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White DP, Messineo L, Thompson E, Hughes B, Lannom WD, Hete B, Joshi A, Noah WH. Kairos positive airway pressure (KPAP) equals continuous PAP in effectiveness, and offers superior comfort for obstructive sleep apnea treatment. Sleep Med 2024; 124:268-275. [PMID: 39341027 DOI: 10.1016/j.sleep.2024.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 09/14/2024] [Accepted: 09/16/2024] [Indexed: 09/30/2024]
Abstract
STUDY OBJECTIVES A recent study challenged the prevailing clinical view that maintaining inspiratory positive airway pressure (IPAP) is necessary for upper airway patency, demonstrating no differences in apnea hypopnea index (AHI) between continuous PAP (CPAP) with and without a resistor to reduce IPAP. In this study, we assessed the effect of Kairos PAP (KPAP), a new algorithm which features multiple drops in IPAP, only returning to therapeutic pressure near the end expiration, on sleep apnea severity and subjective comfort. METHODS Two randomized clinical trials were conducted. In the Efficacy trial, the effect of KPAP vs. CPAP on AHI in PAP-treated OSA patients was examined using a split-night design, adjusting for period, sequence and fraction of supine sleep (mixed models). Unintentional leak differences between treatments were also examined. Exploratory analyses assessed the effect of KPAP vs. CPAP on key polysomnography outcomes. In the Comfort trial, we tested subjective preference for KPAP vs. CPAP at 9 and 13 cmH2O in PAP-naïve OSA patients. RESULTS In the Efficacy trial (N = 48), KPAP reduced AHI more than CPAP (mean difference [95%CI]: -0.5 [-0.8, -0.2] events/h, P = 0.007). Unintentional leak was also reduced by over 50 % (-2.5 [-3.2, -1.7] L/min, P < 0.001). No significant change was observed in the exploratory variables assessed. In the Comfort trial (N = 150), 69 [61, 77] % and 84 [77, 89] % of participants preferred KPAP over CPAP at 9 and 13 cmH2O, respectively (P < 0.001). CONCLUSIONS KPAP is as effective as CPAP in reducing respiratory events, but is more comfortable and potentially better tolerated.
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Affiliation(s)
- David P White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA.
| | | | - Bryan Hughes
- Sleep Centers of Middle Tennessee, Murfreesboro, TN, USA
| | | | - Bernard Hete
- Sleep Centers of Middle Tennessee, Murfreesboro, TN, USA
| | - Abinash Joshi
- Sleep Centers of Middle Tennessee, Murfreesboro, TN, USA
| | - William H Noah
- Sleep Centers of Middle Tennessee, Murfreesboro, TN, USA
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Hillman DR. Treatment options for obstructive sleep apnea: general and perioperative. Int Anesthesiol Clin 2022; 60:74-82. [PMID: 35125482 DOI: 10.1097/aia.0000000000000354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- David R Hillman
- West Australian Sleep Disorders Research Institute, Centre for Sleep Science, University of Western Australia, Perth, Australia
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Ercelik M, Balbay EG, Gulhan PY, Cangur S, Arbak PM, Aytekin F, Elverisli MF. Factors affecting compliance with positive airway pressure therapy in obstructive sleep apnea. Sleep Breath 2021; 26:725-732. [PMID: 34328605 DOI: 10.1007/s11325-021-02447-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the factors affecting compliance with positive airway pressure (PAP) therapy and establish the relationship between compliance and pulmonary function tests (PFT) in patients with OSA. MATERIAL AND METHODS In this prospective study, patients with OSA using PAP devices were questioned about the complaints related to the device. Depression and anxiety scales along with PFT parameters were also assessed. RESULTS Of 98 participants, 63% were men. The mean age was 52.0 ± 9.6 years. Sixty-seven percent of the patients were compliant with their devices. A significant difference was observed between the proportion of the participants compliant or non-compliant with the device, based on OSA severity (p < 0.05). Beck depression inventory (BDI) and Beck anxiety inventory (BAI) scores of the compliant patients were significantly lower than those of the non-compliant patients (p < 0.001, p = 0.044, respectively). No statistically significant difference was detected between the groups regarding individual pulmonary function tests (p > 0.05). The rates of nasal mask use, not having difficulty in tolerating CPAP, falling asleep, absence of abdominal distension, no facial sores, no air leakage, patients benefiting from the device, reduction in daytime sleepiness, and the belief that they are receiving appropriate therapy in participants compliant with the device were higher than those in non-compliant participants (p < 0.05). The rates of claustrophobia and discomfort due to pressure were significantly lower in patients compliant with the device than in the non-compliant patients (p < 0.05). CONCLUSION While no relationship was detected between PFT parameters and PAP therapy compliance, significant factors affecting the device compliance were detected.
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Affiliation(s)
- Merve Ercelik
- Department of Chest Diseases, Afyonkarahisar Dinar State Hospital, 03400, Dinar, Afyonkarahisar, Turkey.
| | - Ege Gulec Balbay
- Department of Chest Diseases, Faculty of Medicine, Duzce University, Duzce, Turkey
| | - Pınar Yıldız Gulhan
- Department of Chest Diseases, Faculty of Medicine, Duzce University, Duzce, Turkey
| | - Sengul Cangur
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Duzce University, Düzce, Turkey
| | - Peri Meram Arbak
- Department of Chest Diseases, Faculty of Medicine, Duzce University, Duzce, Turkey
| | - Fuat Aytekin
- Department of Chest Diseases, Silopi State Hospital, Şırnak, Turkey
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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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Jerrentrup L, Canisius S, Wilhelm S, Kesper K, Ploch T, Vogelmeier C, Greulich T, Becker HF. Work of Breathing in Fixed and Pressure Relief Continuous Positive Airway Pressure (C-Flex™): A post hoc Analysis. Respiration 2016; 93:23-31. [PMID: 27871083 DOI: 10.1159/000452423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 10/11/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Expiratory pressure relief continuous positive airway pressure (pressure relief CPAP; C-Flex™) causes increases in inspiratory duty cycle and shortening of expiratory time. It has been suggested that these changes are caused by an increase in work of breathing. OBJECTIVES We studied the effects of C-Flex on work of breathing and intrinsic positive end-expiratory pressure as compared to fixed CPAP. METHODS Work of breathing was analyzed in 24 patients with obstructive sleep apnea during treatment with fixed CPAP and C-Flex with 3 different pressure relief settings in a randomized order during rapid-eye-movement (REM) and non-REM sleep. Work of breathing was assessed on a breath-by-breath basis using a piezoelectric esophageal pressure catheter and a pneumotachograph for measuring airflow. RESULTS We found there was no increase in inspiratory work of breathing observed using C-Flex compared to fixed CPAP. Instead, we found a linear decrease in inspiratory work of breathing with increasing pressure relief, with a mean difference of 1.22 J/min between CPAP and maximum pressure release (C-Flex 3; 90% of the value with nasal CPAP); however, the decrease was not statistically significant. The decrease in inspiratory work of breathing associated with C-Flex has a significant inverse correlation with BMI. CONCLUSIONS The C-Flex technology does not change work of breathing but shows a tendency towards a reduction of inspiratory work of breathing in patients with a lower BMI using higher C-Flex. The effect is probably caused by diminishing airway resistance generated by the positive end-expiratory pressure. Our findings may lead to additional fields of application of the C-Flex technology, such as chronic obstructive pulmonary disease or muscular dystrophy.
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Affiliation(s)
- Lukas Jerrentrup
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany
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Toraldo DM, De Nuccio F, Nicolardi G. Effects of nCPAP therapy on cardiorespiratory outcomes in obstructive sleep apnea syndrome: compliance and technological advancements. Expert Rev Respir Med 2014; 5:41-7. [DOI: 10.1586/ers.10.86] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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The SomnuSeal Oral Mask Is Reasonably Tolerated by Otherwise CPAP Noncompliant Patients with OSA. SLEEP DISORDERS 2013; 2013:840723. [PMID: 24228181 PMCID: PMC3817673 DOI: 10.1155/2013/840723] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 08/31/2013] [Accepted: 09/14/2013] [Indexed: 11/18/2022]
Abstract
Compliance with CPAP is the major limiting factor in treating patients with OSA. The novel SomnuSeal mask is an oral self-adaptable mask located between the teeth and the lips ensuring that there are no air leaks or skin abrasions. Fifty patients with AHI > 20, who failed previous CPAP trials, were asked to sleep with the mask for one month. In all patients, the mask was connected to an AutoPAP machine with a heated humidifier. Efficacy, convenience, and compliance (average usage for 4 or more hours per night) were monitored. Fifty patients (41 m and 9 f, mean age 57 ± 12 years, BMI 33.6 ± 4.9 kg/m(2), and AHI 47 ± 23/h) participated. Eleven were classified as compliant (average mask usage of 26 nights, 4.7 hours per night), five were only partially compliant (average usage of 13 nights, 2.9 hours per night), and 34 could not comply with it. In all patients who slept with it, the efficacy (assessed by residual AHI derived from the CPAP device) was good with an AHI of less than 8/hour. Interestingly, the required optimal pressure decreased from an average of 9.3 cmH2O to 4.6 cmH2O. The SomnuSeal oral interface is effective and may result in converting noncompliant untreated patients with OSA into well-treated ones.
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Wimms AJ, Richards GN, Benjafield AV. Assessment of the impact on compliance of a new CPAP system in obstructive sleep apnea. Sleep Breath 2013; 17:69-76. [PMID: 22286779 PMCID: PMC3575556 DOI: 10.1007/s11325-012-0651-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Revised: 12/15/2011] [Accepted: 01/13/2012] [Indexed: 11/27/2022]
Abstract
Background Despite the efficacy of continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea (OSA), compliance with therapy remains suboptimal. The aim of this study was to determine whether the use of S9TM increased compliance in established CPAP users. Methods Subjects with OSA (50) were recruited into the study. When subjects entered the study, 28 days of respective compliance data were downloaded from the patient's usual CPAP device. Subjects trialled the S9 CPAP for 28 days. Subjects then resumed use of their usual CPAP for 28 days. Compliance data from the patient's usual CPAP pre- and post-trialling S9 were compared with data from the S9 CPAP. Results Patients were significantly more compliant when using the S9 than their usual CPAP device both pre- and post-S9 based on average daily usage. CPAP pre-S9 = 6.58 ± 1.95 (mean hours ± SD), S9 = 7.08 ± 1.18 h and CPAP post-S9 = 6.71 ± 1.72 h. The difference between CPAP pre-S9 and S9 was 0.5 h (p = 0.003). The difference between S9 and CPAP post-S9 was 0.35 h (p = 0.01). There was no significant difference between CPAP pre-S9 and CPAP post-S9 (p = 0.34). Patients also completed questionnaires comparing the S9 system to their usual device. Subjective feedback showed a strong preference for the S9. Conclusions Participants were significantly more compliant when using the S9 than their usual CPAP device both pre- and post-S9 use.
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Chihara Y, Tsuboi T, Hitomi T, Azuma M, Murase K, Toyama Y, Harada Y, Aihara K, Tanizawa K, Handa T, Yoshimura C, Oga T, Yamamoto K, Mishima M, Chin K. Flexible positive airway pressure improves treatment adherence compared with auto-adjusting PAP. Sleep 2013; 36:229-36. [PMID: 23372270 PMCID: PMC3543062 DOI: 10.5665/sleep.2378] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES There are no clinical data comparing adherence and quality of life between auto-adjusting positive airway pressure (APAP) and two different flex positive airway pressure (PAP) devices (A-Flex, C-Flex) in patients with obstructive sleep apnea (OSA). DESIGN AND SETTING Ninety-three patients in whom OSA was newly diagnosed were randomly assigned to receive 3 mo of APAP (n = 31), APAP with C-Flex (n = 31), or APAP with A-Flex (n = 31). Objective adherence was determined after 3 mo of CPAP treatment, and the Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), and Calgary Sleep Apnea Quality of Life Index (SAQLI) were examined at baseline and after 3 mo. After 3 mo, patients in the APAP with A-Flex group and those in the APAP with C-Flex group were crossed over and those in the APAP group were switched to A-Flex for an additional 3 mo. MEASUREMENTS AND RESULTS The groups were similar demographically. Treatment adherence during the first 3 mo was significantly greater in the APAP with C-Flex group (APAP with C-Flex: 5.19 ± 1.84 h/night versus APAP: 3.96 ± 1.66 h/night versus APAP with A-Flex: 4.27 ± 2.12 h/night, P = 0.04). There was a significant improvement in two of four of the SAQLI domain scores and in the ESS and PSQI in the APAP with C-Flex group. Adherence significantly improved among the poor compliers (< 4 h/night of use) in the APAP group after change to APAP with A-Flex (P = 0.01). CONCLUSIONS Of these three modes of PAP delivery, adherence was greatest with APAP with C-Flex. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00873977.
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Affiliation(s)
- Yuichi Chihara
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomomasa Tsuboi
- Departments of Respiratory Care and Sleep Control Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takefumi Hitomi
- Departments of Respiratory Care and Sleep Control Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masanori Azuma
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kimihiko Murase
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshiro Toyama
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuka Harada
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kensaku Aihara
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kiminobu Tanizawa
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomohiro Handa
- Department of Rehabilitation, Kyoto University Hospital, Kyoto, Japan
| | - Chikara Yoshimura
- Departments of Respiratory Care and Sleep Control Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toru Oga
- Departments of Respiratory Care and Sleep Control Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazuhiko Yamamoto
- Departments of Allergy and Rheumatology, Tokyo University Graduate School of Medicine, Tokyo, Japan
| | - Michiaki Mishima
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazuo Chin
- Departments of Respiratory Care and Sleep Control Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Campbell A, Neill A, Lory R. Ethnicity and socioeconomic status predict initial continuous positive airway pressure compliance in New Zealand adults with obstructive sleep apnoea. Intern Med J 2012; 42:e95-101. [DOI: 10.1111/j.1445-5994.2010.02360.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Masdeu MJ, Patel AV, Seelall V, Rapoport DM, Ayappa I. The supraglottic effect of a reduction in expiratory mask pressure during continuous positive airway pressure. Sleep 2012; 35:263-72. [PMID: 22294817 DOI: 10.5665/sleep.1636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Patients with obstructive sleep apnea may have difficulty exhaling against positive pressure, hence limiting their acceptance of continuous positive airway pressure (CPAP). C-Flex is designed to improve comfort by reducing pressure in the mask during expiration proportionally to expiratory airflow (3 settings correspond to increasing pressure changes). When patients use CPAP, nasal resistance determines how much higher supraglottic pressure is than mask pressure. We hypothesized that increased nasal resistance results in increased expiratory supraglottic pressure swings that could be mitigated by the effects of C-Flex on mask pressure. DESIGN Cohort study. SETTING Sleep center. PARTICIPANTS Seventeen patients with obstructive sleep apnea/hypopnea syndrome and a mechanical model of the upper airway. INTERVENTIONS In patients on fixed CPAP, CPAP with different C-Flex levels was applied multiple times during the night. In the model, 2 different respiratory patterns and resistances were tested. MEASUREMENTS AND RESULTS Airflow, expiratory mask, and supraglottic pressures were measured on CPAP and on C-Flex. Swings in pressure during expiration were determined. On CPAP, higher nasal resistance produced greater expiratory pressure swings in the supraglottis in the patients and in the model, as expected. C-Flex 3 produced expiratory drops in mask pressure (range -0.03 to -2.49 cm H(2)O) but mitigated the expiratory pressure rise in the supraglottis only during a sinusoidal respiratory pattern in the model. CONCLUSIONS Expiratory changes in mask pressure induced by C-Flex did not uniformly transmit to the supraglottis in either patients with obstructive sleep apnea on CPAP or in a mechanical model of the upper airway with fixed resistance. Data suggest that the observed lack of expiratory drop in supraglottic pressure swings is related to dynamics of the C-Flex algorithm.
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Affiliation(s)
- Maria J Masdeu
- Pulmonary Department, Corporacio Sanitaria Parc Tauli, Universitat Autonoma de Barcelona, Sabadell, Barcelona, Spain
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Kushida CA, Berry RB, Blau A, Crabtree T, Fietze I, Kryger MH, Kuna ST, Pegram GV, Penzel T. Positive airway pressure initiation: a randomized controlled trial to assess the impact of therapy mode and titration process on efficacy, adherence, and outcomes. Sleep 2011; 34:1083-92. [PMID: 21804670 DOI: 10.5665/sleep.1166] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES (1) To determine the efficacy of automatically adjusted positive airway pressure (APAP) with a comfort feature (A-Flex) at reducing apneas and hypopneas in participants with moderate to severe OSA. (2) To determine the relative difference between A-Flex, continuous positive airway pressure (CPAP), and APAP-derived optimal pressure for CPAP (CPAP(APAP)) on adherence to treatment. (3) To determine the relative difference between APAP with A-Flex, CPAP, and CPAP(APAP) on long-term change in functional outcomes. DESIGN Randomized, double-blinded, 3-arm, multicenter trial. SETTING University and Veterans Affairs medical centers. PATIENTS OR PARTICIPANTS 168 participants were randomized, and 140 completed the 180-day study. INTERVENTIONS (1) A-Flex; (2) CPAP; (3) APAP for 14 days and then switched to CPAP at a fixed pressure. MEASUREMENTS AND RESULTS Apnea-hypopnea indices, average and minimum oxygen saturation, time spent < 90% were significantly poorer for A-Flex vs. CPAP at the initiation of study treatment; with the exception of minimum oxygen saturation, these differences were absent at 180 days. A-Flex had lower average leak values at both 3 and 6 months. There were no significant differences between groups in major efficacy, adherence, and outcome (subjective sleepiness, objective vigilance, blood pressure, quality of life) measures. No differences between groups in attitudes toward use were observed at 3 or 6 months; participant ratings for CPAP were significantly higher than A-Flex on treatment satisfaction and benefit, but not different for sleep quality and mask comfort. CONCLUSIONS We found that A-Flex shows equivalency, but non-superiority (except for average leak values), in efficacy, adherence, and functional outcomes compared to CPAP after either 3 or 6 months. CLINICAL TRIAL REGISTRY Positive Pressure Treatment of Obstructive Sleep Apnea, http://www.clinicaltrials.gov, NCT00636181.
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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: 586] [Impact Index Per Article: 45.1] [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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Bakker JP, Marshall NS. Flexible pressure delivery modification of continuous positive airway pressure for obstructive sleep apnea does not improve compliance with therapy: systematic review and meta-analysis. Chest 2010; 139:1322-1330. [PMID: 21193533 DOI: 10.1378/chest.10-2379] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) is the first-line therapy for obstructive sleep apnea (OSA), but patient compliance is a major barrier to long-term effectiveness. Flexible pressure delivery of PAP reduces pressure during early exhalation with the aim of improving comfort and, therefore, compliance, leading to subsequent symptoms improvement. METHODS We undertook a systematic literature search of PubMed (January 1, 2000, to July 11, 2010) to identify all randomized trials comparing flexible and standard CPAP in adult patients with OSA with at least 1-week follow-up. Either we or the original trial investigators extracted means, SEs, and sample sizes for all relevant outcome measures. We then performed meta-analyses quantifying improvements in objective compliance and symptoms as measured by the Epworth Sleepiness Scale (ESS), the Maintenance of Wakefulness Test (MWT), and the Psychomotor Vigilance Task (PVT). RESULTS We found 10 relevant trials (599 patients). Meta-analysis of the seven trials where we could extract compliance data (514 patients) indicated that flexible pressure did not improve compliance compared with CPAP in either the parallel (0.16 h; 95% CI, -0.09-0.42; P = .21) or the crossover trials (0.20 h; 95% CI, -0.26-0.66; P = .39). Flexible pressure caused no improvement over CPAP in any secondary outcome (ESS, MWT, PVT, and residual OSA, all P > .05). CONCLUSIONS Flexible pressure modification neither significantly improves compliance with CPAP in patients with OSA nor significantly improves patient outcomes beyond the effects of CPAP. Unfortunately, we were unable to locate compliance data in the correct format for three out of the 10 suitable trials.
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Affiliation(s)
- Jessie P Bakker
- WellSleep Sleep Investigation Centre, Department of Medicine, University of Otago, Wellington, New Zealand.
| | - Nathaniel S Marshall
- National Health and Medical Research Council (NHMRC) Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
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Desai T, Khan M, Bhatt NY. Positive Airway Pressure Treatment of Adult Patients with Obstructive Sleep Apnea. Sleep Med Clin 2010. [DOI: 10.1016/j.jsmc.2010.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Arfoosh R, Rowley JA. Adherence to Positive Airway Pressure Therapy. Sleep Med Clin 2010. [DOI: 10.1016/j.jsmc.2010.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Bakker J, Campbell A, Neill A. Randomized controlled trial comparing flexible and continuous positive airway pressure delivery: effects on compliance, objective and subjective sleepiness and vigilance. Sleep 2010; 33:523-9. [PMID: 20394322 DOI: 10.1093/sleep/33.4.523] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES Positive airway pressure (PAP) treatment for obstructive sleep apnea (OSA) can be limited by suboptimal compliance. C-Flex technology (Philips Respironics, PA, USA) reduces pressure during expiration, aiming to improve comfort and therefore compliance. This may be of particular relevance to patients requiring high pressures. Many studies thus far have suffered from design limitations and small sample sizes. This study aimed to compare compliance with C-Flex and CPAP, as well as analyzing objective and subjective sleepiness and vigilance. DESIGN Three-month, double-blinded, parallel-arm randomized controlled trial. SETTING A university-based sleep laboratory. PATIENTS 76 consecutive patients with severe OSA (mean +/- SD AHI 60.2 +/- 32.9 events/hour, ESS 13.6 +/- 4.5/24, BMI 35.6 +/- 7.8 kg/m2), without significant cardiac, respiratory, psychiatric, or sleep comorbidities. INTERVENTIONS Patients were randomized to C-Flex (dip level 2) or CPAP. MEASUREMENTS AND RESULTS Patients underwent titration with C-Flex/CPAP (mean pressure 11.6 cm H2O). Modified maintenance of wakefulness tests (mod-MWT), psychomotor vigilance tasks (PVT) and questionnaires were administered at baseline and after one and 3 months. Median compliance was 5.51 and 5.89 h/night in the C-Flex and CPAP groups respectively (P = 0.82). There were no significant differences between groups in terms of PVT reaction time, subjective sleepiness, sleep quality, health-related quality of life, or treatment comfort. There was no significant difference between the groups regarding the change in mod-MWT sleep latency values. CONCLUSIONS In patients with severe OSA both CPAP and C-Flex resulted in substantial improvements in sleepiness, vigilance, and quality of life. The use of C-Flex did not result in greater compliance, and neither treatment appeared superior.
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Affiliation(s)
- Jessie Bakker
- WellSleep Sleep Investigation Centre, Department of Medicine, University of Otago, Wellington, New Zealand.
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Matthews EE, Aloia MS. Continuous Positive Airway Pressure Treatment and Adherence in Obstructive Sleep Apnea. Sleep Med Clin 2009. [DOI: 10.1016/j.jsmc.2009.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Smith I, Lasserson TJ. Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev 2009:CD003531. [PMID: 19821310 DOI: 10.1002/14651858.cd003531.pub3] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Continuous Positive Airways Pressure (CPAP) is considered to be the cornerstone of therapy for obstructive sleep apnoea (OSA). However, compliance with this treatment is frequently poor, which may lead to ongoing symptoms of sleep disruption, daytime sleepiness and poor waking cognitive function. Mechanical interventions which involve changing the way that positive pressure is delivered, and the addition of humidification, might improve compliance. OBJECTIVES To determine the efficacy of pressure level modifications and additional humidification in increasing CPAP machine usage. SEARCH STRATEGY We searched the Cochrane Airways Group Specialised Register (September 2008). SELECTION CRITERIA Randomised controlled trials (RCTs) assessing interventions to improve compliance with CPAP usage. Control groups received fixed pressure CPAP. DATA COLLECTION AND ANALYSIS Two authors assessed articles for inclusion in the review and extracted data. We made attempts to obtain additional unpublished data from the trialists. MAIN RESULTS Forty-five studies met the inclusion criteria (1874 participants). Auto-CPAP (30 studies, 1136 participants): a statistically significant difference in machine usage of 0.21 hours/night (0.08 to 0.35) was observed in favour of auto-CPAP from cross-over studies. This difference is of questionable clinical significance. Pooled effect estimates from parallel group trials detected a similar sized difference for average nightly machine usage, but this was not statistically significant. Evidence from parallel group studies did not identify a statistically significant difference between pressure modes in Epworth Sleepiness Scores, but there was an overall reduction of 0.64 units with cross-over studies (-0.12 to -1.16) in favour of auto-CPAP. Parallel group studies did not identify a significant difference. More participants preferred auto-CPAP to fixed CPAP where this was measured. Bi-level PAP (six studies, 285 participants): no significant differences were observed in machine usage. One small study found no difference in preference. C-Flex (six studies, 318 participants): no significant difference was observed in machine usage. Humidification (three studies, 135 participants): there were conflicting findings between the studies. Two parallel group trials found no significant difference in machine usage, whereas a cross-over study found a significant difference. AUTHORS' CONCLUSIONS Improvement in average machine use of auto-CPAP was superior in studies with a cross-over design; the point estimate in parallel group trials was similar, but did not reach statistical significance. It is uncertain how use of machines in study settings relates to 'real world' use. Where preference was measured participants preferred auto-CPAP to fixed pressure CPAP. Further studies are required to assess the evidence for Bi-PAP, C-Flex(TM) and humidification. The studies assembled were characterised by high machine usage in the control groups, and low withdrawal rates. Future studies need to consider the effects of treatment in participants with more mild disease, and those who struggle to accept therapy despite persistent symptoms.
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Affiliation(s)
- Ian Smith
- Respiratory Support and Sleep Centre, Papworth Hospital, Papworth Everard, Cambridge, UK, CB3 8RE
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