1
|
Arslan NG. Factors Determining the Need For Bilevel Therapy in Obstructive Sleep Apnea Patients. JOURNAL OF TURKISH SLEEP MEDICINE 2023. [DOI: 10.4274/jtsm.galenos.2022.27136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
|
2
|
BaHammam AS, Aleissi SA, Nashwan SZ, Olaish AH, Almeneessier AS. Results of CPAP Titration and Short-Term Adherence Rates in Patients with Obesity Hypoventilation Syndrome and Mild/Moderate Obstructive Sleep Apnea. Nat Sci Sleep 2022; 14:1137-1148. [PMID: 35733818 PMCID: PMC9207127 DOI: 10.2147/nss.s369316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/09/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE No study has assessed the titration success of CPAP therapy in patients with obesity hypoventilation syndrome (OHS) and an apnea-hypopnea index (AHI) <30 event/h. This study aimed to assess the titration success of CPAP therapy under polysomnography and subsequent short-term adherence (1 month) in patients with OHS and an AHI <30 event/h. METHODS Consecutive OHS patients with an AHI <30 events/h between 2010 and 2019 were included (n=54). All OHS patients were first started on CPAP during the therapeutic sleep-study. If the therapeutic-study showed that the SpO2 remained < 90% for 20% of the total sleep time, a second therapeutic study was arranged with bi-level PAP (BPAP). Thirty patients agreed to participate in the 1-month follow-up adherence study. We applied the American-Thoracic-Society criteria for PAP adherence. RESULTS The mean age was 54.8±14.6 years, and the mean BMI was 45.9±12.2 kg/m2. Successful titration on CPAP was attained in 36 (66.7%) patients, and 18 (33.3%) required BPAP. Patients who failed the CPAP trial had a significantly higher PaCO2 and bicarbonate, a more restrictive respiratory pattern on spirometry, and a significantly higher time with SpO2<90% (mins) during sleep. The only independent correlate of CPAP-titration success on the multivariable regression analysis was the desaturation index (OR: 1.33 [1.033-1.712]). More than 80% of the participants were using CPAP therapy after one-month with no differences in adherence between the CPAP and BPAP groups. CONCLUSIONS The current results suggest that CPAP therapy could be an acceptable alternative therapy to BPAP in patients with OHS without severe OSA.
Collapse
Affiliation(s)
- Ahmed S BaHammam
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Salih A Aleissi
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Samar Z Nashwan
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Awad H Olaish
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Aljohara S Almeneessier
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
3
|
Optimal Noninvasive Medicare Access Promotion: Patients with Obstructive Sleep Apnea A Technical Expert Panel Report from the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society. Chest 2021; 160:e409-e417. [PMID: 34339689 DOI: 10.1016/j.chest.2021.06.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/26/2021] [Accepted: 06/10/2021] [Indexed: 11/24/2022] Open
Abstract
This document summarizes the work of the CPAP and Bilevel PAP Therapy for Obstructive Sleep Apnea (OSA) Technical Expert Panel working group. For PAP therapy, the most pressing current coverage barriers identified were: an insufficient symptom list describing all potential symptoms in patients with mild OSA; the 4 hours/night of PAP usage requirement to keep the device; the additional sleep studies requirement to re-qualify for PAP or supplemental oxygen; the inability to use telehealth visits for followup visits. Critical evidence support changes to current policies and include: symptom list inadequate to cover all scenarios based on updated clinical practice guidelines; published evidence that 2 hours/night of PAP use can result in benefit to quality of life and other metrics; the costs of another sleep study not justified for all non-adherent patients or for supplemental oxygen due to other types of assessment currently available; and the remarkable success and acceptance of telehealth visits. In order to achieve optimal access for patients on PAP therapy, we make the following key suggestions: removing symptom criteria for mild OSA; reduce continued coverage criteria to > 2 hours/night; eliminate the need for a sleep study to re-qualify if non-adherent or for new CMS beneficiaries already on and adherent to PAP therapy; allow telehealth visits for documenting benefit and adherence; and allow PAP reports and domiciliary oximetry to qualify for supplemental oxygen with PAP if needed. This paper shares our best vision for bringing the right device to the right patient at the right time.
Collapse
|
4
|
Feinsilver SH. Obstructive Sleep Apnea: Treatment with Positive Airway Pressure. Clin Geriatr Med 2021; 37:417-427. [PMID: 34210447 DOI: 10.1016/j.cger.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
As in other adults, continuous positive airway pressure treatment for obstructive sleep apnea should be the mainstay of treatment. Benefits include improvements in sleepiness and quality of life, as well as improvements in hypertension control, arrhythmias, cardiovascular risk, and mortality. This article discusses issues in prescribing this treatment, including those related specifically to elderly individuals.
Collapse
Affiliation(s)
- Steven H Feinsilver
- Zucker School of Medicine at Hofstra Northwell Health, Lenox Hill Hospital, New York, NY, USA.
| |
Collapse
|
5
|
Freedman N. Treatment of Obstructive Sleep Apnea: Choosing the Best Positive Airway Pressure Device. Sleep Med Clin 2020; 15:205-218. [PMID: 32386695 DOI: 10.1016/j.jsmc.2020.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Positive airway pressure (PAP) remains primary therapy for most patients with obstructive sleep apnea (OSA). CPAP, APAP, and BPAP are all reasonable therapies that can be used for patients with uncomplicated OSA across the spectrum of disease severity. BPAP should be considered for patients who are nonadherent to CPAP or APAP therapy because of pressure intolerance. Several additional factors should be considered when choosing the type of PAP device for a given patient, including associated symptoms and comorbid medical problems, cost, access to online data management and patient portals, and the portability for the device for patients who travel frequently.
Collapse
Affiliation(s)
- Neil Freedman
- Pulmonary, Critical Care, Allergy and Immunology, Department of Medicine, North Shore University Health System, 2650 Ridge Avenue, Evanston, IL 60201, USA.
| |
Collapse
|
6
|
Shah S, Smotherman C, Louis M. Determinants of bilevel therapy in the management of obstructive sleep apnea. Sleep Breath 2020; 25:1181-1186. [PMID: 32965586 DOI: 10.1007/s11325-020-02193-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/28/2020] [Accepted: 09/12/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to investigate potential patient or polysomnogram (PSG) characteristics that can help determine who might benefit from bilevel positive airway pressure (BPAP) in the treatment of uncomplicated OSA. STUDY DESIGN This was a single center, retrospective, observational study in which 19 patients who met our inclusion criteria for BPAP were matched to 40 patients in the control group. Data on patient baseline characteristics as well as PSG results were analyzed. RESULTS Baseline patient and PSG characteristics were similar with the exception of shorter sleep time in the BPAP group, 290 min compared with 351 min (p = 0.005). Analysis of oxygen saturations revealed that the percent of total sleep time (TST) spent below 90% (SpO2 < 90%) was statistically higher in BPAP group (mean 21.4% ± 23.6%) compared with CPAP (mean 9.1% ± 11.1%, p = 0.045). For every 5% increase in TST at SpO2 < 90%, there is a 28% increase in the odds of BPAP prescription (OR = 1.276, 95%CI 1.029, 1.582, p = 0.027), and for every 10% increase, there is an increase of 63% (OR 1.627, 95%CI 1.058-2.502). The Hosmer-Lemeshow goodness-of-fit test revealed a good fit (p = 0.23). The AUC was 0.7. CONCLUSION There is an association between duration of hypoxemia on the PSG and the likelihood of requiring BPAP for the treatment of uncomplicated OSA. More research is needed to understand the best patient-centered therapy when initiating PAP in the management of OSA.
Collapse
Affiliation(s)
- Stuart Shah
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Jacksonville Suite 7-088, C-54 UF Health Clinical Center, 655 west 8th Street, Jacksonville, FL, 32209, USA
| | - Carmen Smotherman
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Jacksonville Suite 7-088, C-54 UF Health Clinical Center, 655 west 8th Street, Jacksonville, FL, 32209, USA
| | - Mariam Louis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Jacksonville Suite 7-088, C-54 UF Health Clinical Center, 655 west 8th Street, Jacksonville, FL, 32209, USA.
| |
Collapse
|
7
|
González Mangado N, Egea-Santaolalla CJ, Chiner Vives E, Mediano O. Apnea obstructiva del sueño. OPEN RESPIRATORY ARCHIVES 2020. [DOI: 10.1016/j.opresp.2020.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
|
8
|
Noda A, Hayano J, Ito N, Miyata S, Yasuma F, Yasuda Y. Very low frequency component of heart rate variability as a marker for therapeutic efficacy in patients with obstructive sleep apnea: Preliminary study. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2019; 24:84. [PMID: 31620183 PMCID: PMC6788180 DOI: 10.4103/jrms.jrms_62_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 11/14/2018] [Accepted: 07/01/2019] [Indexed: 12/14/2022]
Abstract
Background: Although positive airway pressure (PAP) therapy is effective for treating obstructive sleep apnea (OSA), some patients with severe OSA are intolerable to this treatment, which may lead to an increase in the mortality and morbidity of cardiovascular diseases. We investigated the relationship between heart rate variability (HRV) and sleep parameters during natural sleep and treatment of patients with OSA. Materials and Methods: This was the cross-sectional observation study. Patients were 17 males with severe OSA who were unable to accept continuous PAP. Standard polysomnography was performed for two consecutive nights, i.e., during natural sleep and following night with bilevel PAP (BiPAP) treatment. Time-dependent responses of the amplitudes of low frequency (LF), very low frequency (VLF), and high frequency components of HRV were assessed with the technique of complex demodulation. Results: Apnea–hypopnea index, oxygen desaturation time, and percentage of stage 1 sleep were significantly reduced, whereas the percentages of rapid eye movement and stages 3 + 4 sleep were increased, by BiPAP treatment. Therapy also reduced the amplitudes of VLF and LF components of HRV. Difference in amplitudes of VLF during natural sleep and treatment with BiPAP was significantly correlated with difference in percentages of stage 1 and stages 3 + 4 sleep. Conclusion: Therapy-induced amelioration of OSA and sleep quality was accompanied by decrease in the amplitudes of VLF components of HRV. The VLF component may thus reflect physiological changes in both autonomic activity and sleep structure and serve as an objective marker for therapeutic efficacy in patients with severe OSA.
Collapse
Affiliation(s)
- Akiko Noda
- Department of Biomedical Sciences, Chubu University Graduate School of Life and Health Sciences, Kasugai, Japan.,Innovative Research Center for Preventive Medical Engineering, Nagoya University, Nagoya, Japan
| | - Junichiro Hayano
- Department of Medical Education, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Nami Ito
- Department of Medical Technology, Nagoya University School of Health Sciences, Nagoya, Japan
| | - Seiko Miyata
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumihiko Yasuma
- Department of Internal Medicine, National Hospital Organization Suzuka Hospital, Suzuka, Japan
| | - Yoshinari Yasuda
- Department of CKD Intitatives, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
9
|
Omobomi O, Quan SF. BPAP for CPAP failures: For the many or the few. Respirology 2019; 25:358-359. [PMID: 31441156 DOI: 10.1111/resp.13687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/08/2019] [Indexed: 01/20/2023]
Affiliation(s)
- Olabimpe Omobomi
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stuart F Quan
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Asthma and Airways Research Center, University of Arizona College of Medicine, Tucson, AZ, USA
| |
Collapse
|
10
|
Tingting X, Danming Y, Xin C. Non-surgical treatment of obstructive sleep apnea syndrome. Eur Arch Otorhinolaryngol 2017; 275:335-346. [PMID: 29177626 DOI: 10.1007/s00405-017-4818-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 11/15/2017] [Indexed: 12/12/2022]
Abstract
Obstructive sleep apnea syndrome (OSAS), a pervasive disease, is closely associated with complications such as cardiovascular diseases, neurocognitive diseases, and metabolic syndromes. Continuous positive airway pressure (CPAP) is the standard treatment for OSAS, with low compliance due to multifarious factors. The two other modes of ventilation, bi-level positive airway pressure (BPAP) and autotitrating positive airway pressure (APAP), which were developed from CPAP, are slightly different from CPAP in specific groups, as well as the corresponding treatment effect and compliance. The compliance of traditional positional therapy is not high, but with the emergence of the neck-based position treatment device, its compliance and indications have changed. Although CPAP is superior to mandibular advancement device (MAD) in improving AHI, MAD seems to be comparable to CPAP in improving other indicators. Corticosteroids and leukotriene receptor antagonists are effective treatments for mild OSAS children. Whether corticosteroids can be used in other OSAS groups and their adjunctive functions to CPAP remains unclear. The combination of these two kinds of drugs appears to be more effective than single drug. Researches on transcutaneous electrical stimulation are still not enough. Its effectiveness and stimulation settings still need further study. This review summarized the various OSAS non-surgical treatments from indications, treatment outcomes, compliance, adverse reactions, and recent progress.
Collapse
Affiliation(s)
- Xu Tingting
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, 253 Gongye Road, Guangzhou, 510282, People's Republic of China
| | - You Danming
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, 253 Gongye Road, Guangzhou, 510282, People's Republic of China
| | - Chen Xin
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, 253 Gongye Road, Guangzhou, 510282, People's Republic of China.
| |
Collapse
|
11
|
Abstract
Positive airway pressure (PAP) remains primary therapy for most patients with obstructive sleep apnea (OSA). CPAP, APAP, and BPAP are all reasonable therapies that can be used for patients with uncomplicated OSA across the spectrum of disease severity. BPAP should be considered for patients who are nonadherent to CPAP or APAP therapy because of pressure intolerance. Several additional factors should be considered when choosing the type of PAP device for a given patient, including associated symptoms and comorbid medical problems, cost, access to online data management and patient portals, and the portability for the device for patients who travel frequently.
Collapse
|
12
|
Dzierzewski JM, Wallace DM, Wohlgemuth WK. Adherence to Continuous Positive Airway Pressure in Existing Users: Self-Efficacy Enhances the Association between Continuous Positive Airway Pressure and Adherence. J Clin Sleep Med 2017; 12:169-76. [PMID: 26350607 DOI: 10.5664/jcsm.5478] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 07/24/2015] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common sleep disorder associated with a myriad of sequelae. OSAHS is effectively treated with continuous positive airway pressure (CPAP) therapy. However, fewer than 50% of patients are compliant with their CPAP therapy prescriptions. The current study sought to explore an integrated, biopsychological approach to CPAP adherence among experienced CPAP users. METHODS We performed a retrospective, cross-sectional analysis of a cohort of veterans with a diagnosis of OSAHS (n = 191) who were prescribed CPAP therapy and returned for adherence download at the Miami VA Sleep Clinic. The relationships between biomedical characteristics (e.g., CPAP pressure, self-reported sleepiness, and change in sleep efficiency) and psychological factors (e.g., self-efficacy beliefs and psychological diagnoses) and objectively measured CPAP use were examined to determine whether psychological factors moderated the relationships between biomedical characteristics and CPAP adherence. RESULTS Hierarchical regression analyses predicting CPAP adherence (adjusting for time since CPAP prescription, age, education, prescribed CPAP pressure, daytime sleepiness, changes in sleep efficiency with CPAP, and psychiatric conditions) revealed the following: (1) CPAP self-efficacy and CPAP pressure were positively related to adherence, and (2) CPAP self-efficacy moderates the relationship between CPAP pressure and CPAP adherence. CONCLUSIONS There was no relationship between CPAP pressure and adherence in individuals with low self-efficacy beliefs. However, for individuals with high self-efficacy beliefs, there was a significant positive relationship between CPAP pressure and adherence. Self-efficacy beliefs appear to be a prime target for focused interventions aimed at improving CPAP adherence among those individuals with higher pressure prescriptions.
Collapse
Affiliation(s)
- Joseph M Dzierzewski
- David Geffen School of Medicine, University of California, Los Angeles, CA.,Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA
| | - Douglas M Wallace
- Department of Neurology, Sleep Medicine Division, University of Miami Miller School of Medicine, Miami, FL.,Neurology Service, Bruce W. Carter VA Medical Center, Miami, FL
| | - William K Wohlgemuth
- Department of Neurology, Sleep Medicine Division, University of Miami Miller School of Medicine, Miami, FL
| |
Collapse
|
13
|
Donovan LM, Boeder S, Malhotra A, Patel SR. New developments in the use of positive airway pressure for obstructive sleep apnea. J Thorac Dis 2015; 7:1323-42. [PMID: 26380760 DOI: 10.3978/j.issn.2072-1439.2015.07.30] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 07/03/2015] [Indexed: 12/14/2022]
Abstract
Obstructive sleep apnea (OSA) is a disorder which afflicts a large number of individuals around the world. OSA causes sleepiness and is a major cardiovascular risk factor. Since its inception in the early 1980's, continuous positive airway pressure (CPAP) has emerged as the major treatment of OSA, and it has been shown to improve sleepiness, hypertension, and a number of cardiovascular indices. Despite its successes, adherence with treatment remains a major limitation. Herein we will review the evidence behind the use of positive airway pressure (PAP) therapy, its various modes, and the methods employed to improve adherence. We will also discuss the future of PAP therapy in OSA and personalization of care.
Collapse
Affiliation(s)
- Lucas M Donovan
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Schafer Boeder
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Atul Malhotra
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sanjay R Patel
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
14
|
Sharples L, Glover M, Clutterbuck-James A, Bennett M, Jordan J, Chadwick R, Pittman M, East C, Cameron M, Davies M, Oscroft N, Smith I, Morrell M, Fox-Rushby J, Quinnell T. Clinical effectiveness and cost-effectiveness results from the randomised controlled Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and long-term economic analysis of oral devices and continuous positive airway pressure. Health Technol Assess 2015; 18:1-296. [PMID: 25359435 DOI: 10.3310/hta18670] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Obstructive sleep apnoea-hypopnoea (OSAH) causes excessive daytime sleepiness (EDS), impairs quality of life (QoL) and increases cardiovascular disease and road traffic accident risks. Continuous positive airway pressure (CPAP) treatment is clinically effective but undermined by intolerance, and its cost-effectiveness is borderline in milder cases. Mandibular advancement devices (MADs) are another option, but evidence is lacking regarding their clinical effectiveness and cost-effectiveness in milder disease. OBJECTIVES (1) Conduct a randomised controlled trial (RCT) examining the clinical effectiveness and cost-effectiveness of MADs against no treatment in mild to moderate OSAH. (2) Update systematic reviews and an existing health economic decision model with data from the Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and newly published results to better inform long-term clinical effectiveness and cost-effectiveness of MADs and CPAP in mild to moderate OSAH. TOMADO A crossover RCT comparing clinical effectiveness and cost-effectiveness of three MADs: self-moulded [SleepPro 1™ (SP1); Meditas Ltd, Winchester, UK]; semibespoke [SleepPro 2™ (SP2); Meditas Ltd, Winchester, UK]; and fully bespoke [bespoke MAD (bMAD); NHS Oral-Maxillofacial Laboratory, Addenbrooke's Hospital, Cambridge, UK] against no treatment, in 90 adults with mild to moderate OSAH. All devices improved primary outcome [apnoea-hypopnoea index (AHI)] compared with no treatment: relative risk 0.74 [95% confidence interval (CI) 0.62 to 0.89] for SP1; relative risk 0.67 (95% CI 0.59 to 0.76) for SP2; and relative risk 0.64 (95% CI 0.55 to 0.76) for bMAD (p < 0.001). Differences between MADs were not significant. Sleepiness [as measured by the Epworth Sleepiness Scale (ESS)] was scored 1.51 [95% CI 0.73 to 2.29 (SP1)] to 2.37 [95% CI 1.53 to 3.22 (bMAD)] lower than no treatment (p < 0.001), with SP2 and bMAD significantly better than SP1. All MADs improved disease-specific QoL. Compliance was lower for SP1, which was unpopular at trial exit. At 4 weeks, all devices were cost-effective at £20,000/quality-adjusted life-year (QALY), with SP2 the best value below £39,800/QALY. META-ANALYSIS A MEDLINE, EMBASE and Science Citation Index search updating two existing systematic reviews (one from November 2006 and the other from June 2008) to August 2013 identified 77 RCTs in adult OSAH patients comparing MAD with conservative management (CM), MADs with CPAP or CPAP with CM. MADs and CPAP significantly improved AHI [MAD -9.3/hour (p < 0.001); CPAP -25.4/hour (p < 0.001)]. Effect difference between CPAP and MADs was 7.0/hour (p < 0.001), favouring CPAP. No trials compared CPAP with MADs in mild OSAH. MAD and CPAP reduced the ESS score similarly [MAD 1.6 (p < 0.001); CPAP 1.6 (p < 0.001)]. LONG-TERM COST-EFFECTIVENESS An existing model assessed lifetime cost-utility of MAD and CPAP in mild to moderate OSAH, using the revised meta-analysis to update input values. The TOMADO provided utility estimates, mapping ESS score to European Quality of Life-5 Dimensions three-level version for device cost-utility. Using SP2 as the standard device, MADs produced higher mean costs and mean QALYs than CM [incremental cost-effectiveness ratio (ICER) £6687/QALY]. From a willingness to pay (WTP) of £15,367/QALY, CPAP is cost-effective, although the likelihood of MADs (p = 0.48) and CPAP (p = 0.49) being cost-effective is very similar. Both were better than CM, but there was much uncertainty in the choice between CPAP and MAD (at a WTP £20,000/QALY, the probability of being the most cost-effective was 47% for MAD and 52% for CPAP). When SP2 lifespan increased to 18 months, the ICER for CPAP compared with MAD became £44,066. The ICER for SP1 compared with CM was £1552, and for bMAD compared with CM the ICER was £13,836. The ICER for CPAP compared with SP1 was £89,182, but CPAP produced lower mean costs and higher mean QALYs than bMAD. Differential compliance rates for CPAP reduces cost-effectiveness so MADs become less costly and more clinically effective with CPAP compliance 90% of SP2. CONCLUSIONS Mandibular advancement devices are clinically effective and cost-effective in mild to moderate OSAH. A semi-bespoke MAD is the appropriate first choice in most patients in the short term. Future work should explore whether or not adjustable MADs give additional clinical and cost benefits. Further data on longer-term cardiovascular risk and its risk factors would reduce uncertainty in the health economic model and improve precision of effectiveness estimates. TRIAL REGISTRATION This trial is registered as ISRCTN02309506. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 67. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Linda Sharples
- University of Leeds Clinical Trials Research Unit, Leeds, UK
| | - Matthew Glover
- Health Economics Research Unit, Brunel University, Uxbridge, UK
| | | | - Maxine Bennett
- Medical Research Council Biostatistics Unit, Cambridge, UK
| | - Jake Jordan
- Health Economics Research Unit, Brunel University, Uxbridge, UK
| | - Rebecca Chadwick
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Marcus Pittman
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Clare East
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Malcolm Cameron
- Maxillofacial Unit, Addenbrooke's NHS Foundation Trust, Cambridge, UK
| | - Mike Davies
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Nick Oscroft
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Ian Smith
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Mary Morrell
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Timothy Quinnell
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| |
Collapse
|
15
|
Mansukhani MP, Kolla BP, Olson EJ, Ramar K, Morgenthaler TI. Bilevel positive airway pressure for obstructive sleep apnea. Expert Rev Med Devices 2014; 11:283-94. [PMID: 24666419 DOI: 10.1586/17434440.2014.900435] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
For most patients with obstructive sleep apnea syndrome (OSA), continuous positive airway pressure (CPAP) is an effective therapy. However, for a subset of individuals, CPAP is either not effective or is poorly tolerated. Bilevel positive airway pressure (BPAP) is potentially capable of treating OSA at a lower mean pressure than CPAP and can help augment ventilation via pressure support. This review summarizes the evidence for the use of BPAP in spontaneous mode in the initial treatment of patients with OSA and in those who are poorly compliant with CPAP therapy. It also examines evidence regarding use of BPAP in OSA with associated hypoventilation, such as in chronic obstructive pulmonary disease or severe obesity. Finally, current clinical guidelines that help determine which patients would be candidates for a BPAP device and how to manually titrate BPAP to determine the optimal settings to be prescribed are also discussed.
Collapse
Affiliation(s)
- Meghna P Mansukhani
- Sleep Medicine, Affiliated Communities Medical Center, 101 Willmar Avenue SW, Willmar, MN, USA
| | | | | | | | | |
Collapse
|
16
|
Atwood CW. Progress toward a clearer understanding of the role of bilevel positive airway pressure therapy for obstructive sleep apnea. J Clin Sleep Med 2013; 9:337-8. [PMID: 23585748 DOI: 10.5664/jcsm.2582] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Charles W Atwood
- VA Pittsburgh Healthcare System and the UPMC Sleep Medicine Center, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh and VA Pittsburgh Healthcare System, Pittsburgh, PA 15213, USA.
| |
Collapse
|