Equivalence of nasal and oronasal masks during initial CPAP titration for obstructive sleep apnea syndrome

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.

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.

Oronasal vs Nasal Masks: The Impact of Mask Type on CPAP Requirement, Pharyngeal Critical Closing Pressure (Pcrit), and Upper Airway Cross-Sectional Areas in Patients With OSA

BACKGROUND

CPAP delivered via an oronasal mask is associated with lower adherence, higher residual apnea-hypopnea index (AHI), and increased CPAP therapeutic pressure compared with nasal masks. However, the mechanisms underlying the increased pressure requirements are not well understood.

RESEARCH QUESTION

How do oronasal masks affect upper airway anatomy and collapsibility?

STUDY DESIGN AND METHODS

Fourteen patients with OSA underwent a sleep study with both a nasal and oronasal mask, each for one-half of the night (order randomized). CPAP was manually titrated to determine therapeutic pressure. Upper airway collapsibility was assessed using the pharyngeal critical closing pressure (Pcrit) technique. Cine MRI was done to dynamically assess the cross-sectional area of the retroglossal and retropalatal airway throughout the respiratory cycle with each mask interface. Scans were repeated at 4 cm H2O and at the nasal and oronasal therapeutic pressures.

RESULTS

The oronasal mask was associated with higher therapeutic pressure requirements (ΔM ± SEM; +2.6 ± 0.5; P < .001) and higher Pcrit (+2.4 ± 0.5 cm H2O; P = .001) compared with the nasal mask. The change in therapeutic pressure between masks was strongly correlated with the change in Pcrit (r2 = 0.73; P = .003). Increasing CPAP increased both the retroglossal and retropalatal airway dimensions across both masks. After controlling for pressure and breath phase, the retropalatal cross-sectional area was moderately larger when using a nasal vs an oronasal mask (+17.2 mm2; 95% CI, 6.2-28.2, P < .001) while nasal breathing.

INTERPRETATION

Oronasal masks are associated with a more collapsible airway than nasal masks, which likely contributes to the need for a higher therapeutic pressure.

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.

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.

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.

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.

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.

Efficacy and adherence of noninvasive ventilation treatment in children with Down syndrome

OBJECTIVE

Children with Down syndrome (DS) have an increased prevalence of obstructive sleep apnea (OSA). Noninvasive ventilation (NIV) is a common modality of OSA treatment in this cohort. This study aimed to measure adherence and efficiency of NIV delivery in children with DS.

STUDY DESIGN

This was a retrospective cohort study involving 106 children with confirmed OSA and home NIV with downloadable data capacity. Children were divided into DS (n = 44) and non-DS cohorts (n = 62). Adherence, clinical outcomes apnea-hypopnoea index (AHI), positive airway pressure delivery, and leakage were recorded and compared between DS and non-DS cohorts and within the DS cohort based on past surgical history.

RESULTS

Significantly greater NIV usage was observed in the DS cohort, they showed more consistent use with an increased percentage of days used relative to their non-DS counterparts (78.95 ± 2.26 vs. 72.11 ± 2.14, p = .031). However, despite greater usage, poorer clinical outcomes in the form of increased AHI (p = .0493) was observed in the DS cohort, where significantly greater leakage was also shown 41.00 ± 1.61 L/min versus 36.52 ± 1.18 L/min (p = .022). Twenty children with DS had prior cardiac surgery; compliance across all parameters was significantly reduced relative to those without.

CONCLUSION

These data confirm that satisfactory NIV adherence is achievable in children with DS. However, we have identified excessive system leak at the machine-patient interface as a factor, which could undermine NIV efficacy in children with DS.

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.

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.

[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.

Interfaces, Circuits and Humidifiers

Long-term non-invasive ventilation (LTNIV) has been increasingly used in children to manage chronic respiratory failure and airway obstruction. Interfaces are of paramount importance for non-invasive ventilation (NIV) effectiveness and patient compliance. However, historically, the choice of pediatric mask has been limited by the scarce availability of commercial interfaces. In recent years, an increasing number of different masks have been commercialized for children, allowing to increase the number of patients who could benefit from LTNIV. Factors such as the age of the child, disease, craniofacial conformation, type of ventilator and mode of ventilation, and children's and family's preferences should be taken into account when selecting the appropriate mask. Adverse events such as skin lesions, facial growth impairment, and leaks must be prevented and promptly corrected. Humidification is a controversial issue on NIV, but it may be useful in certain circumstances. Regular cleaning and disinfection of interfaces and equipment must be addressed. During follow-up, educational programs, close supervision, and continuous support to children and families are crucial to the success of LTNIV therapy.

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.

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.

Upper Airway Video Endoscopy: Assessment of the response to positive pressure ventilation and mechanical in-exsufflation

Upper airways (UA) include the nasal cavities, pharynx, and larynx, and its main function is to warm and filter the inspired air. UA dysfunction is in the pathogenesis of various disorders, such as obstructive sleep apnea syndrome (OSAS) and vocal cord dysfunction. In addition, in some neurodegenerative diseases (e.g. Amyotrophic Lateral Sclerosis - ALS), UA dysfunction may also compromise the effective use of ventilatory support (VS). In this context, the endoscopic evaluation of UA may be useful in understanding the OSAS mechanisms, in determining the causes for treatment-induced airway obstruction and even in helping to titrate noninvasive ventilation (NIV) in ALS patients with bulbar or pseudo-bulbar (spastic) dysfunction. Specifically, in OSAS patients, when residual obstructive events persist, although an optimal ventilatory mode has been apparently achieved, along with interface and equipment, the endoscopic evaluation of UA seems to be a valuable tool in understanding its mechanisms, even assisting adjustments to NIV parameters. In addition, it has also been described as being useful in laryngeal response to mechanical in-exsufflation (MI-E) and Exercise-Induced Laryngeal Obstruction (EILO). However, no protocol has yet been published or validated for this. For this reason, a literature review was conducted on UA function and its response to positive pressure and MI-E. Special emphasis has also been given to the current indication for video endoscopy in chronically ventilated patients.

Impact of Mask Type on the Effectiveness of and Adherence to Unattended Home-Based CPAP Titration

OBJECTIVES

To compare interfaces performance during home-based automatic titration (APAP).

METHODS

Retrospective study based on APAP titration from Obstructive Sleep Apnea Syndrome (OSA) patients.

RESULTS

707 patients, 513 men (70.6%), were titrated. Masks were 104 pillows (14.7%), group I (GI); 532 nasal (75.2%), group II (GII); and 71 oronasal masks (10%), group III (GIII). We found differences in effective pressure to the device (P90/P95) (GI: 7.13±1.9 vs. GII: 8.3±2.1 vs. GIII: 9.3±2.6 cmH2O, p <0.001) but not in final pressure titrated manually (GI: 7.9±1.4 vs. GII: 8.6±1.6 vs. GIII: 9.2±1.9 cm of H2O, p >0.5), where lower residual AHI for pillows was p <0.001 and leaks for nasal were p <0.001. No differences were found in compliance (hours) (GI: 6.3±1.2 vs. GII: 6.2±1.1 vs. GIII: 6.1±1.0, p <0.4).

CONCLUSION

During auto-adjusting titration by CPAP-naïve patients, nasal masks had lower leak rates and nasal pillows presented a similar performance.

Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment

INTRODUCTION

The purpose of this systematic review is to provide supporting evidence for the clinical practice guideline for the treatment of obstructive sleep apnea (OSA) in adults using positive airway pressure (PAP).

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of PAP with no treatment as well as studies that compared different PAP modalities. Meta-analyses were performed to determine the clinical significance of using PAP in several modalities (ie, continuous PAP, auto-adjusting PAP, and bilevel PAP), to treat OSA in adults. In addition, meta-analyses were performed to determine the clinical significance of using an in-laboratory versus ambulatory strategy for the initiation of PAP, educational and behavioral interventions, telemonitoring, humidification, different mask interfaces, and flexible or modified pressure profile PAP in conjunction with PAP to treat OSA in adults. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 336 studies that met inclusion criteria; 184 studies provided data suitable for meta-analyses. The data demonstrated that PAP compared to no treatment results in a clinically significant reduction in disease severity, sleepiness, blood pressure, and motor vehicle accidents, and improvement in sleep-related quality of life in adults with OSA. In addition, the initiation of PAP in the home demonstrated equivalent effects on patient outcomes when compared to an in-laboratory titration approach. The data also demonstrated that the use of auto-adjusting or bilevel PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP. Furthermore, data demonstrated a clinically significant improvement in PAP adherence with the use of educational, behavioral, troubleshooting, and telemonitoring interventions. Systematic reviews for specific PAP delivery method were also performed and suggested that nasal interfaces compared to oronasal interfaces have improved adherence and slightly greater reductions in OSA severity, heated humidification compared to no humidification reduces some continuous PAP-related side effects, and pressure profile PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP.

Choosing the right mask for your Asian patient with sleep apnoea: A randomized, crossover trial of CPAP interfaces

BACKGROUND AND OBJECTIVE

A major challenge with the treatment of obstructive sleep apnoea (OSA) is adherence to continuous positive airway pressure (CPAP) therapy. Mask tolerability is an important determinant of adherence, however evidence to guide selection of mask interfaces is lacking.

METHODS

We conducted a randomized crossover trial of mask interfaces in CPAP therapy for moderate-to-severe OSA to assess adherence and efficacy of CPAP therapy with nasal mask, nasal pillow and oronasal masks. Demographic data, Nasal Obstruction Symptom Evaluation (NOSE) scores and craniofacial measurements were also analysed for associations with adherence with oronasal masks.

RESULTS

Eighty-five patients were included in the study (mean ± SD age: 46 ± 12 years; body mass index: 29.9 ± 5.6 kg/m² ; apnoea-hypopnoea index (AHI): 53.6 ± 24.0 events/h). Patients had better adherence with nasal masks (average night use: 3.96 ± 2.26 h/night) compared to oronasal masks (3.26 ± 2.18 h/night, P < 0.001) and nasal pillows (3.48 ± 2.20 h/night, P = 0.007). Residual AHI was higher with oronasal masks (7.2 ± 5.2) compared to nasal masks (4.0 ± 4.2, P < 0.001) and nasal pillows (4.1 ± 3.3, P < 0.001). Twenty-two (25.9%) patients had the best adherence with oronasal masks (4.22 ± 2.14 vs 2.93 ± 2.12 h/night, P = 0.016). These patients had lower NOSE scores (15 (0-35) vs 40 (10-55), P = 0.024) and larger menton-labrale inferioris/biocular width ratios (31 ± 3% vs 28 ± 4%, P = 0.019).

CONCLUSION

Nasal masks are the preferred interface during CPAP initiation. Patients with less nasal obstruction and a proportionally increased chin-lower lip distance to mid-face width may have better CPAP adherence with an oronasal mask interface.

Oronasal mask may compromise the efficacy of continuous positive airway pressure on OSA treatment: is there evidence for avoiding the oronasal route?

PURPOSE OF REVIEW

Continuous positive airway pressure (CPAP) delivered by nasal mask is the gold standard treatment for obstructive sleep apnea (OSA). However, oral and oronasal masks are also available. We considered experimental evidence and reviewed clinical trials that evaluated the impact of oral and oronasal mask on OSA treatment.

RECENT FINDINGS

One recent study in 18 OSA patients that slept with a customized oronasal mask with two sealed compartments showed that the change of CPAP flow from nasal to oronasal and oral caused upper airway obstruction because of posterior displacement of the tongue demonstrated by nasoendoscopy. Oral masks use a mouthpiece that may stabilize the jaw and the tongue and have shown to be effective. However, oral masks are not widely used in clinical practice. Four out of five observational studies and all five reviewed randomized studies showed a worse performance of oronasal when compared with nasal masks. Oronasal masks were associated with higher residual apnea-hypopnea index, lower adherence, more leaks, and less satisfaction than nasal mask in the majority of the studies.

SUMMARY

Nasal CPAP must be the first choice to treat OSA. Patients on oronasal mask should be carefully followed. VIDEO ABSTRACT.

Comparing the Efficacy, Mask Leak, Patient Adherence, and Patient Preference of Three Different CPAP Interfaces to Treat Moderate-Severe Obstructive Sleep Apnea

STUDY OBJECTIVES

To determine if the type of continuous positive airway pressure (CPAP) mask interface influences CPAP treatment efficacy, adherence, side effects, comfort and sleep quality in patients with moderate-severe obstructive sleep apnea (OSA).

METHODS

This took place in a hospital-based tertiary sleep disorders unit. It is a prospective, randomized, crossover trial comparing three CPAP interfaces: nasal mask (NM), nasal mask plus chinstrap (NM-CS) and oronasal mask (ONM) each tried in random order, for 4 weeks. After each 4-week period, patient outcomes were assessed. Participants had a new diagnosis of obstructive sleep apneas. Forty-eight patients with moderate-severe OSA (32 males, mean ± standard deviation apnea-hypopnea index (AHI) 55.6 ± 21.1 events/h, age 54.9 ± 13.1 years, body mass index 35.8 ± 7.2 kg/m²) were randomized. Thirty-five participants completed the full study, with complete data available for 34 patients.

RESULTS

There was no statistically significant difference in CPAP adherence; however, residual AHI was higher with ONM than NM and NM-CS (residual AHI 7.1 ± 7.7, 4.0 ± 3.1, 4.2 ± 3.7 events/h respectively, main effect P = .001). Patient satisfaction and quality of sleep were higher with the NM and NM-CS than the ONM. Fewer leak and mask fit problems were reported with NM (all chi-square P < .05), which patients preferred over the NM-CS and ONM options (n = 22, 9 and 4 respectively, P = .001).

CONCLUSIONS

The CPAP adherence did not differ between the three different mask interfaces but the residual AHI was lower with NM than ONM and patients reported greater mask comfort, better sleep, and overall preference for a NM. A nasal mask with or without chinstrap should be the first choice for patients with OSA referred for CPAP treatment.

CLINICAL TRIAL REGISTRATION

Registry: Australian and New Zealand Clinical Trials Registry, URL: https://www.anzctr.org.au, title: A comparison of continuous positive airway pressure (CPAP) interface in the control of leak, patient compliance and patient preference: nasal CPAP mask and chinstrap versus full face mask in patients with obstructive sleep apnoea (OSA), identifier: ACTRN12609000029291.

Gel pillow designed specifically for obstructive sleep apnea treatment with continuous positive airway pressure

Objective:

To determine whether the use of a gel pillow with side cutouts designed to accommodate a continuous positive airway pressure (CPAP) mask and reduce head temperature improves the efficacy of and adherence to auto-CPAP therapy.

Methods:

Twenty-three consecutive CPAP-naïve patients with obstructive sleep apnea were enrolled in the study. Patients were given an auto-CPAP machine with an appropriate CPAP mask and were instructed to use CPAP for 15 nights. They were instructed to sleep with their own pillow (the control pillow) from nights 1 to 5 and with either a foam pillow or a gel pillow, both of which had side cutouts, for 5 consecutive nights each, in random order. After night 15, auto-CPAP machine data were downloaded and patients rated their satisfaction with each pillow on a visual analog scale.

Results:

Twenty-two patients completed the protocol. The pressures administered, residual apnea-hypopnea index, air leaks, and mean duration of CPAP use did not differ among the periods during which each pillow was used. Patients were significantly more satisfied with the gel pillow than with the control pillow and the foam pillow (p = 0.022 and p = 0.004, respectively), their level of satisfaction with the gel pillow correlating significantly with excessive daytime sleepiness (r² = 0.19; p = 0.0443).

Conclusions:

Among obstructive sleep apnea patients treated with nasal CPAP, the use of a gel pillow with side cutouts appears to have no impact on treatment effectiveness. Nevertheless, such patients seem to prefer a gel pillow over other types of pillows.

A Randomized Crossover Trial Comparing Autotitrating and Continuous Positive Airway Pressure in Subjects With Symptoms of Aerophagia: Effects on Compliance and Subjective Symptoms

STUDY OBJECTIVES

To assess the benefit and tolerance of autotitrating positive airway pressure (APAP) versus continuous positive airway pressure (CPAP) in subjects who experience aerophagia.

METHODS

This is the report of a prospective, two-week, double-blinded, randomized crossover trial set in an Australian clinical sleep laboratory in a tertiary hospital. Fifty-six subjects who reported symptoms of aerophagia that they attributed to CPAP were recruited. Full face masks were used by 39 of the 56 subjects recruited. Subjects were randomly and blindly allocated to either CPAP at their treatment recommended pressure or APAP 6-20 cm H₂O, in random order. Subjects spent two weeks on each therapy mode. Therapy usage hours, 95th centile pressure, maximum pressure, 95th centile leak, and residual apnea-hypopnea index (AHI) were reported at the end of each two-week treatment period. Functional Outcome of Sleepiness Questionnaire, Epworth Sleepiness Scale, and visual analog scale to measure symptoms of aerophagia were also completed at the end of each 2-week treatment arm.

RESULTS

The median pressure (P < .001) and 95th centile pressure (P < .001) were reduced with APAP but no differences in compliance (P = .120) and residual AHI were observed. APAP reduced the symptoms of bloating (P = .011), worst episode of bloating (P = .040), flatulence (P = .010), and belching (P = .001) compared to CPAP. There were no differences in Epworth Sleepiness Scale or Functional Outcome of Sleepiness Questionnaire outcomes between CPAP and APAP.

CONCLUSIONS

APAP therapy reduces the symptoms of aerophagia while not affecting compliance when compared with CPAP therapy.

CLINICAL TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry at https://www.anzctr.org.au, trial number ACTRN12611001250921.

COMMENTARY

A commentary on this article appears in this issue on page 859.

Factors Contributing to Unintentional Leak During CPAP Treatment: A Systematic Review

CPAP is the first-line treatment for moderate to severe OSA syndrome. Up to 25% of patients with OSA syndrome discontinue CPAP treatment due to side effects. Unintentional leakage and its associated annoying consequences are the most frequently reported adverse effects of CPAP. Successive technological improvements have not succeeded in addressing this issue. A systematic review was conducted (1) to assess the impact of different technological advances on unintentional leaks and (2) to determine if any patient characteristics have already been identified as determinants of unintentional leakage. No CPAP modality was superior to another in reducing unintentional leaks and, surprisingly, oronasal masks were associated with higher unintentional leaks. Nasal obstruction, older age, higher BMI, central fat distribution, and male sex might be associated with an increased risk of unintentional leakage. Such leaks remain an important problem. Further studies are needed to improve the understanding of underlying clinical factors so that patients at risk of unintentional leaks may be identified and individualized solutions applied.

A new predictive model for continuous positive airway pressure in the treatment of obstructive sleep apnea

BACKGROUND

Numerous mathematical formulas have been developed to determine continuous positive airway pressure (CPAP) without an in-laboratory titration study. Recent studies have shown that style of CPAP mask can affect the optimal pressure requirement. However, none of the current models take mask style into account. Therefore, the goal of this study was to develop new predictive models of CPAP that take into account the style of mask interface.

METHODS

Data from 200 subjects with attended CPAP titrations during overnight polysomnograms using nasal masks and 132 subjects using oronasal masks were randomized and split into either a model development or validation group. Predictive models were then created in each model development group and the accuracy of the models was then tested in the model validation groups.

RESULTS

The correlation between our new oronasal model and laboratory determined optimal CPAP was significant, r = 0.61, p < 0.001. Our nasal formula was also significantly related to laboratory determined optimal CPAP, r = 0.35, p < 0.001. The oronasal model created in our study significantly outperformed the original CPAP predictive model developed by Miljeteig and Hoffstein, z = 1.99, p < 0.05. The predictive performance of our new nasal model did not differ significantly from Miljeteig and Hoffstein's original model, z = -0.16, p < 0.90. The best predictors for the nasal mask group were AHI, lowest SaO2, and neck size, whereas the top predictors in the oronasal group were AHI and lowest SaO2.

CONCLUSION

Our data show that predictive models of CPAP that take into account mask style can significantly improve the formula's accuracy. Most of the past models likely focused on model development with nasal masks (mask style used for model development was not typically reported in previous investigations) and are not well suited for patients using an oronasal interface. Our new oronasal CPAP prediction equation produced significantly improved performance compared to the well-known Miljeteig and Hoffstein formula in patients titrated on CPAP with an oronasal mask and was also significantly related to laboratory determined optimal CPAP.

Oronasal Masks Require a Higher Pressure than Nasal and Nasal Pillow Masks for the Treatment of Obstructive Sleep Apnea

STUDY OBJECTIVES

Oronasal masks are frequently used for continuous positive airway pressure (CPAP) treatment in patients with obstructive sleep apnea (OSA). The aim of this study was to (1) determine if CPAP requirements are higher for oronasal masks compared to nasal mask interfaces and (2) assess whether polysomnography and patient characteristics differed among mask preference groups.

METHODS

Retrospective analysis of all CPAP implementation polysomnograms between July 2013 and June 2014. Prescribed CPAP level, polysomnography results and patient data were compared according to mask type (n = 358).

RESULTS

Oronasal masks were used in 46%, nasal masks in 35% and nasal pillow masks in 19%. There was no difference according to mask type for baseline apnea-hypopnea index (AHI), body mass index (BMI), waist or neck circumference. CPAP level was higher for oronasal masks, 12 (10-15.5) cm H2O compared to nasal pillow masks, 11 (8-12.5) cm H2O and nasal masks, 10 (8-12) cm H2O, p < 0.0001 (Median [interquartile range]). Oronasal mask type, AHI, age, and BMI were independent predictors of a higher CPAP pressure (p < 0.0005, adjusted R(2) = 0.26.). For patients with CPAP ≥ 15 cm H2O, there was an odds ratio of 4.5 (95% CI 2.5-8.0) for having an oronasal compared to a nasal or nasal pillow mask. Residual median AHI was higher for oronasal masks (11.3 events/h) than for nasal masks (6.4 events/h) and nasal pillows (6.7 events/h), p < 0.001.

CONCLUSIONS

Compared to nasal mask types, oronasal masks are associated with higher CPAP pressures (particularly pressures ≥ 15 cm H2O) and a higher residual AHI. Further evaluation with a randomized control trial is required to definitively establish the effect of mask type on pressure requirements.

COMMENTARY

A commentary on this article appears in this issue on page 1209.

Choosing an Oronasal Mask to Deliver Continuous Positive Airway Pressure May Cause More Upper Airway Obstruction or Lead to Higher Continuous Positive Airway Pressure Requirements than a Nasal Mask in Some Patients: A Case Series

STUDY OBJECTIVES

The choice of mask interface used with continuous positive airway pressure (CPAP) therapy can affect the control of upper airway obstruction (UAO) in obstructive sleep apnea (OSA). We describe a case series of four patients with paradoxical worsening of UAO with an oronasal mask and the effect of changing to a nasal mask.

METHODS

We retrospectively reviewed the case histories of 4 patients and recorded patient demographics, in-laboratory and ambulatory CPAP titration data, CPAP therapy data, type of mask interface used and potential confounding factors.

RESULTS

The 4 cases (mean ± SD: age = 59 ± 16 y; BMI = 30.5 ± 4.5 kg/m(2)) had a high residual apnoea-hypopnea index (AHI) (43 ± 14.2 events/h) and high CPAP pressure requirements (14.9 ± 6.6 cmH2O) with an oronasal mask. Changing to a nasal mask allowed adequate control of UAO with a significant reduction in the average residual AHI (3.1 ± 1.5 events/h). In two of the four cases, it was demonstrated that control of UAO was obtained at a much lower CPAP pressure compared to the oronasal mask (Case one = 17.5 cmH2O vs 12cmH2O; Case two = 17.9 cmH2O vs 7.8 cmH2O). Other potential confounding factors were unchanged. There are various physiological observations that may explain these findings but it is uncertain which individuals are susceptible to these mechanisms.

CONCLUSIONS

If patients have OSA incompletely controlled by CPAP with evidence of residual UAO and/or are requiring surprisingly high CPAP pressure to control OSA with an oronasal mask, the choice of mask should be reviewed and consideration be given to a trial of a nasal mask.

COMMENTARY

A commentary on this article appears in this issue on page 1209.

Impact of the type of mask on the effectiveness of and adherence to continuous positive airway pressure treatment for obstructive sleep apnea

Continuous positive airway pressure (CPAP) is the gold standard for the treatment of obstructive sleep apnea (OSA). Although CPAP was originally applied with a nasal mask, various interfaces are currently available. This study reviews theoretical concepts and questions the premise that all types of interfaces produce similar results. We revised the evidence in the literature about the impact that the type of CPAP interface has on the effectiveness of and adherence to OSA treatment. We searched the PubMed database using the search terms "CPAP", "mask", and "obstructive sleep apnea". Although we identified 91 studies, only 12 described the impact of the type of CPAP interface on treatment effectiveness (n = 6) or adherence (n = 6). Despite conflicting results, we found no consistent evidence that nasal pillows and oral masks alter OSA treatment effectiveness or adherence. In contrast, most studies showed that oronasal masks are less effective and are more often associated with lower adherence and higher CPAP abandonment than are nasal masks. We concluded that oronasal masks can compromise CPAP OSA treatment adherence and effectiveness. Further studies are needed in order to understand the exact mechanisms involved in this effect.

Comparison of the upper airway dynamics of oronasal and nasal masks with positive airway pressure treatment using cine magnetic resonance imaging

PURPOSE

It is known that oronasal masks are not as effective at opening the upper airway compared to nasal only continuous positive airway pressure (CPAP) masks in patients with sleep-disordered breathing. However, the physiological mechanism for this difference in efficacy is not known; although, it has been hypothesized to involve the retroglossal and/or retropalatal region of the upper airway. The objective of this study was to investigate differences in retroglossal and retropalatal anterior-posterior space with the use of oronasal vs. nasal CPAP masks using real-time cine magnetic resonance imaging (cMRI).

METHODS

Ten subjects (eight men, two women) with obstructive sleep apnea (OSA) were given cMRI with both nasal and oronasal CPAP masks. Each subject was imaged with each interface at pressures of 5, 10, and 15 cm of H2O, while in the supine position along the sagittal plane.

RESULTS

The oronasal mask produced significantly less airway opening in the retropalatal region of the upper airway compared to the nasal mask interface. During exhalation, mask style had a significant effect on anterior-posterior distance p = 0.016. No differences were found in the retroglossal region between mask styles.

CONCLUSIONS

Our study confirmed previous findings showing differences in treatment efficacy between oronasal and nasal mask styles. We have shown anatomic evidence that the nasal mask is more effective in opening the upper airway compared to the oronasal mask in the retropalatal region.

[Acceptability and compliance to long-term continuous positive pressure treatment]

INTRODUCTION

Compliance with continuous positive pressure treatment (CPAP) is a determining factor in the management of the obstructive sleep apnea syndrome (OSAS). Long-term compliance has been poorly studied.

METHODS

The probability of long-term continuation of CPAP was evaluated retrospectively by an analysis of survival in 252 patients treated by CPAP after a screening of 472 patients during the years 2002 and 2003.

RESULTS

Twenty-eight patients fulfilling the criteria for CPAP immediately refused the treatment. The mean follow-up for the 252 treated patients was 76.9±46.4 months, with 38 patients having died and 75 having discontinued treatment during the period. The 136 patients who continued treatment used CPAP for a mean of 7.4±1.6hours daily. The probability of continuing treatment was 71% at 5 years and 68% at 10 years. The severity of OSAS was a predictive factor for long-term CPAP compliance, with a 10-year compliance of 82% in patients having an apnoea/hypopnoea index >60, versus 68% with an index between 30-60 and 44% with an index <30.

CONCLUSION

Long-term CPAP treatment is globally well accepted, with a 68% probability of continuing treatment for 10 years, particularly in the most severely affected patients. Long-term daily compliance is very satisfactory.

Higher effective oronasal versus nasal continuous positive airway pressure in obstructive sleep apnea: effect of mandibular stabilization

BACKGROUND

In some individuals with obstructive sleep apnea (OSA), oronasal continuous positive airway pressure (CPAP) leads to poorer OSA correction than nasal CPAP. The authors hypothesized that this results from posterior mandibular displacement caused by the oronasal mask.

OBJECTIVE

To test this hypothesis using a mandibular advancement device (MAD) for mandibular stabilization.

METHODS

Subjects whose OSA was not adequately corrected by oronasal CPAP at pressures for which nasal CPAP was effective were identified. These subjects underwent polysomnography (PSG) CPAP titration with each nasal and oronasal mask consecutively, with esophageal pressure and leak monitoring, to obtain the effective pressure (Peff) of CPAP for correcting obstructive events with each mask (maximum 20 cmH2O). PSG titration was repeated using a MAD in the neutral position. Cephalometry was performed.

RESULTS

Six subjects with mean (± SD) nasal Peff 10.4±3.0 cmH2O were studied. Oronasal Peff was greater than nasal Peff in all subjects, with obstructive events persisting at 20 cmH2O by oronasal mask in four cases. This was not due to excessive leak. With the MAD, oronasal Peff was reduced in three subjects, and Peff <20 cmH2O could be obtained in two of the four subjects with Peff >20 cmH2O by oronasal mask alone. Subjects' cephalometric variables were similar to published norms.

CONCLUSION

In subjects with OSA with higher oronasal than nasal Peff, this is partially explained by posterior mandibular displacement caused by the oronasal mask. Combination treatment with oronasal mask and MAD may be useful in some individuals if a nasal mask is not tolerated.

Effect of addition of chin strap on PAP compliance, nightly duration of use, and other factors

STUDY OBJECTIVES

A chinstrap is potentially useful to reduce unintentional air leak by preventing mouth opening during PAP treatment. This study examines whether the addition of a chinstrap to PAP therapy has any effect on adherence, nightly duration of use, air leak, and residual AHI.

METHODS

This was a retrospective study performed at an AASM-accredited VAMC sleep center. Clinical sleep data of veterans (n = 124) prescribed PAP therapy for sleep apnea was evaluated, and the effect of chinstrap use vs non-use on the above parameters was assessed.

RESULTS

Chinstrap users had significantly greater PAP adherence, longer nightly duration of PAP use, lower residual AHI and lower leak compared to chinstrap non-users at first follow up visit.

CONCLUSIONS

The addition of a chin strap to PAP therapy is a simple and inexpensive method of increasing PAP adherence.

Oronasal masks require higher levels of positive airway pressure than nasal masks to treat obstructive sleep apnea

PURPOSE

The purpose of this study was to compare the therapeutic pressure determined by an automated CPAP device (AutoCPAP) during the titration period, between nasal and oronasal mask and the residual apnea-hypopnea index (AHI) on a subsequent poligraphy performed with the established therapeutic CPAP.

METHODS

As a retrospective study, 109 subjects with moderate and severe obstructive sleep apnea-hypopnea (apnea-hypopnea index≥15 events/h) were studied. CPAP titration was performed using an auto-titrating device.

RESULTS

There was significant difference in the mean pressure delivered with autoCPAP between the group of patients using the nasal mask (mean 10.0 cmH2O±2.0 SD) and the group which used the oronasal mask (mean 11.2 cmH2O±2.1) (p<0.05). Residual apneas were lower when using a nasal mask: average AHI of 2.6±2.5 compared to 4.5±4.0 using an oronasal mask (p<0.05). On multivariate analysis, the only independent predictor of the level of therapeutic pressure of CPAP was the type of mask used (r=0.245, p 0.008).

CONCLUSIONS

Therapeutic CPAP level for OSAH is higher when administered via oronasal mask, leaving more residual events. These findings suggest that nasal mask should be the first choice for OSAH treatment.

A randomised controlled trial on the effect of mask choice on residual respiratory events with continuous positive airway pressure treatment

INTRODUCTION

It has been found that mask style can affect the amount of continuous positive airway pressure (CPAP) required to reduce an apnoea/hyponoea index (AHI) to < 5/h on a titration study. However, it was not previously known whether switching from one CPAP mask style to another post titration could affect the residual AHI with CPAP. The purpose of this study was to investigate the differences in residual AHI with CPAP treatment between oronasal and nasal masks.

METHODS

Twenty-one subjects (age mean (M)=62.9, body mass index (BMI) M=29.6 kg/m2) were randomised (14 subjects completed the protocol) to undergo an in-laboratory CPAP titration with either a nasal mask or an oronasal mask. Subjects were then assigned this mask for 3weeks of at-home CPAP use with the optimal treatment pressure determined on the laboratory study (CPAP M=8.4 cm of H2O). At the end of this 3-week period, data were collected from the CPAP machine and the subject was given the other mask to use with the same CPAP settings for the next 3weeks at home (if the nasal mask was given initially, the oronasal one was given later and vice versa). On completion of the second 3-week period, data on residual AHI were again collected and compared with the first 3-week period on CPAP.

RESULTS

A Wilcoxon Signed-Rank Test (two-tailed) revealed that residual AHI with CPAP treatment was significantly higher with the oronasal compared with the nasal mask (z = -3.296, p<0.001). All 14 subjects had a higher residual AHI with the oronasal versus nasal mask, and 50% of the subjects had a residual AHI >10/h in the oronasal mask condition, even though all of these subjects were titrated to an AHI of < 5/h in the laboratory.

CONCLUSION

A higher residual AHI was seen in all patients with the use of an oronasal mask compared with a nasal mask. Switching to an oronasal mask post titration results in an increase in residual AHI with CPAP treatment, and pressure adjustment may be warranted.

A multicenter evaluation of oral pressure therapy for the treatment of obstructive sleep apnea

OBJECTIVE

We aimed to evaluate the impact of a novel noninvasive oral pressure therapy (OPT) (Winx®, ApniCure) system on polysomnographic measures of sleep-disordered breathing, sleep architecture, and sleep stability in obstructive sleep apnea (OSA).

SUBJECTS AND METHODS

A 4-week, multicenter, prospective, open-label, randomized, crossover, first-night order of control vs treatment, single-arm trial was conducted in five American Academy of Sleep Medicine (AASM) - accredited sleep clinics and one research laboratory. Sixty-three subjects (analysis cohort) were studied from a screening cohort of 367 subjects. The analysis cohort was 69.8% men, ages 53.6±8.9 years (mean±SD), body mass index of 32.3±4.5kg/m(2), with mild to severe OSA. At treatment initiation, subjects received random assignment to one night with and one without (control) treatment, and they were assessed again following 28 nights of treatment. Breathing and sleep architecture were assessed each night based on blind scoring by a single centralized scorer using AASM criteria.

RESULTS

Average nightly usage across the take-home period was 6.0±1.4h. There were no severe or serious device-related adverse events (AEs). Median apnea-hypopnea index (AHI) was 27.5 events per hour on the control night, 13.4 events per hour on the first treatment night, and 14.8 events per hour after 28days of treatment. A clinically significant response (treatment AHI ⩽10/h and ⩽50% of control values) was seen in 20 of the 63 subjects evaluated. Rapid eye movement percentage (REM%) was significantly increased, and N1%, stage shifts to N1 sleep, overall stage shifts, total awakenings, and arousals per hour were all significantly reduced at both treatment nights compared to controls. Mean Epworth sleepiness scale (ESS) was significantly reduced from 12.1 to 8.6 (Cohen d effect size, 0.68) in those untreated for two or more weeks prior to OPT study participation and remained unchanged in subjects who directly switched from continuous positive airway pressure (CPAP) therapy to OPT.

CONCLUSION

Clinically significant improvements in sleep quality and continuity, AHI, ODI, ESS, and overall clinical status were achieved in an easily identified subgroup. OPT was safe and well-tolerated and nightly usage was high.