Telemedicine Applications in Sleep Disordered Breathing

Distance follow-up by a remote medical care centre improves adherence to CPAP in patients with obstructive sleep apnoea over the short and long term

BACKGROUND

Adherence to continuous positive air pressure (CPAP) in patients with obstructive sleep apnoea (OSA) has remained invariably low over the last decades. Remote monitoring of the nocturnal CPAP treatment, within telemedicine (TM)-based follow-up programs, in these patients has been suggested as a potential tool to improve adherence and release the workload of sleep units. The aim of this study was therefore to assess whether a follow-up program carried out by a Remote Medical Care Centre (RMCC), outside the sleep unit, improves adherence to CPAP in the short and long term in patients with OSA.

METHODS

In this pilot protocol, we enrolled 37 patients starting CPAP in our Sleep Centre (SC). After three months of standard care in our SC, patients initiated a six-month remote follow-up carried out by the RMCC, functioning as an intermediary between patients and SC. Monthly reports and indication for face-to-face visits were sent to the SC for six months. After this period patients returned to usual care for one year. Results were compared with those obtained in 38 patients (controls) followed with usual care over the same time range.

RESULTS

Mean nightly use of CPAP increased from 3.2 ± 2.4 h pre-RMCC to 5.2 ± 1.9 h post-RMCC (p < 0.0001). Nights/month of CPAP use improved from 19.8 ± 9.2 to 25.2 ± 2.5 (p < 0.05) and nights/month with CPAP use >4 h from 12.5 ± 10 to 21.03 ± 8.9 (p < 0.05). This improvement remained stable after 12 months from the return of patients to usual care. No significant changes in CPAP use were observed in controls over the time.

CONCLUSION

A six-month follow-up through a remote facility can significantly improve adherence to CPAP in the short and long term. This pilot study provides a solid base for the design of multicentre randomized trials focusing on new models which are able to increase the long-term efficacy of TM programs.

Modifying UTAUT2 for a cross-country comparison of telemedicine adoption

The ongoing COVID19 pandemic has put digital health technologies in the spotlight. To gain a deeper understanding of patients’ usage intentions of virtual doctor appointments, the present research adapts the Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) by integrating perceived security and perceived product advantage, two known barriers to successful telemedicine adoption. Applying age-stratified sampling, an online survey was distributed to 800 citizens in Germany and the United States of America. 710 completed and valid questionnaires were subsequently analyzed using SPSS and AMOS (versions 24).

Significant, direct, and positive effects of performance expectancy, hedonic motivation, perceived security, and perceived product advantage on the behavioral intention to use virtual doctor appointments were found. The analysis of the moderating variables, age and gender, showed significant differences in user's performance expectancy and effort expectancy, and perceived product advantage, respectively. With virtual health care models on the rise, these results are important for stakeholders such as policymakers, governments, employers, but also physicians, and insurance companies as they offer clear recommendations to design telemedicine adoption strategies to ensure successful patient engagement.

Adherence Monitoring Using Telemonitoring Techniques

Telemonitoring is a frequently used tool in the long-term management of many chronic diseases, such as chronic obstructive pulmonary disease or chronic heart failure. The use of new sensors and telemedical tools will shape medical practice in the future, particularly in sleep medicine. During the last decades, the number of people with sleep disordered breathing has been increasing.Telemedicine (TM) approaches could be used in various ways in sleep medicine: telediagnostics, teleconsultation, teletherapy, and telemonitoring of patients being treated with positive pressure devices.This chapter aims to summarize the recent scientific progresses of these techniques as well as their potential clinical applications and tries to give consideration to the remaining problems with TM applications.

New Paths in Respiratory Sleep Medicine: Consumer Devices, e-Health, and Digital Health Measurements

Sleep health and tracking sleep with contemporary wearables have become more popular. Sleep disorders, in particular, sleep-disordered breathing, have a higher prevalence than estimated previously. Many patients with apnea and hypopnea events suffer whereas others do not report complaints or show cardiovascular consequences. Assessment with wearables may support efforts to distinguish which type of apnea is related to aging and which to cardiovascular comorbidities. Innovative methods offer smart solutions for problems that are insufficiently addressed. Telemedical concepts help bring patients to sleep medicine expertise at an early stage. To use these methods clinically, they must be certified as medical devices.

Telemedicine in Sleep-Disordered Breathing: Expanding the Horizons

Interest in telemedicine has increased exponentially. There is a growing body of published evidence on the use of telemedicine for patients using continuous positive airway pressure. Telemedicine-ready devices can support the transmission on use time, apnea-hypopnea index, and leakage. This approach enables early activation of troubleshooting. Automated, personalized feedback for patients and patient access to their own data provide unprecedented opportunities for integrating comanagement approaches, multiactor interactions, and patient empowerment. Telemedicine is likely cost effective, but requires better evidence. Notwithstanding barriers for implementation that remain, telemedicine has to be embraced, leaving the physician and patient to accept it or not.

Video Consultation as an Adequate Alternative to Face-to-Face Consultation in Continuous Positive Airway Pressure Use for Newly Diagnosed Patients With Obstructive Sleep Apnea: Randomized Controlled Trial

Background

The effectiveness of continuous positive airway pressure (CPAP) is dependent on the degree of use, so adherence is essential. Cognitive components (eg, self-efficacy) and support during treatment have been found to be important in CPAP use. Video consultation may be useful to support patients during treatment. So far, video consultation has rarely been evaluated in thorough controlled research, with only a limited number of outcomes assessed.

Objective

The aim of the study was to evaluate the superiority of video consultation over face-to-face consultation for patients with obstructive sleep apnea (OSA) on CPAP use (minutes per night), adherence, self-efficacy, risk outcomes, outcome expectancies, expectations and experiences with video consultation, and satisfaction of patients and nurses.

Methods

A randomized controlled trial was conducted with an intervention (video consultation) and a usual care group (face-to-face consultation). Patients with confirmed OSA (apnea-hypopnea index >15), requiring CPAP treatment, no history of CPAP treatment, having access to a tablet or smartphone, and proficient in the Dutch language were recruited from a large teaching hospital. CPAP use was monitored remotely, with short-term (weeks 1 to 4) and long-term (week 4, week 12, and week 24) assessments. Questionnaires were completed at baseline and after 4 weeks on self-efficacy, risk perception, outcome expectancies (Self-Efficacy Measure for Sleep Apnea), expectations and experiences with video consultation (covering constructs of the unified theory of acceptance and use of technology), and satisfaction. Nurse satisfaction was evaluated using questionnaires.

Results

A total of 140 patients were randomized (1:1 allocation). The use of video consultation for OSA patients does not lead to superior results on CPAP use and adherence compared with face-to-face consultation. A significant difference in change over time was found between groups for short-term (P-interaction=.008) but not long-term (P-interaction=.68) CPAP use. CPAP use decreased in the long term (P=.008), but no significant difference was found between groups (P=.09). Change over time for adherence was not significantly different in the short term (P-interaction=.17) or long term (P-interaction=.51). A relation was found between CPAP use and self-efficacy (P=.001), regardless of the intervention arm (P=.25). No significant difference between groups was found for outcome expectancies (P=.64), self-efficacy (P=.41), and risk perception (P=.30). The experiences were positive, and 95% (60/63) intended to keep using video consultation. Patients in both groups rated the consultations on average with an 8.4. Overall, nurses (n=3) were satisfied with the video consultation system.

Conclusions

Support of OSA patients with video consultation does not lead to superior results on CPAP use and adherence compared with face-to-face consultation. The findings of this research suggest that self-efficacy is an important factor in improving CPAP use and that video consultation may be a feasible way to support patients starting CPAP. Future research should focus on blended care approaches in which self-efficacy receives greater emphasis.

Trial Registration

Clinicaltrials.gov NCT04563169; https://clinicaltrials.gov/show/NCT04563169

Spanish Society of Pulmonology and Thoracic Surgery positioning on the use of telemedine in sleep-disordered breathing and mechanical ventilation

The rapid introduction of new information and communication technologies into medical practice has prompted Spanish Society of Pulmonology and Thoracic SurgeryR to publish a position paper on sleep-disordered breathing, especially in relation to positive pressure treatment. It should be pointed out that the scientific literature is to some extent controversial due to a paucity of large randomized multicenter studies with long-term follow-up. Moreover, the telematics devices and systems on the market vary widely. As a result, the recommendations are based primarily on a consensus of expert professionals. Another very important aspect addressed extensively in this document is the obvious lack of regulations on legal matters and the operations of commercial companies. The most important recommendations included in this position paper are that telemedicine is primarily advocated in subjects with travel problems or who live far from the hospital, in patients with poor CPAP compliance, and in most cases treated with non-invasive mechanical ventilation. A key element is patient individualization. It is imperative that the relevant technical, legal and ethical requirements (medical device regulations, data protection, and informed consent) are met. Finally, expert professionals from our society must contribute to and become involved in spearheading this technological change.

Enablers of Patient Knowledge Empowerment for Self-Management of Chronic Disease: An Integrative Review

The non-development of the concept of patient knowledge empowerment for disease self-management and the non-development of the theory of patient knowledge empowerment in patients with chronic diseases, cause methodological inconsistency of patient empowerment theory and does not provide a methodological basis to present patient knowledge empowerment preconditions. Therefore, the aim of the present integrative review was to synthesize and critically analyze the patient knowledge enablers distinguished in the public health management theory, the knowledge sharing enablers presented in the knowledge management theory and to integrate them by providing a comprehensive framework of patient knowledge enablers. To implement the purpose of the study, in answering the study question of what patient knowledge empowerments are and across which levels of patient knowledge empowerment they operate, an integrative review approach was applied as proposed by Cronin and George. A screening process resulted in a final sample of 78 papers published in open access, peer-review journals in the fields of public health management and knowledge management theories. Based on the results of the study, the Enablers of Patient Knowledge Empowerment for Self-Management of Chronic Disease Framework was created. It revealed that it is important to look at patient knowledge empowerment as a pathway across the empowerment levels through which both knowledge enablers identified in public health management theory and knowledge sharing enablers singled out in knowledge management theory operate. The integration of these two perspectives across patient empowerment levels uncovers a holistic framework for patient knowledge empowerment.

Wearable monitoring of sleep-disordered breathing: estimation of the apnea-hypopnea index using wrist-worn reflective photoplethysmography

A large part of the worldwide population suffers from obstructive sleep apnea (OSA), a disorder impairing the restorative function of sleep and constituting a risk factor for several cardiovascular pathologies. The standard diagnostic metric to define OSA is the apnea-hypopnea index (AHI), typically obtained by manually annotating polysomnographic recordings. However, this clinical procedure cannot be employed for screening and for long-term monitoring of OSA due to its obtrusiveness and cost. Here, we propose an automatic unobtrusive AHI estimation method fully based on wrist-worn reflective photoplethysmography (rPPG), employing a deep learning model exploiting cardiorespiratory and sleep information extracted from the rPPG signal trained with 250 recordings. We tested our method with an independent set of 188 heterogeneously disordered clinical recordings and we found it estimates the AHI with a good agreement to the gold standard polysomnography reference (correlation = 0.61, estimation error = 3±10 events/h). The estimated AHI was shown to reliably assess OSA severity (weighted Cohen's kappa = 0.51) and screen for OSA (ROC-AUC = 0.84/0.86/0.85 for mild/moderate/severe OSA). These findings suggest that wrist-worn rPPG measurements that can be implemented in wearables such as smartwatches, have the potential to complement standard OSA diagnostic techniques by allowing unobtrusive sleep and respiratory monitoring.

The Impact of Telehealth on the Organization of the Health System and Integrated Care

Sleep medicine is a rapidly developing field of medicine that is well-suited to initiatives such as Telehealth to provide safe, effective clinical care to an expanding group of patients. The increasing prevalence of sleep disorders has resulted in long waiting lists and lack of specialist availability. Telemedicine has potential to facilitate a move toward an integrated care model, which involves professionals from different disciplines and different organizations working together in a team-oriented way toward a shared goal of delivering all of a person's care requirements. Issues around consumer health technology and nonphysician sleep providers are discussed further in the article.

Evaluating the feasibility of implementing a Telesleep pilot program using two-tiered external facilitation

BACKGROUND

Obstructive sleep apnea (OSA) can negatively impact patients' health status and outcomes. Positive airway pressure (PAP) reverses airway obstruction and may reduce the risk of adverse outcomes. Remote monitoring of PAP (as opposed to in-person visits) may improve access to sleep medicine services. This study aimed to evaluate the feasibility of implementing a clinical program that delivers treatment for OSA through PAP remote monitoring using external facilitation as an implementation strategy.

METHODS

Participants included patients with OSA at a Veteran Affairs Medical Center (VAMC). PAP adherence and clinical disease severity on treatment (measured by the apnea hypopnea index [AHI]) were the preliminary effectiveness outcomes across two delivery models: usual care (in-person) and Telehealth nurse-delivered remote monitoring. We also assessed visit duration and travel distance. A prospective, mixed-methods evaluation examined the two-tiered external facilitation implementation strategy.

RESULTS

The pilot project included N = 52 usual care patients and N = 38 Telehealth nurse-delivered remote monitoring patients. PAP adherence and disease severity were similar across the delivery modalities. However, remote monitoring visits were 50% shorter than in-person visits and saved a mean of 72 miles of travel (median = 45.6, SD = 59.0, mode = 17.8, range 5.4-220). A total of 62 interviews were conducted during implementation with a purposive sample of 12 clinical staff involved in program implementation. Weekly external facilitation delivered to both front-line staff and supervisory physicians was necessary to ensure patient enrollment and treatment. Synchronized, "two-tiered" facilitation at the executive and coordinator levels proved crucial to developing the clinical and administrative infrastructure to support a PAP remote monitoring program and to overcome implementation barriers.

CONCLUSIONS

Remote PAP monitoring had similar efficacy to in-person PAP services in this Veteran population. Although external facilitation is a widely-recognized implementation strategy in quality improvement projects, less is known about how multiple facilitators work together to help implement complex programs. Two-tiered facilitation offers a model well-suited to programs where innovations span disciplines, disrupt professional hierarchies (such as those between service chiefs, clinicians, and technicians) and bring together providers who do not know each other, yet must collaborate to improve access to care.

Mobile health application to support CPAP therapy in obstructive sleep apnoea: design, feasibility and perspectives

Background

Current continuous positive airway pressure (CPAP) devices can be monitored remotely; however, in-person visits are kept for clinical follow-up in order to promote CPAP use and resolve potential side-effects. Mobile health is a promising way to provide remote and easy clinical control for CPAP follow-up and support. We aimed to evaluate the feasibility and acceptance by obstructive sleep apnoea (OSA) patients and healthcare professionals of a newly designed mobile app (Appnea-Q) to promote clinical control through a self-monitoring tool for patients with CPAP supervised by sleep professionals.

Methods

Appnea-Q incorporates a simple follow-up questionnaire with automated responses, together with frequent problems and lifestyle recommendations sections. Feasibility, acceptance and usefulness were assessed. First, an internal validation was performed during outpatient CPAP follow-up visits with sleep professionals from various sleep units. Second, an external validation was performed in a subgroup of 15 patients at home.

Results

Most patients (n=75) considered the app useful and were willing to use it and recommend it (72-88%). Up to 64.87% agreed on its capacity to reduce hospital visits. Appnea-Q was rated as acceptable (79.37±19.29) by the system usability score. Sleep professionals (n=30) concurred on its usefulness for OSA patient follow-up, particularly during the first month of CPAP therapy. The external validation showed its feasibility among 11 out of 15 patients and their data were received accordingly on the professionals' web platform.

Conclusions

According to our validation process, and the viewpoints of the patients and professionals, our new mobile app is a feasible and well-received tool for personal OSA management. Future clinical trials should substantiate its performance and cost-effectiveness in the clinical arena.

Estimation of the apnea-hypopnea index in a heterogeneous sleep-disordered population using optimised cardiovascular features

Obstructive sleep apnea (OSA) is a highly prevalent sleep disorder, which results in daytime symptoms, a reduced quality of life as well as long-term negative health consequences. OSA diagnosis and severity rating is typically based on the apnea-hypopnea index (AHI) retrieved from overnight poly(somno)graphy. However, polysomnography is costly, obtrusive and not suitable for long-term recordings. Here, we present a method for unobtrusive estimation of the AHI using ECG-based features to detect OSA-related events. Moreover, adding ECG-based sleep/wake scoring yields a fully automatic method for AHI-estimation. Importantly, our algorithm was developed and validated on a combination of clinical datasets, including datasets selectively including OSA-pathology but also a heterogeneous, “real-world” clinical sleep disordered population (262 participants in the validation set). The algorithm provides a good representation of the current gold standard AHI (0.72 correlation, estimation error of 0.56 ± 14.74 events/h), and can also be employed as a screening tool for a large range of OSA severities (ROC AUC ≥ 0.86, Cohen’s kappa ≥ 0.53 and precision ≥70%). The method compares favourably to other OSA monitoring strategies, showing the feasibility of cardiovascular-based surrogates for sleep monitoring to evolve into clinically usable tools.

New organisation for follow-up and assessment of treatment efficacy in sleep apnoea

Obstructive sleep apnoea (OSA) is a highly prevalent disease, and there is an increased demand for OSA diagnosis and treatment. However, resources are limited compared with the growing needs for OSA diagnosis and management, and alternative strategies need to be developed to optimise the OSA clinical pathway. In this review, we propose a management strategy for OSA, and in general for sleep-disordered breathing, to be implemented from diagnosis to follow-up. For this purpose, the best current options seem to be: 1) networking at different levels of care, from primary physicians to specialised sleep laboratories; and 2) use of telemedicine. Telemedicine can contribute to the improved cost-effectiveness of OSA management during both the diagnostic and therapeutic phases. However, although the technology is already in place and different commercial platforms are in use, it is still unclear how to use telemedicine effectively in the sleep field. Application of telemedicine for titration of positive airway pressure treatment, follow-up to improve compliance to treatment through early identification and solution of problems, and teleconsultation all appear to be promising areas for improved OSA management.

Telemedicine could improve the management of sleep apnoea and other breathing disorders during sleep.http://bit.ly/2XPoPW1

Telemedicine in the diagnosis and treatment of sleep apnoea

Telemedicine (TM) is a current tool in the landscape of medicine. It helps to address public health challenges such as increases in chronic disease in an ageing society and the associated burden in healthcare costs. Sleep TM refers to patient data exchange with the purpose of enhancing disease management. Obstructive sleep apnoea (OSA) syndrome is a chronic disorder associated with a significant morbidity, mainly cardiometabolic, and mortality. Obtaining adequate compliance to continuous positive airway pressure (CPAP) remains the greatest challenge related to OSA treatment, and the adoption of TM to support OSA management makes sense. In addition, the prevalence of OSA is growing and OSA is associated with increased healthcare costs that could be streamlined by the application of TM. In OSA, multiple modalities of TM are utilised, such as telediagnostics, teleconsultation, teletherapy and telemonitoring of patients being treated with CPAP. In the present article, I aim to provide an overview of current practice and the recent developments in TM for OSA management. Concerns related to TM use will also be addressed.

Symbolic dynamics to enhance diagnostic ability of portable oximetry from the phone oximeter in the detection of paediatric sleep apnoea

OBJECTIVE

This study is aimed at assessing symbolic dynamics as a reliable technique to characterise complex fluctuations of portable oximetry in the context of automated detection of childhood obstructive sleep apnoea-hypopnoea syndrome (OSAHS).

APPROACH

Nocturnal oximetry signals from 142 children with suspected OSAHS were acquired using the Phone Oximeter: a portable device that integrates a pulse oximeter with a smartphone. An apnoea-hypopnoea index (AHI) ≥5 events/h from simultaneous in-lab polysomnography was used to confirm moderate-to-severe childhood OSAHS. Symbolic dynamics was used to parameterise non-linear changes in the overnight oximetry profile. Conventional indices, anthropometric measures, and time-domain linear statistics were also considered. Forward stepwise logistic regression was used to obtain an optimum feature subset. Logistic regression (LR) was used to identify children with moderate-to-severe OSAHS.

MAIN RESULTS

The histogram of 3-symbol words from symbolic dynamics showed significant differences (p <0.01) between children with AHI <5 events/h and moderate-to-severe patients (AHI ≥5 events/h). Words representing increasing oximetry values after apnoeic events (re-saturations) showed relevant diagnostic information. Regarding the performance of individual characterization approaches, the LR model composed of features from symbolic dynamics alone reached a maximum performance of 78.4% accuracy (65.2% sensitivity; 86.8% specificity) and 0.83 area under the ROC curve (AUC). The classification performance improved combining all features. The optimum model from feature selection achieved 83.3% accuracy (73.5% sensitivity; 89.5% specificity) and 0.89 AUC, significantly (p-value <0.01) outperforming the other models.

SIGNIFICANCE

Symbolic dynamics provides complementary information to conventional oximetry analysis enabling reliable detection of moderate-to-severe paediatric OSAHS from portable oximetry.

Challenges and perspectives in obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is a major challenge for physicians and healthcare systems throughout the world. The high prevalence and the impact on daily life of OSA oblige clinicians to offer effective and acceptable treatment options. However, recent evidence has raised questions about the benefits of positive airway pressure therapy in ameliorating comorbidities.

An international expert group considered the current state of knowledge based on the most relevant publications in the previous 5 years, discussed the current challenges in the field, and proposed topics for future research on epidemiology, phenotyping, underlying mechanisms, prognostic implications and optimal treatment of patients with OSA.

The group concluded that a revision to the diagnostic criteria for OSA is required to include factors that reflect different clinical and pathophysiological phenotypes and relevant comorbidities (e.g.nondipping nocturnal blood pressure). Furthermore, current severity thresholds require revision to reflect factors such as the disparity in the apnoea–hypopnoea index (AHI) between polysomnography and sleep studies that do not include sleep stage measurements, in addition to the poor correlation between AHI and daytime symptoms such as sleepiness. Management decisions should be linked to the underlying phenotype and consider outcomes beyond AHI.

New technology to assess sleep apnea: wearables, smartphones, and accessories

Sleep medicine has been an expanding discipline during the last few decades. The prevalence of sleep disorders is increasing, and sleep centers are expanding in hospitals and in the private care environment to meet the demands. Sleep medicine has evidence-based guidelines for the diagnosis and treatment of sleep disorders. However, the number of sleep centers and caregivers in this area is not sufficient. Many new methods for recording sleep and diagnosing sleep disorders have been developed. Many sleep disorders are chronic conditions and require continuous treatment and monitoring of therapy success. Cost-efficient technologies for the initial diagnosis and for follow-up monitoring of treatment are important. It is precisely here that telemedicine technologies can meet the demands of diagnosis and therapy follow-up studies. Wireless recording of sleep and related biosignals allows diagnostic tools and therapy follow-up to be widely and remotely available. Moreover, sleep research requires new technologies to investigate underlying mechanisms in the regulation of sleep in order to better understand the pathophysiology of sleep disorders. Home recording and non-obtrusive recording over extended periods of time with telemedicine methods support this research. Telemedicine allows recording with little subject interference under normal and experimental life conditions.

Compliance with continuous positive airway pressure in Persian patients with obstructive sleep apnea

Background:

Obstructive sleep apnea (OSA) is defined by recurrent apnea and hypopnea during sleep. The main treatment of OSA is continuous positive airway pressure (CPAP). Adherence to CPAP is challenging and depends on multiple factors. This study was designed to evaluate the compliance with CPAP in patients with OSA.

Materials and Methods:

This was a prospective observational study including 106 patients with confirmed OSA by a standard polysomnography. We recorded CPAP usage hours after 7 and 90 days by a smart card. We compared the adherence of the patients with respect to body mass index (BMI), gender, smoking status, living area, and education level.

Results:

Patients in the 18–45 years’ age group had higher compliance in mean (standard deviation) daily use of CPAP (0.93 [0.40] h) compared to the other age groups (P < 0.001). Patients with BMI >35 had better compliance (1.13 [0.44]) than the other patients (P < 0.001). Furthermore, nonsmokers and highly educated patients had better compliance compared to the others (P < 0.001).

Conclusion:

Age, BMI, education, and smoking are important factors in adherence to CPAP in patients with OSA.

Telemonitoring in continuous positive airway pressure-treated patients improves delay to first intervention and early compliance: a randomized trial

OBJECTIVE

Telemonitoring (TM) has been used in continuous positive airway pressure (CPAP)-treated patients to improve compliance, but results have been inconsistent. The purpose of this study was to assess the impact of TM on the delay to the first technical intervention after CPAP initiation. The impact of TM on mean compliance during the first 3 months of treatment was measured as a secondary outcome.

METHODS

Patients diagnosed with moderate to severe obstructive sleep apnea syndrome were prospectively included and randomized to receive usual care (UC) or TM. In both arms, an educational session was scheduled 1 month after CPAP initiation, and medical visits were planned after 1.5 and 3 months. In the TM arm, we added a universal TM unit (T4P) to the CPAP device.

RESULTS

Delay to first intervention was significantly shorter in the TM group (29 ± 25 vs 47 ± 30 days, p = 0.02). The first intervention in the TM group was motivated by detection of problems by the TM system in 39% of patients. Compliance at 3 months was significantly better in the TM group (5.7 ± 1.6 vs 4.2 ± 1.9 h/night, p = 0.018).

CONCLUSION

This is the first randomized study showing that TM reduces delay to first technical intervention in CPAP-treated patients. This early activation of troubleshooting was associated with improved compliance at 3 months. Since CPAP side effects at 1 month have been shown to predict lower 12-month CPAP compliance, TM seems to be an excellent tool for improvement of long-term CPAP acceptance.