Polysomnographic predictors of persistent continuous positive airway pressure adherence in patients with moderate and severe obstructive sleep apnea

Therapeutic adherence in patients with Obstructive Sleep Apnea Syndrome: a retrospective cohort study

INTRODUCTION

Obstructive Sleep Apnea Syndrome (OSAS) is a respiratory disorder characterized by repeated episodes of partial or complete airway obstruction. Continuous Positive Airway Pressure therapy (CPAP) is effective in improving sleep quality and daytime sleepiness. The aim of the study was to evaluate therapeutic adherence in a sample of patients with OSAS from the Pneumology ward of the "Cardinal Massaia" Hospital in Asti.

MATERIALS AND METHODS

A sample of 221 patients with OSAS were collected and retrospectively analyzed from January 2019 to December 2021. Ventilation hours during device titration (T1), possible second titration (T2) and one-year control (T3) were considered. The use of the CPAP device equal to or greater than 4 h/night was considered as therapeutic adherence. Age, gender, severity of OSAS, smoking, interface used and Epworth Sleepiness Scale (ESS) score were considered.

RESULTS

The analysis data showed that the percentage of adhesion during T1 was 84%. Only 9% needed T2, with 84% adherence. At T3 the adherence was 86%. Correlation studies showed that only smoking had a positive correlation with adherence, while OSAS severity, gender, ESS score, interface used and age had no statistically significant correlation.

CONCLUSION

It was important to understand that OSAS is a disease with prolonged treatment, which affects the life of the person and his family. Therefore, the concept of assistance network was born, which sees the healthcare operators, the person and his family as the main actors involved in a care process.

Comparative Effectiveness of Supine Avoidance versus Continuous Positive Airway Pressure for Treating Supine-isolated Sleep Apnea: A Clinical Trial

Rationale: About 20-35% of patients with obstructive sleep apnea (OSA) have supine-isolated OSA, for which supine sleep avoidance could be an effective therapy. However, traditional supine discomfort-based methods show poor tolerance and compliance to treatment and so cannot be recommended. Supine alarm devices show promise, but evidence to support favorable adherence to treatment and effectiveness at reducing excessive daytime sleepiness compared with continuous positive airway pressure (CPAP) remains limited. Objectives: To establish if alarm-based supine-avoidance treatment in patients with supine-isolated OSA is noninferior to CPAP in reducing daytime sleepiness. Methods: After baseline questionnaire administration and in-home supine-time and polysomnography assessments, patients with supine-isolated OSA and Epworth Sleepiness Scale scores ⩾8 were randomized to ⩾6 weeks of supine-avoidance or CPAP treatment, followed by crossover to the remaining treatment with repeat assessments. Noninferiority was assessed from change in Epworth Sleepiness Scale with supine avoidance compared with CPAP using a prespecified noninferiority margin of 1.5. Average nightly treatment use over all nights and treatment efficacy and effectiveness at reducing respiratory disturbances were also compared between treatments. Results: The reduction in sleepiness score with supine avoidance (mean [95% confidence interval], -1.9 [-2.8 to -1.0]) was noninferior to that with CPAP (-2.4 [-3.3 to -1.4]) (supine avoidance-CPAP difference, -0.4 [-1.3 to 0.6]), and the lower confidence limit did not cross the noninferiority margin of 1.5 (P = 0.021). Average treatment use was higher with supine avoidance compared with CPAP (mean ± standard deviation, 5.7 ± 2.4 vs. 3.9 ± 2.7 h/night; P < 0.001). Conclusions: In patients with supine-isolated OSA, vibrotactile supine alarm device therapy is noninferior to CPAP for reducing sleepiness and shows superior treatment adherence. Clinical trial registered with www.anzctr.org.au (ACTRN 12613001242718).

Adherence Index: sleep depth and nocturnal hypoventilation predict long-term adherence with positive airway pressure therapy in severe obstructive sleep apnea

STUDY OBJECTIVES

Treatment of obstructive sleep apnea with positive airway pressure (PAP) devices is limited by poor long-term adherence. Early identification of individual patients' probability of long-term PAP adherence would help in their management. We determined whether conventional polysomnogram (PSG) scoring and measures of sleep depth based on the odds ratio product would predict adherence with PAP therapy 12 months after it was started.

METHODS

Patients with obstructive sleep apnea referred to an academic sleep center had split-night PSG, arterial blood gases, and a sleep questionnaire. Multiple linear regression analysis of conventional PSG scoring and the odds ratio product both during diagnostic PSG and PAP titration provided an "Adherence Index," which was correlated with PAP use 12 months later.

RESULTS

Patients with obstructive sleep apnea (n = 236, apnea-hypopnea index 72.2 ± 34.1 events/h) were prescribed PAP therapy (82% received continuous PAP, 18% received bilevel PAP). Each patient's adherence with PAP therapy 12 months later was categorized as "never used," "quit using," "poor adherence," and "good adherence." PSG measures that were most strongly correlated with PAP adherence were apnea-hypopnea index and odds ratio product during nonrapid eye movement sleep; the additional contribution of nocturnal hypoxemia to this correlation was confined to those with chronic hypoventilation treated with bilevel PAP. The Adherence Index derived from these measures, during both diagnostic PSG and PAP titration, was strongly correlated with PAP adherence 12 months later.

CONCLUSIONS

Long-term adherence with PAP therapy can be predicted from diagnostic PSG in patients with severe obstructive sleep apnea, which may facilitate a precision-based approach to PAP management.

CITATION

Younes MK, Beaudin AE, Raneri JK, Gerardy BJ, Hanly PJ. Adherence Index: sleep depth and nocturnal hypoventilation predict long-term adherence with positive airway pressure therapy in severe obstructive sleep apnea. J Clin Sleep Med. 2022:18(8):1933-1944.

Application of personalized medicine to obstructive sleep apnea in China

Obstructive sleep apnea (OSA) is a common sleep disorder whose prevalence is increasing in China consistent with rising obesity trends. OSA is a heterogeneous disorder depends on anatomical and nonanatomical risk factors. Ethnicity differentially influences the attribution of these OSA risk factors. Chinese patients had more craniofacial bony restriction and Caucasians were more obese. This suggests ethnic differences in potential applications for diagnostics and therapeutics. However, current strategies for the management of OSA reflect a one-size-fits-all approach based on the apnea-hypopnea index (AHI). Although continuous positive airway pressure (CPAP) remains the first-line and most efficacious treatment for OSA, the acceptance is unacceptably low in China. Therefore, targeted therapies to treat OSA need to be developed. This review summarizes the differences in OSA pathogenesis of Chinese patients and analyzes the current condition of personalized medicine to patients with OSA in China. The application of personalized medicine to OSA in the Chinese population is still a long way off.

Incidence and predictors of adherence to sleep apnea treatment in rehabilitation inpatients with acquired brain injury

OBJECTIVE

The purpose of this study was to describe incidence and assess predictors of adherence to Positive Airway Pressure (PAP) therapy for Obstructive Sleep Apnea (OSA) in persons with acquired brain injury (ABI).

METHODS

A 2012-2015 retrospective analysis of consecutive ABI patients admitted for neurorehabilitation, referred for polysomnography (PSG), and prescribed PAP for OSA. Univariable linear regressions were conducted to examine predictors of average hours of nightly PAP use. Univariable logistic regressions were conducted to examine predictors of PAP adherence using the conventional clinical definition of ≥4 h per night ≥70% of the time. Persons with traumatic etiology were separately analyzed.

RESULTS

ABI etiology was 51% traumatic, 36% stroke, and 13% other nontraumatic causes. Nearly two-thirds were nonadherent to PAP. For the overall sample, higher average nightly PAP usage was significantly predicted by positive hypertension diagnosis (β = 0.271, p = 0.019). Likewise, greater adherence based on the conventional cutoff was predicted by poorer motor functioning at hospital admission (OR = 0.98, p = 0.001) and lower oxygen saturation nadir (OR = 0.99, p = 0.003). For those with traumatic injuries, greater adherence was predicted by poorer functional status at hospital admission (OR = 0.98, p = 0.010) and positive hypertension diagnosis (OR = 0.16, p = 0.023).

CONCLUSIONS

In this study of hospitalized neurorehabilitation patients with ABI and comorbid OSA, predictors of adherence included lower oxygen saturation, poorer functional status and hypertension diagnosis, perhaps signifying the role of greater severity of illness on treatment adherence. High rates of refusal and nonadherence to frontline PAP therapy for sleep apnea is a concern for persons in recovery form ABI who are at a time of critical neural repair.

Adherence to Continuous Positive Airway Pressure in patients with Obstructive Sleep Apnoea. A ten year real life study

OBJECTIVE

To assess the predictive factors at 12 month and 10 year adherence to Continuous Positive Airway Pressure (CPAP) in patients with Obstructive Sleep Apnoea (OSA).

METHODS

Retrospective data analysis of patients starting CPAP between 2006 and 2009. After 12 months (T1) from start and during a 10 year follow up the following data were recorded: Body Mass Index (BMI), Time of night use, Epworth Sleepiness Scale (ESS) score.

RESULTS

Out of 315 patients, 147 fulfilled inclusion criteria and were evaluated. According to CPAP nighttime use during the first year, patients were divided into two groups: those using the device less < 4.5 h (Poor Adherence (PA): 61 patients), and those using ≥4.5 h: (Good Adherence (GA): 86 patients). Patients of PA group were significantly younger, had greater BMI and required more unscheduled visits during the first year. After 12 months, there were 11 (7.5%) dropouts, all in PA group. Patients using the nasal mask showed a greater prevalence among GA as compared to those using the oro-nasal mask (76.5% vs 57.8% respectively, p = 0.04). After 10 years 83 out of 147 (56.4%) patients were still under CPAP, 51 (59.3% of GA) and 32 (52.4% of PA group) respectively. Dropouts were significantly more frequent during the first 5 years (p = 0.04).

CONCLUSION

Ten years after prescription the majority of patients with OSA undergoing periodical controls, still perform CPAP independent of their adherence to therapy after one year of use. Use of nasal mask may be associate to better adherence.

Comparative analysis of predictive methods for early assessment of compliance with continuous positive airway pressure therapy

Background

Patients suffering obstructive sleep apnea are mainly treated with continuous positive airway pressure (CPAP). Although it is a highly effective treatment, compliance with this therapy is problematic to achieve with serious consequences for the patients’ health. Unfortunately, there is a clear lack of clinical analytical tools to support the early prediction of compliant patients.

Methods

This work intends to take a further step in this direction by building compliance classifiers with CPAP therapy at three different moments of the patient follow-up, before the therapy starts (baseline) and at months 1 and 3 after the baseline.

Results

Results of the clinical trial shows that month 3 was the time-point with the most accurate classifier reaching an f1-score of 87% and 84% in cross-validation and test. At month 1, performances were almost as high as in month 3 with 82% and 84% of f1-score. At baseline, where no information of patients’ CPAP use was given yet, the best classifier achieved 73% and 76% of f1-score in cross-validation and test set respectively. Subsequent analyzes carried out with the best classifiers of each time point revealed baseline factors (i.e. headaches, psychological symptoms, arterial hypertension and EuroQol visual analog scale) closely related to the prediction of compliance independently of the time-point. In addition, among the variables taken only during the follow-up of the patients, Epworth and the average nighttime hours were the most important to predict compliance with CPAP.

Conclusions

Best classifiers reported high performances after one month of treatment, being the third month when significant differences were achieved with respect to the baseline. Four baseline variables were reported relevant for the prediction of compliance with CPAP at each time-point. Two characteristics more were also highlighted for the prediction of compliance at months 1 and 3.

Trial registration

ClinicalTrials.gov Identifier, NCT03116958. Retrospectively registered on 17 April 2017.

Electronic supplementary material

The online version of this article (10.1186/s12911-018-0657-z) contains supplementary material, which is available to authorized users.

CPAP Adherence Predictors in a Randomized Trial of Moderate-to-Severe OSA Enriched With Women and Minorities

BACKGROUND

Suboptimal CPAP adherence in OSA clinical trials involving predominantly white men limits interpretability and generalizability. We examined predictors of CPAP adherence in a clinical trial enriched with minorities.

METHODS

The Sleep Apnea Stress Study-a randomized, double-blind, sham-controlled trial of patients with moderate-to-severe OSA-included participants with complete 8-week adherence data (n = 138). Overnight 14-channel polysomnography, anthropometry, socioeconomic status, mood questionnaires, and week 1 CPAP adherence were analyzed via adjusted linear models relative to CPAP adherence (average minutes per night usage).

RESULTS

Overall, age was 51 ± 12 years, 55% of the patients were male, 55% were white, BMI was 36.7 ± 7.7 kg/m², and median apnea-hypopnea index was 20 (interquartile range, 13-37). In univariate analyses adherence increased with randomization to active CPAP (81 min; 95% CI, 30-132), increasing age (35 min/decade; 95% CI, 13-57), white race (78 min, 95% CI, 26-129), and per hour of week 1 adherence (41 min, 95% CI, 32-51). Active CPAP (48 min, 95% CI, 6-91), increasing age (27 min/decade, 95% CI, 10-44), and higher 1-week adherence (36 min/h, 95% CI, 27-46) were significantly associated with improved adherence in multivariable analyses. Subgroup analyses showed stronger associations of adherence with treatment arm in whites and increasing age in minorities. Increasing age and white race were more strongly associated with adherence in women.

CONCLUSIONS

In this trial with near-even sex distribution and high ethnic minority representation, we identified CPAP assignment, increasing age, and early adherence to be associated with improved adherence in addition to sex-specific and race-specific adherence differences. These results can inform targeted clinical trial adherence optimization strategies.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00607893; URL: www.clinicaltrials.gov.

Residual excessive sleepiness in patients with obstructive sleep apnea on treatment with continuous positive airway pressure

PURPOSE OF REVIEW

One of the most common causes of excessive daytime sleepiness in clinical practice is obstructive sleep apnea syndrome (OSAS). So far, continuous positive airway pressure (CPAP) is the most effective treatment for OSA. Some of the patients do not improve on CPAP and remain sleepy despite using CPAP.This review provides updated information about the possible causes of residual sleepiness whilst using the CPAP in patients with OSAS.

RECENT FINDINGS

Prevalence of OSAS has increased recently to 23.4% in women and 49.7% in men. Periodic limb movement, behaviorally induced insufficient sleep syndrome and depression are the most common causes of persistent sleepiness on CPAP. Residual sleepiness after exclusion of all possible causes is 6%.

SUMMARY

There is still lack of sufficient evidence about the accurate characteristics and possible causes of this residual sleepiness and how to address this in large prospective studies.

CPAP Adherence is Associated With Attentional Improvements in a Group of Primarily Male Patients With Moderate to Severe OSA

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a widespread condition that adversely affects physical health and cognitive functioning. The prevailing treatment for OSA is continuous positive airway pressure (CPAP), but therapeutic benefits are dependent on consistent use. Our goal was to investigate the relationship between CPAP adherence and measures of sustained attention in patients with OSA. Our hypothesis was that the Psychomotor Vigilance Task (PVT) would be sensitive to attention-related improvements resulting from CPAP use.

METHODS

This study was a secondary analysis of a larger clinical trial. Treatment adherence was determined from CPAP use data. Validated sleep-related questionnaires and a sustained-attention and alertness test (PVT) were administered to participants at baseline and at the 6-month time point.

RESULTS

Over a 6-month time period, the average CPAP adherence was 3.32 h/night (standard deviation [SD] = 2.53), average improvement in PVT minor lapses was -4.77 (SD = 13.2), and average improvement in PVT reaction time was -73.1 milliseconds (standard deviation = 211). Multiple linear regression analysis showed that higher CPAP adherence was significantly associated with a greater reduction in minor lapses in attention after 6 months of continuous treatment with CPAP therapy (β = -0.72, standard error = 0.34, P = .037).

CONCLUSIONS

The results of this study showed that higher levels of CPAP adherence were associated with significant improvements in vigilance. Because the PVT is a performance-based measure that is not influenced by prior learning and is not subjective, it may be an important supplement to patient self-reported assessments.

CLINICAL TRIAL REGISTRATION

Name: Effect of Self-Management on Improving Sleep Apnea Outcomes, URL: https://clinicaltrials.gov/ct2/show/NCT00310310, Identifier: NCT00310310.

Barriers to CPAP Use in India: An Exploratory Study

STUDY OBJECTIVES

To investigate adherence to continuous positive airway pressure (CPAP) therapy and identify barriers to CPAP use among patients with obstructive sleep apnea (OSA) in India.

METHODS

A self-devised semistructured questionnaire (which collected patients' demographic information, socioeconomic position, and information about disease status, symptoms, and complications) was administered to consecutive patients with moderate to severe OSA from June 2015 to August 2016. Patients were grouped according to CPAP device buying behavior (buyers versus nonbuyers) and CPAP compliance behavior (compliant versus noncompliant).

RESULTS

Out of 187 patients with moderate-severe OSA, 79 patients were enrolled for this study. The overall adherence rate (usage > 4 hours per night on > 70% nights) was 30.3%. Among the patients in the buyer group, adherence was 82.7%. Fifty patients did not buy a CPAP device; 30 of these 50 patients (60%) said financial constraints were the most important reason for not buying a CPAP device. Patients without financial constraints had higher chances-odds ratio (95% confidence interval) = 4.85 (1.6-16.1)-of buying a CPAP device than patients with financial constraints. Patients with more severe disease (ie, lower nadir oxygen saturation during sleep, higher apnea-hypopnea index, or presence of obesity hypoventilation syndrome) were more likely to buy and use a CPAP device.

CONCLUSIONS

The main cause of nonuse of CPAP in India is the inability to buy a CPAP device. In patients who are able to buy a CPAP device, adherence was significantly higher (82.7%) compared to adherence in the study's overall population (30.3%). Furthermore, patients with more severe OSA were more likely to buy a device and adhere to CPAP. Patients' behaviors and attitudes are also important barriers in using CPAP. There needs to be increased awareness of the benefits of CPAP therapy among patients.

Stem/progenitor cells and obstructive sleep apnea syndrome - new insights for clinical applications

Obstructive sleep apnea syndrome (OSAS) is a widespread disorder, characterized by recurrent upper airway obstruction during sleep, mostly as a result of complete or partial pharyngeal obstruction. Due to the occurrence of frequent and regular hypoxic events, patients with OSAS are at increased risk of cardiovascular disease, stroke, metabolic disorders, occupational errors, motor vehicle accidents and even death. Thus, OSAS has severe consequences and represents a significant economic burden. However, some of the consequences, as well as their costs can be reduced with appropriate detection and treatment. In this context, the recent advances that were made in stem cell biology knowledge and stem cell - based technologies hold a great promise for various medical conditions, including respiratory diseases. However, the investigation of the role of stem cells in OSAS is still recent and rather limited, requiring further studies, both in animal models and humans. The goal of this review is to summarize the current state of knowledge regarding both lung resident as well as circulating stem/progenitor cells and discuss existing controversies in the field in order to identify future research directions for clinical applications in OSAS. Also, the paper highlights the requisite for inter-institutional, multi-disciplinary research collaborations in order to achieve breakthrough results in the field.

Effect of Continuous Positive Airway Pressure on Airway Inflammation and Oxidative Stress in Patients with Obstructive Sleep Apnea

Background. Airway inflammation and oxidative stress may be linked in obstructive sleep apnea (OSA) patients. We determined the effectiveness of continuous positive airway pressure (CPAP) therapy in reducing fractional exhaled nitric oxide (FeNO) and malondialdehyde (MDA) levels in OSA patients. Methods. Thirteen patients with OSA and 13 normal controls were recruited. FeNO and MDA levels were measured in the controls and in OSA patients before and after three months of CPAP therapy. Results. FeNO and MDA levels were higher in the patients compared to the age and gender matched controls (FeNO: 25.9 ± 5.0 versus 17.5 ± 5.9 ppb, P < 0.001; MDA: 14.6 ± 7.8 versus 2.1 ± 0.3 μmol/L, P < 0.001). FeNO and MDA levels were lower post-CPAP compared to pre-CPAP (FeNO: 25.9 ± 5.0 versus 17.0 ± 2.3 ppb, P < 0.001; MDA: 14.6 ± 7.8 versus 10.0 ± 6.4 μmol/L, P < 0.01). Apnea-hypopnea index (15.9 ± 6.6 versus 4.1 ± 2.1/h, P < 0.001) and mean arterial pressure (P < 0.01) decreased following CPAP treatment. Daytime mean SpO₂ (P < 0.05) increased. Conclusion. Our study demonstrates that CPAP therapy yields clinical benefits by reducing upper airway inflammation and oxidative stress in OSA patients.

Validation of overnight oximetry to diagnose patients with moderate to severe obstructive sleep apnea

Background

Polysomnography (PSG) is treated as the gold standard for diagnosing obstructive sleep apnea (OSA). However, it is labor-intensive, time-consuming, and expensive. This study evaluates validity of overnight pulse oximetry as a diagnostic tool for moderate to severe OSA patients.

Methods

A total of 699 patients with possible OSA were recruited for overnight oximetry and PSG examination at the Sleep Center of a University Hospital from Jan. 2004 to Dec. 2005. By excluding 23 patients with poor oximetry recording, poor EEG signals, or respiratory artifacts resulting in a total recording time less than 3 hours; 12 patients with total sleeping time (TST) less than 1 hour, possibly because of insomnia; and 48 patients whose ages less than 20 or more than 85 years old, data of 616 patients were used for further study. By further considering 76 patients with TST < 4 h, a group of 540 patients with TST ≥ 4 h was used to study the effect of insufficient sleeping time. Alice 4 PSG recorder (Respironics Inc., USA) was used to monitor patients with suspected OSA and to record their PSG data. After statistical analysis and feature selection, models built based on support vector machine (SVM) were then used to diagnose moderate and moderate to severe OSA patients with a threshold of AHI = 30 and AHI = 15, respectively.

Results

The SVM models designed based on the oxyhemoglobin desaturation index (ODI) derived from oximetry measurements provided an accuracy of 90.42-90.55%, a sensitivity of 89.36-89.87%, a specificity of 91.08-93.05%, and an area under ROC curve (AUC) of 0.953-0.957 for the diagnosis of severe OSA patients; as well as achieved an accuracy of 87.33-87.77%, a sensitivity of 87.71-88.53%, a specificity of 86.38-86.56%, and an AUC of 0.921-0.924 for the diagnosis of moderate to severe OSA patients. The predictive outcome of ODI to diagnose severe OSA patients is better than to diagnose moderate to severe OSA patients.

Conclusions

Overnight pulse oximetry provides satisfactory diagnostic performance in detecting severe OSA patients. Home-styled oximetry may be a tool for severe OSA diagnosis.