pressure, and nightly average usage. The network meta-analysis was conducted using multivariate random-effects in a frequentist framework where three interfaces were ranked with the surface under the cumulative ranking probabilities. The pairwise comparison was conducted using random-effects meta-analysis. Twenty-nine articles comprising 6378 participants were included. The pairwise comparison showed both nasal masks and nasal pillows were associated with lower residual apnea-hypopnea index, lower continuous positive airway pressure, and higher continuous positive airway pressure adherence compared with oronasal masks. The surface under the cumulative ranking confirmed that nasal masks were associated with the lowest residual apnea-hypopnea index and highest adherence, while pillows were associated with the lowest continuous positive airway pressure. The meta-regression identified that lower pretreatment apnea-hypopnea index and continuous positive airway pressure determined during continuous positive airway pressure titration (versus determined during continuous positive airway pressure therapy) was associated with lower continuous positive airway pressure with nasal masks and nasal pillows. In conclusion, compared with oronasal masks, nasal masks and nasal pillows are better interfaces, especially in patients with lower pretreatment apnea-hypopnea index and those with the therapeutic pressure determined during continuous positive airway pressure titration.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

"The terrible dryness woke me up, I had some trouble breathing"-Critical situations related to oral health as described by CPAP-treated persons with obstructive sleep apnea

Continuous positive airway pressure is a common and effective treatment for obstructive sleep apnea, but adherence remains an issue. Both obstructive sleep apnea and oral diseases are associated with cardiovascular diseases, and as oral dryness contributes to treatment abandonment, oral health is of importance for this patient group. The aim was therefore to explore how persons with continuous positive airway pressure-treated obstructive sleep apnea experience situations associated with their oral health, and which actions they take to manage these. An explorative and descriptive design was adopted using the critical incident technique. Based on a purposeful selection, 18 adults with long-term experience of continuous positive airway pressure-treatment were interviewed using a semi-structured interview guide. Both negative and positive situations were described. Negative situations consisted of challenges with breathing, including mouth-breathing, choking sensations, problems with night-time and daytime oral dryness, changes in the saliva composition, and deteriorating oral health. Positive situations included experiences of reduced mouth-breathing and oral dryness. The situations were often successfully managed by mimicking daytime movements, changing sleeping position, adjusting the CPAP-device and mask, increasing oral hygiene efforts, drinking water, using a humidifier or chinstrap, or contacting their oral healthcare clinic. Long-term experience of persons with continuous positive airway pressure-treated obstructive sleep apnea regard situations and actions from everyday life. Successful management can contribute to long-term adherence and decrease negative effects on oral health. More interdisciplinary collaborations could enable identification and adequate recommendations for persons who experience negative situations during their continuous positive airway pressure treatment.

Practice recommendations for the role of physiotherapy in the management of sleep disorders: the 2022 Brazilian Sleep Association Guidelines

This clinical guideline supported by the Brazilian Sleep Association comprises a brief history of the development of Brazilian sleep physiotherapy, outlines the role of the physiotherapist as part of a sleep health team, and describes the clinical guidelines in respect of the management of some sleep disorders by the physiotherapist (including sleep breathing disorders, i.e., obstructive sleep apnea, central sleep apnea, upper airway resistance syndrome, hypoventilation syndromes and overlap syndrome, and pediatric sleep breathing disorders; sleep bruxism; circadian rhythms disturbances; insomnia; and Willis-Ekbom disease/periodic limb movement disorder. This clinical practice guideline reflects the state of the art at the time of publication and will be reviewed and updated as new information becomes available.

Evaluation of Ventilation with Nasal Versus Face Mask After General Anesthesia Induction in Pediatric Patients

Background

Because of some difficulties during face mask ventilation in unconscious patients, such as upper airway obstruction patients, we conducted this study to compare nasal and face mask ventilation during general anesthesia induction.

Methods

In this clinical trial study, 70 patients between 3 and 12 years old undergoing elective lower abdominal surgery with general anesthesia were randomly divided into two groups. After administration of induction agents, one group was ventilated with the face mask and 100% oxygenation in three minutes and the other with the nasal mask. The mean expiratory volume, airway pressure, end-tidal CO₂ (EtCO₂), blood oxygen saturation (SpO₂), and hemodynamic factors were recorded and compared in the baseline, two minutes after mask ventilation, and five minutes after intubation.

Results

The mean EtCO₂ in the second minute after ventilation was significantly higher in the nasal mask group than in the face mask group (P = 0.04). However, in the fifth minute after intubation, there was no significant difference between the two groups (P = 0.31). Other factors related to ventilation did not significantly differ between the two groups.

Conclusions

It can be concluded that nasal mask ventilation is as effective as facial mask ventilation. The nasal mask can replace the face mask if there is difficult face mask ventilation or airway obstruction.

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

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

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

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

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

BACKGROUND

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

RESEARCH QUESTION

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

STUDY DESIGN AND METHODS

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

RESULTS

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

INTERPRETATION

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

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CITATION

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

Hidden Markov model segmentation to demarcate trajectories of residual apnoea-hypopnoea index in CPAP-treated sleep apnoea patients to personalize follow-up and prevent treatment failure

BACKGROUND

Continuous positive airway pressure (CPAP), the reference treatment for obstructive sleep apnoea (OSA), is used by millions of individuals worldwide with remote telemonitoring providing daily information on CPAP usage and efficacy, a currently underused resource. Here, we aimed to implement data science methods to provide tools for personalizing follow-up and preventing treatment failure.

METHODS

We analysed telemonitoring data from adults prescribed CPAP treatment. Our primary objective was to use Hidden Markov models (HMMs) to identify the underlying state of treatment efficacy and enable early detection of deterioration. Secondary goals were to identify clusters of rAHI trajectories which need distinct therapeutic strategies.

RESULTS

From telemonitoring records of 2860 CPAP-treated patients (age: 66.31 ± 12.92 years, 69.9% male), HMM estimated three states differing in variability within a given state and probability of shifting from one state to another. The daily inferred state informs on the need for a personalized action, while the sequence of states is a predictive indicator of treatment failure. Six clusters of rAHI trajectories were identified ranging from well-controlled patients (cluster 0: 669 (23%); mean rAHI 0.58 ± 0.59 events/h) to the most unstable (cluster 5: 470 (16%); mean rAHI 9.62 ± 5.62 events/h). CPAP adherence was 30 min higher in cluster 0 compared to clusters 4 and 5 (P value < 0.01).

CONCLUSION

This new approach based on HMM might constitute the backbone for deployment of patient-centred CPAP management improving the personalized interpretation of telemonitoring data, identifying individuals for targeted therapy and preventing treatment failure or abandonment.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13167-021-00264-z.

Evaluation of CPAP mask performance during 3 years of mask usage: time for reconsideration of renewal policies?

Background

Continuous positive airway pressure (CPAP) mask renewal policies vary inside and between countries. There are no independent studies on the optimal mask renewal frequency. We aimed to evaluate CPAP mask function over time in a real-life clinical setting, and to compare the results against current renewal policies.

Methods

Daily performance data of 1846 CPAP masks (65% nasal, 22% nasal pillows, 12% oronasal) were recorded from 450 participants (68% male, mean age 59 years) with obstructive sleep apnoea. The unintentional leak, Apnoea-Hypopnoea Index (CPAP-AHI) and usage data were exported from the CPAP device.

Results

Of 656 324 nights of CPAP usage, the mean renewal time was 497 days (SD 327), mean leak 5.7 L/min (SD 8.1) and CPAP-AHI 3.8 events/h (SD 3.6). The difference in mean leak between one (5.2 L/min, SD 7.5), 12 (6.0 L/min, SD 10.2) and 24 months (5.8 L/min, SD 7.5) was minimal (p=0.59). Mean CPAP-AHI remained normal and unchanged in nasal masks and pillows up to 30 months, and was highest in oronasal masks. Different mask manufacturers performed similarly. Masks’ daily or total usage did not affect the results. Shifting the mask renewal policy to 24 months could reduce the mask-related cost up to 50%–88%.

Conclusions

Nasal masks and pillows could be used at least 2 years without significant changes in unintentional leak and CPAP-AHI. We suggest updating the mask renewal policies of nasal masks and pillows; results on oronasal masks and other manufacturers CPAP devices need further verification.

[Impact of AMARA VIEW™ interface on upper airway during nocturnal non invasive ventilation]

INTRODUCTION

Nasal masks can result in mouth leaks with implications on sleep quality. To reduce these leaks, oronasal masks are proposed. It has been shown that an oronasal mask can induce obstructive events in the upper airways (UA). Because of its fit around the nose, the Amara View™ facial mask may have less consequence on UA obstruction.

METHODS

This retrospective study assessed the impact of the Amara View™ mask on UA. The study was conducted on patients with chronic respiratory failure treated by home NIV with standard facial mask. Replacement of the standard facial mask by an Amara View™ mask was performed when the residual apnea hypopnea index recorded from the ventilator software exceeded 5/h. All patients underwent nocturnal respiratory polygraphy when on NIV with a standard facial mask and with an Amara View™ mask. Respiratory polygraphic traces were interpreted following the analysis methods published by the SomnoNIV Group.

RESULTS

Seven patients were studied. Although nocturnal oxygen saturation was similar between both masks, the index of UA obstruction without ventilatory blunting was significantly lower during NIV with the Amara View™ mask compared to the standard facial mask (P=0.01).

CONCLUSIONS

Nocturnal NIV using an Amara View™ facial interface may avoid UA obstruction without ventilatory command blunting.

The Importance of Mask Selection on Continuous Positive Airway Pressure Outcomes for Obstructive Sleep Apnea. An Official American Thoracic Society Workshop Report

Continuous positive airway pressure (CPAP) remains the major treatment option for obstructive sleep apnea (OSA). The American Thoracic Society organized a workshop to discuss the importance of mask selection for OSA treatment with CPAP. In this workshop report, we summarize available evidence about the breathing route during nasal and oronasal CPAP and the importance of nasal symptoms for CPAP outcomes. We explore the mechanisms of air leaks during CPAP treatment and possible alternatives for leak control. The impact of nasal and oronasal CPAP on adherence, residual apnea-hypopnea index, unintentional leaks, and pressure requirements are also compared. Finally, recommendations for patient and partner involvement in mask selection are presented, and future directions to promote personalized mask selection are discussed.

Factors affecting compliance with positive airway pressure therapy in obstructive sleep apnea

OBJECTIVE

To investigate the factors affecting compliance with positive airway pressure (PAP) therapy and establish the relationship between compliance and pulmonary function tests (PFT) in patients with OSA.

MATERIAL AND METHODS

In this prospective study, patients with OSA using PAP devices were questioned about the complaints related to the device. Depression and anxiety scales along with PFT parameters were also assessed.

RESULTS

Of 98 participants, 63% were men. The mean age was 52.0 ± 9.6 years. Sixty-seven percent of the patients were compliant with their devices. A significant difference was observed between the proportion of the participants compliant or non-compliant with the device, based on OSA severity (p < 0.05). Beck depression inventory (BDI) and Beck anxiety inventory (BAI) scores of the compliant patients were significantly lower than those of the non-compliant patients (p < 0.001, p = 0.044, respectively). No statistically significant difference was detected between the groups regarding individual pulmonary function tests (p > 0.05). The rates of nasal mask use, not having difficulty in tolerating CPAP, falling asleep, absence of abdominal distension, no facial sores, no air leakage, patients benefiting from the device, reduction in daytime sleepiness, and the belief that they are receiving appropriate therapy in participants compliant with the device were higher than those in non-compliant participants (p < 0.05). The rates of claustrophobia and discomfort due to pressure were significantly lower in patients compliant with the device than in the non-compliant patients (p < 0.05).

CONCLUSION

While no relationship was detected between PFT parameters and PAP therapy compliance, significant factors affecting the device compliance were detected.

Risk-seeking attitude in health and safety domain is associated with continuous positive airway pressure discontinuation in patients with obstructive sleep apnea-a multicenter prospective cohort study

STUDY OBJECTIVES

Many studies have already looked at factors that may influence adherence to continuous positive airway pressure (CPAP) (severity of obstructive sleep apnea (OSA), patients' age, technical aspects, socioeconomic factors, living conditions, psychological factors). Although it has been shown that individuals' preference for risky behaviors in daily life can influence the use of care or adherence to drug therapies in care settings, this has never been tested in OSA. This study aims to analyze the association between risk attitude in the health/safety domain and CPAP discontinuation in a cohort of OSA patients.

METHODS

In a prospective multicenter cohort study nested within the IRSR sleep cohort, consecutive patients who were prescribed CPAP were monitored for at least 6 months. In addition to the data usually collected in the IRSR sleep cohort at baseline, patients also completed a risk-taking questionnaire using the Domain-Specific Risk-Taking (DOSPERT) scale. Cox's proportional hazards regression was used to model the risk of CPAP discontinuation as a function of a linear combination of variables hypothetically related to this risk including health risk attitude.

RESULTS

Of the 489 patients under CPAP, 12.1% (n = 59) were risk-seeking, 87.9% (n = 430) were risk-neutral, and none were risk-averse. Cox's model indicated that a risk-seeking attitude (p = 0.04) and an AHI <30 (p < 0.01) were significantly associated with CPAP discontinuation.

CONCLUSIONS

Patients with risk-seeking behaviors in daily life have been shown to be more likely to discontinue CPAP. The DOSPERT scale can be a useful tool for screening this specific group of patients in clinical practice.

Nasal versus oronasal masks for home non-invasive ventilation in patients with chronic hypercapnia: a systematic review and individual participant data meta-analysis

BACKGROUND

The optimal interface for the delivery of home non-invasive ventilation (NIV) to treat chronic respiratory failure has not yet been determined. The aim of this individual participant data (IPD) meta-analysis was to compare the effect of nasal and oronasal masks on treatment efficacy and adherence in patients with COPD and obesity hypoventilation syndrome (OHS).

METHODS

We searched Medline and Cochrane Central Register of Controlled Trials for prospective randomised controlled trials (RCTs) of at least 1 month's duration, published between January 1994 and April 2019, that assessed NIV efficacy in patients with OHS and COPD. The main outcomes were diurnal PaCO₂, PaO₂ and NIV adherence (PROSPERO CRD42019132398).

FINDINGS

Of 1576 articles identified, 34 RCTs met the inclusion criteria and IPD were obtained for 18. Ten RCTs were excluded because only one type of mask was used, or mask data were missing. Data from 8 RCTs, including 290 IPD, underwent meta-analysis. Oronasal masks were used in 86% of cases. There were no differences between oronasal and nasal masks for PaCO₂ (0.61 mm Hg (95% CI -2.15 to 3.38); p=0.68), PaO₂ (-0.00 mm Hg (95% CI -4.59 to 4.58); p=1) or NIV adherence (0·29 hour/day (95% CI -0.74 to 1.32); p=0.58). There was no interaction between the underlying pathology and the effect of mask type on any outcome.

INTERPRETATION

Oronasal masks are the most used interface for the delivery of home NIV in patients with OHS and COPD; however, there is no difference in the efficacy or tolerance of oronasal or nasal masks.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Can drug-induced sleep endoscopy (DISE) predict compliance with positive airway pressure therapy? A pilot study

PURPOSE

Drug-induced sleep endoscopy (DISE) has been poorly explored as an examination to assess positive airway pressure (PAP) therapy in patients with obstructive sleep apnea (OSA). The present study aimed to identify by DISE possible characteristics related to low compliance with PAP therapy due to respiratory complaints.

METHODS

Patients using PAP for OSA underwent DISE in two conditions: (1) baseline (without PAP) and (2) PAP (with the same mask and airway pressure used at home). We compared patients reporting low compliance to PAP due to respiratory complaints to those well-adapted to therapy. VOTE classification (assessment of velopharynx, oropharynx, tongue base, and epiglottis) and TOTAL VOTE score (the sum of VOTE scores at each anatomical site) were assessed. ROC curve analyzed the accuracy of TOTAL VOTE to predict low compliance due to persistent pharyngeal obstruction in both conditions.

RESULTS

Of 19 patients enrolled, all presented multilevel pharyngeal obstruction at baseline condition, with no difference between groups at this study point. When PAP was added, the median VOTE value was higher in the epiglottis (P value=0.02) and tended to be higher at the velum and tongue base in the poorly adapted group; TOTAL VOTE score was also significantly increased in patients with low compliance (P value<0.001). ROC curve demonstrated that patients with TOTAL VOTE scored 2.5 or more during DISE with PAP presented a 4.6-fold higher risk for low compliance with PAP therapy due to pharyngeal obstruction (AUC: 0.88±0.07; P value<0.01; sensitivity: 77%; specificity: 83%).

CONCLUSIONS

Adding PAP during a DISE examination may help to predict persistent pharyngeal obstruction during PAP therapy.

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

BACKGROUND AND OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS/IMPLICATIONS

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

Seasonal effects on the continuous positive airway pressure adherence of patients with obstructive sleep apnea

OBJECTIVE

This study examined seasonal differences in continuous positive airway pressure (CPAP) therapy adherence among patients with obstructive sleep apnea (OSA).

METHODS

Patients aged ≥20 years with OSA who had used CPAP devices on the automatic setting for >12 consecutive months (n = 141) were included in this retrospective study from December 2015-2016. The information of CPAP use (pressure, hours of actual use) was extracted from database downloaded from patients' CPAP devices. Patients were divided into adherent and non-adherent groups using the cutoff point of 70% CPAP use for ≥4 h daily over the 1-year study period. CPAP use data were averaged for each season.

RESULTS

Patients in the adherent group were significantly older than those in the non-adherent group (p < 0.001). In the adherent group, the rate of ≥4 h daily CPAP use was significantly lower, the daily duration of CPAP use was significantly shorter, and the residual apnea-hypopnea index (AHI; events/hour) was significantly higher in summer than in other seasons (all p < 0.001). In the non-adherent group, the duration of daily CPAP use and the AHI differed significantly between winter and summer (p = 0.008 and p < 0.001, respectively).

CONCLUSIONS

Seasonal changes were associated with the CPAP adherence of patients with OSA. The study findings suggest that there is possibility of increasing the duration of CPAP use by adjusting the bedroom environment in hot and humid seasons.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

Continuous Positive Airway Pressure-Mandibular Advancement Device Combination Therapy for Moderate-to-Severe Obstructive Sleep Apnea: A Preliminary Study

Objectives  The purpose of this pilot study was to determine whether compliance to auto-adjusting positive airway pressure (APAP) improves with the addition of a mandibular advancement device (MAD). Secondary outcome measures included were APAP pressure, subjective daytime sleepiness, apnea–hypopnea index (AHI), and mask leaks.

Setting and Sample Population  Participants included were diagnosed with moderate-to-severe obstructive sleep apnea (OSA) and became noncompliant to prescribed APAP. Thirteen participants with a mean age of 61.6 years were recruited for this study.

Materials and Methods  All participants were given a MAD to use with their APAP. Parameters measured included APAP pressure, AHI, mask leak reported via ResMed AirViewTM software, and self-reported daytime sleepiness (Epworth Sleepiness Scale [ESS]). A paired two-sample for mean t -test was performed to determine significance.

Results  The mean difference of pre- and postintervention APAP compliance was 23.1%, which was statistically significant ( p = 0.015). The mean APAP air pressures were unchanged. The difference between pre- and postintervention mean ESS scores was 1.4 and was statistically significant ( p = 0.027). The mean difference between pre- and postintervention AHI values and mask leak showed no significant difference.

Conclusion  This study showed that combination of APAP-MAD therapy, for patients with moderate-to-severe OSA who were noncompliant to APAP use, significantly increased compliance with APAP therapy, and significantly decreased the daytime sleepiness of participants.

Efficacy of nasal masks versus nasal pillows masks during continuous positive airway pressure titration for patients with obstructive sleep apnea

PURPOSE

Nasal masks are usually the first choice for CPAP therapy, but patients may experience side effects. There are limited data regarding the efficacy of nasal pillows masks during CPAP titration. This study aimed to compare the polysomnography outcomes during CPAP titration while comparing two types of masks (nasal and pillows) and to assess whether or not the patient characteristics differed between mask preferences.

METHODS

In a sleep-disorders clinic, we prospectively analyzed all patients undergoing CPAP titration for three consecutive months. CPAP pressures were manually titrated. Anthropometric data (age, sex, body mass index, and neck and waist circumferences) and OSA severity were documented. Patients completed a self-administered questionnaire that measured nasal obstruction (NOSE scale). Before titration, both types of masks were presented to patients, and each of them chose the one they preferred.

RESULTS

Of 157 patients, 55% (n = 86) used nasal masks, and 45% (n = 71) used nasal pillows masks. There was no difference according to mask type chosen by age, sex, body mass index, neck and waist circumferences, and NOSE scale. Polysomnography outcomes were similar between the mask groups. The mean CPAP level was 9.4 ± 1.8 cm H₂O for nasal masks and 9.1 ± 2.0 cm H₂O for nasal pillows (p = 0.61). Residual apnea-hypopnea index was 3.0 ± 2.8 events/h for nasal mask and 3.5 ± 4.1 events/h for pillow mask (p = 0.28). Baseline AHI, body mass index, neck and waist circumferences, and residual AHI were independent predictors of a higher CPAP pressure for both groups (p < 0.0001).

CONCLUSIONS

Nasal pillows masks seem to be as effective as nasal masks and may be considered to be an initial choice for CPAP titration.

Treatment of Obstructive Sleep Apnea: Achieving Adherence to Positive Airway Pressure Treatment and Dealing with Complications

Obstructive sleep apnea is a common and treatable condition, but therapeutic adherence is limited by numerous factors. Despite advances in positive airway pressure (PAP) technology and a multitude of effective pharmacologic and behavioral therapeutic interventions to overcome the most common barriers to PAP, adherence has not increased significantly over the past 30 years. This review aims to identify the most important factors that impact adherence, common barriers to treatment, and evidence-based treatment strategies to maximize the effectiveness of PAP treatment. Complications of PAP treatment and mitigation techniques are also discussed.

Determination of risks of lower adherence to CPAP treatment before their first use by patients

A better understanding of Continuous Positive Airway Pressure (CPAP) adherence is a priority in improving patient care. To Identify adherence typology with a longitudinal approach, and explore the early determinants of lower adherence to CPAP. Obstructive sleep apnea patients (N = 204). Prospective and longitudinal study.A classification into four profiles was observed: "Regular Adherents," "Non-Regular Adherents," "Persistent Non-Adherents," and "Non-Persistent Non-Adherents." Specific biopsychosocial factors make it possible to evaluate the risk of belonging to a lower adherence profile. We propose a novel approach of CPAP treatment adherence. Several pre-determinants have been identified.

Nasal versus oronasal mask in patients under auto-adjusting continuous positive airway pressure titration: a real-life study

PURPOSE

Mask type (nasal versus oronasal) can affect the optimal pressure required to correct the apnea/hypopnea index (AHI) in obstructive sleep apnea (OSA) subjects treated with CPAP. Our objective was to evaluate if mask type influenced CPAP titration outcomes in OSA patients.

METHODS

A retrospective study of individuals with a baseline AHI ≥ 15.0/h, who received an auto-adjusting CPAP titrating device (S9 AutoSet ResMed^®) in a sleep-lab setting. The mask type oronasal (OM) or nasal (NM) was always selected by the patients. Optimal pressure requirements, leak, and residual AHI were compared based on mask type.

RESULTS

Overall, 436 patients were included: 283 with NM (64.9%) and 153 with OM (35.1%). At baseline, NM and OM cohorts had similar AHI (p = 0.160). Patients allocated to the OM cohort had a higher 95th percentile pressure, a higher 95th percentile leak, and a higher residual AHI than those with a NM: pressure requirement: 12.9 cm H₂O (IQR: 10.6-15.0) versus 10.7 cm H₂O (IQR: 9.2-12.3); leak: 21.6 L/min (IQR: 9.6-37.2) versus 9.6 L/min (IQR: 3.6-19.2); and residual AHI: 4.9/h (IQR: 2.4-10.2) versus 2.2/h (IQR: 1.0-4.4), respectively (p < 0.001 for all).

CONCLUSIONS

CPAP mask type based on individual preferences exerts profound effects on optimal CPAP pressures and efficacy. Patients titrated with OM showed higher pressure requirements, had higher a leak, and higher residual AHI when compared to NM, which may adversely impact treatment adherence and other health outcomes.

Use of the WatchPAT to detect occult residual sleep-disordered breathing in patients on CPAP for obstructive sleep apnea

STUDY OBJECTIVES

To determine the accuracy of the apnea-hypopnea index (AHI) as measured by continuous positive airway pressure (CPAP) machines by simultaneously employing a home sleep apnea testing device (WatchPAT 200, Itamar Medical, Israel [WPAT]) in patients suspected of having residual sleep-disordered breathing (SDB).

METHODS

Patients with new, recurrent, or worsening signs, symptoms, or comorbidities associated with obstructive sleep apnea underwent home sleep apnea testing using WPAT while simultaneously using CPAP at their usual prescribed settings. CPAP AHI and WPAT AHI, respiratory disturbance index, and oximetry readings were then compared.

RESULTS

We identified an elevated AHI with WPAT testing in nearly half of patients with clinically suspected residual SDB and a normal CPAP AHI. WPAT detected additional respiratory events as well, including rapid eye movement-related apneas, respiratory effort-related arousals, and hypoxemia.

CONCLUSIONS

WPAT AHI was significantly higher than simultaneous CPAP AHI in nearly half of those patients with clinically suspected residual SDB being treated with CPAP. Additional respiratory disturbances, including rapid eye movement-related respiratory events, respiratory effort-related arousals, and hypoxemia, were elucidated only with the use of the WPAT. Residual SDB may have potential clinical consequences, including reduced CPAP adherence, ongoing hypersomnolence, and other health-related sequelae. Simultaneous WPAT testing of patients with a normal CPAP AHI may represent a valuable tool to detect clinically suspected residual SDB or to ensure adequate treatment in high-risk patients with obstructive sleep apnea in general.

Clinical presentation and comorbidities of obstructive sleep apnea-COPD overlap syndrome

Background

More advanced knowledge is needed on how COPD alters the clinical presentation of obstructive sleep apnea (OSA) and how the association of both diseases, known as ‘overlap syndrome’ (OVS), impacts on cardiovascular health.

Objective

To investigate differences between patients with OVS and those with moderate-to-severe OSA alone.

Methods

A cross-sectional study conducted in the French National Sleep Apnea Registry between January 1997 and January 2017. Univariable and multivariable logistic regression models were used to compare OVS versus OSA alone on symptoms and cardiovascular health.

Results

46,786 patients had moderate-to-severe OSA. Valid spirometry was available for 16,466 patients: 14,368 (87%) had moderate-to-severe OSA alone and 2098 (13%) had OVS. A lower proportion of OVS patients complained of snoring, morning headaches and excessive daytime sleepiness compared to OSA alone (median Epworth Sleepiness Scale score: 9 [interquartile range (IQR) 6–13] versus 10 (IQR 6–13), respectively; P <0.02). Similarly, a lower proportion of OVS patients (35.6% versus 39.4%, respectively; P <0.01) experienced sleepiness while driving. In contrast, 63.5% of the OVS population experienced nocturia compared to 58.0% of the OSA population (P<0.01). Apnea hypopnea index (36 [25; 52] vs 33.1 [23.3; 50]), oxygen desaturation index (28 [15; 48] vs 25.2 [14; 45]) and mean nocturnal SaO2 (92 [90; 93.8] vs 93 [91.3; 94]) were significantly more altered in the OVS group. Associated COPD had no effect on the prevalence of hypertension and stroke. After controlling for main confounders, COPD severity was associated in a dose-response relationship with a higher prevalence of coronary heart disease, heart failure and peripheral arteriopathy.

Conclusions

In adults with moderate-to-severe OSA, OVS was minimally symptomatic, but exhibited higher odds for prevalent coronary heart disease, heart failure and peripheral arteriopathy.

Feasibility of Type 3 Polygraphy for Evaluating Leak Determinants in CPAP-Treated OSA Patients: A Step Toward Personalized Leak Management

BACKGROUND

Unintentional leaks (ULs) are frequent adverse effects in CPAP-treated patients. We previously published a novel methodology for analyzing the determinants of UL using polysomnography. We now propose a simplified recording system using a type 3 polygraphic device (Somnolter; Nomics S.A.).

RESEARCH QUESTION

(1) To describe individual UL determinants provided by the Somnolter software in automatic-CPAP-treated OSA patients; (2) To subsequently describe the clinical consensus of four physicians on how to manage each individual UL situation.

STUDY DESIGN AND METHODS

Somnoler recordings performed under nasal automatic-CPAP were automatically analyzed with APIOS software. For each polygraphic recording, APIOS provided the OR and the CIs for potential determinants of UL: mouth opening, CPAP pressure, body position, and mandibular oscillation. Based on these results, each of four physicians was asked to choose one of four strategies: (1) increase or decrease therapeutic pressure; (2) change nasal mask for oro-nasal mask/chinstrap; (3) favor a nonsupine or supine position; (4) no action for individual leak management. Subsequently, a meeting was held to determine a consensus choice for each individual case.

RESULTS

Seventy-eight consecutive patients underwent home-polygraphy with Somnolter. Fifty recordings were analyzed (16 females; 65 [57-75] years of age; BMI = 31.1 [27.4-35.3]). Individual diagnosis of UL was routinely feasible. The determinants of UL were heterogeneous in the population, and diagnosis of UL was not feasible in 10 patients. Based on the results from this analysis, we established consensus leak management strategies at the individual level. The average Cohen κ coefficient for the four raters was 0.58. Pressure modification was proposed in 36% of patients, no action in 24%, installation of a facial mask/chinstrap in 22%, and positional treatment in 18%.

INTERPRETATION

The use of type 3 polygraphy for characterizing leak determinants in patients treated with nasal automatic-CPAP is feasible in routine practice. Leak determinants are patient specific. Interrater concordance for determining individual leak management strategies demonstrated a "fair" level of agreement.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT03381508; URL: www.clinicaltrials.gov).

[Telemonitoring in continuous positive airway pressure-treated patients with obstructive sleep apnoea syndrome: An algorithm proposal]

Most of the continuous positive airway pressure (CPAP) devices currently in use allow telemonitoring of observance, leaks and the apnoea-hypopnoea index (AHI). La Société française de recherche et de médecine du sommeil (SFRMS) and La Société de pneumologie de langue française (SPLF) workgroup offer to CPAP prescribers and to home care providers a scientific document which has the following purposes: to underline the relevance of the telemonitoring of leaks and the AHI, to define alert thresholds, to describe the principal mechanisms generating excessive leaks and high AHI, and to propose a diagnostic algorithm.

Nasal vs. oronasal mask during PAP treatment: a comparative DISE study

PURPOSE

The present study evaluated the upper airway pattern of obstruction in individuals undergoing drug-induced sleep endoscopy (DISE) exam with positive airway pressure (PAP), and compared this effect through a nasal or oronasal mask.

METHODS

Prospective study. Patients requiring PAP due to obstructive sleep apnea (OSA) were evaluated through DISE at three different moments: (1) a baseline condition (without PAP); (2) PAP treatment with a nasal mask; and (3) PAP with an oronasal mask at the same pressure. The conditions were compared intra-individually, following VOTE classification. A TOTAL VOTE score (the sum of VOTE scores observed for each anatomical site) was also applied to compare intra-individual results.

RESULTS

Thirteen patients were enrolled in the study. All patients presented multi-level pharyngeal obstruction at baseline condition. In six patients, the pattern of obstruction differed according to the mask. Nasal mask significantly decreased the obstruction score when compared with baseline condition both in velum (P value < 0.05) and oropharynx regions (P value < 0.005). TOTAL VOTE score was also significantly lower during nasal mask evaluation when compared with basal condition (P value < 0.005). Remarkably, oronasal mask with the same pressure was not as effective as nasal masks. Obstruction levels observed at the tongue base or epiglottis levels were more resistant to PAP treatment.

CONCLUSIONS

Collapse in velum and oropharyngeal sites is more compliant to PAP than obstruction at lower levels of the pharynx, either with nasal or oronasal masks. Nasal mask is superior to prevent pharyngeal collapse than oronasal devices under the same pressure.

Practical Aspects of Interface Application in CPAP Treatment

While continuous positive airway pressure (CPAP) is an effective first-line therapy for sleep apnea, CPAP fails in one third of patients mainly due to poor adherence to the CPAP device and masks. The role of the medical team is to guide the patient in choosing the best mask, thus insuring good CPAP therapy adherence. Once a suitable mask is found, the brand of the mask does not affect patient satisfaction or CPAP adherence. For the majority of patients, nasal masks are by far more suitable than oronasal masks. Orosanal masks are indicated in case of nasal stuffiness or when an air leak manifests through the mouth. Re-evaluation of the efficacy of CPAP therapy is recommended when switching to oronasal masks.

Predictors of oronasal breathing among obstructive sleep apnea patients and controls

Oronasal breathing may adversely impact obstructive sleep apnea (OSA) patients either by increasing upper airway collapsibility or by influencing continuous positive airway pressure (CPAP) treatment outcomes. Predicting a preferential breathing route would be helpful to guide CPAP interface prescription. We hypothesized that anthropometric measurements but not self-reported oronasal breathing are predictors of objectively measured oronasal breathing. Seventeen OSA patients and nine healthy subjects underwent overnight polysomnography with an oronasal mask with two sealed compartments attached to independent pneumotacographs. Subjects answered questionnaires about nasal symptoms and perceived breathing route. Oronasal breathing was more common (P = <0.001) among OSA patients than controls while awake (62 ± 44 vs. 5 ± 6%) and during sleep (59 ± 39 vs. 25 ± 21%, respectively). Oronasal breathing was associated with OSA severity (P = 0.009), age (P = 0.005), body mass index (P = 0.044), and neck circumference (P = 0.004). There was no agreement between objective measurement and self-reported breathing route among OSA patients while awake (κ = -0.12) and asleep (κ = -0.02). The breathing route remained unchanged after 92% of obstructive apneas. These results suggest that oronasal breathing is more common among OSA patients than controls during both wakefulness and sleep and is associated with OSA severity and anthropometric measures. Self-reporting is not a reliable predictor of oronasal breathing and should not be considered an indication for oronasal CPAP.NEW & NOTEWORTHY Continuous positive airway pressure (CPAP) interface choice for obstructive sleep apnea (OSA) patients is often guided by nasal symptoms and self-reported breathing route. We showed that oronasal breathing can be predicted by anthropometric measurements and OSA severity but not by self-reported oronasal breathing. Self-reported breathing and nasal symptoms should not be considered for CPAP interface choice.

Comparison of Auto- and Fixed-Continuous Positive Airway Pressure on Air Leak in Patients with Obstructive Sleep Apnea: Data from a Randomized Controlled Trial

Auto-CPAP may cause sleep fragmentation due to variations in pressure and unintentional leaks. The aim of this study was to compare air leak between fixed-CPAP and auto-CPAP after 4 months of CPAP treatment. This study is an ancillary analysis of a randomized, double-blind, parallel, controlled trial over 4 months, comparing fixed- and auto-CPAP in newly diagnosed patients with OSA. The following data were extracted from the CPAP devices: mean and 90th percentile pressure, residual apnea-hypopnea index, mean CPAP use, and amount of leak. Within each arm, patients were also randomly allocated to use of one of the three different brands of devices. Since the leak was reported differently for each device, median leak value was determined for each brand and leaks were classified as “above the median” or “below the median”. Data from 269 patients were analyzed. The univariate analysis showed that tobacco consumption, CPAP level, and oronasal masks were associated with leaks above the median value but not the type of CPAP. The multivariate analysis showed that only CPAP level and oronasal masks were associated with leaks below the median. There were no differences in the types of mask used between fixed- and auto-CPAP. There was no impact of the type of CPAP on leaks or the type of interface used. We used a method based on the median leak value to standardize comparisons across devices which report leaks with different definitions.

Prevention of leakage due to mouth opening through applying an oral shield device (Sominpax™) during nasal CPAP therapy of patients with obstructive sleep apnea

BACKGROUND/OBJECTIVE

The first line treatment for obstructive sleep apnea (OSA) is nasal continuous positive airway pressure (nCPAP), for which a variety of masks are available. While nasal masks (NM) are the first choice; oronasal masks (ONM) are also frequently used to prevent mouth dryness resulting from mouth opening. Our cross-sectional, prospective, randomized, un-blinded study addressed the efficacy of wearing an oral shield in addition to NM in preventing mouth leakage METHODS: Patients with OSA and established therapy using NM and complaining about mouth dryness (n = 29) underwent three polysomnographies (PSGs) using NM, ONM or a nose mask in combination with an oral shield (NMS). Mask leakage was continuously documented and objective sleep quality was assessed.

RESULTS

There were significant differences in the apnea-hypopnea-index (AHI) between ONM (8.5/h; SD 6,7) and NM/nasal mask combined with oral shield device (NMS) (2.6/h; SD 2,3; 2.7/h; SD 2,6) (p < 0,05) as well as in leakage [ONM (39.7 l/min SD 12,4); NM (34.6 l/min SD 9,4); NMS (33.1 l/min SD 9,6)] (p = 0.011). Furthermore, analysis of sleep quality (NREM3) favored NM and NMS over ONM (p = 0.02). There were no significant differences between NM and NMS in any objective outcome.

CONCLUSIONS

Our data consistently confirmed the NM as the first choice for continuous positive airway pressure (CPAP) therapy of OSA. Notably, we demonstrated a high potential of the oral shield for patients with mouth opening to achieve additional comfort and thereby possibly compliance, without affecting nCPAP therapy effectiveness.

Partial failure of CPAP treatment for sleep apnoea: Analysis of the French national sleep database

BACKGROUND AND OBJECTIVE

Continuous positive airway pressure (CPAP) is the first-line therapy for obstructive sleep apnoea (OSA). Residual apnoea and/or hypopnoea events, that is an apnoea-hypopnoea index (AHI) > 5, during CPAP contribute to treatment drop-out. The clinical scenarios triggering residual events during CPAP use are poorly described. Underlying co-morbidities, especially cardiovascular diseases, lifestyle factors, OSA characteristics at diagnosis and type of mask have been suggested as potential contributors.

METHODS

Patients from the prospective French sleep apnoea registry diagnosed with OSA (AHI ≥ 15 events/h) treated with CPAP were included. Logistic regression analysis identified factors associated with a risk of residual AHI > 5 events/h on CPAP.

RESULTS

The 12 285 OSA patients were predominantly men (n = 8715, 70.9%), middle-aged (58.2 (49.8; 66.1) years) and obese (median body mass index: 31.3 (27.7; 35.6) kg/m² ). Most had an AHI ≤ 5 events/h (n = 9573, 77.9%) versus 22.1% with AHI > 5/h. The latter were less CPAP adherent (5.75 (4.01; 7.00) vs 6.00 (4.53; 7.00) h/night). In multivariable analysis, factors associated with residual AHI >5/h were male sex, age, sedentary lifestyle, OSA severity, cardiovascular co-morbidities (heart failure and arrhythmia) and type of interface (orofacial mask versus nasal mask: OR = 2.15 (95%CI: 1.95; 2.37)). A subgroup analysis found that patients using pressures above 10 cm H₂ O were 1.43 (95% CI: 1.3; 1.57) times more likely to have residual AHI > 5/h.

CONCLUSION

Knowing about risk factors for residual apnoeic-hypopnoeic events may assist in the timely provision of personalized care including the type of PAP therapy, attention to co-morbidities and choice of interface.