Short-term CPAP adherence in obstructive sleep apnea: a big data analysis using real world data

Remote Monitoring for Prediction and Management of Acute Exacerbations in Chronic Obstructive Pulmonary Disease (AECOPD)

The progression of chronic obstructive pulmonary disease (COPD) is characterized by episodes of acute exacerbation (AECOPD) of symptoms, decline in respiratory function, and reduction in quality-of-life increasing morbi-mortality and often requiring hospitalization. Exacerbations can be triggered by environmental exposures, changes in lifestyle, and/or physiological and psychological factors to greater or lesser extents depending on the individual’s COPD phenotype. The prediction and early detection of an exacerbation might allow patients and physicians to better manage the acute phase. We summarize the recent scientific data on remote telemonitoring (TM) for the prediction and management of acute exacerbations in COPD patients. We discuss the components of remote monitoring platforms, including the integration of environmental monitoring data; patient reported outcomes collected via interactive Smartphone apps, with data from wearable devices that monitor physical activity, heart rate, etc.; and data from medical devices such as connected non-invasive ventilators. We consider how telemonitoring and the deluge of data it potentially generates could be combined with electronic health records to provide personalized care and multi-disease management for COPD patients.

Electronic health record-derived outcomes in obstructive sleep apnea managed with positive airway pressure tracking systems

STUDY OBJECTIVES

To assess the effectiveness of continuous positive airway pressure (CPAP) management guided by CPAP machine downloads in newly diagnosed patients with obstructive sleep apnea (OSA) using electronic health record-derived health care utilization, biometric variables, and laboratory data.

METHODS

Electronic health record data of patients seen at the University of Utah Sleep Program from 2012-2015 were reviewed to identify patients with new diagnosis of OSA in whom CPAP adherence and residual apnea-hypopnea index as measured by a positive airway pressure adherence tracking device data for ≥ 1 year were available. Biometric data, laboratory data, and system-wide charges were compared in the 1 year before and after CPAP therapy. Subgroups were divided by whether patients met tracking criteria, mean nightly usage, and OSA severity.

RESULTS

976 consecutive, newly diagnosed participants with OSA (median age 55 years, 56.6% male) met inclusion criteria. There was a mean decrease of systolic blood pressure (BP) of 1.2 mm Hg and diastolic BP of 1.0 mm Hg within a year of initiation of CPAP therapy. BP improvements in the subgroup meeting CPAP tracking targets were 1.36 mmHg (systolic) and 1.37 mmHg (diastolic). No significant change was noted in body mass index, glycated hemoglobin, or serum creatinine values within a year of starting CPAP therapy, and health care utilization increased (mean acute care visits 0.22 per year to 0.53 per year; mean charges of $3,997 per year to $8,986 per year).

CONCLUSIONS

An improvement in BP was noted within a year of CPAP therapy in newly diagnosed patients with OSA, with no difference in the magnitude of improvement between those meeting tracking system adherence targets.

CITATION

Locke BW, Neill SE, Howe HE, Crotty MC, Kim J, Sundar KM. Electronic health record-derived outcomes in obstructive sleep apnea managed with positive airway pressure tracking systems. J Clin Sleep Med. 2022;18(3):885-894.

Overview of the Role of Pharmacological Management of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) remains a prominent disease state characterized by the recurrent collapse of the upper airway while sleeping. To date, current treatment may include continuous positive airway pressure (CPAP), lifestyle changes, behavioral modification, mandibular advancement devices, and surgical treatment. However, due to the desire for a more convenient mode of management, pharmacological treatment has been thoroughly investigated as a means for a potential alternative in OSA treatment. OSA can be distinguished into various endotypic or phenotypic classes, allowing pharmacological treatment to better target the root cause or symptoms of OSA. Some medications available for use include antidepressants, CNS stimulants, nasal decongestants, carbonic anhydrase inhibitors, and potassium channel blockers. This review will cover the findings of currently available and future study medications that could potentially play a role in OSA therapy.

Beyond Usual Care: A Multidisciplinary Approach Towards the Treatment of Obstructive Sleep Apnoea

Obstructive Sleep Apnoea (OSA) is common and characterised by repeated apnoeas and hypopnoeas while asleep due to collapse of the upper airway. OSA can have a significant impact on physical and mental health and, when left untreated, is associated with increased risk of developing cardiovascular ill health. Besides cardiorespiratory implications excessive daytime sleepiness, morning headaches, limited memory function and lack of concentration are some further symptoms caused by OSA. Continuous Positive Airway Pressure (CPAP) therapy is the evidence-based treatment to maintain upper airway patency in patients with moderate to severe OSA. Proper adherence to CPAP therapy successfully abolishes nocturnal apnoeas and hypopnoeas, and diminishes consequences of uncontrolled OSA, such as treatment resistant hypertension. However, long term adherence to CPAP remains an unresolved limitation of this method. Although alternatives to CPAP therapy may be less efficacious, there is a variety of non-CPAP treatments that includes conventional lifestyle advice, postural advice, the use of mandibular advancement devices (MADs), surgical treatment options, such as uvulopalatopharyngoplasty, tonsillectomy, or maxillomandibular advancement, and the use of electrical stimulation of the upper airway dilator muscles. Hypoglossal Nerve Stimulation is available as an invasive (HNS) and a transcutaneous (TESLA) approach. For the management of “difficult-to-treat” patients with OSA, particularly in those in whom first line therapy proved to be unsuccessful, a multidisciplinary team approach may be helpful to incorporate the available options of non-CPAP therapy and provide appropriate choices. Symptom control, patient-related outcome measures and long-term cardiovascular health should be prioritised when choosing long-term therapies to treat OSA. The inclusion of patients in the choice of successful management options of their condition will facilitate better long-term adherence. Advancing clinical trials in the field will further help to resolve the relative lack of evidence for effective non-CPAP methods.

Cardiopulmonary Coupling

Cardiopulmonary coupling (CPC) is a technique that generates sleep spectrogram by calculating the cross-spectral power and coherence of heart rate variability and respiratory tidal volume fluctuations. There are several forms of CPC in the sleep spectrogram, which may provide information about normal sleep physiology and pathological sleep states. Since CPC can be calculated from any signal recording containing heart rate and respiration information, such as photoplethysmography (PPG) or blood pressure, it can be widely used in various applications, including wearables and non-contact devices. When derived from PPG, an automatic apnea-hypopnea index can be calculated from CPC-oximetry as PPG can be obtained from oximetry alone. CPC-based sleep profiling reveals the effects of stable and unstable sleep on sleep apnea, insomnia, cardiovascular regulation, and metabolic disorders. Here, we introduce, with examples, the current knowledge and understanding of the CPC technique, especially the physiological basis, analytical methods, and its clinical applications.

Obstructive sleep apnea

Obstructive sleep apnea (OSA) is a disease that results from loss of upper airway muscle tone leading to upper airway collapse during sleep in anatomically susceptible persons, leading to recurrent periods of hypoventilation, hypoxia, and arousals from sleep. Significant clinical consequences of the disorder cover a wide spectrum and include daytime hypersomnolence, neurocognitive dysfunction, cardiovascular disease, metabolic dysfunction, respiratory failure, and pulmonary hypertension. With escalating rates of obesity a major risk factor for OSA, the public health burden from OSA and its sequalae are expected to increase, as well. In this chapter, we review the mechanisms responsible for the development of OSA and associated neurocognitive and cardiometabolic comorbidities. Emphasis is placed on the neural control of the striated muscles that control the pharyngeal passages, especially regulation of hypoglossal motoneuron activity throughout the sleep/wake cycle, the neurocognitive complications of OSA, and the therapeutic options available to treat OSA including recent pharmacotherapeutic developments.

Continuous positive airway pressure adherence in people with obstructive sleep apnoea

OBJECTIVES

This cross-sectional study aimed to identify whether five factors of the health belief model were related to continuous positive airway pressure adherence in Thai people with obstructive sleep apnoea.

BACKGROUND

Obstructive sleep apnoea is a disorder impacting health, social wellbeing and the economy. Continuous positive airway pressure is a gold standard of treatment; however, poor adherence to treatment is an important issue that is related to a multiplicity of psychological and behavioural factors.

METHODS

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional studies was used to report the study. Purposive sampling was used to recruit 94 patients newly diagnosed with sleep apnoea and using CPAP devices from a sleep clinic. Participants completed a demographic record, the Thai versions of the Functional Outcomes of Sleep Questionnaire, the Perceived Barriers Questionnaire and the Self-Efficacy Measure for Sleep Apnea. CPAP adherence was measured by using information downloaded from the smart card of the devices. Data were analysed using descriptive statistics and logistic regression.

RESULTS

Only 54.3% of participants adhered to CPAP treatment using standard protocols. Perceived seriousness of their condition was significantly associated with CPAP adherence, whereas perceived susceptibility, benefits, barriers and self-efficacy were not.

CONCLUSIONS

We found a low rate of CPAP adherence among participants. The only factor related to CPAP adherence was perceived seriousness.

RELEVANCE FOR THE CLINICAL PRACTICE

With a low rate of CPAP adherence, healthcare professionals, especially nurses, should encourage patients to use CPAP regularly by providing them with support and education regarding the severity of the disease if untreated and the benefits of CPAP treatment on the disease. Healthcare professionals should be aware of psychological factors impacting patients' perception of sleep apnoea and CPAP treatment. Interventions dealing with these factors should be developed and implemented in practice.

Factors Affecting Long-Term Compliance of CPAP Treatment-A Single Centre Experience

Continuous positive airway pressure (CPAP) has been the standard treatment of obstructive sleep apnoea/hypopnoea syndrome (OSA) for almost four decades. Though usually effective, this treatment suffers from poor long-term compliance. Therefore, the aim of our one centre retrospective study was to assess factors responsible for treatment failure and long-term compliance. Four hundred subsequent patients diagnosed with OSA and qualified for CPAP treatment were chosen from our database and compliance data were obtained from medical charts. Many differing factors kept patients from starting CPAP or led to termination of treatment. Overall, almost half of patients ended treatment during the mean time of observation of 3.5 years. Survival analysis revealed that 25% of patients failed at a median time of 38.2 months. From several demographic and clinical covariates in Cox’s hazard model, only the presence of a mild OSA, i.e., AHI (apnoea/hypopnoea index) below 15/h was a factor strongly associated with long term CPAP failure. The compliance results of our study are in line with numerous studies addressing this issue. Contrary to them, some demographic or clinical variables that we used in our survival model were not related to CPAP adherence.

Hidden Markov model segmentation to demarcate trajectories of residual apnoea-hypopnoea index in CPAP-treated sleep apnoea patients to personalize follow-up and prevent treatment failure

BACKGROUND

Continuous positive airway pressure (CPAP), the reference treatment for obstructive sleep apnoea (OSA), is used by millions of individuals worldwide with remote telemonitoring providing daily information on CPAP usage and efficacy, a currently underused resource. Here, we aimed to implement data science methods to provide tools for personalizing follow-up and preventing treatment failure.

METHODS

We analysed telemonitoring data from adults prescribed CPAP treatment. Our primary objective was to use Hidden Markov models (HMMs) to identify the underlying state of treatment efficacy and enable early detection of deterioration. Secondary goals were to identify clusters of rAHI trajectories which need distinct therapeutic strategies.

RESULTS

From telemonitoring records of 2860 CPAP-treated patients (age: 66.31 ± 12.92 years, 69.9% male), HMM estimated three states differing in variability within a given state and probability of shifting from one state to another. The daily inferred state informs on the need for a personalized action, while the sequence of states is a predictive indicator of treatment failure. Six clusters of rAHI trajectories were identified ranging from well-controlled patients (cluster 0: 669 (23%); mean rAHI 0.58 ± 0.59 events/h) to the most unstable (cluster 5: 470 (16%); mean rAHI 9.62 ± 5.62 events/h). CPAP adherence was 30 min higher in cluster 0 compared to clusters 4 and 5 (P value < 0.01).

CONCLUSION

This new approach based on HMM might constitute the backbone for deployment of patient-centred CPAP management improving the personalized interpretation of telemonitoring data, identifying individuals for targeted therapy and preventing treatment failure or abandonment.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13167-021-00264-z.

Treatment outcomes among rural and urban patients with obstructive sleep apnea: a prospective cohort study

STUDY OBJECTIVES

To determine whether adherence to continuous positive airway pressure (CPAP) in adults with uncomplicated OSA differs by rural versus urban residential address.

METHODS

In this prospective cohort study, we recruited adults who initiated CPAP for uncomplicated OSA that was diagnosed by a physician using sleep specialist-interpreted diagnostic testing. Participants were classified as urban (community size > 100,000) or rural by translating residential postal code into geographic census area. The primary outcome was mean daily hours of CPAP use compared between rural and urban patients. Secondary outcomes included: the proportion of patients who were adherent to CPAP; change in Epworth Sleepiness Scale (ESS) score; change in EuroQOL-5D score; and Visit-Specific Satisfaction Instrument score. All outcomes were measured three months after CPAP initiation.

RESULTS

We enrolled 242 patients (100 rural) with mean (SD) age 51 (13) years and respiratory event index 24 (18) events/hour. Mean (95% CI) CPAP use was 3.19 (2.8,3.58) hours/night and 35% were CPAP-adherent, with no difference between urban and rural patients. Among the 65% of patients who were using CPAP at three months, mean CPAP use was 4.89 (4.51,5.28) hours/night and was not different between rural and urban patients. Improvement in ESS and patient satisfaction were similar between groups, but EuroQOL-5D score improved to a greater extent in rural patients. Urban or rural residence was not associated with CPAP adherence in multivariable regression analysis.

CONCLUSIONS

Rural versus urban residence was not associated with differences in CPAP adherence when guided by specialist-interpreted diagnostic sleep testing.

Continuous positive airway pressure and adverse cardiovascular events in obstructive sleep apnea: are participants of randomized trials representative of sleep clinic patients?

STUDY OBJECTIVES

Randomized controlled trials (RCTs) have shown no reduction in adverse cardiovascular (CV) events in patients randomized to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). This study examined whether randomized study populations were representative of OSA patients attending a sleep clinic.

METHODS

Sleep clinic patients were 3,965 consecutive adults diagnosed with OSA by in-laboratory polysomnography from 2006 to 2010 at a tertiary hospital sleep clinic. Characteristics of these patients were compared with participants of five recent RCTs examining the effect of CPAP on adverse CV events in OSA. The percentage of patients with severe (apnea-hypopnea index, [AHI] ≥ 30 events/h) or any OSA (AHI ≥ 5 events/h) who met the eligibility criteria of each RCT was determined, and those criteria that excluded the most patients identified.

RESULTS

Compared to RCT participants, sleep clinic OSA patients were younger, sleepier, more likely to be female and less likely to have established CV disease. The percentage of patients with severe or any OSA who met the RCT eligibility criteria ranged from 1.2% to 20.9% and 0.8% to 21.9%, respectively. The eligibility criteria that excluded most patients were preexisting CV disease, symptoms of excessive sleepiness, nocturnal hypoxemia and co-morbidities.

CONCLUSIONS

A minority of sleep clinic patients diagnosed with OSA meet the eligibility criteria of RCTs of CPAP on adverse CV events in OSA. OSA populations in these RCTs differ considerably from typical sleep clinic OSA patients. This suggests that the findings of such OSA treatment-related RCTs are not generalizable to sleep clinic OSA patients.Randomized Intervention with Continuous Positive Airway Pressure in CAD and OSA (RICCADSA) trial, https://clinicaltrials.gov/ct2/show/NCT00519597, ClinicalTrials.gov number, NCT00519597.Usefulness of Nasal Continuous Positive Airway Pressure (CPAP) Treatment in Patients with a First Ever Stroke and Sleep Apnea Syndrome, https://clinicaltrials.gov/ct2/show/NCT00202501, ClinicalTrials.gov number, NCT00202501.Effect of Continuous Positive Airway Pressure (CPAP) on Hypertension and Cardiovascular Morbidity-Mortality in Patients with Sleep Apnea and no Daytime Sleepiness, https://clinicaltrials.gov/ct2/show/NCT00127348, ClinicalTrials.gov number, NCT00127348.Continuous Positive Airway Pressure (CPAP) in Patients with Acute Coronary Syndrome and Obstructive Sleep Apnea (OSA) (ISAACC), https://clinicaltrials.gov/ct2/show/NCT01335087, ClinicalTrials.gov number, NCT01335087.

Wavelet-based CNN for Predicting PAP Adherence Using Overnight Polysomnography Recordings: a Pilot Study

Obstructive sleep apnea (OSA) is a common sleep disorder. Positive airway pressure (PAP) therapy is the first-line treatment, while its effectiveness is significantly limited by incomplete adherence in many patients. This work aims to find a predictive association between data from in-laboratory sleep studies during treatment (PAP titration polysomnogram, or PSG) and PAP adherence. Based on a PAP titration PSG database, we present a pipeline to develop a wavelet-based deep learning model and address two challenges. First, to tackle the problem of extremely long overnight PSG signals, it randomly draws segments and extracts features locally. The global representation for the entire signal is achieved by local feature P-norm pooling. Second, to tackle the problem of limited dataset size, the pre-trained EfficienNet-B7 is used as an unsupervised feature extractor to transfer ImageNet knowledge to PSG signals in the wavelet domain. The trained pipeline achieves 78% balanced accuracy and 83% AUC on the test set using airflow and frontal EEG signals, which, we believe, is a compelling result as a pilot study.

Sleep apnoea in the elderly: a great challenge for the future

Due in part to overall improvements in health, the population of elderly individuals is increasing rapidly. Similarly, obstructive sleep apnoea (OSA) is both gaining increased recognition and also increasing due to the worldwide obesity epidemic. The overlap of OSA and aging is large, but there is strong plausibility for causation in both directions: OSA is associated with pathological processes that may accelerate aging and aging related processes; aging may cause physical and neurological changes that predispose to obstructive (and central) apnoea. In addition, the common symptoms (e.g. excessive daytime somnolence, defects in memory and cognition), possible physiological consequences of OSA (e.g. accelerated cardiovascular and cerebrovascular atherosclerosis), and changes in metabolic and inflammatory markers overlap with the symptoms and associated conditions seen in aging. There is also the possibility of synergy in the effects of these symptoms and conditions on quality of life, as well as a need to separate treatable consequences of OSA from age-related complaints. Taken together, the above make it essential to review the interaction of OSA and aging, both proven and suspected. The present review examines some aspects of what is known and points to the need for further investigation of the relationships, given the large number of potentially affected subjects.

A Fully Remote Diagnostic and Treatment Pathway in Patients with Obstructive Sleep Apnoea during the COVID-19 Pandemic: A Single Centre Experience

The COVID-19 pandemic led to significant delays in the diagnostic and management pathway of patients with obstructive sleep apnoea (OSA). During the first wave of COVID-19, our department adopted a fully remote diagnostic (home cardiorespiratory polygraphy) and treatment (autoset continuous positive airway pressure, CPAP) approach. As a novel mode of service delivery, our aim was to evaluate our pathway and analyse factors associated with adherence to CPAP. We analysed the first 300 patients (51 ± 13 years, 48% men) who were set up on remote CPAP between 20 May 2020 and 11 September 2020. The associations between CPAP usage at 90 days and age, gender, body mass index, disease severity, Epworth Sleepiness Scale and comorbidities were investigated with linear and logistic regression analyses. A total of 124 patients (41.3%) were fully-adherent to CPAP therapy, defined as CPAP usage ≥ 4 h on ≥ 70% of the days. Only driving status was associated with adherence to CPAP. Patients who were adherent at 28 days were more likely to stay adherent at 90 days (3.77 odd ratio /3.10-4.45/ 95% confidence interval). We have shown that a fully remote diagnostic and treatment pathway for patients with OSA can be successfully delivered, and our preliminary outcomes of adherence to CPAP are comparable with published data.

Mandibular Advancement Device Treatment Efficacy Is Associated with Polysomnographic Endotypes

Rationale: Mandibular advancement device (MAD) treatment efficacy varies among patients with obstructive sleep apnea.Objectives: The current study aims to explain underlying individual differences in efficacy using obstructive sleep apnea endotypic traits calculated from baseline clinical polysomnography: collapsibility (airflow at normal ventilatory drive), loop gain (drive response to reduced airflow), arousal threshold (drive preceding arousal), compensation (increase in airflow as drive increases), and the ventilatory response to arousal (increase in drive explained by arousal). On the basis of previous research, we hypothesized that responders to MAD treatment have a lower loop gain and milder collapsibility.Methods: Thirty-six patients (median apnea-hypopnea index [AHI], 23.5 [interquartile range (IQR), 19.7-29.8] events/h) underwent baseline and 3-month follow-up full polysomnography, with MAD fixed at 75% of maximal protrusion. Traits were estimated using baseline polysomnography according to Sands and colleagues. Response was defined as an AHI reduction ≥ 50%.Results: MAD treatment significantly reduced AHI (49.7%_baseline [23.9-63.6], median [IQR]). Responders exhibited lower loop gain (mean [95% confidence interval], 0.53 [0.48-0.58] vs. 0.65 [0.57-0.73]; P = 0.020) at baseline than nonresponders, a difference that persisted after adjustment for baseline AHI and body mass index. Elevated loop gain remained associated with nonresponse after adjustment for collapsibility (odds ratio, 3.03 [1.16-7.88] per 1-standard deviation (SD) increase in loop gain [SD, 0.15]; P = 0.023).Conclusions: MAD nonresponders exhibit greater ventilatory instability, expressed as higher loop gain. Assessment of the baseline degree of ventilatory instability using this approach may improve upfront MAD treatment patient selection.Clinical trial registered with www.clinicaltrials.gov (NCT01532050).

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation.

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 upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea 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 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), oxygen desaturation index (ODI), increase in lowest oxygen saturation (LSAT), sleep quality, and improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI, and increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, ODI, and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggest that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline

Introduction

This guideline establishes clinical practice recommendations for referring adults with obstructive sleep apnea (OSA) for surgical consultation.

Methods

The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine, otolaryngology, and bariatric surgery to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using the GRADE process. The task force evaluated the relevant literature and the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations that support the recommendations. The AASM Board of Directors approved the final recommendations.

Recommendations

The following recommendations are intended as a guide for clinicians who treat adults with OSA. Each recommendations statement is assigned a strength ("Strong" or "Conditional"). A "Strong" recommendation (i.e., "We recommend…") is one that clinicians should follow under most circumstances. A "Conditional" recommendation is one that requires that the clinician use clinical knowledge and experience, and strongly consider the patient's values and preferences to determine the best course of action. 1. We recommend that clinicians discuss referral to a sleep surgeon with adults with OSA and BMI<40 who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options. (STRONG) 2. We recommend that clinicians discuss referral to a bariatric surgeon with adults with OSA and obesity (class II/III, BMI ≥35) who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options. (STRONG) 3. We suggest that clinicians discuss referral to a sleep surgeon with adults with OSA, BMI<40, and persistent inadequate PAP adherence due to pressure-related side effects as part of a patient-oriented discussion of adjunctive or alternative treatment options. (CONDITIONAL) 4. We suggest clinicians recommend PAP as initial therapy for adults with OSA and a major upper airway anatomic abnormality prior to consideration of referral for upper airway surgery. (CONDITIONAL).

Landscape of biomedical informatics standards and terminologies for clinical sleep medicine research: A systematic review

A systematic literature review was conducted to understand the current landscape of standards and terminologies used in clinical sleep medicine. Literature search on PubMed, EMBASE, Medline and Web of Science was performed in March 2021 using terms related to sleep, terminologies, standards, harmonization, semantics, ontology, and electronic health records (EHR). Systematic review was carried out according to PRISMA. Among 128 included studies, 35 were eligible for review. Articles were broadly classified into six topics: standard terminology efforts, reporting standards, databases and resources, data integration efforts, EHR abstraction and standards for automated sleep scoring. This review highlights the progress and challenges related to establishing computable terminologies in sleep medicine, and identifies gaps, limitations and research opportunities related to data integration that could improve adoption of clinical research informatics in this field. There is a need for the systematic adoption of standardized terminologies in all areas of sleep medicine. Existing data aggregation resources could be leveraged to support the development of an integrated infrastructure and subsequent deployment in EHR systems within sleep centers. Ultimately, the adoption of standardized practices for documenting sleep disorders and related traits facilitates data sharing, thus accelerating discovery and clinical translation of informatics approaches applied to sleep medicine.

Neighborhoods with Greater Prevalence of Minority Residents Have Lower Continuous Positive Airway Pressure Adherence

Rationale: Limited data suggest racial disparities in continuous positive airway pressure (CPAP) adherence exist.Objectives: To assess whether CPAP adherence varies by neighborhood racial composition at a national scale.Methods: Telemonitoring data from a CPAP manufacturer database were used to assess adherence in adult patients initiating CPAP therapy between November 2015 and October 2018. Mapping ZIP code to ZIP code tabulation areas, age- and sex-adjusted CPAP adherence data at a neighborhood level was computed as a function of neighborhood racial composition. Secondary analyses adjusted for neighborhood education and poverty.Measurements and Main Results: Among 787,236 patients living in 26,180 ZIP code tabulation areas, the prevalence of CPAP adherence was 1.3% (95% confidence interval [CI], 1.0-1.6%) lower in neighborhoods with high (⩾25%) versus low (<1%) percentages of Black residents and 1.2% (95% CI, 0.9-1.5%) lower in neighborhoods with high versus low percentages of Hispanic residents (P < 0.001 for both), even after adjusting for neighborhood differences in poverty and education. Mean CPAP usage was similar across neighborhoods for the first 2 days, but by 90 days, differences in CPAP usage increased to 22 minutes (95% CI, 18-27 min) between neighborhoods with high versus low percentages of Black residents and 22 minutes (95% CI 17-27 min) between neighborhoods with high versus low percentages of Hispanic residents (P < 0.001 for both).Conclusions: CPAP adherence is lower in neighborhoods with greater proportions of Black and Hispanic residents, independent of education or poverty. These differences lead to a lower likelihood of meeting insurance coverage requirements for CPAP therapy, potentially exacerbating sleep health disparities.

Sleep Disorders in Adults with Down Syndrome

Sleep disorders, despite being very frequent in adults with Down syndrome (DS), are often overlooked due to a lack of awareness by families and physicians and the absence of specific clinical sleep guidelines. Untreated sleep disorders have a negative impact on physical and mental health, behavior, and cognitive performance. Growing evidence suggests that sleep disruption may also accelerate the progression to symptomatic Alzheimer’s disease (AD) in this population. It is therefore imperative to have a better understanding of the sleep disorders associated with DS in order to treat them, and in doing so, improve cognition and quality of life, and prevent related comorbidities. This paper reviews the current knowledge of the main sleep disorders in adults with DS, including evaluation and management. It highlights the existing gaps in knowledge and discusses future directions to achieve earlier diagnosis and better treatment of sleep disorders most frequently found in this population.

Racial disparities in positive airway pressure therapy adherence among veterans with obstructive sleep apnea

STUDY OBJECTIVES

Black individuals are disproportionately affected by diabetes, cardiovascular disease, obesity, and OSA. Adherence to PAP therapy has been reported to be lower among black individuals. This study seeks to examine associations between black race and PAP adherence among veterans with OSA.

METHODS

This was a retrospective study. Veterans newly diagnosed with OSA at a single Department of Veterans Affairs sleep center who were prescribed a modem-enabled PAP device between January 2015 and November 2017 were enrolled. PAP adherence was defined as ≥ 4 hours nightly usage for at least 70% of nights measured at 30 days from PAP setup. We examined the relationship between race and adherence, controlling for sex, marital status, age, socioeconomic status, residual apnea-hypopnea index), and mask leak.

RESULTS

Of 3013 patients identified with OSA, 2571 (85%) were newly started on PAP therapy (95% male, aged 59 years ± 14 years, 45% married, 8% with neighborhood socioeconomic disadvantage). Twenty-five percent of participants were black, and 57% were white. PAP adherence at 30 days was 50% overall (42% among blacks, 53% among nonblacks). Black race was associated with reduced 30-day PAP adherence in unadjusted (P < .001) and adjusted logistic regression models (odds ratio = 0.64; 95% CI, 0.53 - 0.78; P < .001).

CONCLUSIONS

Among veterans with OSA, black race was associated with reduced PAP adherence. These findings suggest health inequality among black individuals in the treatment of OSA.

Characterizing respiratory parameters, settings and adherence in real-world patients using adaptive servo ventilation therapy: big data analysis

STUDY OBJECTIVES

There is minimal guidance around how to optimize inspiratory positive airway pressure (IPAP) levels during use of adaptive servo ventilation (ASV) in clinical practice. This real-world data analysis investigated the effects of IPAP and minimum pressure support (PSmin) settings on respiratory parameters and adherence in ASV-treated patients.

METHODS

A US-based telemonitoring database was queried for patients starting ASV between 1 August 2014 and 30 November 2019. Patients meeting the following criteria were included: US-based patients aged ≥18 years; AirCurve 10 device (ResMed); and ≥1 session with usage of ≥1 hour in the first 90 days. Key outcomes were mask leak and residual apnea-hypopnea index (AHI) at different IPAP settings, adherence and therapy termination rates, and respiratory parameters at different PSmin settings.

RESULTS

63,996 patients were included. Higher IPAP was associated with increased residual AHI and mask leak but did not impact device usage per session (average >6 h/day at all IPAP settings; 6.7 h/day at 95^th percentile IPAP 25 cmH₂O). There were no clinically relevant differences in respiratory rate, minute ventilation, leak and residual AHI across all possible PSmin settings. Patients with a higher 95^th percentile IPAP or with PSmin of 3 cmH₂O were most likely to remain on ASV therapy at 1 year.

CONCLUSIONS

Our findings showed robust levels of longer-term adherence to ASV therapy in a large group of real-world patients. There were no clinically important differences in respiratory parameters across a range of pressure and pressure settings. Future work should focus on the different phenotypes of patients using ASV therapy.

Paediatric CPAP in the digital age

OBJECTIVES

Adherence to Continuous Positive Airway Pressure (CPAP) in children can be challenging. Advancements in CPAP technology have potential to influence adherence. The aim of this study was to compare adherence rates of children with obstructive sleep apnoea (OSA) initiated on autotitrating CPAP (APAP) with remote modem monitoring compared to a cohort started on fixed pressure CPAP alone.

METHODS

Children aged over 3 years starting APAP at our centre between February 2017 and February 2020 were included. Therapy data was obtained for the initial 90 days. Data was compared to a cohort of children started on CPAP between July 2004 and September 2008.

RESULTS

A total of 61 patients with a median age of 14.3 years formed the APAP group, and were significantly older than the CPAP group who had a median age of 8.6 years (p = 0.02). Co-morbid conditions were present in 51% compared with 69% in the earlier cohort (p = 0.11). No significant difference was found in any adherence parameters between the groups. The value closest to achieving a significant difference was hours used per day used, with an median of 5.2 h in the CPAP group compared with 7.0 h in the APAP group (p = 0.07). Two-way ANOVA including age group (above or below 13 years) showed that both age group and treatment group (CPAP vs APAP) were significantly associated with a difference in adherence (F = 4.41, p = 0.006), with mean hours used on days used being highest in the APAP group aged under 13 years. However no significant interaction was found between age and treatment group.

CONCLUSION

Despite the convenience for patients with outpatient initiation and ability to achieve optimal pressures quickly and remotely, our results show no improvement in adherence using APAP with remote monitoring, with the possible exception of children aged under 13 years. A large randomized controlled trial would be required to confirm these findings.

Defining the patterns of PAP adherence in pediatric obstructive sleep apnea: a clustering analysis using real-world data

STUDY OBJECTIVES

The implementation of positive airway pressure (PAP) therapy to treat obstructive sleep apnea in children is a complex process. PAP therapy data are highly heterogeneous in pediatrics, and the clinical management cannot be generalized. We hypothesize that pediatric PAP users can be subgrouped via clustering analysis to guide tailored interventions.

METHODS

PAP therapy data for 250 children with obstructive sleep apnea were retrospectively examined using unsupervised hierarchical cluster analysis based on (1) PAP tolerance (average hours on days used) and (2) consistency of PAP use (percentage of days used). Clinical features in each cluster were defined, and a tree decision analysis was generated for clinical implementation.

RESULTS

We were able to subclassify all 250 children (median age = 11.5 years) into five clusters: A (13.6%), B (29.6%), C (17.6%), D (16.4%), and E (22.8%). The clusters showed significant differences in PAP use patterns (Kruskal-Wallis P value < 1e-16). The most consistent PAP use patterns were seen in clusters A, B, and C. Major differences across clusters included the prevalence of obesity, PAP setting, developmental delay, and adenotonsillectomy. We also identified important differences in mask acceptance, OSA severity, and individual responses to PAP therapy based on objective apnea-hypopnea reductions in PAP downloads.

CONCLUSIONS

A simple method to subset PAP use patterns in children can be implemented by analyzing cloud-based PAP therapy data. This novel approach may contribute to optimization of PAP therapy in children of all ages based on real-world evidence at the individual level.

Randomized clinical trials of cardiovascular disease in obstructive sleep apnea: understanding and overcoming bias

Three recent randomized control trials (RCTs) found that treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) did not reduce rates of future cardiovascular events. This article discusses the biases in these RCTs that may explain their negative results, and how to overcome these biases in future studies. First, sample selection bias affected each RCT. The subjects recruited were not patients typically presenting for treatment of OSA. In particular, subjects with excessive sleepiness were excluded due to ethical concerns. As recent data indicate that the excessively sleepy OSA subtype has increased cardiovascular risk, subjects most likely to benefit from treatment were excluded. Second, RCTs had low adherence to therapy. Reported adherence is lower than found clinically, suggesting it is in part related to selection bias. Each RCT showed a CPAP benefit consistent with epidemiological studies when restricting to adherent patients, but was underpowered. Future studies need to include sleepy individuals and maximize adherence. Since it is unethical and impractical to randomize very sleepy subjects to no therapy, alternative designs are required. Observational designs using propensity scores, which are accepted by FDA for studies of medical devices, provide an opportunity. The design needs to ensure covariate balance, including measures assessing healthy user and healthy adherer biases, between regular users of CPAP and non-users. Sensitivity analyses can evaluate the robustness of results to unmeasured confounding, thereby improving confidence in conclusions. Thus, these designs can robustly assess the cardiovascular benefit of CPAP in real-world patients, overcoming biases in RCTs.

One-Year Adherence to Continuous Positive Airway Pressure With Telemonitoring in Sleep Apnea Hypopnea Syndrome: A Randomized Controlled Trial

Study Objective: Telemedicine (TM) for continuous positive airway pressure (CPAP) treated patients may save health-care resources without compromising treatment effectiveness. We assessed the effect of TM (AirView Online System, ResMed) during the CPAP habituation phase on 3-month and 1-year treatment adherence and efficacy in patients with moderate-to-severe obstructive sleep apnea (OSA).

Methods: At CPAP initiation, 120 patients diagnosed with OSA were randomized to either usual care (UC) or TM during the habituation phase (clinical registration: ISRCTN12865936). Both groups received a first face-to-face appointment with a sleep care giver at CPAP initiation. Within the following month, 2 other physical visits were scheduled in the UC group whereas two phone consultations were planned in the TM group, in which CPAP parameters were remotely adapted. Additional physical visits were programmed at the patient's request. Face-to-face consultations were scheduled at 3 and 12 months after CPAP initiation. The primary outcome was the mean CPAP daily use over the course of 12 months.

Results: Twenty of 60 patients stopped CPAP therapy in the UC group vs. 14 of 60 in the TM group (p = 0.24). In per protocol analysis, mean [95% CI] daily CPAP use among 86 patients still using CPAP at 12 months was 279 [237; 321] min in the 38 patients on UC and 279 [247; 311] min in the 43 patients on TM, mean difference [95% CI]: 0 [−52; 52] min, P = 0.99. Total consultation time per patient was not different between groups, TM: 163 [147; 178] min, UC: 178 [159; 197] min, difference: −15 [−39; 9] min, p = 0.22.

Conclusions: Telemedicine during the CPAP habituation phase did not alter daily CPAP use or treatment adherence and did not require more healthcare time. Telemedicine may support clinic attendance for CPAP titration.

Clinical Trial Registration: [ISRCTN], identifier [ISRCTN12865936].

Adherence with positive airway pressure therapy for obstructive sleep apnea in developing vs. developed countries: a big data study

STUDY OBJECTIVES

Minimal focus has been placed on variations in health care delivery for obstructive sleep apnea (OSA). This study compared positive airway pressure usage in developing countries (Brazil and Mexico) vs. a developed country (United States) and investigated the impact of a patient engagement tool (myAir; ResMed, San Diego, CA) on adherence.

METHODS

Deidentified data from the AirView database (ResMed) for patients receiving positive airway pressure therapy with wirelessly connected Air10 (AirSense and AirCurve) devices in Brazil, Mexico, and the United States were analyzed. Adherence was defined using US Center for Medicare and Medicaid Services (CMS) criteria (usage ≥ 4 h/night on ≥ 70% of nights in the first 90 days).

RESULTS

The analysis included 4,181,490 patients (Brazil: 31,672; Mexico 16,934; United States: 4,132,884). CMS adherence over 90 days was slightly lower in Latin America vs. the United States (Brazil: 71.7%; Mexico: 66.4%; United States: 74.0%). Significantly fewer patients were using the patient engagement tool in Brazil (8.1%) and Mexico (2.8%) vs. the United States (26%; both P < .001). Patients registered to use an engagement tool had a higher rate of CMS adherence and were twice as likely to achieve CMS adherence. Average daily usage and days with usage > 4 hours in the first week were the strongest predictors of CMS adherence. Across all countries, > 80% of patients meeting CMS criteria at 3 months were still using positive airway pressure therapy at 1 year, with 1-year adherences rates of > 75%.

CONCLUSIONS

Short-term and long-term positive airway pressure adherence rates in Brazil and Mexico were similar to those achieved in the United States. Patients who registered to use an engagement tool consistently had better adherence than those who did not.

Effect of healthcare benefits on short-term adherence of positive airway pressure therapy

PURPOSE

The objective of this study was to assess the impact of healthcare benefits on adherence to positive airway pressure (PAP) therapy in obstructive sleep apnea (OSA) patients.

METHODS

Medical records of OSA patients at the Veterans Health Service Medical Center were retrospectively reviewed. OSA patients were assigned to two groups as the date of prescribing PAP: after (=Group A) and before (=Group B) July 1, 2018 when PAP therapy starts to be included in healthcare insurance coverage for OSA patients in South Korea. PAP adherence was compared over a 3-month period between the two groups; subjective improvement after therapy was evaluated using the Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index scores. In addition, we evaluated a number of OSA patients who chose to start PAP therapy without healthcare benefit (from July 2018 to December 2018).

RESULTS

Each of the 50 patients in the Group A and B exhibited PAP adherence rates of 82% and 26%, respectively (P < .001). Age did not affect PAP adherence in the Group A. The mean apnea-hypopnea index (from 36.7 to 1.34, P < .001) and ESS (from 7.6 to 5.6, P = .004) scores of patients in the Group A had significantly improved within the first three months. Twenty-three (23 out of 334, 6.9%) OSA patients did not have any healthcare insurance, but they medically needed PAP therapy. However, only one of the 23 patients began PAP treatment.

CONCLUSION

Short-term PAP adherence significantly improved after PAP therapy was included in healthcare insurance coverage.

Positive Airway Pressure Therapy Adherence with Mask Resupply: A Propensity-Matched Analysis

There are currently few data on the impact of mask resupply on longer-term adherence to positive airway pressure (PAP) therapy. This retrospective analysis investigated the effects of mask/mask cushion resupply on the adherence to PAP versus no resupply. Deidentified patient billing data for PAP supply items were merged with telemonitoring data from Cloud-connected AirSense 10/AirCurve 10 devices via AirView^TM (ResMed). Eligible patients started PAP between 1 July 2014 and 17 June 2016, had ≥360 days of PAP device data, and achieved initial U.S. Medicare adherence criteria. Patients who received a resupply of mask systems/cushions (resupply group) were propensity-score-matched with those not receiving any mask/cushion resupply (control group). A total of 100,370 patients were included. From days 91 to 360, the mean device usage was 5.6 and 4.5 h/night in the resupply and control groups, respectively (p < 0.0001). The proportion of patients with a mean device usage ≥4 h/night was significantly higher in the resupply group versus the control group (77% vs. 59%; p < 0.0001). The therapy termination rate was significantly lower in the resupply group versus the control group (14.7% vs. 31.9%; p < 0.0001); there was a trend toward lower therapy termination rates as the number of resupplies increased. The replacement of mask interface components was associated with better longer-term adherence to PAP therapy versus no resupply.

What is a Clinically Meaningful Target for Positive Airway Pressure Adherence?

Although good adherence to continuous positive airway pressure (PAP) traditionally is defined as greater than or equal to 4 hours/night, the origins and rationale for this remain unclear. Research studies report variation in optimal duration of PAP adherence, depending on outcome of interest. Evidence demonstrates benefit with PAP for daytime sleepiness, quality of life, neurocognitive outcomes, depression, and hypertension, predominantly in symptomatic, moderate-severe obstructive sleep apnea. Recent randomized controlled trials, however, have failed to demonstrate a reduction in cardiovascular and mortality risks. This review explores the question of what can be considered a clinically meaningful outcome for PAP adherence.

Positive Airway Pressure Therapy in Sleep-Disordered Breathing

Obstructive sleep apnea (OSA) is a highly prevalent condition with major neurocognitive and cardiovascular health effects. Positive airway pressure (PAP) therapy prevents the collapse of the pharyngeal airway to improve hypoxemia, hypercapnia, and sleep fragmentation caused by OSA. While adherence to PAP therapy has been thought to be a barrier to use, consistent usage is likely much higher than commonly thought. In addition, many strategies have been developed to assist providers in improving their patients' PAP adherence.

Using the Remote Monitoring Framework to Promote Adherence to Continuous Positive Airway Pressure

The ability to remotely monitor positive airway pressure therapy adherence and efficacy provides a unique opportunity for the field of sleep medicine to quickly and efficiently improve patient adherence. Smaller randomized studies and larger-scale retrospective evaluations show that telemedicine interventions leveraging these data can increase average usage and efficiency of care. However, more evidence on the impact of these programs on longer-term adherence and improving patient-reported outcomes is needed. Combining data from remote monitoring with clinical information in electronic health records may prove to be invaluable to the future of clinical sleep medicine practice and research.

Common risk factors and therapeutic targets in obstructive sleep apnea and osteoarthritis: An unexpectable link?

Osteoarthritis (OA) and Obstructive Sleep Apnea (OSA) are two highly prevalent chronic diseases for which effective therapies are urgently needed. Recent epidemiologic studies, although scarce, suggest that the concomitant occurrence of OA and OSA is associated with more severe manifestations of both diseases. Moreover, OA and OSA share risk factors, such as aging and metabolic disturbances, and co-morbidities, including cardiovascular and metabolic diseases, sleep deprivation and depression. Whether this coincidental occurrence is fortuitous or involves cause-effect relationships is unknown. This review aims at collating and integrating present knowledge on both diseases by providing a brief overview of their epidemiology and pathophysiology, analyzing current evidences relating OA and OSA and discussing potential common mechanisms by which they can aggravate each other. Such mechanisms constitute potential therapeutic targets whose pharmacological modulation may provide more efficient ways of reducing the consequences of OA and OSA and, thus, lessen the huge individual and social burden that they impose.

What Do We Know About Adherence to Oral Appliances?

Long-term effective therapy is essential for obstructive sleep apnea (OSA) control and preventing comorbidity. OSA patients are often reported to be more receptive to oral appliance therapy over positive airway pressure (PAP). Oral appliance usage can now be objectively recorded by temperature microsensors. Studies using commercially available microsensor chips have reported data out to 1 year, with high rates of adherence (>80%), albeit in small samples. There is opportunity to further use this technology to understand individual adherence factors and patterns and in obtaining objective measures of treatment effectiveness, particularly for longer-term health outcomes and allowing comparison to PAP.

Technologic advances in the assessment and management of obstructive sleep apnoea beyond the apnoea-hypopnoea index: a narrative review

Obstructive sleep apnoea (OSA) is a growing and serious worldwide health problem with significant health and socioeconomic consequences. Current diagnostic testing strategies are limited by cost, access to resources and over reliance on one measure, namely the apnoea-hypopnoea frequency per hour (AHI). Recent evidence supports moving away from the AHI as the principle measure of OSA severity towards a more personalised approach to OSA diagnosis and treatment that includes phenotypic and biological traits. Novel advances in technology include the use of signals such as heart rate variability (HRV), oximetry and peripheral arterial tonometry (PAT) as alternative or additional measures. Ubiquitous use of smartphones and developments in wearable technology have also led to increased availability of applications and devices to facilitate home screening of at-risk populations, although current evidence indicates relatively poor accuracy in comparison with the traditional gold standard polysomnography (PSG). In this review, we evaluate the current strategies for diagnosing OSA in the context of their limitations, potential physiological targets as alternatives to AHI and the role of novel technology in OSA. We also evaluate the current evidence for using newer technologies in OSA diagnosis, the physiological targets such as smartphone applications and wearable technology. Future developments in OSA diagnosis and assessment will likely focus increasingly on systemic effects of sleep disordered breathing (SDB) such as changes in nocturnal oxygen and blood pressure (BP); and may also include other factors such as circulating biomarkers. These developments will likely require a re-evaluation of the diagnostic and grading criteria for clinically significant OSA.

A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study

STUDY OBJECTIVES

To investigate treatment models using cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) for people with obstructive sleep apnea (OSA) and comorbid insomnia.

METHODS

121 adults with OSA and comorbid insomnia were randomized to receive CBT-I followed by PAP, CBT-I concurrent with PAP, or PAP only. PAP was delivered following standard clinical procedures for in-lab titration and home setup and CBT-I was delivered in four individual sessions. The primary outcome measure was PAP adherence across the first 90 days, with regular PAP use (≥4 h on ≥70% of nights during a 30-day period) serving as the clinical endpoint. The secondary outcome measures were the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) with good sleeper (PSQI <5), remission (ISI <8), and response (ISI reduction from baseline >7) serving as the clinical endpoints.

RESULTS

No significant differences were found between the concomitant treatment arms and PAP only on PAP adherence measures, including the percentage of participants who met the clinical endpoint. Compared to PAP alone, the concomitant treatment arms reported a significantly greater reduction from baseline on the ISI (p = .0009) and had a greater percentage of participants who were good sleepers (p = .044) and remitters (p = .008). No significant differences were found between the sequential and concurrent treatment models on any outcome measure.

CONCLUSIONS

The findings from this study indicate that combining CBT-I with PAP is superior to PAP alone on insomnia outcomes but does not significantly improve adherence to PAP.

[Conservative treatment of obstructive sleep apnea using non-PAP therapies]

In Germany about one third of adults aged between 30 and 69 years suffer from obstructive sleep apnea (OSA). Snoring, inspiratory flow limitations, hypopneas, and apneas occur, leading to disturbed sleep, reduced daytime performance, and increased cardiovascular morbidity and mortality. Positive airway pressure therapy (PAP therapy) can be successfully administered in every OSA severity. However, other conservative treatments have to be considered for some patients, particularly in PAP failure or intolerance. The individual treatment concept is based on poly(somno)graphic, morphological, and functional assessment, taking treatment acceptance, adherence, and compliance into account.

Acetazolamide for OSA and Central Sleep Apnea: A Comprehensive Systematic Review and Meta-Analysis

BACKGROUND

Therapy options for OSA and central sleep apnea (CSA) are limited, thus many patients remain untreated. Clinically, acetazolamide is sometimes used for CSA; however, given overlapping pathophysiologic properties of OSA and CSA, we hypothesized that acetazolamide is equally effective for both types. Prior reviews focused on specific subtypes of sleep apnea, study designs, and languages, thus including few studies (typically ≤3) limiting insights.

RESEARCH QUESTION

How efficacious is acetazolamide for sleep apnea, and is its effect modified by sleep apnea type or acetazolamide dose?

STUDY DESIGN AND METHODS

We queried MEDLINE, EMBASE, and ClinicalTrials.gov from inception until March 11, 2019. Any study in which adults with OSA/CSA received oral acetazolamide vs no acetazolamide (control) that reported sleep apnea-related outcomes was eligible, independent of study design or language. Two reviewers independently assessed eligibility and abstracted data. Primary outcomes were apnea-hypopnea index (AHI) and oxygen saturation nadir. Quality of evidence (QoE) was rated with the use of Grades of Recommendation Assessment, Development and Evaluation methods.

RESULTS

We included 28 studies (13 OSA/15 CSA; N_{Subjects,Acetazolamide} = 542; N_{Subjects,Control} = 553) that enabled meta-analyses for 24 outcomes. Acetazolamide doses ranged from 36 to 1000 mg/d and treatment duration from 1 to 90 d (median, 6 d). Overall, acetazolamide vs control lowered the AHI by -0.7 effect sizes (95% CI, -0.83 to -0.58; I² = 0%; moderate QoE) that corresponded to a reduction of 37.7% (95% CI, -44.7 to -31.3) or 13.8/h (95% CI, -16.3 to -11.4; AHI_Control = 36.5/h). The AHI reduction was similar in OSA vs CSA, but significantly greater with higher doses (at least up to 500 mg/d). Furthermore, acetazolamide improved oxygen saturation nadir by +4.4% (95% CI, 2.3 to 6.5; I² = 63%; no evidence of effect modification; very low QoE) and several secondary outcomes that included sleep quality measures and BP (mostly low QoE).

INTERPRETATION

Short-term acetazolamide improved both OSA and CSA. Rigorous studies with long-term follow up are warranted to assess Acetazolamide's value for the chronic treatment of patients with sleep apnea.

CLINICAL TRIAL REGISTRATION

PROSPERO (CRD42019147504).

Impact of COVID-19 lockdown on adherence to continuous positive airway pressure by obstructive sleep apnoea patients

The psychological effects of the coronavirus 2019 (COVID-19) lockdown and fear of aerosolisation made us think that adherence to continuous positive airway pressure (CPAP) treatment might be reduced and consequently the morbidity and mortality of vulnerable obstructive sleep apnoea (OSA) patients increased.

In a large prospective cohort of sleep apnoea patients treated by CPAP, adherence to CPAP was significantly increased during the COVID-19 lockdown. This was associated with a shift of patients considered as low adherers to average or high adherers.https://bit.ly/3cBBOhs

Age and Sex Disparities in Adherence to CPAP

BACKGROUND

CPAP effectiveness is limited by suboptimal adherence. Prior studies of adherence have focused on middle-aged men.

RESEARCH QUESTION

Does CPAP adherence vary by age and sex?

STUDY DESIGN AND METHODS

Telemonitoring data from a CPAP manufacturer database were used to assess adherence in patients initiating CPAP therapy between November 2015 and October 2018. Analyses were restricted to patients in the United States aged 18 to 90 years.

RESULTS

Across 789,260 patients initiated on CPAP (mean age, 55 ± 14 years; 58.2% male), overall adherence by US Centers of Medicare & Medicaid Services criteria was 72.6%, but it varied dramatically by age and sex, ranging from 51.3% in 18- to 30-year-old women to 80.6% in 71- to 80-year-old men. Patterns of use over the first 90 days demonstrated that younger age groups had peak CPAP use by the 2^nd night, with a subsequent decay in use, including abandonment of CPAP, which was greatest among 18- to 30-year-old women. In contrast, older patients steadily increase use, taking more than a week to maximize usage, and then they have much slower decays in use over time. Younger, but not older, patients have lower use of CPAP on weekends compared with weekday nights.

INTERPRETATION

CPAP adherence rates vary substantially by demographics, with 18- to 30-year-old women having the lowest adherence. The pattern of use over the first 90 days also varies substantially by age and sex. Further research to understand and address the causes of disparities will be crucial to maximizing the benefits of CPAP therapy.

Telehealth, Telemedicine, and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) telehealth management may improve initial and chronic care access, time to diagnosis and treatment, between-visit care, e-communications and e-education, workflows, costs, and therapy outcomes. OSA telehealth options may be used to replace or supplement none, some, or all steps in the evaluation, testing, treatments, and management of OSA. All telehealth steps must adhere to OSA guidelines. OSA telehealth may be adapted for continuous positive airway pressure (CPAP) and non-CPAP treatments. E-data collection enhances uses for individual and group analytics, phenotyping, testing and treatment selections, high-risk identification and targeted support, and comparative and multispecialty therapy studies.