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

Genetic Analysis of Obstructive Sleep Apnea and Its Relationship with Severe COVID-19

Rationale: Although patients with obstructive sleep apnea (OSA) have a higher risk for coronavirus disease (COVID-19) hospitalization, the causal relationship has remained unexplored. Objectives: To understand the causal relationship between OSA and COVID-19 by leveraging data from vaccination and electronic health records, genetic risk factors from genome-wide association studies, and Mendelian randomization. Methods: We elucidated genetic risk factors for OSA using FinnGen (total N = 377,277), performing genome-wide association. We used the associated variants as instruments for univariate and multivariate Mendelian randomization (MR) analyses and computed absolute risk reduction against COVID-19 hospitalization with or without vaccination. Results: We identified nine novel loci for OSA and replicated our findings in the Million Veteran Program. Furthermore, MR analysis showed that OSA was a causal risk factor for severe COVID-19 (P = 9.41 × 10-4). Probabilistic modeling showed that the strongest genetic risk factor for OSA at the FTO locus reflected a signal of higher body mass index (BMI), whereas BMI-independent association was seen with the earlier reported SLC9A4 locus and a MECOM locus, which is a transcriptional regulator with 210-fold enrichment in the Finnish population. Similarly, multivariate MR analysis showed that the causality for severe COVID-19 was driven by BMI (multivariate MR P = 5.97 × 10-6, β = 0.47). Finally, vaccination reduced the risk for COVID-19 hospitalization more in the patients with OSA than in the non-OSA controls, with respective absolute risk reductions of 13.3% versus 6.3%. Conclusions: Our analysis identified novel genetic risk factors for OSA and showed that OSA is a causal risk factor for severe COVID-19. The effect is predominantly explained by higher BMI and suggests BMI-dependent effects at the level of individual variants and at the level of comorbid causality.

Personality traits and pre-treatment beliefs and cognitions predicting patient adherence to continuous positive airway pressure: A systematic review

Adherence to Continuous Positive Airway Pressure (CPAP) for obstructive sleep apnoea (OSA) can be improved by behavioural interventions which modify patients' beliefs and cognitions about OSA, CPAP, and themselves. We have conducted the first systematic review of the literature on beliefs and cognitions held before starting treatment, and personality (which influences the former) that predict the decision to purchase or start CPAP, or CPAP adherence one month or more after CPAP initiation. A systematic search and screen of articles identified 21 eligible publications from an initial 1317. Quality assessment performed using an adapted Newcastle-Ottawa Scale demonstrated that 13 (62%) studies were poor quality and only seven (33%) were high quality. Eighteen factors, such as self-efficacy (confidence) in using CPAP and value placed on health predicted CPAP adherence; however, for only six (33%), utility as an intervention target is known, from calculation of individual predictive power. Studies did not use new behavioural frameworks effective at explaining adherence behaviours, nor did they interview patients to collect in-depth data on barriers and facilitators of CPAP use. Future studies cannot have these limitations if high quality evidence is to be generated for intervention development, which is currently sparse as highlighted by this review.

Adherence to CPAP therapy for sleep apnea in patients aged over 70 years old

Purpose

Adherence to continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) syndrome has not been established in patients over 70 years of age, whereas several studies have reported adherence below that age. This trial was designed to address this evidence gap.

Methods

Consecutive senior (> 70 years) patients with OSA, mean respiratory event index (REI) 34/h, body mass index (BMI) 31 kg/m², and junior (< 50 years) patients (REI 37/h, BMI 31 kg/m²) were included.

Results

At year follow-up among 72 senior patients (35 women) and 71 junior patients (17 women), there was no difference in the percentage of patients abandoning CPAP (senior 47% vs. junior 43%) or in CPAP daily use (4:53 ± 2:44 hh:min vs. 4:23 ± 3:00 hh:min).

Conclusions

CPAP adherence in senior patients with OSA was not poorer than that of a younger group of OSA patients. Advanced age should not be an obstacle to CPAP initiation.

No changes in nocturnal respiration with hypoglossal neurostimulation therapy for obstructive sleep apnoea

STUDY OBJECTIVES

We initiated Hypoglossal Neurostimulation therapy (HGNS) at the Helsinki University Hospital in late 2014. Here, we report our experience.

METHODS

We included all 15 HGNS patients. All patients had previously failed both CPAP and oral appliance therapy for sleep apnoea. Overnight polysomnography parameters were analysed before and at 1.5 years with HGNS.

RESULTS

Mean ± SD patient age was 53 ± 6 years; 2 women and 13 men were included. Mean ± SD efficient CPAP level was 11.4 ± 3.4 cm H₂ O. Implantation technically succeeded in all patients. There were no significant changes of AHI and ODI4 after HGNS [median (quartile) 29.2/h (19.8-38.7) versus 30.1/h (15.6-52.6) and 15.0/h (5.9-20) versus 12.5/h (6.9-30.2) respectively].

CONCLUSION

We did not observe significant changes in AHI and ODI4 indices with HGNS therapy. Larger multicentre randomised controlled trials are necessary before wider international use of HGNS.

Practical Aspects of Interface Application in CPAP Treatment

While continuous positive airway pressure (CPAP) is an effective first-line therapy for sleep apnea, CPAP fails in one third of patients mainly due to poor adherence to the CPAP device and masks. The role of the medical team is to guide the patient in choosing the best mask, thus insuring good CPAP therapy adherence. Once a suitable mask is found, the brand of the mask does not affect patient satisfaction or CPAP adherence. For the majority of patients, nasal masks are by far more suitable than oronasal masks. Orosanal masks are indicated in case of nasal stuffiness or when an air leak manifests through the mouth. Re-evaluation of the efficacy of CPAP therapy is recommended when switching to oronasal masks.

Symptoms During CPAP Therapy Are the Major Reason for Contacting the Sleep Unit Between Two Routine Contacts

STUDY OBJECTIVES

The demand for continuous positive airway pressure (CPAP) therapy outpaces available resources in most health care settings. We sought to evaluate predictors of nonroutine CPAP follow-up visits to improve resource utilization.

METHODS

We randomly analyzed 1,141 of the 2,446 patients who had received at least 1 year of CPAP therapy. Reasons for contacts, type (routine = R, nonroutine = NR), and mode (face-to-face or not, physician, nurse) were collected.

RESULTS

A total of 771 patients were classified R, and 370 NR. Age, profession, and sex did not affect the NR frequency. Symptoms increased the odds ratio for NR 12.1-fold, somnolence 34.8-fold, and suffocation at night 10.4-fold. Patients with nonroutine reasons abandoned CPAP therapy significantly (7.6-fold) more frequently than patients with routine reasons.

CONCLUSIONS

Symptoms during CPAP therapy predicted the nonroutine contacts well. In line with this, patients with symptoms have become a priority follow-up group, and could constitute the only follow-up policy when dealing with insufficient medical resources.

Acceptability of placebo multiparticulate formulations in children and adults

Patient acceptability is an important consideration in the design of medicines for children. The aim of this study was to investigate acceptability of multiparticulates in healthy children and adults. A randomised, single-blind acceptability testing was performed involving 71 children (4-12 years) and 61 adults (18-37 years). Each participant received three 500 mg samples of microcrystalline cellulose pellets administered on a medicine spoon with water at 5-10 minutes intervals. Acceptability was measured based on voluntary intake of the samples, facial expressions, ratings on hedonic scales and reported willingness to take multiparticulates everyday as a medicine. Multiparticulates were voluntarily swallowed by 92% of children and 100% of adults. However, palatability issues were identified, with emphasis on textural aspects. Grittiness perception received negative ratings on hedonic scales by 60% of children and 51% of adults. Researcher observations revealed that 72% of children and 42% of adults displayed negative facial expressions towards the samples. Children reported their willingness to take multiparticulates as a medicine in 30% of the cases, compared to 74% in adults. This study demonstrates that multiparticulates may be a suitable formulation platform for children and adults, although palatability concerns have been highlighted. Additional work is required to define acceptability criteria and to standardise methodologies.

Oral appliance in sleep apnea treatment: respiratory and clinical effects and long-term adherence

PURPOSE

There is an increasing tendency to use oral appliance (OA) as an alternative treatment for sleep apnea. Here we report the long-term adherence and clinical effects of OA therapy.

METHODS

All sleep apnea patients treated at the Department of Dentistry between the years 2006 and 2013 (n = 1208) were reviewed. A questionnaire about OA adherence, asthma symptoms (Asthma Control Test™, ACT), and general health was sent to all patients who continued OA therapy after the 1-month follow-up visit (n = 811). OA was adjusted to obtain at least 70 % of the maximal protrusion of the mandible.

RESULTS

The response rate was 37.4 % (99 women, 204 men). The mean ± SD age and BMI were 58.7 ± 10.3 years and 27.3 ± 4.0 kg/m(2), respectively. During the mean follow-up period of 3.3 years, there was no significant variation in BMI. Forty-one patients abandoned OA therapy yielding an adherence rate of 86 %. Ninety-seven percent of patients used OA ≥4 h/day, and the mean daily use was 7.2 ± 1.1 h. The ACT score improved with OA use from 16.0 ± 5.9 to 20.1 ± 3.8 (p = 0.004), indicating better asthma control. The apnea and hypopnea index decreased significantly from 27 ± 19 at baseline to 10 ± 10 with OA therapy (p = 0.001).

CONCLUSIONS

After a 1-month trial period, the long-term adherence to oral appliance was good. OA therapy decreased apneas and hypopneas significantly, and its long-term use was associated with an improvement in respiratory and asthma symptoms.

Development of the Usability of Sleep Apnea Equipment-Positive Airway Pressure (USE-PAP) questionnaire

BACKGROUND

A growing number of positive airway pressure (PAP) device users will develop physical/sensory impairments such as arthritis. For these individuals, the usability of their PAP devices (e.g., efficiency and satisfaction) may impact the frequency and safety of device usage. Questionnaires to assess PAP usability are unavailable; therefore, we developed the Usability of Sleep Apnea Equipment-Positive Airway Pressure (USE-PAP) questionnaire.

METHODS

Questionnaire development included in-depth interviews to identify relevant content areas, a technical advisory panel to review/edit items, cognitive interviews to refine items, and a cross-sectional survey of Veterans Affairs sleep clinic patients assessing PAP device usability overall (one multi-item scale), usability of PAP components (multi-item scales for machine controls, mask/headgear, tubing, and humidifier), frequency of usability-related issues (one multi-item scale), PAP device characteristics, and demographics.

RESULTS

After conducting 19 in-depth interviews, a panel meeting, and 10 cognitive interviews, we administered the survey to 100 PAP device users (67% ≥60 years; 90% male). The items assessing machine control usability received the least favorable ratings. Twenty percent of respondents reported difficulty getting equipment ready for use, and 33 percent had difficulty cleaning equipment. The six multi-item scales had excellent internal consistency reliability (alpha ≥0.84) and item-rest correlations (≥0.39).

CONCLUSIONS

This study provides initial support for the USE-PAP for measuring PAP device usability. Studies that include large samples are needed to further evaluate the psychometric properties of the USE-PAP. In addition, comparisons of USE-PAP responses with direct observations of PAP-related tasks and objectively measured PAP adherence are needed to fully evaluate the questionnaire.