Sociological determinants of adherence to continuous positive airway pressure in the management of sleep apnoea syndrome: protocol for a transdisciplinary, prospective observational study

INTRODUCTION

Obstructive sleep apnoea syndrome (OSAS) is a chronic multiorgan pathology that has a negative impact on quality of life. Continuous positive airway pressure (CPAP) is the first-line treatment for OSAS. However, CPAP termination rates remain very high, and adherence to therapy is a major issue. To date, studies targeting predictive factors of CPAP adherence by OSAS patients mainly include clinical data. The social, socioeconomic, psychological, and home environment aspects have been far less studied and largely underestimated. This study aims to obtain solid quantitative results examining the relationship between the determinants of refusal, non-adherence, or termination of CPAP treatment, and in particular the pivotal role played by health literacy.

METHODS AND ANALYSIS

This is a prospective, multicentre, observational study recruiting patients attending the sleep clinic of the Grenoble Alpes University Hospital, France. Consecutive adults (>18 years) recently diagnosed with OSAS and prescribed CPAP treatment with telemonitoring will be enrolled in the present study. They will benefit from home visits by a CPAP technician or nurse at CPAP initiation. Patients will then be followed up for 6 months through the telemonitoring platform of a home-care provider. The primary objective is to evaluate the impact of health literacy (health literacy, measured by the European Health Literacy Survey questionnaire (HLS-EU-16) on the refusal, non-adherence or termination of CPAP treatment in newly diagnosed OSAS patients, during the first 6 months after diagnosis. The target sample size is 250 participants.

ETHICS AND DISSEMINATION

The study protocol, patient information, and the non-opposition form were approved by the French national ethics committee (CPP 2021-92, January 2022). All patients are required to have signed a written informed consent form permitting their anonymised personal and medical data to be used for clinical research purposes. We will publish the results in a peer-reviewed medical journal and on our institutional websites.

TRIAL REGISTRATION NUMBER

NCT05385302.

Did COVID-19 impact Positive Airway Pressure adherence in 2020? A cross-sectional study of 8477 patients with sleep apnea

Background

Whether the COVID-19 pandemic impacts Positive Airway Pressure (PAP) adherence over the long-term is unknown and only preliminary short-term data have been reported.

Methods

With the aim of describing the impact of the first and second waves of COVID-19 on PAP adherence during 2020 in France, we designed a cross-sectional study of Sleep-Apnea (SA)-patients under PAP telemonitoring. To examine PAP adherence in adult SA patients, we assessed de-identified data from a non-profit healthcare provider database during the period January 1, 2019 to December 31, 2020. Included patients met the following criteria: (i) PAP-treated for at least 4 months before January 1, 2019 and with continuous PAP during both 2019 and 2020; (ii) ≥ 360 daily PAP telemonitored data per year. For PAP adherence, data were collected using the PAP-software.

Results

8477/10482 patients were finally included in the analysis [72.4% male, median age 70 years (IQ_25–75: 61–77], 25.6% < 62 years old, initial Apnea–Hypopnea Index (AHI) of 41 (31–59)/h. Median PAP adherence was 7.21 (6.12–8.10) h/day in 2020 versus 7.12 (6.05–8.02) h/day in 2019, p < 0.001. The median difference in PAP adherence between the first 2020 lockdown and the corresponding 2019 weeks was 9.75 (CI_95% 8.75–10.75) min/day, p < 0.001. The median difference in PAP adherence between the second 2020 lockdown and the corresponding 2019 weeks was 5.00 (CI_95% 4.00–6.00) min/day, p < 0.001. If we consider the minimal clinically important difference of 30 min for PAP adherence, 30.4% and 26% of the patients increased their PAP adherence by at least 30 min during the first and second lockdowns respectively; 17.6% and 19.3% of the patients lowered their PAP adherence by at least 30 min in the first and second lockdowns, respectively.

Conclusion

During the first and second lockdowns, the COVID-19 pandemic had a clinically irrelevant effect on PAP adherence for the study population. Future studies are needed to describe COVID-19 pandemic impact on PAP adherence not only for long-term PAP-treated SA patients but also for incident cases.

Trial registration The COVADENE study was registered on March 1st, 2021 on ClinicalTrials.gov (Identifier: NCT04775966)

Peer-driven intervention to help patients resume CPAP therapy following discontinuation: a multicentre, randomised clinical trial with patient involvement

INTRODUCTION

Obstructive sleep apnoea syndrome (OSAS) is one of the most common chronic diseases. It may be associated with symptoms of excessive daytime sleepiness and neurocognitive and cardiovascular complications. First line therapy for OSAS involves home continuous positive airway pressure (CPAP), however, nearly half of patients do not adhere with this treatment over the long term. Cognitive-behavioural interventions that include health professionals and patient and public involvement are increasingly advocated in the fields of education and research. We hypothesise that a peer-driven intervention could help patients with OSAS to resume CPAP use after discontinuation.

METHODS AND ANALYSIS

We have designed a prospective, multicentre randomised, controlled trial that will be coconducted by health professionals, a home provider of CPAP and patients as experts or peers or participants. The primary aim is to evaluate the impact of a 6-month, peer-driven intervention to promote the resumption of CPAP after discontinuation. We anticipate that 20% of patients in the intervention group will reuse CPAP as compared with 6% in control group, thus, 104 patients must be included in each group. The secondary aims are (1) to evaluate the impact of the peer-driven intervention on adherence to CPAP compared with the control group (mean adherence and percentage of nights with at least 4 hours' use/night for 70% of nights); (2) to determine factors associated with resumption of CPAP; (3) to assess patient satisfaction with the peer-driven intervention at 6 months; (4) to evaluate the feasibility and the execution of the peer-driven intervention and peer satisfaction. Adult outpatients with an established diagnosis of severe OSA (Apnoea-Hypopnoea Index >30 events/hour) that have stopped using CPAP within 4-12 months after initiation will be recruited. The peers who will perform the intervention will be patients with OSAS treated with CPAP with good adherence (at least 4 hours/night, 70% of nights) and trained in motivational enhancement and cognitive-behavioural therapies. Trained peers will conduct three interviews within 6 months with participants.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the French Regional Ethics Committee CPP Ouest II-Angers, (IRB 21.02.25.68606 (2021/2025)). All participants will sign written informed consent. The results will be presented at conferences and published in peer-reviewed journals as well as public media.

TRIAL REGISTRATION NUMBER

NCT04538274.

What are the barriers to the completion of a home-based rehabilitation programme for patients awaiting surgery for lung cancer: a prospective observational study

OBJECTIVES

Home-based rehabilitation programmes (H-RPs) could facilitate the implementation of pulmonary rehabilitation prior to resection for non-small cell lung cancer (NSCLC), but their feasibility has not been evaluated. The aim of this study was to identify determinants of non-completion of an H-RP and the factors associated with medical events occurring 30 days after hospital discharge.

DESIGN

A prospective observational study.

INTERVENTION

All patients with confirmed or suspected NSCLC were enrolled in a four-component H-RP prior to surgery: (i) smoking cessation, (ii) nutritional support, (iii) physiotherapy (at least one session/week) and (iv) home cycle-ergometry (at least three times/week).

OUTCOMES

The H-RP was defined as 'completed' if the four components were performed before surgery.

RESULTS

Out of 50 patients included, 42 underwent surgery (80% men; median age: 69 (IQR 25%-75%; 60-74) years; 64% Chronic Obstructive Pulmonary Disease (COPD); 29% type 2 diabetes). Twenty patients (48%) completed 100% of the programme. The median (IQR) duration of the H-RP was 32 (19; 46) days. Multivariate analysis showed polypharmacy (n=24) OR=12.2 (95% CI 2.0 to 74.2), living alone (n=8) (single vs couple) OR=21.5 (95% CI 1.4 to >100) and a long delay before starting the H-RP (n=18) OR=6.24 (95% CI 1.1 to 36.6) were independently associated with a risk of non-completion. In univariate analyses, factors associated with medical events at 30 days were H-RP non-completion, diabetes, polypharmacy, social precariousness and female sex.

CONCLUSION

Facing multiple comorbidities, living alone and a long delay before starting the rehabilitation increase the risk of not completing preoperative H-RP.

TRIAL REGISTRATION NUMBER

NCT03530059.

Continuous positive airway pressure-treated patients' behaviours during the COVID-19 crisis

Obstructive sleep apnoea (OSA) is one of the most prevalent chronic diseases, affecting nearly one billion people worldwide [1]. Continuous positive airway pressure (CPAP) is the first-line therapy for OSA [2], and is currently used by over one million people throughout France. A focus on the OSA population during the COVID-19 outbreak is of particular interest for the following two main reasons. 1) OSA is a multi-morbid disease with up to 70% of patients being obese [3] and exhibiting a high prevalence of cardiometabolic comorbidities. Such a clinical context is expected to be associated with a higher risk of severe forms of COVID-19 and a higher mortality rate [4]. 2) CPAP treatment is considered a high-risk aerosol-generating procedure potentially facilitating viral dispersion into the environment and transmission of infection [5–7].

The #COVID19 pandemic has had limited impact on CPAP use by obstructive sleep apnoea patients. Mainly only those with suspected or proven COVID-19 stopped CPAP use, sometimes without a physician's advice, and were more likely to move to a separate bedroom.https://bit.ly/2RxQDZO

Impact of Interface Type on Noninvasive Ventilation Efficacy in Patients With Neuromuscular Disease: A Randomized Cross-Over Trial

BACKGROUND AND OBJECTIVE

Around 25% of patients with neuro-muscular diseases (NMD) are treated by home noninvasive ventilation (NIV) through an oronasal mask. However, there is growing evidence that nasal masks require lower NIV pressures and result in fewer residual obstructive events. We hypothesized that nasal masks would improve efficacy and reduce side effects compared to oronasal masks in this population.

METHODS

open label, cross-over, randomized, study in 2 tertiary care hospitals. Patients with NMD treated by home NIV were randomized for one-week periods to nasal and oronasal interfaces respectively (cross-over). At the end of each period, nocturnal polygraphy (monitoring mouth opening) under NIV, synchronized with transcutaneous partial pressure in CO₂ (tcCO₂) was performed. Data were collected from the NIV built-in software and NIV side-effects were collected. Intention-to-treat and per protocol analyses were performed. The primary outcome was mean nocturnal SpO₂. The secondary outcomes were: percentage of sleep with SpO₂<90%, oxygen desaturation index (ODI), mean tcCO₂, mean duration of mouth opening during sleep, level of non-intentional leaks and side-effects.

RESULTS

Thirty patients with NMD were included. There were no between-group differences for either the primary or secondary outcomes. Post hoc comparisons showed that changing between interfaces reduced NIV efficacy: mean nocturnal SpO₂ (p=0.04), ODI (p=0.01), mean tcCO2 (p=0.048), side-effects (p=0.008).

CONCLUSION

Nasal masks did not improve NIV efficacy or reduce side effects compared to oronasal masks in patients with NMD treated by home NIV. The efficacy of NIV is reduced during the transition to another interface, requiring close monitoring. Registration number: NCT03458507.

Obstructive Sleep Apnea Syndrome, Objectively Measured Physical Activity and Exercise Training Interventions: A Systematic Review and Meta-Analysis

A systematic review of English and French articles using Pubmed/Medline and Embase included studies assessing objective physical activity levels of obstructive sleep apnea (OSA) patients and exploring the effects of exercise training on OSA severity, body mass index (BMI), sleepiness, and cardiorespiratory fitness [peak oxygen consumption (VO2peak)]. Two independent reviewers analyzed the studies, extracted the data, and assessed the quality of evidence. For objective physical activity levels, eight studies were included. The mean number of steps per day across studies was 5,388 (95% CI: 3,831–6,945; p < 0.001), which was by far lower than the recommended threshold of 10,000 steps per day. For exercise training, six randomized trials were included. There was a significant decrease in apnea–hypopnea-index following exercise training (mean decrease of 8.9 events/h; 95% CI: −13.4 to −4.3; p < 0.01), which was accompanied by a reduction in subjective sleepiness, an increase in VO2peak and no change in BMI. OSA patients present low levels of physical activity and exercise training is associated with improved outcomes. Future interventions (including exercise training) focusing on increasing physical activity levels may have important clinical impacts on both OSA severity and the burden of associated co-morbidities. Objective measurement of physical activity in routine OSA management and well-designed clinical trials are recommended.

Registration # CRD42017057319 (Prospero).

Prevention and care of respiratory failure in obese patients

With the increase in the global prevalence of obesity, there is a parallel rise in the proportion of obese patients admitted to intensive care units, referred for major surgery or requiring long-term non-invasive ventilation (NIV) at home for chronic respiratory failure. We describe the physiological effect of obesity on the respiratory system mainly in terms of respiratory mechanics, respiratory drive, and patency of the upper airways. Particular attention is given to the prevention and the clinical management of respiratory failure in obese patients with a main focus on invasive and NIV in intensive care during the perioperative period and long-term use of NIV on return home. We also address other aspects of care of obese patients, including antibiotic dosing and catheter-related infections.

Effect of high-flow nasal therapy during acute aerobic exercise in patients with chronic obstructive pulmonary disease after exacerbation: protocol for a randomised, controlled, cross-over trial

INTRODUCTION

Early pulmonary rehabilitation is recommended after a severe exacerbation of chronic obstructive pulmonary disease (COPD). However, this is difficult to implement, particularly for exercise training. High-flow nasal therapy (HFNT) may reduce the work of breathing and dyspnoea and may improve exercise tolerance.

METHODS AND ANALYSIS

This is a single-centre, prospective, controlled, randomised, cross-over study. Eligible patients will have a diagnosis of COPD (postbronchodilator forced expiratory volume in 1 s/forced vital capacity ratio of <0.7). Two constant work rate exercise tests at 80% of the peak work rate will be carried out on two consecutive days with and without HFNT. The primary outcome will be the difference in endurance time between the two conditions. Secondary outcomes will be the change in muscle oxygenation during exercise, dyspnoea and muscle fatigue, respiratory muscle strength after exercise, respiratory rate, cardiac frequency, transcutaneous CO₂ pressure and pulsed O₂ saturation. Nineteen patients will be included. Data will be analysed as intention to treat by a blinded statistician.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Ethics Committees Nord-Ouest III, Caen, France (N° ID RCB: 2016-A01325-46). The study will begin in April 2017 for a duration of 2 years. The results of the trial will be presented at national and international meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03058081.

Epistasis in intra- and inter-gene pool crosses of the common bean

Epistasis has been shown to have an important role in the genetic control of several quantitative traits in the common bean. This study aimed to investigate the occurrence of epistasis in intra- and inter-pool gene crosses of the common bean. Four elite lines adapted to Brazilian conditions were used as parents, two from the Andean gene pool (ESAL 686; BRS Radiante) and two from the Mesoamerican gene pool (BRSMG Majestoso; BRS Valente). Four F2 populations were obtained: "A" (ESAL 686 x BRS Radiante), "B" (BRSMG Majestoso x BRS Valente), "C" (BRS Radiante x BRSMG Majestoso), and "D" (BRS Valente x ESAL 686). A random sample of F2 plants from each population was backcrossed to parents and F1 individuals, according to the triple test cross. Three types of progenies from each population were evaluated in contiguous trials. Seed yield and 100-seed weight were evaluated. Dominance genetic variance was predominant in most cases. However, the estimates of genetic variance may be biased by the occurrence of linkage disequilibrium and epistasis. Epistasis was detected for both traits; however, the occurrence differed among the populations and between the two traits. The results of this study reinforce the hypothesis that epistasis is present in the genetic control of traits in the common bean and suggest that the phenomenon is more frequent in inter-gene pool crosses than in intra-gene pool crosses.

Arterial stiffness in COPD

In patients with COPD, cardiovascular diseases are the most common concomitant chronic diseases, a leading cause of hospitalization, and one of the main causes of death. A close connection exists between COPD and cardiovascular diseases. Cardiovascular risk scores aim to predict the effect of cardiovascular comorbidities on COPD mortality, but there is a need to better characterize occult and suboccult cardiovascular disease, even in patients with mild to moderate COPD. Among various surrogate markers of cardiovascular risk, arterial stiffness plays a central role and is a strong independent predictor of cardiovascular events beyond classic cardiovascular risk factors. Its measurement is highly suitable, validated, and relatively easy to perform in routine COPD clinical practice. The growing awareness of the increased cardiovascular risk associated with COPD has led to a call for respiratory physicians to measure arterial pulse wave velocity in routine practice. Cross-sectional data establish elevated arterial stiffness as being independently linked to COPD. Candidate mechanisms have been proposed, but surprisingly, only limited data are available regarding the impact of the different COPD treatment modalities on arterial stiffness, although initial studies have suggested a significant positive impact. In this review, we present the various surrogate markers of cardiovascular morbidity in COPD and the central role of arterial stiffness and the underlying mechanisms explaining vascular remodeling in COPD. We also consider the therapeutic impact of COPD medications and exercise training on arterial stiffness and the assessments that should be implemented in COPD care and follow-up.

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

RATIONALE

In obstructive sleep apnea patients (OSA), continuous positive airway pressure (CPAP) adherence is crucial to improve symptoms and cardiometabolic outcomes. The choice of mask may influence CPAP adherence but this issue has never been addressed properly.

OBJECTIVE

To evaluate the impact of nasal pillows, nasal and oronasal masks on CPAP adherence in a cohort of OSA.

METHODS

Newly CPAP treated OSA participating in "Observatoire Sommeil de la Fédération de Pneumologie", a French national prospective cohort, were included between March 2009 and December 2011. Anthropometric data, medical history, OSA severity, sleepiness, depressive status, treatment modalities (auto-CPAP versus fixed pressure, pressure level, interface type, use of humidifiers) and CPAP-related side effects were included in multivariate analysis to determine independent variables associated with CPAP adherence.

RESULTS

2311 OSA (age = 57(12) years, apnea+hypopnea index = 41(21)/h, 29% female) were included. Nasal masks, oronasal masks and nasal pillows were used by 62.4, 26.2 and 11.4% of the patients, respectively. In univariate analysis, oronasal masks and nasal pillows were associated with higher risk of CPAP non-adherence. CPAP non-adherence was also associated with younger age, female gender, mild OSA, gastroesophageal reflux, depression status, low effective pressure and CPAP-related side effects. In multivariate analysis, CPAP non-adherence was associated with the use of oronasal masks (OR = 2.0; 95%CI = 1.6; 2.5), depression, low effective pressure, and side effects.

CONCLUSION

As oronasal masks negatively impact on CPAP adherence, a nasal mask should be preferred as the first option. Patients on oronasal masks should be carefully followed.

Intentional leaks in industrial masks have a significant impact on efficacy of bilevel noninvasive ventilation: a bench test study

BACKGROUND

During noninvasive ventilation, nonintentional leaks have a detrimental effect on the efficacy of ventilation. A wide range of industrial masks are available, with intentional leaks of different importance. The potential impact of this variability in intentional leaks on performances of bilevel ventilators has not been assessed.

OBJECTIVE

To measure intentional leaks in seven different industrial masks and determine whether higher leaks modify ventilator performance and quality of ventilation.

METHODS

Seven interfaces connected to four ventilators, the VPAP III ST (ResMed; NorthRyde, Australia), the BiPAP Harmony (Respironics; Monroeville, PA), the SmartAir ST (Covidien/Airox; Pau, France), and the GoodKnight 425 ST Bilevel (Covidien/Tyco-Nellcor/Puritan Bennett; Pleasanton, CA), were adapted on a mannequin connected to a lung model (ASL5000, IngMar Medical; Pittsburgh, PA). Inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure were 14 and 4 cm H(2)O, respectively. The lung model was set with a respiratory rate of 15 cycles per min and a duration of inspiration of 1 s in three simulated conditions (normal, restrictive, and obstructive). Inspiratory trigger delay and effort, capacity to achieve and maintain IPAP, expiratory cycling and tidal volume were analyzed for all masks and ventilators in the three simulated lung conditions.

RESULTS

The level of intentional leaks in the seven masks ranged from 30 to 45 L/min for an IPAP of 14 cm H(2)O. Importance of leaks did not influence trigger performances. However, capacity to achieve and maintain IPAP was significantly decreased with all ventilators and in all simulated lung conditions when intentional leaks increased. This led to a maximum reduction in delivered tidal volume of 48 mL. Expiratory cycling was not affected by the level of intentional leaks except in obstructive lung conditions.

CONCLUSION

Mask intentional leaks can impair efficacy of ventilation, especially when > 40 L/min.

[Closed locked nailing of complex femoral fractures in adults. Apropos of 68 cases]

Complex fractures of the femoral shaft rise problems due to high energy trauma with major soft-tissues injuries and bone comminution so increasing operative difficulties, risk of infection and delayed union. Our aim was to appraise the outcome of these problems when using a closed intramedullary locked nailing. There were 52 men and 16 women. Aged 16 to 83 years. 52 patients had multiple-injuries. There were 17 open fractures. The 68 cases were subdivided according to a classification in 3 types. Stable fractures type A and B1 were excluded. The shaft was divided into 5 zones. Patients were initially treated by skeletal traction closed nailing was performed 1-36 days later (average 9.5). All patients were reviewed until complete healing. Final follow-up was 6 to 35 months postoperatively (average 15). A dynamisation was performed in 19 cases at a average delay of 12 weeks. Sixty six of the 68 fractures united. Open fractures united after 26.4 weeks, in average and closed fractures after 23.25 weeks (p < .05). There was no correlation between time of surgery following the injury and the delay of healing. Shortening was noted in 4 cases. 8 patients had an angulation 5-15 degrees of in the varus or the valgus plane. 3 patients (4.4 per cent) had more than 5 degrees of angulation in the AP plane. An external rotation deformity of 10-35 degrees was noted in 4 patients. The incidence of deformities was the main problem. It could be minimize by a precise technique. Mobility of the knee was the other problem, but it appeared generally to depend much more on knee injury than on femoral fracture.

[Modifications of occlusal and axial morphology in removable partial denture]

The axial and occlusal preparation of the teeth is necessary to the sustentation, the stabilization and retention of a removable partial denture. The preparations by subtraction concern the axial and occlusal surfaces. The creation of guided surfaces within the enamel of the proximal surfaces, always start before the realisation of the occlusal boxes. The preparation by addition using composites present an esthetic and economic solution to the remodeling of the axial contour of the teeth. This promising technique has however no long term results.