Heated humidification did not improve compliance of positive airway pressure and subjective daytime sleepiness in obstructive sleep apnea syndrome: A meta-analysis

Current treatment strategies in managing side effects associated with domiciliary positive airway pressure (PAP) therapy for patients with sleep disordered breathing: A systematic review and meta-analysis

Sleep disordered breathing is commonly treated with positive airway pressure therapy. Positive airway pressure therapy is delivered via a tight-fitting mask with common side effects including: leak, ineffective treatment, residual sleep disordered breathing, eye irritation, nasal congestion, pressure ulcers and poor concordance with therapy. This systematic review and meta-analysis aimed to identify the effectiveness of current treatment strategies for managing side effects associated with positive airway pressure therapy. Five databases were searched and 10,809 articles were screened, with 36 articles included in the review. Studies investigated: dressings, nasal spray/douche, chin straps, heated humidification and interfaces. No intervention either improved or detrimentally affected: positive airway pressure concordance, Epworth Sleepiness Score, residual apnoea hypopnea index or interface leak. The review was limited by study heterogeneity, particularly for outcome measures. Additionally, patient demographics were not reported, making it difficult to apply the findings to a broad clinical population. This review highlights the paucity of evidence supporting treatment strategies to manage side effects of positive airway pressure therapy.

Factors associated with treatment adherence to mandibular advancement devices: a scoping review

PURPOSE

Obstructive sleep apnea (OSA) is frequently treated with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs). For various reasons, both treatment options are often affected by low adherence. While factors associated with low CPAP adherence are described in the literature extensively, less is known about adherence to MAD therapy. This scoping review aimed to synthesize the body of literature on the factors associated with adherence to MAD treatment.

METHODS

A systematic literature search was conducted using bibliographic databases PubMed, Embase.com , Web of Science, and the Cochrane Library (Wiley) to identify relevant studies that described factors associated with adherence to MAD in the treatment of OSA or snoring combined with OSA in adults.

RESULTS

The literature search yielded a total of 694 references. Forty studies were found eligible for inclusion. The literature showed that factors with a possible negative influence on the adherence to MAD treatment are personality aspects; failing effectiveness of MAD; side effects during MAD therapy; using a thermoplastic MAD; dental treatments during MAD therapy; and a poor first experience with the MAD with inadequate guidance by professionals. Factors that may have a positive effect on MAD adherence include effectiveness of therapy, custom-made MAD, good communication skills of the practitioner, early recognition of side effects, stepwise titration of the MAD, and positive first experience with MAD.

CONCLUSIONS

The knowledge of factors associated with MAD adherence can be used to provide further insight into individual adherence to OSA treatments.

Treatment of obstructive sleep apnea with a simple CPAP device

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Effects of heated humidification on positive airway pressure side effects in patients with obstructive sleep apnoea: a meta-analysis

PURPOSE

An earlier study found that heated humidification reduced the side effects of positive airway pressure (PAP) in patients with obstructive sleep apnoea (OSA). However, other studies disagreed with this finding. Therefore, we evaluated the relationship between heated humidification and the side effects of PAP in patients with OSA.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, six databases were searched for relevant randomised controlled trials (RCTs) performed from January 1999 to June 2021.

RESULTS

From 1012 retrieved articles, we identified 9 eligible RCTs. Compared to the control group, the heated humidification group reported improvements in dry nose (pooled standardised mean difference [SMD] =  - 0.70, 95% confidence interval [CI] =  - 0.96 to - 0.45, I² = 0%, p < 0.00001), blocked nose (SMD =  - 0.47, 95%CI - 0.69 to - 0.25, I² = 36%, p < 0.0001), runny nose (SMD =  - 0.22, 95%CI - 0.44 to 0, I² = 0%, p = 0.05), dry mouth (SMD =  - 0.62, 95%CI - 0.87 to - 0.37, I² = 0%, p < 0.00001), and dry throat (SMD =  - 0.61, 95%CI - 0.90 to - 0.33, I² = 41%, p < 0.0001), but did not enhance positive airway pressure adherence (pooled mean difference [MD] = 0.24, 95% CI - 0.10 to 0.58, I² = 0%, p = 0.17).

CONCLUSIONS

Heated humidification improved some PAP side effects in patients with OSA but did not increase PAP adherence. Additional large-scale multi-centre RCTs are needed to verify the long-term effects.

A Multivariate Study on the Adherence With Non-invasive Ventilation in People With Obstructive Sleep Apnea

Background

Obstructive Sleep Apnea (OSA) is a sleep disorder that affects a significant number of people worldwide. While Continuous Positive Airway Pressure (CPAP) devices have been proven to be effective in relieving symptoms, ensuring consistent use of those devices throughout the year can be challenging for a lot of patients.

Objective

The present quantitative observational study in non-invasive ventilation for OSA patients explores adherence and attempts to identify independent predicting factors and year-round adherence differences in a large sample of OSA patients from Greece.

Methods

Data from 1987 OSA patients using Continuous Positive Airway Pressure (CPAP) devices were collected in 2023. Factors evaluated in the study included the Apnea-Hypopnea Index (AHI), mask type, mask leaks and hours of CPAP device usage.

Results

The majority were males (77.2%), aged over 60 years (57.9%). CPAP use varied, with 14.0% in their first year, 44.2% for 2-4 years, and 41.7% for <4 years. Adherence was highest in more than 4 years users (54.9%) and nasal/pillow mask users (59.1%). Seasonal adherence varied, with summer having the most non-adherent patients (32.8%). Multinomial logistic regression showed BMI, mask type and seasonal severity influenced adherence. Full-face masks positively impacted adherence (OR=0.585, p=0.001). Non-adherence was associated with higher mask leaking in spring (OR=3.051, p=0.018) and usage of CPAP for < 4 years (OR=3.855, p=0.001). For 50% and 75% adherence, seasonal mask leaking and usage duration influenced adherence.

Conclusion

CPAP device data can provide valuable insights to OSA therapy compliance. Seasonality plays an important role in adherence to the CPAP device use as is the type of mask with relation to air leaking.

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.

Early objective adherence to hypoglossal nerve stimulation therapy

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CITATION

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

The Impact of Device Modifications and Pressure Delivery on Adherence

This article reviews the evidence to date examining whether adherence to positive airway pressure (PAP) therapy is affected by any device modifications to pressure delivery. To date there is no robust evidence from systematic reviews and meta-analyses indicating that any modification to standard fixed-pressure PAP makes a clinically significant difference to patient adherence to therapy. The main modifications are reviewed in this article and whether improving pressure could drive adherence, in turn improving patient outcomes, is discussed.

Weight Loss as the First-Line Therapy in Patients with Severe Obesity and Obstructive Sleep Apnea Syndrome: the Role of Laparoscopic Sleeve Gastrectomy

PURPOSE

The objective of this study is to investigate the effects of laparoscopic sleeve gastrectomy (LSG) on the polysomnographic parameters related to OSAS.

MATERIALS AND METHODS

We conducted this 3-year prospective cohort study in a tertiary care center between December 2016 and December 2019. In total, we enrolled 31 patients with severe obesity who underwent full-night polysomnography (PSG) before LSG. Later, the patients were re-evaluated by full-night PSG 12 months after the surgery.

RESULTS

The mean age of the patients was 44.1 ± 9.6 years. The mean body mass index (BMI) decreased significantly from a mean value of 49.8 ± 8.5 kg/m² at baseline to 33.2 ± 8.2 kg/m² and a percent BMI (%BMI) reduction of 33.8 ± 10.4% and a percent total weight loss (%TWL) of 35.4 ± 10.8% was achieved on the same day of the postsurgical PSG (p < 0.001). There was a remarkable improvement in the AHI (baseline: 36.1 ± 27.1, 12 months after the surgery: 10.3 ± 11.8; difference: 25.8 ± 22.8 events per hour) (p < 0.001). Importantly, there was a decrease in the percentage of non-rapid eye movement (NREM) 2 (p < 0.001), whereas NREM 3 and REM stages witnessed a significant increase (p = 0.001 and p < 0.001, respectively) after the surgery.

CONCLUSION

The results of this study showed that weight loss after LSG yields improvement not only in AHI but also in many polysomnographic parameters such as sleep quality and desaturation indices.

Effects of continuous positive airway pressure (CPAP) therapy on neurological and functional rehabilitation in Basal Ganglia Stroke patients with obstructive sleep apnea: A prospective multicenter study

Obstructive sleep apnea (OSA) adversely affects neurological recovery. This study aimed to determine the impact of continuous positive airway pressure (CPAP) and/or rehabilitation in basal ganglia stroke patients with OSA.A prospective controlled trial was conducted in 2015-2018. The subjects received routine rehabilitation training for up to 2 years and were assigned to the intervention and control groups treated with CPAP or without, respectively. Then, treatment effects on sleep parameters, motor function, stroke severity, daily life activities, cognitive function, and psychological states were assessed at different time points.At 6 months, the CPAP group showed significantly lower mean apnea-hypopnea index (AHI), percentage of time with SpO2 at <90% (TS90%), micro-arousal index, and percentages of time in non-rapid eye movement (non-REM) stages 1-2 and REM stage in total sleeping time compared with the control group, and significantly higher mean minimum of peripheral oxygen saturation (L-SaO2%) and percentage of time in stage 3 (P < .001) sleep. The CPAP group showed significant improvements in average the National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer assessment scale (FMA), Barthel index (BI), Minimental state examination (MMSE), Hamilton anxiety scale (HAMA) and Hamilton depression rating scale for depression (HRSD) scores at different times versus the control group, respectively (P < .05). However, no difference in body mass index (BMI) management was observed (P > .05). Repeated-measures ANOVA revealed significant interactions between the two groups for change in FMA, MMSE, BI, HAMA, and HRSD scores from admission to 24 months (P < .001), but no significant was found for BMI (P = .582).Basal ganglia stroke patients with OSA tend to have significantly greater sleeping, neurological and functional recovery after CPAP, and rehabilitation over 2 years.