Continuous positive airway pressure requirement during the first month of treatment in patients with severe obstructive sleep apnea

Practical and rapidly-implemented parameters for assessing APAP titration failure

BACKGROUND

This study aimed to show the predictive value of simple polysomnographic parameters including latency of deep sleep (nREM3), latency of rapid eye movement sleep (REM), and minimum oxygen saturation (SpO₂) for predicting failure of autoadjusting positive airway pressure (APAP) titration.

METHODS

Out of 1470 patients with moderate to severe obstructive sleep apnea syndrome (OSAS) who underwent APAP titration between July 1, 2016, and December 31, 2017, 22 patients with titration failure were enrolled in the study. The demographic and polysomnographic characteristics of this group were compared with 44 patients with an adequate APAP titration who were matched with the titration failure group by age, sex, and OSAS severity. The periods between the start of sleep and the start of REM and nREM3 stages were noted as REM latency and nREM3 latency, respectively.

RESULTS

The between group differences in the parameters including nREM3 latency, REM latency, and minimum SpO₂ during the titration test were statistically significant (p = 0.004, p = 0.008, p <0.001 respectively). Possible threshold values to predict failure of APAP titration were found as 40 min and 135 min for nREM3 and REM latencies, respectively. The best threshold for minimum SpO₂ was 86% with an 86.4% of sensitivity. Despite the high negative predictive values (81% for nREM3 latency, 75% for REM latency), the sensitivities (63.6% for nREM3 latency, 54.5% for REM latency) of the prior parameters in determining titration failure were relatively low.

CONCLUSION

The minimum SpO₂ < 86% can be used as a readily available indicator of APAP titration failure. nREM3 and REM latencies may be regarded as supplementary indicators in detecting the patients who may need an advanced PAP device.

Impact of sleep-disordered breathing treatment on upper airway anatomy and physiology

Sleep-disordered breathing (SDB) is a major public health problem. Various anatomic, pathophysiologic, and environmental changes contribute to SDB. The successful treatment of SDB reverses many of these abnormal processes. The present article discusses the current clinical evidence that supports the reversibility and its potential application in the management of SDB. Continuous positive airway pressure reduces angiogenesis and inflammatory edema, increases pharyngeal size, and improves surrogate markers of vascular inflammation and tongue muscle fiber types. Mandibular advancement devices lead to favorable maxillary and mandibular changes, increase pharyngeal area, and improve hypertension. Uvulopalatopharyngoplasty increases posterior airway space and pharyngeal volume, reduces nasal and oral resistance, and lowers response to high CO2. Weight loss reduces nasopharyngeal collapsibility, critical closing pressure of the airway, apnea-hypopnea index, and improves oxygen saturations. Potential clinical benefits of these changes in the management of SDB and patient compliance with treatment are discussed.

Treatment of cardiomyopathy with PAP therapy in a patient with severe obstructive sleep apnea

Obstructive sleep apnea is common in patients with heart failure. This case illustrates that treatment with PAP therapy can improve cardiac function in patients with both conditions. CPAP-emergent central apnea, as seen in this patient, has multiple etiologies. It is commonly seen in patients with severe sleep apnea, usually resolves over time, and does not need treatment with adaptive servoventilation.

[Update on therapy with positive airway pressure in sleep-related breathing disorders]

Positive airway pressure (PAP) is the therapy of choice for most sleep-related breathing disorders. A variety of PAP devices exist (continuous PAP, bi-level PAP, automatic PAP, adaptive servo-ventilation) and must be carefully considered before application. The data presented are from an ENT sleep laboratory perspective and are designed to help the inexperienced ENT practitioner support patients before and after PAP therapy has begun. Patient compliance can be increased with individualized therapy. PAP treatment is very effective in eliminating obstruction-related sleep diseases and symptoms. However, because it generally has to be used throughout the patient's life, the optimal PAP device must be carefully selected, taking into account side effects that influence compliance.

A randomized cross-over study of auto-continuous positive airway pressure versus fixed-continuous positive airway pressure in patients with obstructive sleep apnoea

BACKGROUND AND OBJECTIVES

To compare the efficacy of auto-CPAP (AutoSet Spirit, ResMed) versus fixed-CPAP (S6 Elite, ResMed) in improving daytime sleepiness, health status, objective compliance and the ultimate treatment preference in patients with severe OSA.

METHODS

The study recruited 43 subjects aged 18-65 years with newly diagnosed severe OSA (AHI >30/h). Patients were initially treated with either auto-CPAP or fixed-CPAP for 2 months and then crossed over after a washout period of 1 week for another 2 months.

RESULTS

The study was completed by 41 patients. Results are presented as mean (SE). Use of auto-CPAP in the first and the second month was significantly higher than that of fixed-CPAP [129.7 (9.9) and 130.5 (10.7) h vs 115.2 (9.5) and 113.2 (9.4) h, P = 0.04 and 0.01], whereas mean hourly use per night was 4.3 and 4.4 h versus 3.8 and 3.7 h, respectively. The Epworth sleepiness scores improved after 1 month in both treatments (13.4 to 8.5 and 8.2, P < 0.01 for both). The Sleep apnoea quality of life index improved in the first month in both compared with baseline [4.6 (0.2) to 5.0 (0.2) for auto-CPAP and 4.9 (0.2) for fixed-CPAP, P = 0.01 and 0.04, respectively], with no difference between the two treatments. Nine and 30 patients preferred auto-CPAP and fixed-CPAP, respectively, at the end of the trial, whereas 14 and 25 patients would have chosen the same treatments if cost had not been a consideration.

CONCLUSIONS

Auto-CPAP and fixed-CPAP were equally effective in improving symptoms and health status in patients with severe OSA. Usage was higher with auto-CPAP, but more patients ultimately chose fixed-CPAP.

Split-night polysomnography

Obstructive sleep apnea (OSA) is a common disorder associated with serious health consequences, increased health-care utilization, and economic burden. With greater public and medical attention to sleep disorders, the volume of referrals for sleep studies over the last decade has increased by approximately 12-fold. Despite the steep growth of infrastructure to diagnose and treat OSA, access to such services remains a sizeable problem, and demand overwhelms capacity. To expedite diagnosis of sleep apnea and prescription of treatment, one strategy adopted by sleep specialists is to employ split-night polysomnography, a strategy that encompasses both diagnosis of OSA and initiation of positive pressure therapy in a single night. This article reviews the literature examining this combined diagnostic/therapeutic strategy and discusses the applicable third-party issues of procedural coding and reimbursement.

Depression and anxiety in obstructive sleep apnea syndrome: a review

OBJECTIVE - To provide an update on recent research on depression and anxiety in obstructive sleep apnea syndrome (OSAS). METHODS - A review was carried out on reports drawn from MEDLINE and PSYCHLIT (January 1995-June 2006) and identified from their list of references. The selection criteria were met by 55 articles. RESULTS - Sample sizes in the reviewed studies varied widely and consisted mainly of working age men. Depression and anxiety were mostly evaluated with commonly used mood scales; only a few studies provided a psychiatric diagnosis. Prevalence figures fluctuated considerably for both depression (7-63%) and anxiety (11-70%). The effect of the continuous positive airway pressure (CPAP) on mood was inconsistent. CONCLUSIONS - Variations in the prevalence of depression and anxiety are affected by patient characteristics, mood assessment methods, and overlap between mood alterations and OSAS-related symptoms. CPAP might improve mood alterations but more long-term follow-up studies are needed to verify the effectiveness.

Positive airway pressure treatment for obstructive sleep apnea

Positive airway pressure (PAP) is the treatment of choice for patients with moderate-to-severe obstructive sleep apnea (OSA). Randomized controlled trials have demonstrated that PAP can effectively reduce the apnea-hypopnea index and improve subjective and objective sleepiness. Some studies have also demonstrated benefits in sleep quality and quality of life for both the patient and bed partner. Observational studies have shown a reduction in the risk of cardiovascular events in OSA patients treated with PAP compared to untreated patients. Since continuous PAP (CPAP) treatment of OSA was described, additional modes of pressure delivery have been developed (bilevel PAP, autoadjusting PAP, flexible PAP). While none of the variants of PAP improves adherence in unselected patients compared to CPAP, individual patients may respond to a change in pressure mode. Attended PAP titration remains the standard of practice for selecting a treatment pressure. However, use of autotitrating PAP devices in the unattended setting can provide an effective titration alternative with careful patient selection and review of titration results. More choices of mask interface are now available to improve comfort and intervene for mask or mouth leaks. However, despite the increase in PAP treatment options, lack of acceptance and inadequate adherence to PAP therapy remain the major causes of treatment failure. Some studies suggest that heated humidification can improve PAP adherence, especially in patients with nasal congestion or dryness. A systematic approach to PAP treatment including education, objective adherence monitoring, early intervention for side effects, and telephone and clinic support is essential to optimize adherence.

Arbitrary-Pressure Continuous Positive Airway Pressure for Obstructive Sleep Apnea Syndrome

Current resources are inadequate to meet the demand for polysomnography, resulting in long waiting lists. This study aimed to evaluate the role of arbitrary-pressure continuous positive airway pressure (CPAP) as a method to reduce delays in commencing treatment. The study was of an open, randomized, parallel design. Ninety-one subjects with obstructive sleep apnea syndrome were randomized to either arbitrary-pressure CPAP based on body mass index before treatment polysomnography or to CPAP at settings determined by polysomnography. Both interventions resulted in similar improvements in clinical outcomes as determined by Epworth Sleepiness Score, Short Form-36 Quality of Life questionnaire, objective compliance, and subjective attitudes to treatment. There was higher sleep efficiency at treatment polysomnography in the group commenced at arbitrary pressure (81.8 +/- 10.1% [mean +/- SD] compared with 72.2 +/- 18.0%, p = 0.01). Subjects unable to tolerate CPAP were identified by the use of arbitrary pressure, leading to a reduction in the proportion of "wasted" treatment polysomnograms (studies performed in subjects not persisting with treatment) relative to commencing therapy after treatment polysomnography (3 of 39 compared with 12 of 35, p = 0.01). This approach to initiating treatment with CPAP appears feasible when there are long waiting lists for polysomnography.

Nasal CPAP treatment for obstructive sleep apnea: developing a new perspective on dosing strategies and compliance

Nasal continuous positive airway pressure (CPAP) is presently considered as the "treatment of choice" for obstructive sleep apnea (OSA). Though some OSA patients adhere to treatment recommendations and ultimately respond quite well to CPAP therapy, there is a substantial subgroup for which compliance is a particularly difficult issue. Despite receiving recommendations to the contrary and for reasons that are incompletely understood, the majority of OSA patients settle for a partial compliance pattern. Whether a partial compliance schedule is beneficial or harmful is virtually unexamined: Unlike other medical treatments, there are few data concerning the "dose-response relationship" of CPAP to its desired effects. We argue that CPAP "dose" is a function not only of CPAP pressure but of time-on-CPAP as well. Critical questions that remain unanswered are what "dose" of CPAP is needed to effect an appropriate treatment outcome and which treatment outcomes should form the basis of our recommendations. Recent placebo-controlled studies comparing CPAP to suboptimal CPAP pressures may be informative in this regard. Directions for future research are suggested.

Clinical outcomes related to interface type in patients with obstructive sleep apnea/hypopnea syndrome who are using continuous positive airway pressure

STUDY OBJECTIVES

To evaluate the effect of interface on objective compliance, patient satisfaction, adverse effects, quality of life, and residual sleep-disordered breathing in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS) using continuous positive airway pressure (CPAP).

DESIGN

Randomized, cross-over.

SETTING

Two suburban community-based hospital sleep laboratories.

PATIENTS

Data were collected on 39 patients with OSAHS (mean age, 48.7 years), in whom CPAP was a novel treatment.

INTERVENTIONS

Interventions were nasal pillows (Breeze; Mallinckrodt Corporation; Minneapolis, MN) and nasal mask (Contour; Respironics; Murrysville, PA).

MEASUREMENTS AND RESULTS

Outcomes assessed at the completion of each 3-week treatment period were objective compliance, adverse effects, and satisfaction with CPAP (CPAP questionnaire), daytime sleepiness (Epworth sleepiness scale [ESS]), quality of life (Functional Outcomes of Sleep Questionnaire [FOSQ]), sleep diary, and residual sleep-disordered breathing (apnea-hypopnea index [AHI]). Patients were randomly assigned to use the nasal pillows or the nasal mask following laboratory titration and initiated on CPAP (pressure range, 5 to 14 cm H(2)O). The percentage of days utilized favored the nasal pillows (94.1% vs 85.7%; p = 0.02), but minutes of use per night did not differ (nasal pillows, 223 min; nasal mask, 288 min). ESS scores were lower and the FOSQ total scores were higher following CPAP treatment (p < 0.001), but no differential treatment effects were noted. Fewer adverse effects, less trouble getting to sleep and staying asleep, and less air leak were reported with nasal pillows (p < 0.04). The mean +/- SD pretreatment AHI (47.1 +/- 35.1/h) was significantly lower following treatment with CPAP for both types of interface (nasal pillows, 10.2 +/- 9.8/h; nasal mask, 7.0 +/- 7.7/h; p < 0.001).

CONCLUSIONS

Nasal pillows are a well-tolerated and effective interface for OSAHS patients receiving CPAP at < or = 14 cm H(2)O. Use of nasal pillows was associated with fewer adverse effects and better sleep quality during the first 3 weeks of CPAP therapy. Further investigation is needed to determine whether interface type affects long-term CPAP use.

Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS)

Though continuous positive airway pressure (CPAP) is the treatment of choice for the sleep apnoea/hypopnoea syndrome (SAHS), suboptimal adherence to CPAP is common. Internationally, some 5-50% of SAHS patients recommended for CPAP either reject this treatment option or discontinue within the first week, and 12-25% of remaining patients can be expected to have discontinued CPAP by 3 years. Biomedical investigations of patients' CPAP use reveal frequent adverse effects, weak prospective relationships between symptomatic or physiological disease severity and CPAP use, and moderate correlations between use and benefit. Relatively expensive high-technological interventions to improve CPAP use (e.g. "intelligent" CPAP, humidification) are the subject of several well-conducted studies favouring their effectiveness. More basic educational and behavioural supports, and low-technological interventions (e.g. chinstraps, mask re-fitting) appear valued, but are currently less rigorously evaluated. In other diseases with demanding treatment regimens, cognitive constructs including health attitudes and beliefs (health value, locus of control, chance, powerful others, self-efficacy) and mental and physical health status are significant predictors of adherence. The enhancement of multidisciplinary models with psychosocial interpretations may provide increased explanatory and interventional potential in models of CPAP use. While acknowledging the scarcity of evidence, a structured, multidisciplinary, cost-efficient model is suggested, containing educational, behavioural and technological components as basic support, and with high-expertise cognitive-behavioural intervention in more difficult cases of low CPAP use.

Comparison between automatic and fixed positive airway pressure therapy in the home

We tested the hypothesis that continuous positive airway pressure (CPAP) use and outcomes can be improved by an autotitrating CPAP device in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) who require higher CPAP (10 cm H2O or more). In this multisite randomized single-blind cross-over study, 44 patients (mean age, 49 +/- 10 years) were randomized to 6 weeks at laboratory-determined fixed pressure and 6 weeks on autotitrating CPAP. Average nightly use was greater in automatic mode (306 versus 271 minutes, p = 0.005); median and 95th centile pressures in automatic mode were lower (p < 0.002). Automatic CPAP resulted in better SF-36 Vitality scores (65 +/- 20 versus 58 +/- 23, p < 0.05) and mental health scores (80 +/- 14 versus 75 +/- 18, p < 0.05), but no significant difference in Epworth score (p = 0.065). During automatic therapy, patients reported more restful sleep, better quality sleep, less discomfort from pressure, and less trouble getting to sleep for both the first week of therapy and for the averaged scores for Weeks 2-6 (all p values < 0.006). Patients who require higher fixed CPAP use autotitrating CPAP more and report greater benefit from this therapy.

Is (re)titration of nasal continuous positive airway pressure for obstructive sleep apnoea necessary?

OBJECTIVE

To assess changes in nasal continuous positive airway pressure (nCPAP) pressure requirements across time in obstructive sleep apnoea (OSA), and whether routine retitrations are indicated.

BACKGROUND

Most sleep laboratories perform one nCPAP titration, although some authors have found changes in pressures with time. A cohort of patients with OSA in a randomised controlled trial of nCPAP provided us with data on changes in titration pressures with time.

METHODS

One hundred and one patients with symptomatic OSA (Epworth Sleepiness Scale > or =10, and >10 episodes/h of >4% dips in SaO(2) overnight) were recruited to a 1 month trial comparing real (autotitrated) and placebo nCPAP. At 1 month all patients were titrated and received real nCPAP thereafter. Eighty five were retitrated at about 6 months.

RESULTS

Average pressures did not change between the initial value and 1 month (95th centile, 8.47 (SD 3.00), 8.94 (2.85) cm H(2)O), although there were large individual changes (mean difference, +0.47, SD 2.30, range -5 to +6 cm H(2)O). There was a small fall at 6 months (mean difference -0.68, SD 2.60, range -6 to +6 cm H(2)O, P<0.03) with no suggestion that the changes from 1-6 months were clinically important.

CONCLUSIONS

This study suggests that routine nCPAP retitrations are not necessary. In conjunction with other published data, the night to night variation we found implies that a nCPAP calibration using an algorithm (based on obesity and OSA severity) might be as clinically successful as conventional one night titrations. However, further studies will be needed to specifically confirm this hypothesis.

Optimal continuous positive airway pressure for the treatment of obstructive sleep apnea/hypopnea

The obstructive sleep apnea/hypopnea syndrome (OSA/H) is characterised by repetitive obstruction of the upper airway during sleep. The consequences of OSA/H include excessive daytime sleepiness, reduced perceived health quality and an increased risk of driving accidents. There is evidence that treatment with nasal continuous positive airway pressure (CPAP) is effective in eliminating these consequences. In addition, OSA/H may also be associated with hypertension and an increased risk of vascular disease, and although there is no clear evidence in this regard, CPAP may be effective alleviating these consequences as well. Nasal CPAP is considered the treatment of choice for clinically significant OSA/H. The optimal CPAP prescription is that which is most effective in eliminating the adverse consequences of OSA/H. Patients should be initially treated with standard CPAP. For those in whom standard CPAP is unsuccessful or intolerable bi-level or self-adjusting modes may be attempted. The nasal CPAP pressure level can be titrated to eliminate apnea, hypopnea, snoring, respiratory arousal and inspiratory flow limitation as a means of predicting successful long-term therapy. The reliability of these physiologic parameters in predicting the optimal long-term CPAP pressure is eroded by the tendency of CPAP pressure-level requirement to decrease with chronic CPAP use, and by other factors that may increase the CPAP pressure requirement. The split-night polysomnogram and unattended auto-CPAP titration have been proposed as efficient means of determining the optimal CPAP pressure, but for patients with subtle OSA/H, underlying cardiopulmonary disease or other forms of sleep-disordered breathing a full-night polysomnogram may be required. The CPAP prescription must include a comfortable well-fitting interface. When CPAP is prescribed it is essential that the patient undergo clinical re-evaluation to ensure that treatment goals are being met.

Effects of augmented continuous positive airway pressure education and support on compliance and outcome in a Chinese population

OBJECTIVES

To study the effects of augmentation of continuous positive airway pressure (CPAP) education and support on compliance and outcome in patients with obstructive sleep apnea (OSA).

DESIGN

A randomized, controlled, parallel study of basic vs augmented CPAP education and support.

SETTING

A university teaching hospital.

PATIENTS

A total of 108 OSA patients randomized into basic-support (BS) and augmented-support (AS) groups.

INTERVENTIONS

Patients in the BS group (n = 54) were given educational brochures on OSA and CPAP, CPAP education by nurses, CPAP acclimatization, and were reviewed by physicians and nurses at weeks 4 and 12. Patients in the AS group (n = 54) received more education, including a videotape, telephone support by nurses, and early review at weeks 1 and 2.

MEASUREMENTS

Objective CPAP compliance, Calgary sleep apnea quality of life index (SAQLI), and cognitive function after 1 month and 3 months; and Epworth sleepiness scale (ESS) after 3 months of CPAP treatment.

RESULTS

At 4 weeks, CPAP usage was 5.3 +/- 0.2 h/night (mean +/- SEM) vs 5.5 +/- 0.2 h/night in the BS and AS groups, respectively (p = 0.4). At 12 weeks, CPAP usage was 5.3 +/- 0.3 h/night vs 5.3 +/- 0.2 h/night in the two groups, respectively (p = 0.98). There was greater improvement of SAQLI at 4 weeks (p = 0.008) and at 12 weeks (p = 0.047) in the AS group. There was no significant difference between BS and AS groups in terms of improvement of ESS and cognitive function.

CONCLUSION

Augmentation of CPAP education and support does not increase CPAP compliance, but leads to a greater improvement of quality of life during the reinforced period.