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Rubanenko AO, Dyachkov VA, Miroshnichenko AI. [Factors affecting adherence to CPAP therapy in patients with obstructive sleep apnea syndrome]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:58-65. [PMID: 38934667 DOI: 10.17116/jnevro202412405258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
OBJECTIVE Analysis of factors affecting adherence to continuous positive airway pressure (CPAP) therapy in patients with obstructive sleep apnea (OSA). MATERIAL AND METHODS The literature search was carried out using the databases PubMED, Google Scholar, E-library, Cyberleninka for the period 2013-2023 and included reviews and original articles. RESULTS The main groups of factors affecting adherence to CPAP therapy in patients with OSA have been established. These include sociodemographic and socioeconomic factors, the severity of OSA and the severity of clinical symptoms, and psychosocial factors. Strategies that can improve adherence were identified (educational technologies for patients, telemedicine technologies, behavioral therapy, modern technical interventions). CONCLUSION Factors that improve adherence to CPAP therapy are high levels of education and income, more severe OSA forms accompanied by daytime sleepiness, support from the patient's spouse and social support. Factors such as low levels of education and income, smoking, symptoms of depression and hypochondria, as well as side-effects worsen adherence to CPAP therapy, including refusal to continue treatment. It should be noted that all the identified factors are very closely associated with each other, so it is necessary to evaluate them comprehensively in each patient with OSA.
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Affiliation(s)
- A O Rubanenko
- Samara State Medical University of the Ministry of Healthcare of the Russia, Samara, Russia
| | - V A Dyachkov
- Samara State Medical University of the Ministry of Healthcare of the Russia, Samara, Russia
| | - A I Miroshnichenko
- Samara State Medical University of the Ministry of Healthcare of the Russia, Samara, Russia
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He K, Crouch T, Kaitz J, Oien AD, De Paul N, Palen BN, Parsons EC. Improving adherence to PAP therapy: A brief PAP coaching intervention for health care providers. PEC INNOVATION 2023; 3:100230. [PMID: 37929052 PMCID: PMC10624969 DOI: 10.1016/j.pecinn.2023.100230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/02/2023] [Accepted: 10/16/2023] [Indexed: 11/07/2023]
Abstract
Objectives To evaluate a training program for non-specialist health care providers in a brief coaching intervention to improve positive airway pressure (PAP) usage in Veterans with sleep apnea. Methods We conducted a national webinar training designed for non-specialist providers to implement a brief telephone coaching intervention to improve PAP adherence. The curriculum was crafted by experts in sleep medicine and behavioral sleep medicine based on principles of PAP desensitization. Providers who participated in this training were asked to complete evaluations at 30 days and 1 year. Results Provider surveys indicated that most respondents had incorporated the intervention into their clinical practice and felt comfortable counseling patients about sleep apnea and adherence to PAP. Provider feedback suggested that future training programs should include refresher trainings, more training on PAP equipment specifics, and facilitated collaboration with local sleep medicine staff. Conclusions This pilot training program demonstrated that a webinar format was a feasible method to increase training in PAP adherence among non-specialist health care providers. Innovation Non-specialists can be trained as PAP coaches in webinar format, improving patients' access to effective strategies and support to be successful with PAP therapy.
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Affiliation(s)
- Ken He
- Veterans Affairs Puget Sound Health Care System, Sleep Medicine, 1660 S Columbian Way, Seattle, WA 98108, USA
- University of Washington, Division of Pulmonary, Critical Care and Sleep Medicine, 4545 Roosevelt Way NE Suite 400, Seattle, WA 98105, USA
| | - Tara Crouch
- Veterans Affairs Puget Sound Health Care System, Sleep Medicine, 1660 S Columbian Way, Seattle, WA 98108, USA
- Veterans Affairs Puget Sound Health Care System, Psychology, 1660 S Columbian Way, Seattle, WA 98108, USA
| | - Jenesse Kaitz
- Veterans Affairs Puget Sound Health Care System, Sleep Medicine, 1660 S Columbian Way, Seattle, WA 98108, USA
| | - Angela D. Oien
- Veterans Affairs Puget Sound Health Care System, Health Services Research and Development Center for Innovation, 1660 S Columbian Way, Seattle, WA 98108, USA
| | - Nicola De Paul
- Veterans Affairs Sierra Nevada Health Care System, Mental Health, 975 Kirman Ave, Mail stop 116, Reno, NV 89502, USA
| | - Brian N. Palen
- Veterans Affairs Puget Sound Health Care System, Sleep Medicine, 1660 S Columbian Way, Seattle, WA 98108, USA
- University of Washington, Division of Pulmonary, Critical Care and Sleep Medicine, 4545 Roosevelt Way NE Suite 400, Seattle, WA 98105, USA
| | - Elizabeth C. Parsons
- Veterans Affairs Puget Sound Health Care System, Sleep Medicine, 1660 S Columbian Way, Seattle, WA 98108, USA
- University of Washington, Division of Pulmonary, Critical Care and Sleep Medicine, 4545 Roosevelt Way NE Suite 400, Seattle, WA 98105, USA
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Cha H, Oh H, Han SA, Kim SY, Kim JK, Park HC, Han DH, Kim DY, Kim HJ. The clinical influence of nasal surgery on PAP compliance and optimal application among OSA subjects uncomfortable with PAP device wear. Sci Rep 2023; 13:4383. [PMID: 36928588 PMCID: PMC10020433 DOI: 10.1038/s41598-023-31588-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
This study aimed to evaluate the alteration of PAP compliance after nasal surgery and to determine the optimal indications of nasal surgery in obstructive sleep apnea (OSA) subjects. Among OSA subjects using PAP devices, 29 subjects who underwent septoturbinoplasty due to nasal obstruction were included and their pre- and postoperative medical and PAP records were reviewed retrospectively. Postoperative autoPAP usage data was further assessed by grouping the compliance (the percentage of days with usage ≥ 4 h) data (group 1: the good compliance group; group 2: the poor compliance group). The data showed that 56% of subjects in group 1 complained of nasal obstruction as the only barrier to using a PAP device and about 89% reported experiencing the efficacy of PAP usage. Both the mean and peak average PAP pressures were significantly reduced in group 1 following nasal surgery. Group 2 had multiple subjective problems that interfered with wearing a PAP device and reported a lack of experiencing the efficacy of PAP usage. Preoperative nasal cavity volume values were smaller and absolute blood eosinophil counts were significantly lower in group 1. The current data demonstrate that nasal surgery might increase the compliance of PAP device wear in OSA subjects who complained of only nasal obstruction as a barrier to wearing PAP and who had small nasal cavity volumes combined with allergic inflammation.
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Affiliation(s)
- Hyunkyung Cha
- Department of Otorhinolaryngology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Republic of Korea
| | - Heonjeong Oh
- Department of Otorhinolaryngology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Sun A Han
- Department of Otorhinolaryngology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Otorhinolaryngology-Head and Neck Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Seo Young Kim
- Department of Otorhinolaryngology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jeong Kyou Kim
- Department of Otorhinolaryngology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hae Chan Park
- Department of Otorhinolaryngology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Doo Hee Han
- Department of Otorhinolaryngology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Sensory Organ Research Institute, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Dong-Young Kim
- Department of Otorhinolaryngology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Sensory Organ Research Institute, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Hyun Jik Kim
- Department of Otorhinolaryngology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Sensory Organ Research Institute, Seoul National University Medical Research Center, Seoul, Republic of Korea.
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Scarpina F, Bastoni I, Cappelli S, Priano L, Giacomotti E, Castelnuovo G, Molinari E, Tovaglieri IMA, Cornacchia M, Fanari P, Mauro A. Short-Term Effects of a Multidisciplinary Residential Rehabilitation Program on Perceived Risks, Confidence Toward Continuous Positive Airway Pressure Treatment, and Self-Efficacy in a Sample of Individuals Affected by Obstructive Sleep Apnea Syndrome. Front Psychol 2021; 12:703089. [PMID: 34484053 PMCID: PMC8416346 DOI: 10.3389/fpsyg.2021.703089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/21/2021] [Indexed: 12/14/2022] Open
Abstract
Continuous positive airway pressure (CPAP) therapy is the standard treatment for obstructive sleep apnea (OSA) syndrome. However, optimizing adherence to CPAP therapy of individuals remains very challenging for clinicians because of the role played by the psychological components. In this study, we verified the changes in cognitions and beliefs of individuals after a four-week multidisciplinary residential rehabilitation program targeting the adaptation to CPAP therapy for OSA syndrome. We assessed the components of perceived risks, confidence toward the treatment, and self-efficacy through the self-report questionnaire, namely the Self-Efficacy Measure for Sleep Apnea (SEMSA) questionnaire. We also explored the role played by the temperamental traits on the changes registered in these components after the treatment. Forty-five participants completed the rehabilitation program, showing a higher level of adherence to the treatment. Significant changes were observed in terms of confidence toward the treatment, although no change was reported in terms of perceived risks and self-efficacy. Moreover, those individuals with a higher persistent temperamental trait reported a significant improvement in perceived risks, in the absence of other significant results. After the rehabilitation treatment, our participants were more prone to consider the effect of CPAP treatment on health outcomes. This was in line with the educational aim of the rehabilitation treatment. The temperament seemed to play only a marginal role in the global changes reported by our participants. We discussed the need for behavioral interventions, in addition to education, in improving self-efficacy.
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Affiliation(s)
- Federica Scarpina
- Istituto Auxologico Italiano, IRCCS, U.O. di Neurologia e Neuroriabilitazione, Ospedale S. Giuseppe, Piancavallo, Italy
- “Rita Levi Montalcini” Department of Neurosciences, University of Turin, Turin, Italy
| | - Ilaria Bastoni
- Istituto Auxologico Italiano, IRCCS, Laboratorio di Psicologia, Ospedale S. Giuseppe, Piancavallo, Italy
| | - Simone Cappelli
- Istituto Auxologico Italiano, IRCCS, Laboratorio di Psicologia, Ospedale S. Giuseppe, Piancavallo, Italy
| | - Lorenzo Priano
- Istituto Auxologico Italiano, IRCCS, U.O. di Neurologia e Neuroriabilitazione, Ospedale S. Giuseppe, Piancavallo, Italy
- “Rita Levi Montalcini” Department of Neurosciences, University of Turin, Turin, Italy
| | - Emanuela Giacomotti
- Istituto Auxologico Italiano, IRCCS, U.O. di Neurologia e Neuroriabilitazione, Ospedale S. Giuseppe, Piancavallo, Italy
| | - Gianluca Castelnuovo
- Istituto Auxologico Italiano, IRCCS, Laboratorio di Psicologia, Ospedale S. Giuseppe, Piancavallo, Italy
- Psychology Department, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Enrico Molinari
- Istituto Auxologico Italiano, IRCCS, Laboratorio di Psicologia, Ospedale S. Giuseppe, Piancavallo, Italy
- Psychology Department, Università Cattolica del Sacro Cuore, Milan, Italy
| | | | - Mauro Cornacchia
- Istituto Auxologico Italiano, IRCCS, U.O. di Riabilitazione Pneumologica, Ospedale S. Giuseppe, Piancavallo, Italy
| | - Paolo Fanari
- Istituto Auxologico Italiano, IRCCS, U.O. di Riabilitazione Pneumologica, Ospedale S. Giuseppe, Piancavallo, Italy
| | - Alessandro Mauro
- Istituto Auxologico Italiano, IRCCS, U.O. di Neurologia e Neuroriabilitazione, Ospedale S. Giuseppe, Piancavallo, Italy
- “Rita Levi Montalcini” Department of Neurosciences, University of Turin, Turin, Italy
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PAP Adherence and Nasal Resistance. A Randomized Controlled Trial of CPAPflex versus CPAP in World Trade Center Responders. Ann Am Thorac Soc 2021; 18:668-677. [PMID: 33202147 DOI: 10.1513/annalsats.202009-1161oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Continuous positive airway pressure (CPAP) adherence is often poor in obstructive sleep apnea (OSA) and may be influenced by nasal resistance. CPAP with a reduction of expiratory pressure (CPAPflex) may reduce discomfort in those with high nasal resistance and improve adherence in this subgroup.Objectives: To evaluate the association of positive airway pressure (PAP) treatment adherence to nasal resistance and examine if CPAPflex improves adherence over CPAP in subjects with high nasal resistance.Methods: A randomized double-blind crossover trial of 4 weeks each of CPAPflex versus CPAP in subjects exposed to World Trade Center dust with OSA stratified by nasal resistance, measured by 4-Phase Rhinomanometry.Results: Three hundred seventeen subjects with OSA (mean, apnea-hypopnea index with 4% O2 desaturation for hypopnea = 17 ± 14/h) were randomized. Overall, PAP adherence was poor, but adherence to CPAP (n = 239; mean hours per night [95% confidence interval (CI)]), 1.97 h (1.68 to 2.26) was greater than adherence to CPAPflex (n = 249; 1.65 h [1.39 to 1.91]; difference of 0.31 h [0.03; 0.6]; P < 0.05). Contrary to our hypothesis there was no correlation between nasal resistance and adherence to CPAP (r = 0.098; P = not significant) or CPAPflex (r = 0.056; P = not significant). There was no difference in adherence between CPAP and CPAPflex (mean Δ hours [95% CI]) in subjects with low resistance (0.33 h [-0.10 to 0.76]) or high nasal resistance (0.26 h [-0.14 to 0.66]). No significant differences were observed in any of the secondary outcomes between PAP modes.Conclusions: Contrary to expectations, our data do not show better adherence to CPAPflex than to CPAP in subjects with high or low nasal resistance and do show clinically insignificant better adherence overall with CPAP.Clinical trial registered with www.clinicaltrials.gov (NCT01753999).
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Askland K, Wright L, Wozniak DR, Emmanuel T, Caston J, Smith I. Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev 2020; 4:CD007736. [PMID: 32255210 PMCID: PMC7137251 DOI: 10.1002/14651858.cd007736.pub3] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although highly effective in the treatment of obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) is not universally accepted by users. Educational, supportive and behavioural interventions may help people with OSA initiate and maintain regular and continued use of CPAP. OBJECTIVES To assess the effectiveness of educational, supportive, behavioural, or mixed (combination of two or more intervention types) strategies that aim to encourage adults who have been prescribed CPAP to use their devices. SEARCH METHODS Searches were conducted on the Cochrane Airways Group Specialised Register of trials. Searches are current to 29 April 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs) that assessed intervention(s) designed to inform participants about CPAP/OSA, to support them in using CPAP, or to modify their behaviour to increase use of CPAP devices. DATA COLLECTION AND ANALYSIS We assessed studies to determine their suitability for inclusion in the review. Data were extracted independently and were entered into RevMan for analysis. 'Risk of bias' assessments were performed, using the updated 'Risk of bias 2' tool, for the primary outcome, CPAP usage. Study-level 'Risk of bias' assessments were performed using the original 'Risk of bias' tool. GRADE assessment was performed using GRADEpro. MAIN RESULTS Forty-one studies (9005 participants) are included in this review; 16 of these studies are newly identified with updated searches. Baseline Epworth Sleepiness Scale (ESS) scores indicate that most participants suffered from excessive daytime sleepiness. The majority of recruited participants had not used CPAP previously. When examining risk of bias for the primary outcome of hourly machine usage/night, 58.3% studies have high overall risk (24/41 studies), 39.0% have some concerns (16/41 studies), and 2.4% have low overall risk (1/41 studies). We are uncertain whether educational interventions improve device usage, as the certainty of evidence was assessed as very low. We were unable to perform meta-analyses for number of withdrawals and symptom scores due to high study heterogeneity. Supportive interventions probably increase device usage by 0.70 hours/night (95% confidence interval (CI) 0.36 to 1.05, N = 1426, 13 studies, moderate-certainty evidence), and low-certainty evidence indicates that the number of participants who used their devices ≥ 4 hours/night may increase from 601 to 717 per 1000 (odds ratio (OR), 1.68, 95% CI 1.08 to 2.60, N = 376, 2 studies). However, the number of withdrawals may also increase from 136 to 167 per 1000 (OR 1.27, 95% CI 0.97 to 1.66, N = 1702, 11 studies, low-certainty evidence). Participants may experience small improvements in symptoms (ESS score -0.32 points, 95% CI -1.19 to 0.56, N = 470, 5 studies, low-certainty evidence), and we are uncertain whether quality of life improves with supportive interventions, as the certainty of evidence was assessed as very low. When compared with usual care, behavioural interventions produce a clinically-meaningful increase in device usage by 1.31 hours/night (95% CI 0.95 to 1.66, N = 578, 8 studies, high-certainty evidence), probably increase the number of participants who used their machines ≥ 4 hours/night from 371 to 501 per 1000 (OR 1.70, 95% CI 1.20 to 2.41, N = 549, 6 studies, high-certainty evidence), and reduce the number of study withdrawals from 146 to 101 per 1000 (OR 0.66, 95% CI 0.44 to 0.98, N = 939, 10 studies, high-certainty evidence). Behavioural interventions may reduce symptoms (ESS score -2.42 points, 95% CI -4.27 to -0.57, N = 272, 5 studies, low-certainty evidence), but probably have no effect on quality of life (Functional Outcomes of Sleep Questionnaire (FOSQ), standardised mean difference (SMD) 0.00, 0.95% CI -0.26 to 0.26, N = 228, 3 studies, moderate-certainty evidence). We are uncertain whether behavioural interventions improve apnoea hypopnoea index (AHI), as the certainty of evidence was assessed as very low. We are uncertain if mixed interventions improve device usage, increase the number of participants using their machines ≥ 4 hours/night, reduce study withdrawals, improve quality of life, or reduce anxiety symptoms, as the certainty of evidence for these outcomes was assessed to be very low. Symptom scores via the ESS could not be measured due to considerable heterogeneity between studies. AUTHORS' CONCLUSIONS In CPAP-naïve people with OSA, high-certainty evidence indicates that behavioural interventions yield a clinically-significant increase in hourly device usage when compared with usual care. Moderate certainty evidence shows that supportive interventions increase usage modestly. Very low-certainty evidence shows that educational and mixed interventions may modestly increase CPAP usage. The impact of improved CPAP usage on daytime sleepiness, quality of life, and mood and anxiety scores remains unclear since these outcomes were not assessed in the majority of included studies. Studies addressing the choice of interventions that best match individual patient needs and therefore result in the most successful and cost-effective therapy are needed.
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Affiliation(s)
- Kathleen Askland
- Waypoint Centre for Mental Health CareWaypoint Research InstitutePenetanguisheneCanada
| | - Lauren Wright
- Waypoint Centre for Mental Health CareWaypoint Research InstitutePenetanguisheneCanada
- AstraZeneca Canada Inc.MississaugaOntarioCanada
| | - Dariusz R Wozniak
- Royal Papworth HospitalRespiratory Support and Sleep CentrePapworth EverardCambridgeUKCB23 3RE
| | - Talia Emmanuel
- Waypoint Centre for Mental Health CareWaypoint Research InstitutePenetanguisheneCanada
| | - Jessica Caston
- Waypoint Centre for Mental Health CareWaypoint Research InstitutePenetanguisheneCanada
| | - Ian Smith
- Royal Papworth HospitalRespiratory Support and Sleep CentrePapworth EverardCambridgeUKCB23 3RE
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Kennedy B, Lasserson TJ, Wozniak DR, Smith I. Pressure modification or humidification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev 2019; 12:CD003531. [PMID: 31792939 PMCID: PMC6888022 DOI: 10.1002/14651858.cd003531.pub4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is the repetitive closure of the upper airway during sleep. This results in disturbed sleep and excessive daytime sleepiness. It is a risk factor for long-term cardiovascular morbidity. Continuous positive airway pressure (CPAP) machines can be applied during sleep. They deliver air pressure by a nasal or oronasal mask to prevent the airway from closing, reducing sleep disturbance and improving sleep quality. Some people find them difficult to tolerate because of high pressure levels and other symptoms such as a dry mouth. Switching to machines that vary the level of air pressure required to reduce sleep disturbance could increase comfort and promote more regular use. Humidification devices humidify the air that is delivered to the upper airway through the CPAP circuit. Humidification may reduce dryness of the throat and mouth and thus improve CPAP tolerability. This updated Cochrane Review looks at modifying the delivery of positive pressure and humidification on machine usage and other clinical outcomes in OSA. OBJECTIVES To determine the effects of positive pressure modification or humidification on increasing CPAP machine usage in adults with OSA. SEARCH METHODS We searched Cochrane Airways Specialised Register and clinical trials registries on 15 October 2018. SELECTION CRITERIA Randomised parallel group or cross-over trials in adults with OSA. We included studies that compared automatically adjusting CPAP (auto-CPAP), bilevel positive airway pressure (bi-PAP), CPAP with expiratory pressure relief (CPAPexp), heated humidification plus fixed CPAP, automatically adjusting CPAP with expiratory pressure relief, Bi-PAP with expiratory pressure relief, auto bi-PAP and CPAPexp with wakefulness detection with fixed pressure setting. DATA COLLECTION AND ANALYSIS We used standard methods expected by Cochrane. We assessed the certainty of evidence using GRADE for the outcomes of machine usage, symptoms (measured by the Epworth Sleepiness Scale (ESS)), Apnoea Hypopnoea Index (AHI), quality of life measured by Functional Outcomes of Sleep Questionnaire (FOSQ), blood pressure, withdrawals and adverse events (e.g. nasal blockage or mask intolerance). The main comparison of interest in the review is auto-CPAP versus fixed CPAP. MAIN RESULTS We included 64 studies (3922 participants, 75% male). The main comparison of auto-CPAP with fixed CPAP is based on 36 studies with 2135 participants from Europe, USA, Hong Kong and Australia. The majority of studies recruited participants who were recently diagnosed with OSA and had not used CPAP previously. They had excessive sleepiness (ESS: 13), severe sleep disturbance (AHI ranged from 22 to 59), and average body mass index (BMI) of 35 kg/m2. Interventions were delivered at home and the duration of most studies was 12 weeks or less. We judged that studies at high or unclear risk of bias likely influenced the effect of auto-CPAP on machine usage, symptoms, quality of life and tolerability, but not for other outcomes. Primary outcome Compared with average usage of about five hours per night with fixed CPAP, people probably use auto-CPAP for 13 minutes longer per night at about six weeks (mean difference (MD) 0.21 hours/night, 95% confidence interval (CI) 0.11 to 0.31; 31 studies, 1452 participants; moderate-certainty evidence). We do not have enough data to determine whether auto-CPAP increases the number of people who use machines for more than four hours per night compared with fixed CPAP (odds ratio (OR) 1.16, 95% CI 0.75 to 1.81; 2 studies, 346 participants; low-certainty evidence). Secondary outcomes Auto-CPAP probably reduces daytime sleepiness compared with fixed CPAP at about six weeks by a small amount (MD -0.44 ESS units, 95% CI -0.72 to -0.16; 25 studies, 1285 participants; moderate-certainty evidence). AHI is slightly higher with auto-CPAP than with fixed CPAP (MD 0.48 events per hour, 95% CI 0.16 to 0.80; 26 studies, 1256 participants; high-certainty evidence), although it fell with both machine types from baseline values in the studies. Ten per cent of people in auto-CPAP and 11% in the fixed CPAP arms withdrew from the studies (OR 0.90, 95% CI 0.64 to 1.27; moderate-certainty evidence). Auto-CPAP and fixed CPAP may have similar effects on quality of life, as measured by the FOSQ but more evidence is needed to be confident in this result (MD 0.12, 95% CI -0.21 to 0.46; 3 studies, 352 participants; low-certainty evidence). Two studies (353 participants) provided data on clinic-measured blood pressure. Auto-CPAP may be slightly less effective at reducing diastolic blood pressure compared to fixed CPAP (MD 2.92 mmHg, 95% CI 1.06 to 4.77 mmHg; low-certainty evidence). The two modalities of CPAP probably do not differ in their effects on systolic blood pressure (MD 1.87 mmHg, 95% CI -1.08 to 4.82; moderate-certainty evidence). Nine studies (574 participants) provided information on adverse events such as nasal blockage, dry mouth, tolerance of treatment pressure and mask leak. They used different scales to capture these outcomes and due to variation in the direction and size of effect between the studies, the comparative effects on tolerability outcomes are uncertain (very low-certainty evidence). The evidence base for other interventions is smaller, and does not provide sufficient information to determine whether there are important differences between pressure modification strategies and fixed CPAP on machine usage outcomes, symptoms and quality of life. As with the evidence for the auto-CPAP, adverse events are measured disparately. AUTHORS' CONCLUSIONS In adults with moderate to severe sleep apnoea starting positive airway pressure therapy, auto-CPAP probably increases machine usage by about 13 minutes per night. The effects on daytime sleepiness scores with auto-CPAP are not clinically meaningful. AHI values are slightly lower with fixed CPAP. Use of validated quality of life instruments in the studies to date has been limited, although where they have been used the effect sizes have not exceeded proposed clinically important differences. The adoption of a standardised approach to measuring tolerability would help decision-makers to balance benefits with harms from the different treatment options available. The evidence available for other pressure modification strategies does not provide a reliable basis on which to draw firm conclusions. Future studies should look at the effects of pressure modification devices and humidification in people who have already used CPAP but are unable to persist with treatment.
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Affiliation(s)
- Barry Kennedy
- St. James's HospitalDepartment of Sleep MedicineDublinIreland
| | - Toby J Lasserson
- Cochrane Central ExecutiveEditorial & Methods DepartmentSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Dariusz R Wozniak
- Royal Papworth HospitalRespiratory Support and Sleep CentrePapworth EverardCambridgeUKCB23 3RE
| | - Ian Smith
- Royal Papworth HospitalRespiratory Support and Sleep CentrePapworth EverardCambridgeUKCB23 3RE
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Sunwoo BY, Light M, Malhotra A. Strategies to augment adherence in the management of sleep-disordered breathing. Respirology 2019; 25:363-371. [PMID: 31270925 DOI: 10.1111/resp.13589] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 02/05/2019] [Accepted: 05/02/2019] [Indexed: 01/05/2023]
Abstract
Continuous positive airway pressure (CPAP) is highly effective in treating sleep-disordered breathing (SDB). However, unlike surgical interventions, this treatment modality relies heavily on patient acceptance and adherence. The current definition of adherence is largely arbitrary and is mainly used by third-party payers to determine CPAP reimbursement but CPAP adherence remains sub-optimal. Strategies to augment adherence, especially early in the course of a CPAP trial, are needed in the management of SDB. An understanding of the basis for observed differences in CPAP and oral appliance (OA) use is necessary in developing these strategies, but to date no single factor has been consistently identified. Consequently, a multidimensional approach using educational, behavioural, technological and potentially pharmacological strategies to target (i) disease characteristics, (ii) patient characteristics including psychosocial factors, (iii) treatment protocols and (iv) technological devices and side effects that may influence adherence, is likely required to augment the complex behaviour of CPAP and OA use. In the near future, we envision a personalized medicine approach to determine the risk of non-adherence and set individualized adherence goals aimed at treating specific symptoms (e.g. excessive daytime sleepiness) and reducing the risk of patient-specific SDB consequences (e.g. atherosclerosis). Resources for interventions to improve adherence such as educational programmes and telemedicine encounters could then be more efficiently allocated.
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Affiliation(s)
- Bernie Y Sunwoo
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, CA, USA
| | - Matthew Light
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, CA, USA
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, CA, USA
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9
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Mehrtash M, Bakker JP, Ayas N. Predictors of Continuous Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea. Lung 2019; 197:115-121. [PMID: 30617618 DOI: 10.1007/s00408-018-00193-1] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 12/29/2018] [Indexed: 01/23/2023]
Abstract
Obstructive sleep apnea (OSA) is a common disease which impacts quality of life, mood, cardiovascular morbidity, and mortality. Continuous positive airway pressure (CPAP) is the first-line treatment for patients with moderate to severe OSA. CPAP ameliorates respiratory disturbances, leading to improvements in daytime sleepiness, quality of life, blood pressure, and cognition. However, despite the high efficacy of this device, CPAP adherence is often sub-optimal. Factors including: socio-demographic/economic characteristics, disease severity, psychological factors, and side-effects are thought to affect CPAP adherence in OSA patients. Intervention studies have suggested that augmented support/education, behavioral therapy, telemedicine and technological interventions may improve CPAP adherence. In this paper, we will extensively review the most common factors including age, gender, race/ethnicity, socioeconomic status, smoking status, severity of OSA, severity of OSA symptoms, psychological variables, social support, marital status/bed partner involvement, dry nose and mouth, mask leak, and nasal congestion that may predict CPAP adherence. We will also extensively review interventions that may increase adherence to CPAP.
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Affiliation(s)
- M Mehrtash
- Experimental Medicine Program, Department of Medicine, University of British Columbia (UBC), Vancouver, BC, Canada
- Sleep Disorders Program, UBC Hospital, Vancouver, BC, Canada
| | - J P Bakker
- Division of Sleep & Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
| | - N Ayas
- Sleep Disorders Program, UBC Hospital, Vancouver, BC, Canada.
- Respiratory and Critical Care Divisions, Department of Medicine, UBC, Vancouver, BC, Canada.
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10
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Bilyukov RG, Nikolov MS, Pencheva VP, Petrova DS, Georgiev OB, Mondeshki TL, Milanova VK. Cognitive Impairment and Affective Disorders in Patients With Obstructive Sleep Apnea Syndrome. Front Psychiatry 2018; 9:357. [PMID: 30131730 PMCID: PMC6091233 DOI: 10.3389/fpsyt.2018.00357] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 07/18/2018] [Indexed: 11/13/2022] Open
Abstract
Sleep-related breathing disorders could be accompanied by or caused by a variety of medical conditions. They are considered to be a significant medical and social problem. Together with excessive daytime sleepiness, patients with obstructive sleep apnea experience neuropsychological symptoms such as anxiety, attention deficits, cognitive impairment, depressive symptoms and other psychological disturbances leading to social adjustment difficulties. Patients diagnosed with obstructive sleep apnea demonstrate a decline in a wide spectrum of cognitive abilities, including memory, attention, psychomotor speed, executive, verbal and visual-spatial skills. The aim of this study is to investigate the cognitive functioning and affective disorders among patients with obstructive sleep apnea syndrome and to examine the frequency and severity of cases in comparison with a control group consisting of healthy volunteers. Our research has shown that there is a relation between sleep apnea and cognitive impairments and affective changes. This relation can be explained by the direct effect of the syndrome on the patient, where the main connecting factor is the severity and the distribution of excessive daytime sleepiness. Along with treatment of the somatic medical condition, it is extremely important that the patient's mental state is treated as well. Trial Registration: 57/2013, Medical University - Sofia, Bulgaria.
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Affiliation(s)
- Radoslav G. Bilyukov
- Department of Propaedeutics of Internal Diseases, Medical University of Sofia, Sofia, Bulgaria
| | | | - Ventsislava P. Pencheva
- Department of Propaedeutics of Internal Diseases, Medical University of Sofia, Sofia, Bulgaria
| | - Daniela S. Petrova
- Department of Propaedeutics of Internal Diseases, Medical University of Sofia, Sofia, Bulgaria
| | - Ognian B. Georgiev
- Department of Propaedeutics of Internal Diseases, Medical University of Sofia, Sofia, Bulgaria
| | - Tsanko L. Mondeshki
- Department of Propaedeutics of Internal Diseases, Medical University of Sofia, Sofia, Bulgaria
| | - Vihra K. Milanova
- Department of Psychiatry, Medical University of Sofia, Sofia, Bulgaria
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11
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Pengo MF, Czaban M, Berry MP, Nirmalan P, Brown R, Birdseye A, Woroszyl A, Chapman J, Kent BD, Hart N, Rossi GP, Steier J. The effect of positive and negative message framing on short term continuous positive airway pressure compliance in patients with obstructive sleep apnea. J Thorac Dis 2018; 10:S160-S169. [PMID: 29445540 DOI: 10.21037/jtd.2017.07.110] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Continuous positive airway pressure (CPAP), the best available treatment for obstructive sleep apnea (OSA), requires long-term compliance to be effective. Behavioral interventions may be used to improve adherence to CPAP. We aimed to investigate whether positive or negative message framing impacts on CPAP compliance in patients with OSA, when compared to standard care. Methods Consenting patients with confirmed OSA were randomly allocated to receive along with their CPAP either positively or negatively framed messages (Pos; Neg), or standard care (Con). Standardized motivational messages were read out to patients during an initial teaching session and through weekly telephone calls. Patients' compliance data were reviewed 2 and 6 weeks following CPAP initiation. Results We randomized 112 patients to groups that were matched for age, BMI, and OSA severity. The positively framed group (Pos) showed greater CPAP usage after 2 weeks (total use 53.7±31.4 hours) as compared to the negatively framed and the control group (35.6±27.4 and 40.8±33.5 hours, P<0.05); however, no differences were seen at 6 weeks. There were more dropouts in the control group than in either framed groups (Pos n=5; Neg n=8; Con n=11; P<0.05). Conclusions Positively framed messages can improve CPAP adherence in patients with OSA in the short-term; however, strategies for implementing its long-term use need to be developed.
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Affiliation(s)
- Martino F Pengo
- Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK.,Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Marcin Czaban
- Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK.,School of Medicine, Faculty of Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Marc P Berry
- Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK
| | - Prajeshan Nirmalan
- Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK.,King's College London School of Medicine, London, UK
| | - Richard Brown
- Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK
| | - Adam Birdseye
- Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK
| | - Asia Woroszyl
- Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK
| | - Julia Chapman
- Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK
| | - Brian D Kent
- Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK
| | - Nicholas Hart
- Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK.,King's College London School of Medicine, London, UK.,King's Health Partners, London, UK.,NIHR Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Gian Paolo Rossi
- Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Joerg Steier
- Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK.,King's College London School of Medicine, London, UK.,King's Health Partners, London, UK
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12
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Deering S, Liu L, Zamora T, Hamilton J, Stepnowsky C. CPAP Adherence is Associated With Attentional Improvements in a Group of Primarily Male Patients With Moderate to Severe OSA. J Clin Sleep Med 2017; 13:1423-1428. [PMID: 29065955 DOI: 10.5664/jcsm.6838] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 08/02/2017] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is a widespread condition that adversely affects physical health and cognitive functioning. The prevailing treatment for OSA is continuous positive airway pressure (CPAP), but therapeutic benefits are dependent on consistent use. Our goal was to investigate the relationship between CPAP adherence and measures of sustained attention in patients with OSA. Our hypothesis was that the Psychomotor Vigilance Task (PVT) would be sensitive to attention-related improvements resulting from CPAP use. METHODS This study was a secondary analysis of a larger clinical trial. Treatment adherence was determined from CPAP use data. Validated sleep-related questionnaires and a sustained-attention and alertness test (PVT) were administered to participants at baseline and at the 6-month time point. RESULTS Over a 6-month time period, the average CPAP adherence was 3.32 h/night (standard deviation [SD] = 2.53), average improvement in PVT minor lapses was -4.77 (SD = 13.2), and average improvement in PVT reaction time was -73.1 milliseconds (standard deviation = 211). Multiple linear regression analysis showed that higher CPAP adherence was significantly associated with a greater reduction in minor lapses in attention after 6 months of continuous treatment with CPAP therapy (β = -0.72, standard error = 0.34, P = .037). CONCLUSIONS The results of this study showed that higher levels of CPAP adherence were associated with significant improvements in vigilance. Because the PVT is a performance-based measure that is not influenced by prior learning and is not subjective, it may be an important supplement to patient self-reported assessments. CLINICAL TRIAL REGISTRATION Name: Effect of Self-Management on Improving Sleep Apnea Outcomes, URL: https://clinicaltrials.gov/ct2/show/NCT00310310, Identifier: NCT00310310.
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Affiliation(s)
- Sean Deering
- Health Services Research and Development, VA San Diego Healthcare System, La Jolla, California
| | - Lin Liu
- Health Services Research and Development, VA San Diego Healthcare System, La Jolla, California.,Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - Tania Zamora
- Health Services Research and Development, VA San Diego Healthcare System, La Jolla, California
| | | | - Carl Stepnowsky
- Health Services Research and Development, VA San Diego Healthcare System, La Jolla, California.,Department of Medicine, University of California San Diego, La Jolla, California
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13
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Fung CH, Alessi C, Truong C, Josephson K, Hays RD, Col N, Patterson ES, Martin JL. Patient-Provider Communication With Older Adults About Sleep Apnea Diagnosis and Treatment. Behav Sleep Med 2017; 15:423-437. [PMID: 27144908 PMCID: PMC5429217 DOI: 10.1080/15402002.2016.1150278] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Patient-provider communication impacts adherence to therapy. We explored older adults' communication with their providers, preferences for communication, and views on communication attributes and decision aid characteristics, by conducting four focus groups. Several participants reported they had received insufficient information about their sleep apnea diagnosis and treatment options. Most participants felt that it would be helpful to have treatment information tailored to their needs, including information on the negative impact of treatment on comfort and convenience and disclosure about common barriers to adherence. Participants provided desired characteristics for a decision aid, including their preferred delivery method, content, and format. These findings have implications for how to design useful decision aids for older adults with newly diagnosed sleep apnea.
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Affiliation(s)
- Constance H. Fung
- VA Greater Los Angeles Healthcare System, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
- Division of Geriatrics, David Geffen School of Medicine at UCLA, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
| | - Cathy Alessi
- VA Greater Los Angeles Healthcare System, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
- Division of Geriatrics, David Geffen School of Medicine at UCLA, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
| | - Cindy Truong
- VA Greater Los Angeles Healthcare System, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
- Division of Geriatrics, David Geffen School of Medicine at UCLA, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
| | - Karen Josephson
- VA Greater Los Angeles Healthcare System, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
| | - Ron D. Hays
- Division of General Internal Medicine and Health Services Research, UCLA Department of Medicine, 911 Broxton Avenue, Los Angeles, CA 90095
| | - Nananda Col
- University of New England, 11 Hills Beach Road, Biddeford, ME 04005
| | - Emily S. Patterson
- School of Health and Rehabilitation Sciences, Ohio State University, 543 Atwell Hall, 453 W. 10 Avenue, Columbus, OH 43210
| | - Jennifer L. Martin
- VA Greater Los Angeles Healthcare System, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
- Division of Geriatrics, David Geffen School of Medicine at UCLA, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
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14
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Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg 2016; 45:43. [PMID: 27542595 PMCID: PMC4992257 DOI: 10.1186/s40463-016-0156-0] [Citation(s) in RCA: 412] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/11/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a common disorder, and continuous airway positive pressure (CPAP) is considered to be the gold standard of therapy. CPAP however is known to have problems with adherence, with many patients eventually abandoning the device. The purpose of this paper is to assess secular trends in CPAP adherence over the long term to see if there have been meaningful improvements in adherence in light of the multiple interventions proposed to do so. METHODS A comprehensive systematic literature review was conducted using the Medline-Ovid, Embase, and Pubmed databases, searching for data regarding CPAP adherence over a twenty year timeframe (1994-2015). Data was assessed for quality and then extracted. The main outcome measure was reported CPAP non-adherence. Secondary outcomes included changes in CPAP non-adherence when comparing short versus long-term, and changes in terms of behavioral counseling. RESULTS Eighty-two papers met study inclusion/exclusion criteria. The overall CPAP non-adherence rate based on a 7-h/night sleep time that was reported in studies conducted over the twenty year time frame was 34.1 %. There was no significant improvement over the time frame. Behavioral intervention improved adherence rates by ~1 h per night on average. CONCLUSIONS The rate of CPAP adherence remains persistently low over twenty years worth of reported data. No clinically significant improvement in CPAP adherence was seen even in recent years despite efforts toward behavioral intervention and patient coaching. This low rate of adherence is problematic, and calls into question the concept of CPAP as gold-standard of therapy for OSA.
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Affiliation(s)
- Brian W Rotenberg
- Department of Otolaryngology - Head and Neck Surgery, Western University, London, ON, Canada
| | - Dorian Murariu
- Department of Otolaryngology - Head and Neck Surgery, Western University, London, ON, Canada
| | - Kenny P Pang
- Asia Sleep Centre, Paragon, 290, Orchard Road, Unit 18-04, Singapore, 238859, Singapore.
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15
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Bakker JP, Wang R, Weng J, Aloia MS, Toth C, Morrical MG, Gleason KJ, Rueschman M, Dorsey C, Patel SR, Ware JH, Mittleman MA, Redline S. Motivational Enhancement for Increasing Adherence to CPAP: A Randomized Controlled Trial. Chest 2016; 150:337-45. [PMID: 27018174 DOI: 10.1016/j.chest.2016.03.019] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/19/2016] [Accepted: 03/01/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Motivational enhancement (ME) shows promise as a means of increasing adherence to CPAP for OSA. METHODS We performed an open-label, parallel-arm, randomized controlled trial of CPAP only or CPAP + ME, recruiting individuals 45 to 75 years with moderate or severe OSA without marked sleepiness and with either established cardiovascular disease (CVD) or at risk for CVD. All participants received standardized CPAP support from a sleep technologist; those randomly assigned to CPAP + ME also received standardized ME delivered by a psychologist during two appointments and six phone calls over 32 weeks. Mixed-effect models with subject-specific intercepts and slopes were fitted to compare objective CPAP adherence between arms, adjusting for follow-up duration, randomization factors, and device manufacturer. All analyses were intention-to-treat. RESULTS Overall, 83 participants (n = 42 CPAP only; n = 41 CPAP + ME) contributed 14,273 nights of data for 6 months. Participants were predominantly male (67%) and had a mean ± SD age of 63.9 ± 7.4 years, a BMI of 31.1 ± 5.2 kg/m(2), and an apnea-hypopnea index of 26.2 ± 12.9 events/h. In our fully adjusted model, average nightly adherence for 6 months was 99.0 min/night higher with CPAP + ME compared with CPAP only (P = .003; primary analysis). A subset of 52 participants remained in the study for 12 months; modeling these data yielded a consistent difference in adherence between arms of 97 min/night (P = .006) favoring CPAP + ME. CONCLUSIONS ME delivered during brief appointments and phone calls resulted in a clinically significant increase in CPAP adherence. This strategy may represent a feasible approach for optimizing management of OSA. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01261390; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Jessie P Bakker
- Division of Sleep & Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Rui Wang
- Division of Sleep & Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA
| | - Jia Weng
- Division of Sleep & Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mark S Aloia
- National Jewish Health, Denver, CO; Philips Respironics, Murrysville, PA
| | - Claudia Toth
- Division of Sleep & Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael G Morrical
- Division of Sleep & Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kevin J Gleason
- Division of Sleep & Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael Rueschman
- Division of Sleep & Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Sanjay R Patel
- Division of Sleep & Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - James H Ware
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA
| | - Murray A Mittleman
- Department of Epidemiology, Harvard TH Chan School of Public Health and Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, Boston, MA
| | - Susan Redline
- Division of Sleep & Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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16
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Ng SSS, Chan TO, To KW, Chan KKP, Ngai J, Tung A, Ko FWS, Hui DSC. Prevalence of obstructive sleep apnea syndrome and CPAP adherence in the elderly Chinese population. PLoS One 2015; 10:e0119829. [PMID: 25774657 PMCID: PMC4361659 DOI: 10.1371/journal.pone.0119829] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 01/28/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND This study assessed the prevalence of obstructive sleep apnea syndrome (OSAS) and CPAP adherence in the elderly Chinese in Hong Kong. METHODS We conducted a sleep questionnaire survey among the elders aged ≥60 years in the community centres followed by level 3 home sleep study (Embletta). Subjects with an apnea hypopnea index (AHI) ≥ 15/hr alone and those with AHI ≥ 5/hr plus either cardiovascular risk factors or Epworth Sleepiness Score (ESS) ≥ 10 were offered CPAP treatment. RESULTS Altogether 819 subjects were interviewed with mean (SD) age of 73.9 (7.5) years, BMI 24.2 (3.6) kg/m2, neck circumference 34.9 (3.4) cm and ESS 6.6 (5.2). Daytime sleepiness was reported by 72.4%, snoring loudly 5.1% and witnessed apnea 4%. Among 234 subjects who underwent home sleep study, 156 (66.7%), 102 (43.6%), 70 (29.9%) and 45 (19.2%) had AHI ≥ 5, ≥ 10, ≥ 15 and ≥ 20/hr respectively, with the prevalence increasing with age and BMI. In the sample, 149 subjects (63.7%) were classified as having OSAS, as defined by an AHI ≥ 5/hr with associated symptoms, involving 81 men (74.3%) and 68 women (54.4%). Neck circumference and snoring frequency were the only positive independent factors associated with the AHI and the diagnosis of OSAS. Among 141 subjects who were offered CPAP treatment, 30 accepted CPAP prescription with improvement of ESS and cognitive function over 12 months with CPAP usage of 4.2 (2.2) h/night. CONCLUSION This study showed a high prevalence of OSAS among the community elders in Hong Kong. Home CPAP acceptance was low but there was significant improvement of subjective sleepiness and cognitive function among those on CPAP treatment.
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Affiliation(s)
- Susanna S. S. Ng
- Division of Respiratory Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong
| | - Tat-On Chan
- Division of Respiratory Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong
| | - Kin-Wang To
- Division of Respiratory Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong
| | - Ken K. P. Chan
- Division of Respiratory Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong
| | - Jenny Ngai
- Division of Respiratory Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong
| | - Alvin Tung
- Division of Respiratory Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong
| | - Fanny W. S. Ko
- Division of Respiratory Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong
| | - David S. C. Hui
- Division of Respiratory Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong
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17
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Immediate and Long-term Neurocognitive Outcome in Patients with Obstructive Sleep Apnea Syndrome After Continuous Positive Airway Pressure Treatment. Indian J Otolaryngol Head Neck Surg 2014; 67:79-85. [PMID: 25621259 DOI: 10.1007/s12070-014-0777-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 09/13/2014] [Indexed: 02/03/2023] Open
Abstract
Neurocognitive dysfunction is a major clinical consequence in patients with obstructive sleep apnea syndrome (OSAS). The effects of continuous positive airway pressure (CPAP) treatment, as the gold standard of treatment in OSAS, on this major complication are controversial. The duration and compliance of CPAP are thought to be important factors but evidence is lacking. This study is designed to evaluate the effects of immediate (one night), long-term (3 months) influence and the compliances of CPAP treatment on the neurocognitive function in OSAS patients. We enrolled newly diagnosed severe OSAS patients. Neurocognitive function test battery, CANTAB (Cambridge Neuropsychological Test Automated Battery), was performed before, one night and 3 months of CPAP treatment. Patients with CPAP compliance rate ≥ 70 % and < 50 % were grouped into good and poor adherence subjects, respectively. Fourteen patients were enrolled in final analyses. Six of them were in poor compliant group. Improvements in attention domain were found in all subjects after one-night treatment and maintained till three-month follow-up. Additional improvements in some attention performances and visual memory performances were gained only after three-month treatment. Significant changes of decision-making and response control function were found between good and poor compliance groups after three-month treatment. CPAP can improve some neurocognitive function at the very first day used. Longer treatment of CPAP can additionally improve some other neurocognitive functions. Compliance of CPAP has influence on the recovery of neurocognitive functions in patients with severe OSAS.
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18
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Ye L, Malhotra A, Kayser K, Willis DG, Horowitz JA, Aloia MS, Weaver TE. Spousal involvement and CPAP adherence: a dyadic perspective. Sleep Med Rev 2014; 19:67-74. [PMID: 24906222 DOI: 10.1016/j.smrv.2014.04.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 03/21/2014] [Accepted: 04/27/2014] [Indexed: 10/25/2022]
Abstract
Poor adherence to continuous positive airway pressure (CPAP) treatment is associated with substantial health care costs, morbidity and mortality, and has been a leading obstacle in the effective management of obstructive sleep apnea (OSA). Successful interventions to improve CPAP adherence may ultimately include a variety of components. For patients living with spouses (refers to all domestic partners), the spouse will likely be an integral component to any successful intervention. Developing understanding of the role of spouses in adherence to CPAP has been identified to be a critical research need. This review expands the investigation of CPAP adherence to a broader context, from an exclusive focus on individual patients to a dyadic perspective encompassing both patients and their spouses. A conceptual framework based on social support and social control theories is proposed to understand spousal involvement in CPAP adherence. Methodologies for future investigations are discussed, along with implications for developing interventions that engage both patients and their spouses to improve CPAP use.
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Affiliation(s)
- Lichuan Ye
- Boston College, William F. Connell School of Nursing, Chestnut Hill, MA, USA.
| | - Atul Malhotra
- University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Karen Kayser
- University of Louisville Kent School of Social Work, Louisville, KY, USA
| | - Danny G Willis
- Boston College, William F. Connell School of Nursing, Chestnut Hill, MA, USA
| | - June A Horowitz
- Thomas Jefferson University School of Nursing, Philadelphia, PA, USA
| | | | - Terri E Weaver
- University of Illinois at Chicago, College of Nursing, Chicago, IL, USA
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19
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Parthasarathy S, Subramanian S, Quan SF. A multicenter prospective comparative effectiveness study of the effect of physician certification and center accreditation on patient-centered outcomes in obstructive sleep apnea. J Clin Sleep Med 2014; 10:243-9. [PMID: 24634620 PMCID: PMC3927428 DOI: 10.5664/jcsm.3518] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To study the effect of sleep center accreditation and Sleep Medicine board certification of physicians on patient-centered outcomes in obstructive sleep apnea (OSA). DESIGN Prospective, multicenter, comparative effectiveness study. SETTING Four sleep centers. PATIENTS 502 patients with OSA. INTERVENTIONS None. MEASUREMENTS AND RESULTS Patients at two accredited and two non-accredited centers underwent polysomnography at participating locations and completed validated questionnaires, with objective measurement of positive airway pressure (PAP) therapy adherence performed three months after therapy initiation. The proportion of patients (age 53 ± 13[SD] years; 26% women; and body mass index 33.6 ± 7.2 kg/m(2)) who were adherent to PAP therapy by Medicare guidelines (> 70% of nights with ≥ 4 h use over a 30-day period) was greater in accredited (79%) than non-accredited sites (64%; p = 0.004). After adjustment for confounding variables, patients who received care from accredited centers (odds ratio [OR] 2.2, 95% confidence interval [CI], 1.2-4.2; p = 0.016) and certified physicians (OR 2.3, 95% CI, 1.3-4.0; p = 0.005) were more likely to be adherent to PAP therapy than those who received care from non-accredited centers and non-certified physicians. Patient satisfaction was associated with greater education received from physician (OR 4.6; 95% CI 2.3-9.3); greater risk perception (OR 2.7; 95% CI 1.0-7.4); physician certification (OR 2.1; 95% CI 1.1-4.2); and inversely related to delays in care (OR 0.5; 95% CI 0.3-0.9; p < 0.05). Such delays were inversely related to accreditation-certification status (p < 0.0001). CONCLUSIONS In patients with OSA, accreditation-certification status of sleep centers and physicians was associated with better PAP adherence, better patient education, better patient satisfaction, and greater timeliness. COMMENTARY A commentary on this article appears in this issue on page 251. CITATION Parthasarathy S; Subramanian S; Quan SF. A multicenter prospective comparative effectiveness study of the effect of physician certification and center accreditation on patient-centered outcomes in obstructive sleep apnea.
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Affiliation(s)
- Sairam Parthasarathy
- Arizona Respiratory Center
- Department of Medicine, University of Arizona, Tucson, AZ
| | - Shyam Subramanian
- Division of Pulmonary, Critical Care, and Sleep, Mercy West Hospital, Cincinnati, OH
| | - Stuart F. Quan
- Arizona Respiratory Center
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
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Bartlett D, Wong K, Richards D, Moy E, Espie CA, Cistulli PA, Grunstein R. Increasing adherence to obstructive sleep apnea treatment with a group social cognitive therapy treatment intervention: a randomized trial. Sleep 2013; 36:1647-54. [PMID: 24179297 DOI: 10.5665/sleep.3118] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To examine whether a social cognitive therapy (SCT) intervention increases continuous positive airway pressure (CPAP) use compared to equivalent social interaction (SI) time. PARTICIPANTS Individuals with obstructive sleep apnea (OSA) referred for CPAP therapy. INTERVENTION Participants received a 30-min group education session regarding OSA and CPAP. Groups of three to four participants were then randomly assigned to an SCT session or social interaction. MEASUREMENTS CPAP usage was assessed at 7 nights, then 1, 3, and 6 months. The two primary outcomes were adherence, usage ≥ 4 h per night at 6 months, and uptake of CPAP. Questionnaires were given pretreatment and posttreatment. RESULTS Two hundred six individuals were randomized to SI (n = 97) or SCT (n = 109). CPAP uptake was not different between groups (82% in SI, 88% in SCT groups, P = 0.35). There were no differences between groups in adherence: 63-66% at 1 week, and at 6 months 55-47% (P = 0.36). Higher pretreatment apnea-hypopnea index, higher baseline self-efficacy, and use of CPAP (≥ 4 h) at 1 week were independent predictors of CPAP adherence at 6 months. CPAP adherence increased by a factor of 1.8 (odds ratio = 1.8, 95% confidence interval 1.1-3.0) for every one-unit increase in self-efficacy. There was no difference between groups postintervention in self-efficacy scores, sleepiness, mood, or sleep quality. CONCLUSIONS In this randomized trial, a single SCT application did not increase adherence when compared with SI time. Although self-efficacy scores prior to CPAP predicted adherence, self-efficacy was not increased by the interventions. Increasing intensity and understanding of SCT interventions may be needed to improve CPAP adherence. CLINICAL TRIALS REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12607000424404.
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Affiliation(s)
- Delwyn Bartlett
- NHMRC Centre for Integrated Research in Understanding of Sleep (CIRUS), University of Sydney, Sydney, Australia ; Sleep and Circadian Research Group Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
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Aloia MS, Arnedt JT, Strand M, Millman RP, Borrelli B. Motivational enhancement to improve adherence to positive airway pressure in patients with obstructive sleep apnea: a randomized controlled trial. Sleep 2013; 36:1655-62. [PMID: 24179298 DOI: 10.5665/sleep.3120] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is associated with a variety of medical conditions. Positive airway pressure (PAP) is an effective treatment for improving sleep, yet adherence rates are low. The aim of the current study is to test two treatments versus standard care in improving adherence to PAP. METHOD Two hundred twenty-seven patients with OSA were randomized to standard care (SC), education (ED) and motivational enhancement therapy (MET). Adherence was measured objectively and the first week of adherence (prior to the intervention) was used as an a priori moderator of the effect of the various interventions. Mediators of treatment response were also examined using theory-based measures of decisional balance and self-efficacy. RESULTS Adherence declined over time for all three groups. There was a significant interaction between level of adherence during the first week of treatment and treatment group. Those who had moderate levels of adherence during their first week of PAP were more likely to adhere to treatment at follow-up if they had MET; those who had high levels of adherence during their first week of PAP were more likely to adhere to treatment at follow-up if they had ED. MET treatment increased the perception of the positive aspects of PAP, but ED did not. CONCLUSIONS Initial adherence to positive airway pressure could help guide subsequent treatment plans. The results also support social cognitive theory in that educational approaches might be best suited for those who are ready for change whereas more motivational approaches might be best for those who are ambivalent about change.
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Affiliation(s)
- Mark S Aloia
- Department of Medicine, National Jewish Health, Denver, CO
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Stanchina ML, Welicky LM, Donat W, Lee D, Corrao W, Malhotra A. Impact of CPAP use and age on mortality in patients with combined COPD and obstructive sleep apnea: the overlap syndrome. J Clin Sleep Med 2013; 9:767-72. [PMID: 23946706 DOI: 10.5664/jcsm.2916] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The overlap syndrome, defined by concurrent existence of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA), is associated with poor outcomes. From a large outpatient cohort we aimed to define better the risk factors for increased mortality in the overlap syndrome and hypothesized that CPAP adherence would be associated with improved survival in patients with overlap syndrome. METHODS A post hoc analysis from an outpatient database of 10,272 patients from 2007-2010, identified 3,396 patients which were classified in 6 groups; patients both alive or deceased, with the known diagnosis of COPD, OSA, and the overlap of COPD plus OSA. Information regarding their gender, age, pulmonary function, obstructive sleep apnea parameters, and CPAP compliance was collected. A multivariate Cox proportional hazards model was generated for the determinants of mortality. RESULTS 1,112 COPD patients and 2,284 OSA patients were identified by diagnostic coding and then comprehensive chart review. Of these, 227 patients were identified with the overlap syndrome. From this group, 17 patients (7.4%) died. Multivariate analysis revealed hours of CPAP use and age as independent predictors of mortality (HR 0.71 and 1.14, p < 0.001, 0.002). Greater time on CPAP was associated with reduced mortality; although age did not correlate with CPAP use (p = 0.2), mean age of those with CPAP use < 2 hours per night was significantly higher than those using CPAP > 2 hours per night. CONCLUSIONS From this observational cohort, mortality in the overlap syndrome is impacted by CPAP use. Age is also an independent factor which has a negative association with survival and CPAP usage.
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Lettieri CJ, Walter RJ. Impact of group education on continuous positive airway pressure adherence. J Clin Sleep Med 2013; 9:537-41. [PMID: 23772185 DOI: 10.5664/jcsm.2742] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
STUDY OBJECTIVES To compare the impact of a group educational program versus individual education on continuous positive airway pressure (CPAP) adherence. METHODS Post hoc assessment of a performance improvement initiative designed to improve clinic efficiency, access to care, and time to initiate therapy. Consecutive patients newly diagnosed with obstructive sleep apnea (OSA) initiating CPAP therapy participated in either an individual or group educational program. The content and information was similar in both strategies. RESULTS Of 2,116 included patients, 1,032 received education regarding OSA and CPAP through a group clinic, and 1,084 received individual education. Among the cohort, 76.6% were men, mean age 48.3 ± 9.2 years, mean body mass index 29.6 ± 4.6 kg/m(2), and mean apnea-hypopnea index was 33.3 ± 24.4 events/hour. Baseline characteristics were similar between groups. CPAP adherence was significantly greater in those participating in a group program than those receiving individual education. Specifically, CPAP was used for more nights (67.2% vs. 62.1%, p = 0.02) and more hours per night during nights used (4.3 ± 2.1 vs. 3.7 ± 2.8, p = 0.03). Further, fewer individuals discontinued therapy (10.6% vs. 14.5%, p < 0.001), more achieved regular use of CPAP (45.2%. vs. 40.6%, p = 0.08), and time to initiate therapy was shorter (13.2 ± 3.1 versus 24.6 ± 7.4 days, p < 0.001). Group education resulted in a 3- to 4-fold increase in the number of patients seen per unit time. CONCLUSIONS A group educational program facilitated improved CPAP adherence. If confirmed by prospective randomized studies, group CPAP education may be an appropriate alternative to individual counseling, may improve acceptance of and adherence to therapy, and decrease time to treatment.
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Affiliation(s)
- Christopher J Lettieri
- Pulmonary, Critical Care, and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.
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Parthasarathy S, Wendel C, Haynes PL, Atwood C, Kuna S. A pilot study of CPAP adherence promotion by peer buddies with sleep apnea. J Clin Sleep Med 2013; 9:543-50. [PMID: 23772186 PMCID: PMC3659373 DOI: 10.5664/jcsm.2744] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To evaluate patient ratings of the acceptability of a peer buddy system (PBS). To promote continuous positive airway pressure (CPAP) therapy adherence in patients with obstructive sleep apnea (OSA). To obtain preliminary data on the effectiveness of PBS on sleep-specific health-related quality of life and CPAP adherence. DESIGN Prospective, randomized, and controlled study. SETTING Academic Center. PARTICIPANTS Thirty-nine patients with OSA and 13 patients with OSA who were experienced CPAP users. INTERVENTIONS Recently diagnosed patients with OSA were randomly assigned to either the PBS to promote CPAP adherence (intervention group) or usual care (control group). MEASUREMENTS Patient satisfaction, Functional Outcomes of Sleep Questionnaire (FOSQ), CPAP adherence, vigilance, self-efficacy, and patient activation were measured. RESULTS Ninety-one percent of the subjects rated the PBS as very satisfactory (68%) or satisfactory (23%). During the 90 days of therapy, weekly CPAP adherence was greater in the intervention than the usual care group (MANOVA; F = 2.29; p = 0.04). Patient satisfaction was positively correlated with CPAP adherence (R(2) = 0.14; p = 0.02). We did not find any group differences for FOSQ, vigilance, self-efficacy, or patient activation in this pilot study. CONCLUSION Our pilot study suggests that the PBS intervention is feasible and received high patient satisfaction ratings. CPAP adherence may be improved by peer-driven intervention, but a larger, adequately powered study is needed. CLINICAL TRIAL INFORMATION ClinicalTrials.gov identifier: NCT01164683. COMMENTARY A commentary on this article appears in this issue on page 551. CITATION Parthasarathy S; Wendel C; Haynes PL; Atwood C; Kuna S. A pilot study of CPAP adherence promotion by peer buddies with sleep apnea. J Clin Sleep Med 2013;9(6):543-550.
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Affiliation(s)
- Sairam Parthasarathy
- Southern Arizona Veterans Administration Health Care System, Tucson, AZ 85723, USA.
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Sampaio R, Graça Pereira M, Winck JC. Obstructive sleep apnea representations, self-efficacy and family coping regarding APAP adherence: a longitudinal study. PSYCHOL HEALTH MED 2013; 19:59-69. [PMID: 23484461 DOI: 10.1080/13548506.2013.774430] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Adherence is still an important issue considering new advances in Obstructive Sleep Apnea (OSA) treatment, as automatic positive airway pressure (APAP). The aim of the present study was to identify and explore relationships between identified predictors of adherence, over time. After overnight sleep study and OSA diagnosis and during a six-month APAP treatment period, a total of 153 patients underwent a three time psychological protocol evaluation. Generalized estimating equations were applied to analyzed repeated measurements in the same individuals. Results show that 40% of patients were poorly adherent and 60% were adherent after six months of treatment. The results confirmed a predictive value of age, self-efficacy, decisional balance index and health-related quality of life (HRQoL) in APAP adherence. Furthermore, the results revealed an interaction between time and illness cognitive representations, and self-efficacy and family coping, in explaining adherence patterns over time. Therefore, understanding the causality of theoretically derived constructs is crucial to predict the continuity of APAP adherence.
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Affiliation(s)
- Rute Sampaio
- a School of Psychology , Minho University , Braga , Portugal
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Patel N, Sam A, Valentin A, Quan SF, Parthasarathy S. Refill rates of accessories for positive airway pressure therapy as a surrogate measure of long-term adherence. J Clin Sleep Med 2012; 8:169-75. [PMID: 22505862 DOI: 10.5664/jcsm.1772] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVES To identify and validate a surrogate measure of long-term adherence to positive airway pressure (PAP) therapy in patients with obstructive sleep apnea (OSA). DESIGN Retrospective cohort study. SETTING Academic center. PARTICIPANTS 220 consecutive patients with OSA. INTERVENTIONS N/A. MEASUREMENTS In patients with OSA who were receiving PAP therapy (for > 1 year), PAP adherence measured by device-download and defined by Medicare criteria was compared to refill rates for mask and other PAP therapy accessories. First, receiver operating characteristic (ROC) curves were constructed to identify a threshold value of refills per year that discriminated best between PAP adherent and non-adherent patients (derivation set; n = 100). Then the predictive accuracy of the threshold value of refills per year was tested in an additional 120 consecutive patients (validation set). RESULTS From the derivation set, ROC curve with good discriminant characteristics (ROC 0.83; 95% confidence intervals [CI], 0.75, 0.91, p < 0.0001) was used to identify a threshold value of refills (0.7 refills/year) for distinguishing PAP adherent and non-adherent patients. Subsequently, when the threshold was applied to the validation set, the likelihood ratio for a positive test (weighted for prevalence) predicting adherence to PAP therapy was 7.3 (95%CI, 3.8, 14), and likelihood ratio for a negative test was 0.6 (95%CI; 0.4, 0.8). CONCLUSION Refill rate of PAP accessories exhibited good test characteristics for predicting long-term PAP adherence. Such a surrogate measure based upon insurance claims data can be a powerful epidemiological tool in bioinformatics-aided comparative-effectiveness research and to monitor clinical performance of health systems.
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Affiliation(s)
- Nimesh Patel
- Southern Arizona Veterans Administration Healthcare System, Tucson, AZ, USA
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Pieh C, Bach M, Popp R, Jara C, Crönlein T, Hajak G, Geisler P. Insomnia symptoms influence CPAP compliance. Sleep Breath 2012; 17:99-104. [PMID: 22311553 DOI: 10.1007/s11325-012-0655-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 12/16/2011] [Accepted: 01/13/2012] [Indexed: 10/14/2022]
Abstract
PURPOSE The aim of this study is to determine parameters which influence 6-month compliance of continuous positive airway pressure therapy (CPAP) in patients with obstructive sleep apnea syndrome (OSAS). METHODS This prospective study investigated 73 patients (24 females) with OSAS and medical indication for CPAP therapy: age 55.1 ± 11.5 years, body mass index (BMI) 30.8 ± 5.0 kg/m2, Apnea-Hypopnea Index (AHI) 39.2 ± 26.7/h, Oxygen Desaturation Index (ODI) 33.2 ± 25.4/h, minimum O(2) saturation 78.9 ± 7.6%. The influence of baseline parameters (demographic and polysomnographic data, sleeping medication intakes, BMI, psychometrics [Epworth Sleepiness Scale, Regensburg Insomnia Scale, Vigilance test and Beck Depression Inventory]) on 6-month compliance was evaluated with a correlation and a linear regression analysis. RESULTS The baseline value of the Regensburg Insomnia Scale (RIS) predicts 6-month CPAP compliance (r = -0.376, R (2) = 0.14, p < 0.001), although no other baseline parameter correlates. Patients with a compliance of <4 h/night show higher RIS scores, i.e., more insomnia symptoms (17.6 ± 8.8) compared to those with ≥4 h/night (12.6 ± 6.9; p < 0.05). CONCLUSIONS Insomnia symptoms prior to the beginning of CPAP treatment show a negative influence on CPAP compliance. Further studies should clarify, if a treatment of insomnia symptoms leads to a benefit in compliance.
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Affiliation(s)
- Christoph Pieh
- Department of Psychiatry and Psychotherapy, Sleep Disorder Center, University Medical Center Regensburg, Regensburg, Germany.
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Basoglu OK, Midilli M, Midilli R, Bilgen C. Adherence to continuous positive airway pressure therapy in obstructive sleep apnea syndrome: effect of visual education. Sleep Breath 2011; 16:1193-200. [PMID: 22167633 DOI: 10.1007/s11325-011-0631-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 11/30/2011] [Accepted: 12/02/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) therapy is the most effective treatment in obstructive sleep apnea syndrome (OSAS) although it is known that adherence to therapy is limited. The aims of this study were to evaluate the effect of visual education on CPAP adherence and to identify the factors affecting adherence. METHODS Out of 133 consecutive newly diagnosed moderate-to-severe OSAS patients, 66 were informed about OSAS and CPAP therapy and received visual education by videotape (video group), whereas only information was given to 67 of them (control group). The patients were followed up in the 1st, 3rd, and 6th months. RESULTS After 6-month follow-up, adherence rate to CPAP therapy was 71.2% in the video group and 56.7% in the control group (p = 0.08). OSAS symptoms, such as witnessed apnea, morning headache, night sweating, dry mouth, and Epworth sleepiness score (ESS), were ameliorated more significantly in the video group (p < 0.05). In order to assess predictors of adherence, 85 patients using CPAP effectively were compared to 48 nonadherent patients; significant improvement in OSAS symptoms and ESS was observed in the adherent patients (p < 0.05). ESS was negatively correlated with the duration of CPAP use (r = -0.524, p < 0.0001). Adverse effects such as mask intolerance, choking, noise, and nasal congestion were related to poorer adherence (p < 0.01). CONCLUSIONS It is shown that adherence rate to CPAP therapy might be improved by visual education although the difference was not significant. Besides, patients with better adherence to CPAP treatment report the greatest improvement in OSAS symptoms and daytime sleepiness, and adverse effects are significantly related to poorer adherence.
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Affiliation(s)
- Ozen K Basoglu
- Department of Chest Diseases, Ege University Medical School, 35100, Bornova, Izmir, Turkey.
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Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE. A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev 2011; 15:343-56. [PMID: 21652236 DOI: 10.1016/j.smrv.2011.01.003] [Citation(s) in RCA: 582] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 01/17/2011] [Accepted: 01/18/2011] [Indexed: 12/11/2022]
Abstract
Continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA) but adherence to the treatment limits its overall effectiveness across all age groups of patients. Factors that influence adherence to CPAP include disease and patient characteristics, treatment titration procedures, technological device factors and side effects, and psychological and social factors. These influential factors have guided the development of interventions to promote CPAP adherence. Various intervention strategies have been described and include educational, technological, psychosocial, pharmacological, and multi-dimensional approaches. Though evidence to date has led to innovative strategies that address adherence in CPAP-treated children, adults, and older adults, significant opportunities exist to develop and test interventions that are clinically applicable, specific to sub-groups of patients likely to demonstrate poor adherence, and address the multi-factorial nature of CPAP adherence. The translation of CPAP adherence promotion interventions to clinical practice is imperative to improve health and functional outcomes in all persons with CPAP-treated OSA.
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Affiliation(s)
- Amy M Sawyer
- University of Pennsylvania School of Nursing, Biobehavioral Health Sciences Division, USA.
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Pandey A, Demede M, Zizi F, Al Haija'a OA, Nwamaghinna F, Jean-Louis G, McFarlane SI. Sleep apnea and diabetes: insights into the emerging epidemic. Curr Diab Rep 2011; 11:35-40. [PMID: 21069483 PMCID: PMC4224959 DOI: 10.1007/s11892-010-0164-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The rampant diabetes pandemic over the past few decades has been associated with an increased rise in cardiovascular events and deaths. Risk factors such as obesity, family history of diabetes, decreased physical activity, and aging are among the most common in the development of diabetes. Emerging evidence in the past 10 years has suggested that sleep apnea is a novel risk factor in the development of diabetes. Associations between diabetes and sleep apnea are supported by both epidemiologic and clinical sleep apnea studies. In this report, we discuss epidemiologic and clinical evidence suggesting that sleep apnea is involved in the pathogenesis of altered glucose metabolism. In light of current evidence, sleep apnea treatment should be incorporated into existing pharmacotherapeutic regimens for optimal management of diabetes among diabetic patients with sleep apnea to reduce associated cardiovascular risk. Suggestions to improve practice guidelines in the management of diabetic patients with sleep apnea are provided.
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Affiliation(s)
- A Pandey
- Brooklyn Health Disparities Center, Department of Medicine, SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 1199, Brooklyn, NY 11203-2098, USA
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Abstract
Objective Sleep apnea syndrome (SAS) is common in older people. Nasal continuous airway pressure (NCPAP) therapy is the treatment of choice for sleep apnea, but is not always accepted by patients. The rate of successful initiation of NCPAP is unknown in geriatric patients. Methods All patients admitted for geriatric rehabilitation were considered for sleep studies. Sleep apnea was assessed using an Edentrace (Nellcor, Hayward, CA) multi-channel recording system. SAS was defined as an apnea-hypopnea-index (AHI) of more than five events per hour plus excessive daytime sleepiness, or an AHI of more than fifteen events per hour regardless of reported sleepiness. Disability was assessed using the Barthel Index of Activities of Daily Living. Results Two hundred sixty nine of 322 consecutive patients (84%) had adequate sleep studies and gave informed consent. SAS was found in 169 subjects (68%). There was no gender difference in the prevalence of SAS. Six subjects (4%) accepted NCPAP therapy. Individuals who accepted NCPAP were younger and less disabled (p < 0.03). Multiple logistic regression analysis revealed disability as the only significant factor predicting NCPAP acceptance. Conclusion NCPAP should not be withheld in the elderly. However, initiation of treatment for SAS remains to be a great challenge in those patients. Geriatric assessment procedures may help better manage older subjects with sleep apnea syndrome.
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Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Ann Am Thorac Soc 2008; 5:173-8. [PMID: 18250209 DOI: 10.1513/pats.200708-119mg] [Citation(s) in RCA: 1031] [Impact Index Per Article: 64.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Despite the high efficacy of continuous positive airway pressure (CPAP) to reverse upper airway obstruction in sleep apnea, treatment effectiveness is limited by variable adherence to prescribed therapy. When adherence is defined as greater than 4 hours of nightly use, 46 to 83% of patients with obstructive sleep apnea have been reported to be nonadherent to treatment. Evidence suggests that use of CPAP for longer than 6 hours decreases sleepiness, improves daily functioning, and restores memory to normal levels. The decision to embrace CPAP occurs during the first few days of treatment. Although many strategies in patient interface with CPAP or machine modality are marketed to improve CPAP usage, there are few data to support this. No single factor has been consistently identified as predictive of adherence. Patient perception of symptoms and improvement in sleepiness and daily functioning may be more important in determining patterns of use than physiologic aspects of disease severity. Emerging data suggest that various behavioral interventions may be effective in improving CPAP adherence.
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Kim H, Dinges DF, Young T. Sleep-disordered breathing and psychomotor vigilance in a community-based sample. Sleep 2008; 30:1309-16. [PMID: 17969464 DOI: 10.1093/sleep/30.10.1309] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVE Sleep-disordered breathing (SDB) has been associated with impaired psychomotor vigilance performance in patients with sleep apnea patients. A bias toward greater referral of sleep apnea patients with severely impaired performance could explain these findings. Furthermore, no studies on the association between SDB and vigilance performance in a large community-based sample have been reported that encompasses the full spectrum of SDB severity. This study investigated the association between SDB and psychomotor vigilance with cross-sectional data from the Wisconsin Sleep Cohort Study. SETTING AND PARTICIPANTS Community-based sample of 265 women and 346 men, mean age of 53.0 +/- 7.9 (age range: 35-74) years was used. Within 6 months of completing an overnight polysomnography protocol for SDB assessment, participants completed a 10-minute psychomotor vigilance task (PVT) during a daytime protocol. MEASUREMENTS Sleep-disordered breathing was indicated by the number of apneas and hypopneas; psychomotor vigilance task variables included (1) mean of 1/reaction time (RT), (2) number of lapses, (3) mean reciprocal of fastest 10% RTs, (4) mean reciprocal of slowest 10% RTs, (5) slope of linear regression line across the 10 minutes of the task fit to 1/RTs, and (5) number of false responses. RESULTS Multiple regression analysis showed a significant negative association between the logarithmically transformed apnea-hypopnea index (LogAHI) and number of lapses, mean of the slowest 10%, and number of false responses from the psychomotor vigilance task, independent of sex and body mass index in participants aged 65 years and older. CONCLUSION SDB in the community population is associated with impaired psychomotor vigilance in older men and women.
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Affiliation(s)
- Hyon Kim
- Department of Population Health Sciences, Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA.
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Abstract
Daytime sleepiness and sleep disordered breathing are increased in older compared to middle-aged adults. The cognitive and cardiovascular sequelae associated with obstructive sleep apnea (OSA) have significant implications for the older adult who may already be suffering from chronic illness. Most of the evidence supporting the utilization of continuous positive airway pressure (CPAP) for the treatment of OSA has been generated from studies employing samples consisting predominately of middle-aged adults. To examine the efficacy of CPAP for the treatment of obstructive sleep apnea in older adults with an emphasis on adherence and related treatment outcomes, this paper reviews findings from clinical trials including older individuals as well as those specifically targeting this population. These studies have demonstrated that following CPAP therapy, older adults have increased alertness, improved neurobehavioral outcomes in cognitive processing, memory, and executive function, decreased sleep disruption from nocturia and a positive effect on factors affecting cardiac function, including vascular resistance, platelet coagulability and other aspects of cardiovascular health. Physiological differences in respiratory structure and function between younger and older adults of similar disease severity are believed to result in older individuals requiring titration at lower CPAP levels. Once initiated, CPAP treatment is tolerated by older adults, including those with Alzheimer's disease. Patterns of adherence in older individuals are consistent with that of middle-aged adults.
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Affiliation(s)
- Terri E Weaver
- Biobehavioral and Health Sciences Division, School of Nursing, Division of Sleep Medicine, Department of Medicine, School of Medicine, University of Pennsylvania, Nursing Education Building, Philadelphia, PA 19104-6096, USA.
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35
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Means MK, Edinger JD, Husain AM. CPAP compliance in sleep apnea patients with and without laboratory CPAP titration. Sleep Breath 2004; 8:7-14. [PMID: 15026934 DOI: 10.1007/s11325-004-0007-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Advances in auto-adjusting positive airway pressure technology for obstructive sleep apnea now permit this treatment to be initiated outside of the sleep laboratory environment, bypassing the need for laboratory-based titration studies. Thus far, little research has addressed how such developments may affect compliance to continuous positive airway pressure (CPAP). We tested the effect of laboratory CPAP exposure and technologist support in a retrospective chart review of 98 veterans with obstructive sleep apnea to determine whether patients who received standard laboratory CPAP titration complied better with CPAP than did patients who received no laboratory CPAP titration. Fifty patients underwent standard technician-attended polysomnography (PSG) with CPAP titration, and 48 patients underwent unattended PSG with no laboratory trial of CPAP (first CPAP exposure was at home). Objective CPAP compliance measures were obtained from CPAP units at follow-up visits. Attended-PSG patients wore CPAP significantly longer per night on average (5.0 hours vs 3.9 hours) and tended to wear CPAP on more nights (76.5% vs 64.2%) compared with unattended-PSG patients. These findings suggest that patients' sleep laboratory experience with CPAP and the support and education provided by sleep technologists are important factors in facilitating CPAP compliance.
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Affiliation(s)
- Melanie K Means
- Department of Veterans Affairs Medical Center, Durham, North Carolina, USA.
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36
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Shochat T, Pillar G. Sleep apnoea in the older adult : pathophysiology, epidemiology, consequences and management. Drugs Aging 2004; 20:551-60. [PMID: 12795623 DOI: 10.2165/00002512-200320080-00001] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Sleep apnoea is a breathing disorder in sleep usually caused by repetitive upper airway obstruction. Its primary symptoms include snoring, daytime sleepiness and decreased cognitive functioning. Risk factors for the condition include obesity, anatomical abnormalities, aging, and family history. It has been associated with hypertension, cardiovascular and pulmonary diseases and increased mortality. The prevalence of sleep apnoea increases with age, although the severity of the disorder, as well as the morbidity and mortality associated with it, may actually decrease in the elderly. A decline in cognitive functioning in older adults with sleep apnoea may resemble dementia. Medical management of sleep apnoea rarely relies on drug treatment, as the few drugs (antidepressants and respiratory stimulants) tested for treatment have been found to be ineffective, or cause tolerance or serious adverse effects and complications. The treatment of choice for sleep apnoea is continuous positive airway pressure, a device which generates positive air pressure through a nose mask, creating a splint which keeps the airway unobstructed throughout the night. Weight loss significantly decreases or eliminates apnoeas. Oral appliances are used to enlarge the airway at night by moving the tongue and mandible forward. Positional therapy involves avoiding the supine position during sleep in patients who mostly have apnoeas while lying on their back. Surgical management may also be considered, although with great caution in the elderly, because of their increased risk of complications related to surgery. Surgical procedures include nasal reconstruction, somnoplasty, laser-assisted uvuloplasty, uvulopalatopharyngoplasty, genioglossus advancement and hyoid myotomy, and maxillomandibular advancement for severe cases when other treatments have failed. As a last option, tracheostomy may be performed.
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Affiliation(s)
- Tamar Shochat
- Sleep Lab, Technion-Israel Institute of Technology, Rambam Medical Center, Haifa, Israel.
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