Adherence to continuous positive airway pressure therapy in obstructive sleep apnea syndrome: effect of visual education

Self-reported oral moistening disorders in obstructive sleep apnoea: A scoping review

BACKGROUND

Obstructive sleep apnoea (OSA) is a highly prevalent problem with significant consequences. Continuous positive airway pressure (CPAP) and oral mandibular advancement device (MAD) are considered the standard treatments for OSA. Patients may experience self-reported oral moistening disorders (OMDs) (i.e. xerostomia or drooling) at the beginning, throughout and after treatment. This affects oral health, quality of life and treatment effectiveness. The exact nature of the associations between OSA and self-reported OMD is still unknown. We aimed to provide an overview of the associations between self-reported OMD on the one hand and OSA and its treatment (namely CPAP and MAD) on the other hand. In addition, we sought to determine whether OMD affects treatment adherence.

MATERIALS AND METHODS

A literature search in PubMed was performed up to 27 September 2022. Two researchers independently assessed studies for eligibility.

RESULTS

In total, 48 studies were included. Thirteen papers investigated the association between OSA and self-reported OMD. They all suggested an association between OSA and xerostomia but not between OSA and drooling. The association between CPAP and OMD was addressed in 20 articles. The majority of studies have indicated xerostomia as a CPAP side effect; however, some have observed that xerostomia diminishes with CPAP therapy. In 15 papers, the association between MAD and OMD was investigated. In most publications, both xerostomia and drooling have been described as common side effects of MADs. These side effects are often mild and transient, and they improve as patients continue to use their appliance. Most studies found that these OMDs do not cause or are not a strong predictor of non-compliance.

CONCLUSION

Xerostomia is a common side effect of CPAP and MAD, as well as a significant symptom of OSA. It may be regarded as one of the indicators of sleep apnoea. Moreover, MAD therapy can be associated with OMD. However, it seems that OMD may be mitigated by being adherent to the therapy.

Randomized controlled trial on the efficacy of audio-visual health educational materials on CPAP adherence: the AHEAD trial

STUDY OBJECTIVES

Educational interventions have been proposed to improve continuous positive airway pressure (CPAP) adherence; however, studies to date have not demonstrated robust effectiveness, due to methodological issues. Furthermore, these educational interventions have not specifically targeted low health literacy communication techniques, which have been demonstrated to improve outcomes in numerous other chronic diseases. We hypothesized that the addition of low-cost audio-visual educational videos (EVs) to usual standard-of-care (SC) education would improve CPAP adherence in adults with obstructive sleep apnea (OSA) syndrome.

METHODS

At CPAP initiation, treatment-naïve adults with OSA syndrome were randomized to (1) usual SC or (2) SC + 5 EVs showing a patient's journey, designed with low health literacy communication techniques to teach patients about OSA and CPAP therapy. The primary endpoint was CPAP usage at 2 months (hours/night) and secondary endpoints were CPAP usage at 12 months and percentage of patients with ≥ 4 hours/night use at 2 months and 12 months.

RESULTS

One hundred and ninety-five patients were randomized (SC 99, EV 96), with a mean age of 57 years (interquartile range [IQR] 44.1-64.8 years). There were no statistically significant differences in patient characteristics at baseline between the SC vs EV groups, with the diagnostic apnea-hypopnea index of 34 events/h (IQR 21-59 events/h) vs 30 events/h (IQR 20-50 events/h) and Epworth Sleepiness Scale score of 12.8 ± 6 vs 11.7 ± 5. At 2 months, there was no significant difference in hours of CPAP usage (SC: 3.45 hours/night [95% confidence interval (CI): 2.76 to 4.13] vs EV: 3.75 hours/night [95% CI: 3.14 to 4.37]) nor in proportion with adequate usage or overall commencement rate. However, at 12 months, there was a significant difference in hours of CPAP usage (SC: 2.50 hours/night [95% CI: 1.94 to 3.06] vs EV: 3.66 hours/night [95% CI: 2.92 to 4.40]). The probability of adequate CPAP usage at 12 months was higher in the intervention arm (odds ratio: 1.33; 95% CI: 1.04 to 1.7; P = .013). Patients with low education backgrounds benefitted substantially from the EV intervention compared with SC (mean difference at 12 months = 2.47 hours/night usage; 95% CI: 1.01 to 2.93; P < .01).

CONCLUSIONS

Low health literacy-designed EVs improve CPAP adherence at 12 months compared with SC, with the greatest impact in patients with a low educational background.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; Name: Randomised controlled trial on the efficacy of audio-visual health educational materials on sleep health literacy and continuous positive airway pressure (CPAP) adherence in Sleep Clinic patients; URL: https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619000523101; Identifier: ACTRN12619000523101.

CITATION

Ellender CM, Samaranayake C, Reid N, et al. Randomized controlled trial on the efficacy of audio-visual health educational materials on CPAP adherence: the AHEAD trial. J Clin Sleep Med. 2022;18(11):2617-2625.

A telemonitoring system to support CPAP therapy in patients with obstructive sleep apnea: a participatory approach in analysis, design, and evaluation

Background

Continues positive airway pressure (CPAP) therapy is a gold standard treatment for moderate to severe cases of OSA (obstructive sleep apnea). The present research aimed to describe the analysis, design, and evaluation of a telemonitoring system to improve CPAP adherence in patients afflicted with OSA.

Methods

The telemonitoring system was developed in five phases. In the exploratory phase, the body of related literature was reviewed. Then a need analysis was conducted through a focus group discussion with sleep medicine specialists and sales company representatives and an interview with patients. The third phase involved data integration. Then the content and system development were done based on the previous phases. Finally, usability and functionality tests were used to evaluate the system.

Results

The exploratory phase and the needs analysis were conducted by four sleep medicine specialists, two medical informatics specialists, six key figures of the sales companies, two system developers, and 46 patients in different phases. Based on the results obtained from the data integration phase, the telemonitoring system involved three main parts: a patient’s application, a doctor’s portal, a selling companies’ portal (operator’s portal) along with facilitating software for patients to send the CPAP data. Usability and functionality tests were given to 7 and 10 patients, respectively. The total number of usability issues reported by users in the evaluation process was 18, with an average of 2.5 issues per user. The installation problems, disrupted links and improper playing of videos were the main functionalities problems that were solved.

Conclusion

The telemonitoring system, as a means of communication between patients, doctors, and selling companies, can be used to support patients clinically and technically. It has the potential to improve CPAP adherence in patients with OSA.

Efficacy of a telemonitoring system in continuous positive airway pressure therapy in Asian obstructive sleep apnea

STUDY OBJECTIVES

A telemonitoring system is a promising wireless technology that possibly enhances adherence to CPAP therapy. The study aimed to determine the effect of a telemonitoring system on CPAP therapy adherence among Asian patients with moderate-to-severe OSA.

METHODS

A prospective randomized controlled trial enrolled 60 Asian adults (70% male) with moderate-to-severe OSA. Thirty patients each were randomized to a group using CPAP with a telemonitoring system or a group using CPAP with usual care. The telemonitoring system functioned by transferring CPAP-usage data via cellular network. When there were any triggers occurring 2 nights consecutively (usage hours < 4 hours per night; leakage > 27 L/min or AHI > 5 events/h), the investigator contacted the patients. The primary outcome was the 4-week CPAP usage hours per night. The secondary outcomes included the percentage of good adherence (defined as a 4-week period of therapy with CPAP usage > 4 hours/night on > 70% of total days), median leakage per night, adverse events from CPAP therapy, sleep quality improvement, and daytime sleepiness reduction.

RESULTS

The mean AHI was 50.3 events/h. The mean 4-week CPAP usage hours per night were insignificantly higher in the telemonitoring group (5.16 ± 1.47 hours/night vs 4.42 ± 1.91 hours/night; P = .18). However, the percentage of good adherence was significantly higher in the telemonitoring group (64.2% vs 34.4%; P = .024). Median leakage per night was also significantly lower in the telemonitoring group. Furthermore, significant sleep quality improvement was observed in the telemonitoring group. Overall adverse events and daytime sleepiness reduction were not different.

CONCLUSIONS

The telemonitoring system implementation showed a trend toward increasing CPAP nightly usage hours and significantly improved adherence and sleep quality among Asian patients with moderate-to-severe OSA.

The effect of non-benzodiazepine sedative hypnotics on CPAP adherence in patients with OSA: a systematic review and meta-analysis

STUDY OBJECTIVES

This meta-analysis aimed to explore the effect of non-benzodiazepine sedative hypnotics (NBSH) on continuous positive airway pressure (CPAP) adherence in patients with obstructive sleep apnea (OSA).

METHODS

We conducted a systematic search through PubMed, Medline, the Cochrane Library, EMBASE, Scopus and ClinicalTrials (all searched from inception to 15 August 2020). Publications were limited to articles, clinical conferences and letters, including randomized controlled trials and retrospective studies. We used a random-effects model to calculate the odds ratio (OR) and mean difference (MD) with corresponding confidence interval (CI). Subgroup analyses were conducted to analyze the sources of heterogeneity.

RESULTS

Eight studies fulfilled the inclusion and exclusion criteria for patients newly diagnosed with obstructive sleep apnea. Overall, the use of NBSH was associated with increased use of CPAP per night (MD = 0.62 h; 95% CI = 0.26-0.98) and use for more nights (MD = 12.08%; 95% CI = 5.27-18.88). When a study seriously affecting heterogeneity was removed, more patients adhered well with CPAP use (pooled OR = 2.48; 95% CI = 1.75-3.52) with good adherence defined as CPAP use for＞4 h/night on＞70% of nights. Among prescribed NBSHs, eszopiclone showed the most significant effect on CPAP adherence.

CONCLUSION

CPAP adherence may increase in OSA patients treated with non-benzodiazepine sedative hypnotics especially eszopiclone. The effect of zolpidem and zaleplon on CPAP adherence requires further investigation by larger scale, randomized, controlled trials.

Treatment of Obstructive Sleep Apnea: Achieving Adherence to Positive Airway Pressure Treatment and Dealing with Complications

Obstructive sleep apnea is a common and treatable condition, but therapeutic adherence is limited by numerous factors. Despite advances in positive airway pressure (PAP) technology and a multitude of effective pharmacologic and behavioral therapeutic interventions to overcome the most common barriers to PAP, adherence has not increased significantly over the past 30 years. This review aims to identify the most important factors that impact adherence, common barriers to treatment, and evidence-based treatment strategies to maximize the effectiveness of PAP treatment. Complications of PAP treatment and mitigation techniques are also discussed.

Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea

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.

Sleep and Migraine: Assessment and Treatment of Comorbid Sleep Disorders

The relationship of sleep and migraine is unequivocal and familiarity with the nature and magnitude of these associations may inform clinical practice. Recent prospective, longitudinal, and time-series analysis has begun to unravel the magnitude and temporal patterns of sleep and migraine. Prospective evidence has shown that sleep variables can trigger acute migraine, precede and predict new onset headache by several years, and indeed, sleep disturbance and snoring are risk factors for chronification. The presence of a sleep disorder is associated with more frequent and severe migraine and portends a poorer headache prognosis. Interestingly, the disorders linked to migraine are quite varied, including insomnia, snoring and obstructive sleep apnea, restless legs, circadian rhythm disorders, narcolepsy, and others. Insomnia is by far the most common sleep disorder in headache patients. In fact, the majority of patients with chronic migraine presenting for treatment have insomnia. Despite a rapidly expanding literature, very few controlled treatment studies have been published to guide clinical practice. This paper focuses on clinical assessment and treatment of sleep disorders. An algorithm is presented for sleep disorders management in the migraine patient, which highlights major sleep disorders and psychiatric comorbidity. Diagnostic procedures are recommended that are conducive to clinical practice. Suggested tools include the sleep history, screening mnemonics, prediction equation, and sleep diary. New developments in treatment have produced abbreviated and cost-effective therapies for insomnia and obstructive sleep apnea that may reach a larger population. Revisions in the diagnostic manuals for sleep and headache disorders enhance recognition of sleep-related headache. Recommendations include behavioral sleep regulation, shown in recent controlled trials to decrease migraine frequency, management for sleep apnea headache, cognitive behavioral therapy (CBT) for insomnia abbreviated for the physician practice setting, sleep-related headache trigger, and others. There is no empirical evidence that sleep evaluation should delay or supersede usual headache care. Rather, sleep management is complimentary to standard headache practice.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

The patient's perioperative perspective during the treatment of obstructive sleep apnea: a pilot study

PURPOSE

This study aims to determine patients' pre-operative and post-operative experiences relating to surgical treatment for obstructive sleep apnea (OSA), while understanding how patients' perceptions influence their outcome and satisfaction.

METHODS

This is a phenomenological qualitative study using a semi-structured interview to evaluate patients who failed continuous positive airway pressure (CPAP) treatment of obstructive sleep apnea and underwent airway surgery. Meaningful codes from the interviews were organized into overarching themes of patient experiences. The same surgeon in a tertiary care otolaryngology practice treated all patients. All patients underwent a modified or traditional uvulopalatopharyngoplasty (UPPP) between 2009 and 2013. Patients were diagnosed with OSA by polysomnogram and had failed CPAP use. Patients were interviewed regarding their experience with OSA, CPAP, and surgery. Thematic saturation was reached after 17 patients.

RESULTS

Six themes exemplify patient's experience of OSA and treatment: (1) OSA impacted patients personally and professionally, (2) CPAP discomfort limited its therapeutic use, (3) patients had personal motivations for undergoing surgery, (4) patient knowledge influenced their perceptions, (5) post-operative challenges exceeded patient expectations, and (6) post-operative outcomes reflected positive effect on patients.

CONCLUSIONS

Patients' experiences prior to surgery can largely influence their perceived outcome and satisfaction. Post-operative sleep studies may not capture the full outcome of the patients' response to surgery. This study suggests that the patient's subjective reported outcomes should be used in conjunction with objective post-operative sleep studies.

Treatment of Obstructive Sleep Apnea: Achieving Adherence to Positive Airway Pressure Treatment and Dealing with Complications

Obstructive sleep apnea is a common and treatable condition, but therapeutic adherence is limited by numerous factors. Despite advances in positive airway pressure (PAP) technology and a multitude of effective pharmacologic and behavioral therapeutic interventions to overcome the most common barriers to PAP, adherence has not increased significantly over the past 30 years. This review aims to identify the most important factors that impact adherence, common barriers to treatment, and evidence-based treatment strategies to maximize the effectiveness of PAP treatment. Complications of PAP treatment and mitigation techniques are also discussed.

Educational video to improve CPAP use in patients with obstructive sleep apnoea at risk for poor adherence: a randomised controlled trial

BACKGROUND

Suboptimal adherence to CPAP limits its clinical effectiveness in patients with obstructive sleep apnoea (OSA). Although rigorous behavioural interventions improve CPAP adherence, their labour-intensive nature has limited widespread implementation. Moreover, these interventions have not been tested in patients at risk of poor CPAP adherence. Our objective was to determine whether an educational video will improve CPAP adherence in patients at risk of poor CPAP adherence.

METHODS

Patients referred by clinicians without sleep medicine expertise to an urban sleep laboratory that serves predominantly minority population were randomised to view an educational video about OSA and CPAP therapy before the polysomnogram, or to usual care. The primary outcome was CPAP adherence during the first 30 days of therapy. Secondary outcomes were show rates to sleep clinic (attended appointment) and 30-day CPAP adherence after the sleep clinic visit date.

RESULTS

A total of 212 patients met the eligibility criteria and were randomised to video education (n=99) or to usual care (n=113). There were no differences in CPAP adherence at 30 days (3.3, 95% CI 2.8 to 3.8 hours/day video education; vs 3.5, 95% CI 3.1 to 4.0 hours/day usual care; p=0.44) or during the 30 days after sleep clinic visit. Sleep clinic show rate was 54% in the video education group and 59% in the usual care group (p=0.41). CPAP adherence, however, significantly worsened in patients who did not show up to the sleep clinic.

CONCLUSIONS

In patients at risk for poor CPAP adherence, an educational video did not improve CPAP adherence or show rates to sleep clinic compared with usual care.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT02553694.

The effects of integrated nursing education on quality of life and health-related outcomes among obstructive sleep apnea patients receiving continuous positive airway pressure therapy

PURPOSE

This study sought to examine the effects of a nursing education program on quality of life and sleep disturbance among obstructive sleep apnea (OSA) patients receiving continuous positive airway pressure (CPAP) therapy.

METHODS

This study was a randomized controlled trial with an intervention group consisting of a nursing education program. The intervention group received the instruction of the CPAP nursing education program, and the control group received routine care. Data was collected for both groups before the intervention (pre-test), on the 7th day measurement after the intervention, and on the 30th day measurement after the intervention.

RESULTS

The results showed, first, that the intervention group reported a significantly reduced level of disturbance from wearing CPAP compared with that of the control group after the intervention (β = -1.83, p = .040). Second, the Calgary sleep apnea quality of life index (SAQLI) total scores significantly improved after the intervention (β = 1.669, p = 0.014). Also, symptoms of the SAQLI sub-items were improved and significantly different (β = 5.69, p = 0.007) after the intervention in the intervention group.

CONCLUSIONS

According to the results of the study, the disturbance from wearing CPAP, the total score of the SAQLI and the symptoms of the SAQLI were significantly improved after the nursing education intervention. Therefore, an adequate nursing education program is recommended for the initial period of CPAP use among OSA patients.

Factors predicting CPAP adherence in obstructive sleep apnea syndrome

PURPOSE

Obstructive sleep apnea (OSA) is associated with a range of neurocognitive and cardiovascular complications, leading to a compromised quality of life. Continuous positive airway pressure (CPAP) is the gold standard therapeutic intervention for this disorder, yet patient compliance remains essential to its success. This study aimed at identifying the determinants of short-term and long-term CPAP adherence in a group of Lebanese patients.

METHODS

This cross-sectional study, conducted at the Sleep Center of Hôtel-Dieu de France hospital in Lebanon, included patients diagnosed with OSA and treated with CPAP for at least one night between June 2008 and January 2015. Adherence was assessed based on patients' self-report.

RESULTS

The study enrolled 138 patients. Adherence rate was 70.3 % at 6 months and around 50 % after 5 years. Cox models showed that use of nasal masks (HR 0.48, p = 0.048) and higher oxygen desaturation index at baseline (HR 0.98 p = 0.048) were associated with a better short-term CPAP adherence. Patients who bought their devices (HR 0.18, p < 0.001), those who were frequently contacted by the CPAP provider (HR 0.85, p 0.024), and those who reported improvement on treatment (HR 0.36, p < 0.001) were significantly more likely to remain adherent on the long term. Conversely, individuals on a diet plan tended to interrupt the treatment earlier (HR 4.85, p 0.039).

CONCLUSION

The present findings should be further explored in order to tailor interventions to the specific needs of different patient profiles and secure an improved CPAP adherence.

Correlates of Pediatric CPAP Adherence

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a common pediatric condition characterized by recurrent partial or complete cessation of airflow during sleep, typically due to inadequate upper airway patency. Continuous positive airway pressure (CPAP) is a therapeutic option that reduces morbidity. Despite efforts to promote use, CPAP adherence is poor in both pediatric and adult populations. We sought to determine whether demographics, insurance status, OSA severity, therapeutic pressure, or comorbid conditions were associated with pediatric CPAP adherence.

METHODS

A retrospective review of adherence download data was performed on all pediatric patients with initiation or adjustment of CPAP treatment over a one-year period with documented in-laboratory CPAP titration. Patients were grouped as CPAP adherent or non-adherent, where adherence was defined as > 70% nightly use and average usage ≥ 4 hours per night. Differences between the groups were analyzed by χ(2) test.

RESULTS

Overall, nearly half of participants were CPAP adherent (49%, 69/140). Of the demographic data collected (age, ethnicity, sex, insurance status), only female sex was associated with better adherence (60.9% vs 39.5% of males adherent; odds ratio [OR] = 2.41, 95%CI = 1.20-4.85; p = 0.01). Severity of OSA (diagnostic apnea-hypopnea index [AHI] and degree of hypoxemia), therapeutic pressure, and residual AHI did not impact CPAP adherence (p > 0.05). Patients with developmental delay (DD) were more likely to be adherent with CPAP than those without a DD diagnosis (OR = 2.55, 95%CI = 1.27-5.13; p = 0.007). Female patients with trisomy 21 tended to be more adherent, but this did not reach significance or account for the overall increased adherence associated with female sex.

CONCLUSIONS

Our study demonstrates that adherence to CPAP therapy is poor but suggests that female sex and developmental delay are associated with better adherence. These findings support efforts to understand the pathophysiology of and to develop adherence-promoting and alternative interventions for pediatric OSA.

Modelling Adherence Behaviour for the Treatment of Obstructive Sleep Apnoea

Continuous positive airway pressure therapy (CPAP) is known to be the most efficacious treatment for obstructive sleep apnoea (OSA). Unfortunately, poor adherence behaviour in using CPAP reduces its effectiveness and thereby also limits beneficial outcomes. In this paper, we model the dynamics and patterns of patient adherence behaviour as a basis for designing effective and economical interventions. Specifically, we define patient CPAP usage behaviour as a state and develop Markov models for diverse patient cohorts in order to examine the stochastic dynamics of CPAP usage behaviours. We also examine the impact of behavioural intervention scenarios using a Markov decision process (MDP), and suggest a guideline for designing interventions to improve CPAP adherence behaviour. Behavioural intervention policy that addresses economic aspects of treatment is imperative for translation to clinical practice, particularly in resource-constrained environments that are clinically engaged in the chronic care of OSA.

Controversies in perioperative anesthetic management of the morbidly obese: I am a surgeon, why should I care?

Over the last four decades, as the rates of obesity have increased, so have the challenges associated with its anesthetic management. In the present review, we discuss perioperative anesthesia management issues that are modifiable by the early involvement of the surgical team. We sum up available evidence or expert opinion on issues like patient positioning, postoperative analgesia, and the effect of continuous positive airway pressure (CPAP) ventilation on surgical anastomosis. We also address established predictors of higher perioperative risk and suggest possible management strategies and concerns of obese patients undergoing same day procedures. Finally, a generalized pharmacological model relevant to altered pharmacokinetics in these patients is presented.

The efficacy of a brief motivational enhancement education program on CPAP adherence in OSA: a randomized controlled trial

BACKGROUND

Poor adherence to CPAP treatment in OSA adversely affects the effectiveness of this therapy. This randomized controlled trial (RCT) examined the efficacy of a brief motivational enhancement education program in improving adherence to CPAP treatment in subjects with OSA.

METHODS

Subjects with newly diagnosed OSA were recruited into this RCT. The control group received usual advice on the importance of CPAP therapy and its care. The intervention group received usual care plus a brief motivational enhancement education program directed at enhancing the subjects' knowledge, motivation, and self-efficacy to use CPAP through the use of a 25-min video, a 20-min patient-centered interview, and a 10-min telephone follow-up. Self-reported daytime sleepiness adherence-related cognitions and quality of life were assessed at 1 month and 3 months. CPAP usage data were downloaded at the completion of this 3-month study.

RESULTS

One hundred subjects with OSA (mean ± SD, age 52 ± 10 years; Epworth Sleepiness Scales [ESS], 9 ± 5; median [interquartile range] apnea-hypopnea index, 29 [20, 53] events/h) prescribed CPAP treatment were recruited. The intervention group had better CPAP use (higher daily CPAP usage by 2 h/d [Cohen d = 1.33, P < .001], a fourfold increase in the number using CPAP for ≥ 70% of days with ≥ 4 h/d [P < .001]), and greater improvements in daytime sleepiness (ESS) by 2.2 units (P = .001) and treatment self-efficacy by 0.2 units (P = .012) compared with the control group.

CONCLUSIONS

Subjects with OSA who received motivational enhancement education in addition to usual care were more likely to show better adherence to CPAP treatment, with greater improvements in treatment self-efficacy and daytime sleepiness.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01173406; URL: www.clinicaltrials.gov.

Nurse-led intensive interventions improve adherence to continuous positive airway pressure therapy and quality of life in obstructive sleep apnea patients

BACKGROUND

Continuous positive airway pressure (CPAP) is widely recommended for the treatment of sleep apnea/hypopnea syndrome (SAHS), but its usage by patients is very low. The aim of this study was to assess intensive educational programs and nursing support for the improvement of CPAP use and outcomes in SAHS patients.

METHODS

Eighty new SAHS patients were randomized to receive nurse-led intensive interventions or usual support at hospital and home. The main outcome measure was CPAP use; changes in sleeping, symptoms, mood, and quality of life were also assessed after 12 months of treatment.

RESULTS

All outcome measures were improved after treatment in both groups. However, patients receiving intensive support with significantly higher CPAP use (higher daily CPAP usage by 2.2 hours/day) had greater improvements in SAHS symptoms and mood (P<0.05). The intervention group further showed an improvement in the Short Form-36 domains of mental and physical health (P<0.05).

CONCLUSION

The CPAP usage and quality of life can be significantly improved by nurse-led intensive program in obstructive sleep apnea patients.

Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea

BACKGROUND

Although 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 recognise the need for regular and continued use of CPAP.

OBJECTIVES

To assess the effectiveness of strategies that are educational, supportive or behavioural in encouraging people who have been prescribed CPAP to use their machines.

SEARCH METHODS

Searches were conducted on the Cochrane Airways Group Specialised Register of trials. Searches are current to 17 January 2013.

SELECTION CRITERIA

We included randomised parallel controlled trials that assessed an intervention designed to inform participants about CPAP or OSA, to support them in using CPAP or to modify their behaviour in increasing their use of CPAP machines. Studies of any duration were considered.

DATA COLLECTION AND ANALYSIS

Two review authors assessed studies to determine their suitability for inclusion in the review. Data were extracted independently and were entered into Review Manager software for analysis.

MAIN RESULTS

Thirty studies (2047 participants) were included. We categorised studies by intervention type: supportive interventions during follow-up, educational interventions and behavioural therapy. Across all three intervention classes, most studies incorporated elements of more than one intervention. For the purposes of this systematic review, we categorised them by the prevailing type of intervention, which we expected would have the greatest impact on the study outcome.Baseline Epworth Sleepiness Scale (ESS) scores indicated that most participants experienced daytime sleepiness, and CPAP was indicated on the basis of sleep disturbance indices. A vast majority of recruited participants had not used CPAP previously. Most of the studies were at an unclear risk of bias overall, although because of the nature of the intervention, blinding of both study personnel and participants was not feasible, and this affected a number of key outcomes. Adverse events were not reported in these studies.Low- to moderate-quality evidence showed that all three types of interventions led to increased machine usage in CPAP-naive participants with moderate to severe OSA syndrome. Compared with usual care, supportive ongoing interventions increased machine usage by about 50 minutes per night (0.82 hours, 95% confidence interval (CI) 0.36 to 1.27, N = 803, 13 studies; low-quality evidence), increased the number of participants who used their machines for longer than four hours per night from 59 to 75 per 100 (odds ratio (OR) 2.06, 95% CI 1.22 to 3.47, N = 268, four studies; low-quality evidence) and reduced the likelihood of study withdrawal (OR 0.65, 95% CI 0.44 to 0.97, N = 903, 12 studies; moderate-quality evidence). With the exception of study withdrawal, considerable variation was evident between the results of individual studies across these outcomes. Evidence of an effect on symptoms and quality of life was statistically imprecise (ESS score -0.60 points, 95% CI -1.81 to 0.62, N = 501, eight studies; very low-quality evidence; Functional Outcomes of Sleep Questionnaire 0.98 units, 95% CI -0.84 to 2.79, N = 70, two studies; low-quality evidence, respectively).Educational interventions increased machine usage by about 35 minutes per night (0.60 hours, 95% CI 0.27 to 0.93, N = 508, seven studies; moderate-quality evidence), increased the number of participants who used their machines for longer than four hours per night from 57 to 70 per 100 (OR 1.80, 95% CI 1.09 to 2.95, N = 285, three studies; low-quality evidence) and reduced the likelihood of withdrawal from the study (OR 0.67, 95% CI 0.45 to 0.98, N = 683, eight studies; low-quality evidence). Participants experienced a small improvement in symptoms, the size of which may not be clinically significant (ESS score -1.17 points, 95% CI -2.07 to -0.26, N = 336, five studies).Behavioural therapy led to substantial improvement in average machine usage of 1.44 hours per night (95% CI 0.43 to 2.45, N = 584, six studies; low-quality evidence) and increased the number of participants who used their machines for longer than four hours per night from 28 to 47 per 100 (OR 2.23, 95% CI 1.45 to 3.45, N = 358, three studies; low-quality evidence) but with high levels of statistical heterogeneity. The estimated lower rate of withdrawal with behavioural interventions was imprecise and did not reach statistical significance (OR 0.85, 95% CI 0.57 to 1.25, N = 609, five studies, very low-quality evidence).

AUTHORS' CONCLUSIONS

In CPAP-naive people with severe sleep apnoea, low-quality evidence indicates that supportive interventions that encourage people to continue to use their CPAP machines increase usage compared with usual care. Moderate-quality evidence shows that a short-term educational intervention results in a modest increase in CPAP usage. Low-quality evidence indicates that behavioural therapy leads to a large increase in CPAP machine usage. The impact of improved CPAP usage on daytime sleepiness, quality of life and long-term cardiovascular risks remains unclear. For outcomes reflecting machine usage, we downgraded for risk of bias and inconsistency. An additional limitation for daytime sleepiness and quality of life measures was imprecision. Trials in people who have struggled to persist with treatment are needed, as currently little evidence is available for this population. Optimal timing and duration and long-term effectiveness of interventions remain uncertain. The relationship between improved machine usage and effect on symptoms and quality of life requires further assessment. 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.

Willingness score obtained after a short CPAP trial predicts CPAP use at 1 year

PURPOSE

To predict continuous positive airway pressure (CPAP) adherence at 1 year.

METHODS

We followed consecutive OSA patients scheduled for CPAP initiation for 1 year. Patients completed a self-efficacy questionnaire (5 = low, 25 = high score) before CPAP initiation. After CPAP initiation, we enquired about patients' satisfaction in CPAP trial and their eagerness and willingness to continue CPAP therapy (0 = unsatisfied, uneager, or refused CPAP; 100 = satisfied, eager, or willing to continue CPAP treatment).

RESULTS

Of the 580 patients we followed, 377 continued CPAP therapy beyond 1 year. A low willingness score (<50) was expressed by 77 patients but only 7 of them used CPAP >4 h daily at 1 year, yielding a specificity of 97 % in predicting CPAP failure. At 1 year, patients with a self-efficacy score >20, expressed prior to CPAP initiation, used CPAP more often than the patients with a score <20 (average use 4.4 ± 2.2 h vs. 3.7 ± 2.3 h, p<0.001).

CONCLUSIONS

A low score of willingness to continue CPAP therapy after a short trial predicts CPAP failure and poor CPAP adherence at 1 year.

Impact of type D personality on adherence to oral appliance therapy for sleep-disordered breathing

PURPOSE

Type D personality, defined as a combination of social inhibition and negative affectivity, has been associated with poor medication adherence and lower adherence to continuous positive airway pressure in patients with sleep-disordered breathing. Up to this date, the association of patient's personality with adherence with a mandibular advancement device (MAD) has not been studied. The purposes of this study were to examine the association between type D personality and poor adherence to MAD treatment and to examine the impact of type D personality on perceived side effects during this treatment.

METHODS

Eighty-two patients out of 113 patients with a known baseline type D scale who have started MAD treatment between June 2006 and December 2009 were included. Information about side effects and adherence were collected via a postal questionnaire. Thirty-three patients were using a monobloc MAD and 49 patients were using a duobloc MAD.

RESULTS

Forty-five percent of type D patients discontinued MAD treatment, whereas only 15 % of non-type D patients reported treatment discontinuation. The odds ratio for treatment discontinuation was 6.03 (95 % confidence interval 1.22-29.81; p = 0.027) for type D personality, adjusted for age, gender, MAD type (monobloc or duobloc), and decrease in apnea severity. In continuing MAD users, no significant difference in perceived side effects was reported between the personality types.

CONCLUSION

This is the first study to examine the relationship between type D personality and adherence to MAD treatment. Type D patients reported a significantly higher discontinuation rate when compared to patients without type D personality.

Breathing irregularity during wakefulness associates with CPAP acceptance in sleep apnea

PURPOSE

Individuals have different breathing patterns at rest, during wakefulness, and during sleep, and patients with sleep apnea are no different. The hypothesis for this study was that breathing irregularity during wakefulness associates with CPAP acceptance in obstructive sleep apnea (OSA).

METHODS

From a 2007-2010-database of patients with a diagnostic polysomnography (PSG) and prescribed CPAP (n = 380), retrospectively, 66 patients who quit CPAP treatment at 6 months were identified. Among them, 27 OSA patients quit despite having no side effects for discontinuing CPAP (Group A) and were compared to a matched group (age, body mass index, and apnea-hypopnea index) with good 6-month CPAP adherence (Group B; n = 21). Five minutes of respiratory signal during wakefulness at the initial PSG were extracted from respiratory inductance plethysmography recordings, and measured in a blinded fashion. The coefficients of variation (CV) for the breath-to-breath inspiration time (T i), expiration time (T e), T i + T e (T tot), and relative tidal volume, as well as an independent information theory-based metric of signal pattern variability (mutual information) were compared between groups.

RESULTS

The CV for tidal volume was significantly greater (p = 0.001), and mutual information was significantly lower (p = 0.041) in Group A as compared to Group B.

CONCLUSIONS

Differences in two independent measures of breathing irregularity correlated with CPAP rejection in OSA patients without nasal symptoms or comorbidity. Prospective studies of adherence should examine traits of breathing stability.