Psychological variables as predictors of adherence to treatment by continuous positive airway pressure

Precision medicine approaches in obstructive sleep apnoea: The role of dentist-sleep physician partnerships

Obstructive Sleep Apnoea (OSA) is a common heterogenous sleep disorder that is associated with a wide range of comorbidities and consequences, including the development of neurocognitive and cardiometabolic disorders. The heterogeneity of OSA necessitates a precision medicine approach to accurately diagnose this condition and to effectively manage patients. One of the primary models of precision medicine is described by the P4 approach of predicting those who are susceptible to disease, preventing the occurrence of disease, personalizing treatment, and encouraging patients to participate in their individual healthcare journey. Recent advances in oral appliance therapy and OSA monitoring techniques have fostered an exciting opportunity for enhanced collaboration between dentists and sleep physicians to optimize OSA precision medicine care. This review aims to discuss the sources of heterogeneity among OSA patients, provide an overview of the growing applications of oral appliance therapy and tailored monitoring programs for OSA that are shifting treatment to a more personalized and participatory model of care, and outline the pivotal role of dentists in managing patients with OSA.

Adherence to continuous positive airway pressure therapy in patients with spinal cord injury and obstructive sleep apnea: trajectories and predictors

PURPOSE

To identify specific determinants of non-adherence or cessation of continuous positive airway pressure (CPAP) therapy in a population of patients with spinal cord injuries (SCI).

METHODS

Retrospective analysis of data from patients with SCI who underwent a full night supervised polysomnography between 2015 and 2021 and presented with moderate to severe obstructive sleep apnea (OSA) and for whom CPAP was indicated. Adherence was studied at 1, 6, and 12 months. Univariate and multivariate analyses were performed to identify factors associated with non-adherence (< 4 h per night or CPAP cessation). Factors studied were demographic and disease-related data and both subjective and objective sleep parameters.

RESULTS

A total of 60 patients were included (40% cervical SCI). In univariate analysis, the only predictive parameters of non-adherence observed at 1, 6, and 12 months were the average use of CPAP on the 1st night (p = 0.02) and over the 1st week (p ≤ 0.001). A complete lesion (AIS-A) was predictive of non-adherence at 1 and 6 months (p = 0.02 at 6 months), while mask leakage was associated with non-adherence at 12 months (p = 0.02). Upper limb autonomy and the presence of family caregivers did not appear to be protective. In multivariate analysis, only the average use in the first week remained predictive of adherence (> 4 h) in the short, medium and long term.

CONCLUSION

In patients with SCI and OSA, the 1st week of CPAP treatment seems to be determinant of short-, medium-, and long-term CPAP adherence. Support for SCI patients from the start of treatment is essential and may help avoid treatment failures.

CPAP resumption after a first termination and impact on all-cause mortality in France

BACKGROUND

Continuation of continuous positive airway pressure (CPAP) therapy after initial prescription has been shown to reduce all-cause mortality versus therapy termination. However, there is a lack of data on the rates and impact of resuming CPAP in patients with obstructive sleep apnoea (OSA). This analysis determined the prevalence of CPAP resumption in the year after termination, characterised determinants of CPAP resumption, and examined the impact of CPAP resumption on all-cause mortality.

METHODS

French national health insurance reimbursement system data for adults aged ≥18 years were used. CPAP prescription was identified by specific treatment codes. Patients who resumed CPAP after first therapy termination and continued to use CPAP for 1 year were matched with those who resumed CPAP then terminated therapy for a second time.

RESULTS

Out of 103 091 individuals with a first CPAP termination, 26% resumed CPAP over the next 12 months, and 65% of these were still using CPAP 1 year later. Significant predictors of CPAP continuation after resumption included male sex, hypertension and CPAP prescription by a pulmonologist. In the matched population, the risk of all-cause death was 38% lower in individuals who continued using CPAP after therapy resumption versus those who had a second therapy discontinuation (hazard ratio 0.62, 95% CI 0.48-0.79; p=0.0001).

CONCLUSION

These data suggest that individuals with OSA who fail initial therapy with CPAP should be offered a second trial with the device to ensure that effective therapy is not withheld from those who might benefit.

[Factors affecting adherence to CPAP therapy in patients with obstructive sleep apnea syndrome]

OBJECTIVE

Analysis of factors affecting adherence to continuous positive airway pressure (CPAP) therapy in patients with obstructive sleep apnea (OSA).

MATERIAL AND METHODS

The literature search was carried out using the databases PubMED, Google Scholar, E-library, Cyberleninka for the period 2013-2023 and included reviews and original articles.

RESULTS

The main groups of factors affecting adherence to CPAP therapy in patients with OSA have been established. These include sociodemographic and socioeconomic factors, the severity of OSA and the severity of clinical symptoms, and psychosocial factors. Strategies that can improve adherence were identified (educational technologies for patients, telemedicine technologies, behavioral therapy, modern technical interventions).

CONCLUSION

Factors that improve adherence to CPAP therapy are high levels of education and income, more severe OSA forms accompanied by daytime sleepiness, support from the patient's spouse and social support. Factors such as low levels of education and income, smoking, symptoms of depression and hypochondria, as well as side-effects worsen adherence to CPAP therapy, including refusal to continue treatment. It should be noted that all the identified factors are very closely associated with each other, so it is necessary to evaluate them comprehensively in each patient with OSA.

Anxiety and depressive symptoms on continuous positive airway pressure: long-term adherence in patients with sleep apnea syndrome

BACKGROUND

Obstructive sleep apnea (OSA) is often associated to mood disorders and anxiety symptoms that may influence negatively the treatment approach. However, the relationship between anxiety, depression and adherence to treatment is still unclear. We investigate the presence of anxiety and depressive symptoms in newly diagnosed OSA patients and the link between psychological symptoms and acceptance or adherence to CPAP after one year.

METHODS

A validated Italian questionnaire for anxiety and depressive symptoms was administered to 249 patients (69F) with a mean age of 57.2±12.2 and a mean AHI of 40.9±21.9 (ev*hr^-1). The CPAP use in the first and last night of acclimatization and one year after prescription was 6.4±2.2, 6.9±1.4 and 5.3±2.2 hr, respectively.

RESULTS

Anxiety symptoms were reported by 15.6% of patients, depressive symptoms by 6% while 12.5% reported both anxiety and depressive symptoms. Adherence to CPAP in the first night was not adequate in 19.7% of patients with relevant difference between groups: 16.4% in AD^-,20.5% in A⁺,13.3% in D⁺ and 38.7% in AD⁺ (χ²=8.6; P=0.03). However, at the end of acclimatization period only 4.4% of patients utilized CPAP<5/h. One-year after prescription the adherence was adequate in 74.7% of patients without difference between groups. A Cox proportional hazard model demonstrated that AHI (OR=0.985, 95% CI: 0.97-0.99; P=0.03) and compliance to CPAP at the first night of use (OR=0.445; 95% CI: 0.246-0.8; P=0.007) are the only predictive factors of long-term compliance.

CONCLUSIONS

Presence of anxiety and depressive symptoms should be checked before PAP titration since they may negatively influence the early acclimatization and adherence.

Identifying longitudinal patterns of CPAP treatment in OSA using growth mixture modeling: Disease characteristics and psychological determinants

In this study, we aim to identify the distinct subtypes of continuous positive airway pressure (CPAP) user profiles based on the telemedicine management platform and to determine clinical and psychological predictors of various patterns of adherence. A total of 301 patients used auto-CPAP (Autoset 10, Resmed Inc.) during the treatment period. Four categories of potential predictors for CPAP adherence were examined: (1) demographic and clinical characteristics, (2) disease severity and comorbidities, (3) sleep-related health issues, and (4) psychological evaluation. Then, growth mixture modeling was conducted using Mplus 8.0 to identify the unique trajectories of adherence over time. Adherence data were collected from the telemedicine management platform (Airview, Resmed Inc.) during the treatment. Three novel subgroups were identified and labeled “adherers” (53.8% of samples, intercept = 385, slope = −51, high mean value, negative slope and moderate decline), “Improvers” (18.6%, intercept = 256, slope = 50, moderate mean value, positive slope and moderate growth) and “non-adherers” (27.6%, intercept = 176, slope = −31, low mean value, negative slope and slight decline). The comorbidities associated with OSA and the apnea–hypopnea index (AHI), which reflects the objective severity of the disease, did not differ significantly among the subgroups. However, “improvers” showed higher levels of daytime sleepiness (8.1 ± 6.0 vs. 12.1 ± 7.0 vs. 8.0 ± 6.1 in SWIFT, p = 0.01), reduced daytime function (4.6 ± 1.6 vs. 3.8 ± 1.6 vs. 4.2 ± 1.8 in QSQ daytime symptoms, p = 0.02), and characteristics of positive coping style (1.8 ± 0.5 vs. 1.9 ± 0.5 vs. 1.7 ± 0.5 in SCSQ positive coping index, p = 0.02). Negative emotion was more pronounced in patients with “non-adherers” (12.9 ± 3.8 vs. 13.7 ± 3.3 vs. 14.6 ± 3.5, p = 0.02 in the HADS depression dimension; 9.0 ± 6.1 vs. 9.8 ± 5.1 vs. 11.5 ± 6.3, p = 0.01 with Negative Affectivity in DS14, and 9.3 ± 6.1 vs. 10.3 ± 5.1 vs. 11.7 ± 6.5, p = 0.01 with Social Inhibition in DS14). Overall, our study demonstrated that CPAP therapy may present distinct trajectories of adherence over time in addition to the traditional binary classification. Self-reported sleep health issues (diurnal sleepiness and daytime dysfunction) as well as psychological characteristics (negative emotions and coping style) were predictors of different adherence subtypes in patients with OSA. Understanding CPAP use profiles and their predictors enable the identification of those who may require additional intervention to improve adherence and further enhance the therapeutic effect in OSA patients.

The Impact of Mouth-Taping in Mouth-Breathers with Mild Obstructive Sleep Apnea: A Preliminary Study

Background: Many patients with obstructive sleep apnea (OSA) are mouth-breathers. Mouth-breathing not only narrows the upper airway, consequently worsening the severity of OSA, but also it affects compliance with nasal continuous positive airway pressure (CPAP) treatment. This study aimed to investigate changes in OSA by the use of mouth tape in mouth-breathers with mild OSA. Method: Mouth-breathers with mild OSA who met inclusion criteria and tolerated the sealing of the mouth were enrolled in the study. We used 3M silicone hypoallergenic tape was used to seal the mouths of the participants during sleep. The home sleep test (HST) used in this study was ApneaLink^®. Subjects received both a baseline HST and an outcome HST to be used 1 week later while their mouths were taped. The changes between the baseline and the outcome HSTs were compared, and the factors that influenced the differences in the sleep-test parameters after the shift of the breathing route were analyzed. A “responder” was defined as a patient who experienced a reduction from the baseline snoring index of at least 50% under mouth-taping in the HST; otherwise, patients were considered as having a poor response. Results: A total of 20 patients with mild OSA were included. Following the taping of the mouth, a good response was found in 13 patients (65%). The median apnea/hypopnea index (AHI) decreased significantly, from 8.3 to 4.7 event/h (by 47%, p = 0.0002), especially in supine AHI (9.4 vs. 5.5 event/h, p = 0.0001). The median snoring index (SI) was also improved (by 47%, 303.8 vs. 121.1 event/h, p = 0.0002). Despite no significant difference in the mean saturation, improvements in the oxygen desaturation index (8.7 vs. 5.8, p = 0.0003) and the lowest saturation (82.5% vs. 87%, p = 0.049) were noted. The change in AHI was associated with baseline AHI (r = −0.52, p = 0.02), oxygen desaturation index (ODI) (r = −0.54, p = 0.01), and SI (r = −0.47, p = 0.04). The change in SI was strongly associated with baseline SI (r = −0.77, p = 0.001). Conclusions: Mouth-taping during sleep improved snoring and the severity of sleep apnea in mouth-breathers with mild OSA, with AHI and SI being reduced by about half. The higher the level of baseline AHI and SI, the greater the improvement was shown after mouth-taping. Mouth-taping could be an alternative treatment in patients with mild OSA before turning to CPAP therapy or surgical intervention.

Impact of patient and family engagement in improving continuous positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial

STUDY OBJECTIVES

The aim of the Improving CPAP Adherence Program was to assess the impact of a multidimensional treatment framework based on shared decision-making, patient activation, and caregiver engagement on improving long-term positive airway pressure (PAP) adherence in patients newly diagnosed with obstructive sleep apnea.

METHODS

In this pilot study, patients aged ≥ 18 years with a new obstructive sleep apnea diagnosis who qualified for PAP treatment and lived with a caregiver were randomly assigned to receive either the multidimensional treatment (intervention, n = 28) or unrelated education (control group, n = 32). All patients and their caregiver participated in a group visit. The intervention group attended 4 structured sessions: interactive education, peer coaching, hands-on experience, and a semistructured motivational interview. The control group was educated on physical activity and lifestyle only. Objective PAP adherence data were obtained at baseline (day that they received PAP machine to group visit), group visit to 3 months, and 3-6 months.

RESULTS

In an age-adjusted model, the mean daily use of PAP increased significantly over the 3 time periods (P = .03). Intervention-arm participants gained a mean 1.23 hours (95% confidence interval, 0.33-2.13) in PAP mean daily use between 3 and 6 months vs those in the control arm (P = .008). We saw no difference in the percentage of PAP adherence across time between the 2 arms.

CONCLUSIONS

A multifaceted patient-centered intervention with caregiver engagement improved PAP adherence vs control levels, a beneficial effect sustained for the 6 months. Our findings suggest that caregivers, with the appropriate training, can improve patients' PAP adherence by providing a socially supportive environment.

CITATION

Khan NNS, Todem D, Bottu S, Badr MS, Olomu A. Impact of patient and family engagement in improving continuous positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial. J Clin Sleep Med. 2022;18(1):181-191.

Factors affecting compliance with positive airway pressure therapy in obstructive sleep apnea

OBJECTIVE

To investigate the factors affecting compliance with positive airway pressure (PAP) therapy and establish the relationship between compliance and pulmonary function tests (PFT) in patients with OSA.

MATERIAL AND METHODS

In this prospective study, patients with OSA using PAP devices were questioned about the complaints related to the device. Depression and anxiety scales along with PFT parameters were also assessed.

RESULTS

Of 98 participants, 63% were men. The mean age was 52.0 ± 9.6 years. Sixty-seven percent of the patients were compliant with their devices. A significant difference was observed between the proportion of the participants compliant or non-compliant with the device, based on OSA severity (p < 0.05). Beck depression inventory (BDI) and Beck anxiety inventory (BAI) scores of the compliant patients were significantly lower than those of the non-compliant patients (p < 0.001, p = 0.044, respectively). No statistically significant difference was detected between the groups regarding individual pulmonary function tests (p > 0.05). The rates of nasal mask use, not having difficulty in tolerating CPAP, falling asleep, absence of abdominal distension, no facial sores, no air leakage, patients benefiting from the device, reduction in daytime sleepiness, and the belief that they are receiving appropriate therapy in participants compliant with the device were higher than those in non-compliant participants (p < 0.05). The rates of claustrophobia and discomfort due to pressure were significantly lower in patients compliant with the device than in the non-compliant patients (p < 0.05).

CONCLUSION

While no relationship was detected between PFT parameters and PAP therapy compliance, significant factors affecting the device compliance were detected.

CPAP-SAVER follow-up study to determine long-term adherence and associated factors

BACKGROUND

Many factors contribute to continuous positive airway pressure (CPAP) nonadherence, affecting health care burden. The original CPAP-SAVER study enrolled 66 CPAP-naive participants and showed high 1-month adherence and significantly higher apnea beliefs and CPAP attitude for the intervention group.

PURPOSE AND METHODS

Thirty-three participants from the original CPAP-SAVER study were recruited for a 3-year follow-up to determine adherence, examine the intervention effect, and identify adherence-associated factors.

RESULTS

Adherence rates dropped to 54.5% at 3 years, with a significant decrease in CPAP use hours (t = -2.37, p = .024) and nights (t = -4.05, p < .001). Group differences in beliefs and attitude were not sustained; however, beliefs (r = 0.57) and attitude (r = 0.44) were significant factors associated with adherence. Life satisfaction was significantly higher at present compared with before wearing CPAP (t = 5.17, p < .001).

IMPLICATIONS FOR PRACTICE

The authors recommend intervention with a focus on apnea beliefs, CPAP attitude, and long-term support to promote CPAP adherence. Focus on CPAP attitude and beliefs and enhanced support early in the obstructive sleep apnea (OSA) treatment trajectory may promote long-term adherence and subsequently reduce the health care burden of OSA disease.

CPAP Therapy Termination Rates by OSA Phenotype: A French Nationwide Database Analysis

The nationwide claims data lake for sleep apnoea (ALASKA)—real-life data for understanding and increasing obstructive sleep apnea (OSA) quality of care study—investigated long-term continuous positive airway pressure (CPAP) termination rates, focusing on the contribution of comorbidities. The French national health insurance reimbursement system data for new CPAP users aged ≥18 years were analyzed. Innovative algorithms were used to determine the presence of specific comorbidities (hypertension, diabetes and chronic obstructive pulmonary disease (COPD)). Therapy termination was defined as cessation of CPAP reimbursements. A total of 480,000 patients were included (mean age 59.3 ± 13.6 years, 65.4% male). An amount of 50.7, 24.4 and 4.3% of patients, respectively, had hypertension, diabetes and COPD. Overall CPAP termination rates after 1, 2 and 3 years were 23.1, 37.1 and 47.7%, respectively. On multivariable analysis, age categories, female sex (1.09 (1.08–1.10) and COPD (1.12 (1.10–1.13)) and diabetes (1.18 (1.16–1.19)) were significantly associated with higher CPAP termination risk; patients with hypertension were more likely to continue using CPAP (hazard ratio 0.96 (95% confidence interval 0.95–0.97)). Therapy termination rates were highest in younger or older patients with ≥1 comorbidity. Comorbidities have an important influence on long-term CPAP continuation in patients with OSA.

CPAP combined with oral appliance therapy reduces CPAP requirements and pharyngeal pressure swings in obstructive sleep apnea

Oral appliance (OA) therapy is the leading alternative to continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA). It is well tolerated compared with CPAP. However, ≥50% of patients using OA therapy have incomplete resolution of their OSA. Combination therapy with CPAP and oral appliance (CPAP + OA) is a potential alternative for incomplete responders to OA therapy. This study aimed to determine the extent to which combination therapy reduces therapeutic CPAP requirements using gold-standard physiological methodology in those who have an incomplete response to OA therapy alone. Sixteen incomplete responders [residual apnea/hypopnea index (AHI) > 10 events/h] to a novel OA with a built-in oral airway were recruited (3 women:13 men, aged 31-65 yr, body mass index: 22-38 kg/m², residual AHI range: 13-63 events/h). Participants were fitted with a nasal mask, pneumotachograph, epiglottic pressure catheter, and standard polysomnography equipment. CPAP titrations were performed during non-rapid eye movement (NREM) supine sleep in each participant during three conditions (order randomized): CPAP only, CPAP + OA (oral airway open), and CPAP + OA (oral airway closed). OSA was resolved at pressures of 4 ± 2 and 5 ± 2 cmH₂O during CPAP + OA (oral airway open) and CPAP + OA (oral airway closed) conditions versus 8 ± 2 cmH₂O during CPAP only (P < 0.01). Negative epiglottic pressure swings in oral airway open and closed conditions were normalized to CPAP only levels [-2.5(-3.7, -2.6) vs. -2.3(-3.2, -2.4) vs. -2.1(-2.7, -2.3) cmH₂O]. Combined CPAP and OA therapy reduces therapeutic CPAP requirements by 35%-45% and minimizes epiglottic pressure swings. This combination may be a therapeutic alternative for patients with incomplete responses to OA therapy alone and those who cannot tolerate high CPAP levels.NEW & NOTEWORTHY Combined CPAP and oral appliance therapy has been suggested as an alternative for incomplete responders to oral appliance therapy. We used a novel oral appliance incorporating an oral airway together with CPAP to show that pharyngeal pressure swings were normalized at reduced CPAP levels. Our findings demonstrate that using CPAP and oral appliance together may be a beneficial alternative for incomplete responders to oral appliance therapy and intolerant CPAP users due to high-pressure requirements.

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.

Acute effects of continuous positive airway pressure in patients with obstructive sleep apnea

Objectives. To enhance the initial compliance of continuous positive airway pressure (CPAP) in the patient with obstructive sleep apnea (OSA), we investigate the acute effects of one-night CPAP on morning blood pressure (BP) and, if any exist, to determine which factors predict BP-lowering effects of one-night CPAP in OSA subgroups stratified by the presence or absence of uncontrolled hypertension. Design. Newly diagnosed OSA patients (a respiratory distress index (RDI) ≥ 15) without a history of hypertension were stratified by the presence or absence of morning hypertension. Comparisons were made of morning BP, overnight change in mean BP (MBP), and circadian BP pattern (R_M/E, the ratio of morning to evening MBP) between two time points of diagnostic and CPAP titrations in each subgroup. In the subgroup with a significantly reduced morning BP, predictors of changes in morning MBP were determined by multiple linear regression analyses. Results. The prevalence of morning hypertension was 48.8%. One-night CPAP reduced BP immediately only in patients with morning hypertension. By contrast, patients without morning hypertension did not experience any BP-lowering effects. In the subgroup with morning hypertension, baseline morning MBP, female sex, and R_M/E were independently associated with reduced morning MBP, and R_M/E was the most important predictor. Conclusions. These results confirm the acute effects of one-night CPAP on lowering BP in OSA patients with morning hypertension. An unfavorable circadian BP pattern is the most important predictor.

Effect of the CPAP-SAVER Intervention on Adherence

Obstructive sleep apnea (OSA) is the most common form of sleep-disordered breathing. Continuous positive airway pressure (CPAP) is the treatment of choice, but adherence is poor, contributing to a myriad of comorbidities that increase health burden. The study purpose was to examine the effect of the CPAP-SAVER intervention on adherence among adults with newly diagnosed OSA. Sixty-six participants were randomly assigned to intervention or standard care groups. Data were analyzed using chi-square, t-tests, and correlations. At one month, there was no significant difference in adherence between groups; CPAP beliefs and attitude were significantly higher and attitude significantly increased for the intervention group. Focus on CPAP beliefs and attitude by practitioners may impact CPAP adherence. With further research and replication of this study in larger samples to determine generalizability, the CPAP-SAVER intervention may provide underpinnings for the eventual development of an OSA-CPAP adherence management protocol.

Factors Influencing Adherence to Auto-CPAP: An Observational Monocentric Study Comparing Patients With and Without Cardiovascular Diseases

Introduction: Obstructive sleep apnea/hypopnea (OSAH) affects more than 15% of the general population and increases the occurrence of cardiovascular (CV) and metabolic events. Continuous positive airway pressure (CPAP) treatment is currently the gold standard treatment of OSAH and could prevent the occurrence of such events. However, long-term adherence to CPAP is a problem where a significant rate stop device treatment use. OSAH patients suffering CV disease could be less compliant due to less diurnal symptoms. Methods: We performed a prospective study of 408 non-CV or CV disease patients suffering severe OSAH syndrome and followed them during the first 5 months as well as a mean of 3 years of CPAP treatment use. Results: We demonstrated that in adult OSAH patients that two variables were associated with a low compliance (<5 h/night): age <60 y and lower maximal positive airway pressure level used. There was no significant impact of the presence of CV disease on compliance of 5 months. After 3 years of CPAP, age <60 y as well as diabetes were independent factors of low compliance. There was no significant association between gender, mask types, 90th centile positive airway pressure level, apnea/hypopnea index and short- or long-term compliance in our population. Conclusions: We did not find lower compliance of CPAP in CV OSAH patients. Most of our population (68-73%) demonstrated an optimal night treatment duration at 3 years of follow-up, allowing a reduction of CV occurrence or recurrence. We hypothesize that an early and short education of OSAH as we routinely proposed could allow a significant increase in the optimal observance of CPAP in at-risk populations.

A review of psychosocial factors and personality in the treatment of obstructive sleep apnoea

Effective treatment of obstructive sleep apnoea (OSA) is primarily determined by adherence to the selected intervention. The most common treatment pathways are mechanical devices such as continuous positive airway pressure (CPAP) or a mandibular advancement device, often combined with weight loss therapy. Weight reduction is usually an adjunct therapy but may be used as a secondary treatment in mild-to-moderate OSA when mechanical treatments cannot be tolerated. To enhance the uptake and adherence to treatment, clinicians may assess patient's personality profiles and psychological readiness. There is a paucity of evidence related to these aspects of patient care and this article outlines the current research in relation to patient presentation, treatment uptake and barriers, and methods to enhance treatment adherence.

This article disseminates personality traits observed in patients with OSA and identifies vulnerable groups who may require additional support to increase treatment adherence. It summarises the current evidence for treatment barriers in patients with OSA. Low self-efficacy in relation to CPAP and weight loss adherence will be explored as well as the potential to predict treatment responders and enhance therapeutic uptake and adherence. Extending personality traits into research and clinical practice could potentially result in more successful CPAP therapy and weight loss treatment outcomes.

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.

Post-approval upper airway stimulation predictors of treatment effectiveness in the ADHERE registry

Upper airway stimulation (UAS) has been shown to reduce severity of obstructive sleep apnoea. The aim of this study was to identify predictors of UAS therapy response in an international multicentre registry.Patients who underwent UAS implantation in the United States and Germany were enrolled in an observational registry. Data collected included patient characteristics, apnoea/hypopnoea index (AHI), Epworth sleepiness scale (ESS), objective adherence, adverse events and patient satisfaction measures. Post hoc univariate and multiple logistic regression were performed to evaluate factors associated with treatment success.Between October 2016 and January 2018, 508 participants were enrolled from 14 centres. Median AHI was reduced from 34 to 7 events·h^-1, median ESS reduced from 12 to 7 from baseline to final visit at 12-month post-implant. In post hoc analyses, for each 1-year increase in age, there was a 4% increase in odds of treatment success. For each 1-unit increase in body mass index (BMI), there was 9% reduced odds of treatment success. In the multivariable model, age persisted in serving as statistically significant predictor of treatment success.In a large multicentre international registry, UAS is an effective treatment option with high patient satisfaction and low adverse events. Increasing age and reduced BMI are predictors of treatment response.

Marital quality, partner's engagement and continuous positive airway pressure adherence in obstructive sleep apnea

BACKGROUND

Continuous positive airway pressure (CPAP) is the first line therapy for obstructive sleep apnea (OSA) but its effectiveness requires high adherence. We aimed to assess the impacts of the spouse's/partner's involvement and the quality of the couple's relationship on CPAP adherence.

METHODS

In a multicenter prospective study conducted in France, patients reported their subjective views regarding their partner's engagement in their CPAP treatment and the quality of their marital relationship using the Quality of Marriage Index. A hierarchical linear model was built to assess the predictors of CPAP adherence at day 120. Structural equation modeling was performed to evaluate the direct and indirect effects of the spouse's/partner's engagement and the quality of the couple's relationship on CPAP adherence.

RESULTS

The 290 OSA patients were predominantly male (77%), with a median age of 53 years IQR: [46; 62], median BMI: 32 kg/m² [28.6; 35.9] and median apnea + hypopnea index: 43/per hour [33; 58]. Independent factors for CPAP adherence at day 120 were the partner's encouragement of CPAP usage and a stable relationship exceeding 30 years, although emotional support or collaboration were not associated with CPAP adherence. Structural equation modeling demonstrated that spouse's/partner's engagement is directly related to CPAP adherence and improvement of symptoms, and that CPAP adherence is a mediator of disease-specific health-related quality of life. Marital quality was a significant moderator of these interactions meaning that a spouse's/partner's engagement improved adherence only when the quality of marriage index was high.

CONCLUSION

Future research and integrated OSA management should systematically include and document the role of the spouse/partner in CPAP adherence.

Predictors of positive airway pressure therapy termination in the first year: analysis of big data from a German homecare provider

Background

There is a lack of robust data about factors predicting continuation (or termination) of positive airway pressure therapy (PAP) for sleep apnea. This analysis of big data from a German homecare provider describes patients treated with PAP, analyzes the therapy termination rate over the first year, and investigates predictive factors for therapy termination.

Methods

Data from a German homecare service provider were analyzed retrospectively. Patients who had started their first PAP therapy between September 2009 and April 2014 were eligible. Patient demographics, therapy start date, and the date of and reason for therapy termination were obtained. At 1 year, patients were classified as having compliance-related therapy termination or remaining on therapy. These groups were compared, and significant predictors of therapy termination determined.

Results

Of 98,329 patients included in the analysis, 11,702 (12%) terminated PAP therapy within the first year (after mean 171 ± 91 days). There was a U-shaped relationship between therapy termination and age; therapy termination was higher in the youngest (< 30 years, 15.5%) and oldest (≥ 80 years, 19.8%) patients, and lower in those aged 50–59 years (9.9%). Therapy termination was significantly more likely in females versus males (hazard ratio 1.48, 95% confidence interval 1.42–1.54), in those with public versus private insurance (1.75, 1.64–1.86) and in patients whose first device was automatically adjusting or fixed-level continuous positive airway pressure versus bilevel or adaptive servo-ventilation (1.28, 1.2–1.38).

Conclusions

This analysis of the largest dataset investigating PAP therapy termination identified a number of predictive factors. These can help health care providers chose the most appropriate PAP modality, identify specific patient phenotypes at higher risk of stopping PAP and target interventions to support ongoing therapy to these groups, as well as allow them to develop a risk stratification tool.

Managing comorbid cardiovascular disease and sleep apnea with pharmacotherapy

INTRODUCTION

Highly prevalent sleep disordered breathing (SDB) has been recognized as an independent cardiovascular disease (CVD) risk factor. Although these two entities often coexist, there is a shortage of sufficiently-powered studies testing the interplay between the course of sleep apnea and CVD pharmacotherapy. The mutual relationship between treated/untreated obstructive sleep apnea (OSA) with ongoing cardiovascular pharmacotherapies is an evident gap in clinical expertise.

AREAS COVERED

In this article, the authors review the available evidence and outline future research directions concerning the reciprocal relationship between the pharmacological treatment of CVD and SDB. Several attempts have been made to identify the most efficacious hypotensive agents for patients with both OSA and hypertension. Various cardiovascular drugs are also evaluated in terms of their influence on sleep apnea severity.

EXPERT OPINION

The question of whether OSA should be included in cardiovascular pharmacotherapy individualization algorithms is a matter of debate and more evidence is needed. Cautious intensification of diuretics with the use of aldosterone receptor antagonists deserves attention when both high blood pressure and sleep apnea coexist.

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.

Association Between Titration Method and Outcomes of First Night Satisfaction and CPAP Compliance

Introduction

The gold standard therapy for obstructive sleep apnoea syndrome (OSAS) is continuous positive airway pressure (CPAP). Our study evaluated the relationship between first night satisfaction and CPAP compliance, and the effect of using the titration method in this relationship.

Methods

Between January 2012 and December 2012, 40 patients with the diagnosis of OSAS and without comorbidities, who had undergone CPAP titration, were included. Of these, 20 patients had undergone manual titration (MT) with polysomnography, whereas 20 patients had undergone auto-adjusted CPAP (APAP) titration. Questionnaires were administered during the morning of the titration night. The first-year adherence to treatment and patient compliance were evaluated.

Results

Forty patients were randomised in two groups; 35 patients who could procure the CPAP and were available at the end of the first year completed the study. From the 35 patients, 20 (6 males; 40%) were in the MT group while 15 (6 males; 30%) were in the APAP group. No significant difference was detected between the mean titration pressure levels obtained with the MT or APAP group. There was no difference in terms of responses to the questions on the questionnaire between the two groups. At the first-year evaluation, no significant difference was detected between the groups.

Conclusions

The titration method used to detect CPAP pressure, MT, or APAP does not affect patient satisfaction on the day following the titration night, and does not affect first-year compliance.

[Importance of the emotional dimension when providing information to patients with obstructive sleep apnea syndrome]

INTRODUCTION

To promote adaptation to treatment with continuous positive airway pressure, an information document was developed for people starting their treatment with continuous positive airway pressure.

METHODS

Seven patients with obstructive sleep apnea took part in a focus group. This allowed the identification both of useful information and the best way that this information could be presented.

RESULTS

The key specific information objectives and the best emotional register to use were as follows: (1) develop awareness about the physiological mechanisms and consequences that can occur from obstructive sleep apnea syndrome, using formulations arousing fear, (2) enable the recognition of the symptoms, risk factors and chronicity of this syndrome, (3) reassure and motivate the patient about treatment with continuous positive airway pressure.

CONCLUSIONS

To promote adaptation to positive airway pressure in early care, combining different emotional tones is preferable, mixing both fear and reassurance.

Barriers to acceptance and adherence to continuous positive airway pressure therapy in patients with obstructive sleep apnea: a report from Kermanshah province, western Iran

PURPOSE

Continuous positive airway pressure (CPAP) is the gold standard treatment for obstructive sleep apnea (OSA). CPAP acceptance and adherence are critical issues for optimal treatment outcome. Identifying barriers to acceptance and adherence can improve intervention development and outcomes. This study aimed to investigate the barriers to CPAP acceptance/adherence in patients with OSA in western Iran.

PATIENTS AND METHODS

Patients with OSA, who had been prescribed CPAP by the Sleep Disorders Research Center of Kermanshah University of Medical Sciences, were recruited. They were interviewed via telephone regarding acceptance (ie, CPAP use during the first 2 weeks) and adherence (ie, CPAP use 4 h/d for 70% of the nights per week). Barriers to acceptance and adherence were solicited.

RESULTS

Out of a possible sample of 101, 97 patients (79 male) were reached and included in the study. They had a mean age of 48.76 years (SD =12.04) and mean apnea/hypopnea index score of 36.06 (SD =1.87). Patients were categorized into the following acceptance/adherence groups: nonacceptance (CPAP not purchased; 72.2%), poor adherence (5.2%), and adherent (22.7%). Inability to afford a CPAP device, perception of symptom reduction/no need for treatment, and dissatisfaction with treatment were among the most common reasons for nonacceptance and poor adherence.

CONCLUSION

CPAP acceptance and adherence in western Iran are low. Approximately 70% of the patients did not accept CPAP treatment (due to not obtaining the device) and 5% did not adhere. To improve acceptance/adherence, increased access (ie, reduced cost or increased insurance coverage) and enhanced education about the benefits of the treatment are recommended. Treatment monitoring via regular follow-ups may also prove beneficial.

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.

Adaptive servo ventilation for central sleep apnoea in heart failure: SERVE-HF on-treatment analysis

This on-treatment analysis was conducted to facilitate understanding of mechanisms underlying the increased risk of all-cause and cardiovascular mortality in heart failure patients with reduced ejection fraction and predominant central sleep apnoea randomised to adaptive servo ventilation versus the control group in the SERVE-HF trial.Time-dependent on-treatment analyses were conducted (unadjusted and adjusted for predictive covariates). A comprehensive, time-dependent model was developed to correct for asymmetric selection effects (to minimise bias).The comprehensive model showed increased cardiovascular death hazard ratios during adaptive servo ventilation usage periods, slightly lower than those in the SERVE-HF intention-to-treat analysis. Self-selection bias was evident. Patients randomised to adaptive servo ventilation who crossed over to the control group were at higher risk of cardiovascular death than controls, while control patients with crossover to adaptive servo ventilation showed a trend towards lower risk of cardiovascular death than patients randomised to adaptive servo ventilation. Cardiovascular risk did not increase as nightly adaptive servo ventilation usage increased.On-treatment analysis showed similar results to the SERVE-HF intention-to-treat analysis, with an increased risk of cardiovascular death in heart failure with reduced ejection fraction patients with predominant central sleep apnoea treated with adaptive servo ventilation. Bias is inevitable and needs to be taken into account in any kind of on-treatment analysis in positive airway pressure studies.

Awareness of obstructive sleep apnea-hypopnea syndrome among the general population of the Lorraine Region of France

OBJECTIVE

Obstructive sleep apnea-hypopnea syndrome (OSAHS) seems to be underdiagnosed. The aim of this study was to assess awareness of OSAHS among the general population of the Lorraine Region of France.

METHODS

A descriptive epidemiological study was carried out from July to November 2015 in the Lorraine Region, using an anonymous questionnaire that assessed knowledge of OSAHS-related symptoms and complications. The survey was also circulated on the Internet via social media. Exclusion criteria comprised age under 18 years, refusal to fill out the questionnaire and linguistic barrier.

RESULTS

1307 subjects filled out the survey: 1020 on paper format and 287 via the Internet. About two-thirds of the population recognized a majority of symptoms. However, there was a significant lack of knowledge of complications, especially cardiological and neurological. Suffering from OSAHS, having had higher education, and being under 40 years of age, were factors linked to better awareness of the syndrome. Internet respondents also showed better awareness.

CONCLUSION

Despite encouraging results regarding OSAHS symptoms, the general population showed limited awareness of its complications. Innovative educational campaigns must be organized to inform practitioners and the general public about the disease and raise awareness of its complications.

Adherence to Continuous Positive Airway Pressure in Existing Users: Self-Efficacy Enhances the Association between Continuous Positive Airway Pressure and Adherence

STUDY OBJECTIVES

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common sleep disorder associated with a myriad of sequelae. OSAHS is effectively treated with continuous positive airway pressure (CPAP) therapy. However, fewer than 50% of patients are compliant with their CPAP therapy prescriptions. The current study sought to explore an integrated, biopsychological approach to CPAP adherence among experienced CPAP users.

METHODS

We performed a retrospective, cross-sectional analysis of a cohort of veterans with a diagnosis of OSAHS (n = 191) who were prescribed CPAP therapy and returned for adherence download at the Miami VA Sleep Clinic. The relationships between biomedical characteristics (e.g., CPAP pressure, self-reported sleepiness, and change in sleep efficiency) and psychological factors (e.g., self-efficacy beliefs and psychological diagnoses) and objectively measured CPAP use were examined to determine whether psychological factors moderated the relationships between biomedical characteristics and CPAP adherence.

RESULTS

Hierarchical regression analyses predicting CPAP adherence (adjusting for time since CPAP prescription, age, education, prescribed CPAP pressure, daytime sleepiness, changes in sleep efficiency with CPAP, and psychiatric conditions) revealed the following: (1) CPAP self-efficacy and CPAP pressure were positively related to adherence, and (2) CPAP self-efficacy moderates the relationship between CPAP pressure and CPAP adherence.

CONCLUSIONS

There was no relationship between CPAP pressure and adherence in individuals with low self-efficacy beliefs. However, for individuals with high self-efficacy beliefs, there was a significant positive relationship between CPAP pressure and adherence. Self-efficacy beliefs appear to be a prime target for focused interventions aimed at improving CPAP adherence among those individuals with higher pressure prescriptions.

Adherence to Positive Airway Pressure Therapy in Hospitalized Patients with Decompensated Heart Failure and Sleep-Disordered Breathing

STUDY OBJECTIVES

Sleep-disordered breathing (SDB) has been implicated as a risk factor for the development of several adverse cardiovascular outcomes, but can be mitigated with positive airway pressure therapy (PAP). The nonadherence of patients with SDB on PAP in the outpatient setting ranges from 29% to 84%. However, adherence of PAP in patients with congestive heart failure (CHF) admitted for decompensated CHF and in whom SDB has been diagnosed in the hospital setting is not known. We hypothesized that despite a diagnosis in the hospital, the compliance of these patients with PAP therapy would not be different from the well-established adherence in patients with a diagnosis and treatment in the outpatient setting.

METHODS

The study was a retrospective analysis of patients admitted to an academic tertiary care hospital between March 2013 and February 2014. Patients presenting with decompensated CHF were screened and high-risk patients were started on PAP empirically and advised to undergo a postdischarge polysomnogram. Compliance of the patients with PAP was tracked for over 12 mo. Data from a similar outpatient group who underwent polysomnography during the study period were also reviewed.

RESULTS

Ninety-one patients underwent polysomnograhy postdischarge. Of the 91 patients, 81 patients agreed to PAP therapy. One patient was excluded as data were missing. The adherence at 3, 6, and 12 mo was 52%, 37%, and 27%, which was not significantly different than an outpatient control group. There was a trend for those with CHF plus SDB and compliant with PAP to have a higher probability of survival compared to those who were noncompliant (p = 0.07).

CONCLUSIONS

Adherence of patients to PAP therapy in whom a SDB diagnosis is made during acute hospitalization for heart failure is comparable to patients in the ambulatory setting. Adherence in first 3 mo is a predictive marker for improved survival trend.

Therapeutic outcomes of mandibular advancement devices as an initial treatment modality for obstructive sleep apnea

Although continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA), there is a need for alternative treatment options, such as sleep surgeries and mandibular advancement devices (MADs), to overcome the limitations of CPAP.This study aimed to analyze the therapeutic outcomes of OSA subjects who were treated with a MAD, and to estimate the clinical impact of MAD as a first-line treatment for OSA.Forty-seven patients diagnosed with OSA received an adjustable MAD as an initial treatment. Drug-induced sleep endoscopic findings and sleep parameters (both pre-MAD and post-MAD treatment), such as apnea index, oxygen saturation, and degree of daytime sleepiness, were assessed retrospectively.The MAD treatment resulted in a significant reduction in apnea-hypopnea index, and also a significant elevation in lowest oxygen saturation. Satisfactory results of MAD treatment as a first treatment modality were observed in 27 patients, and a successful outcome was reached in approximately 72% of patients. The OSA patients who had lower body mass index and upper airway narrowing at the level of palate and tongue base showed relatively higher rates of a satisfactory outcome even in cases of moderate or severe OSA.These results suggest that the use of a MAD may be an alternative treatment option in OSA patients with retropalatal and retroglossal area narrowing regardless of disease severity. Additionally, MADs can be recommended as an initial treatment modality, and the effectiveness of MADs in achieving success may not be inferior to CPAP.

Effect of Nasal Continuous Positive Pressure on the Nostrils of Patients with Sleep Apnea Syndrome and no Previous Nasal Pathology. Predictive Factors for Compliance

OBJECTIVE

To evaluate the effect of continuous positive airway pressure (CPAP) on the nostrils of patients with sleep apnea-hypopnea syndrome and its impact on quality of life, and to identify predictive factors for compliance.

METHODS

Longitudinal prospective study. Thirty-six consecutive patients evaluated before and 2 months after CPAP using the following variables: clinical (eye, nose and throat [ENT] symptoms, Epworth test, anxiety/depression scales, general and rhinoconjunctivitis-specific quality of life); anatomical (ENT examination, computed tomography); functional (auditive and Eustachian tube function, nasal flow, mucociliary transport); biological (nasal cytology); and polisomnographics. The sample was divided into compliers (≥4h/d) and non-compliers (<4h/d).

RESULTS

A significant improvement was observed in daytime sleepiness (p=0.000), anxiety (P=.006), and depression (P=.023). Nasal dryness (P=.000), increased neutrophils in nasal cytology (P=.000), and deteriorating ciliary function were evidenced, particularly in compliers. No significant differences were observed in the other variables. Baseline sleepiness was the only factor predictive of compliance.

CONCLUSIONS

CPAP in patients without previous nasal pathology leads to an improvement in a series of clinical parameters and causes rhinitis and airway dryness. Some ENT variables worsened in compliers. Sleepiness was the only prognostic factor for poor tolerance.

Facilitators and Barriers to Noninvasive Ventilation Adherence in Youth with Nocturnal Hypoventilation Secondary to Obesity or Neuromuscular Disease

OBJECTIVE

Many youth struggle with adherence to bilevel noninvasive ventilation (NIV), often shortly after initiation of treatment. Anecdotal evidence suggests youths with comorbid obesity struggle with adherence while youths with comorbid neuromuscular disease demonstrate better adherence rates. The objective of this study was to explore factors relating to bilevel NIV adherence, and to compare these between youths with underlying obesity or neuromuscular disease.

METHODS

An exploratory qualitative approach was used to examine youth and caregivers' experiences with and perceptions of bilevel NIV. Semi-structured interviews (n = 16) of caregivers and youths were conducted. Youths 12 years and older with nocturnal hypoventilation diagnosed on polysomnography and managed with bilevel NIV, with either concurrent obesity or neuromuscular disease were included. Thematic analysis of interview data was conducted using qualitative analysis software.

RESULTS

Factors associated with positive bilevel NIV adherence included previous encouraging experiences with therapy; subjective symptom improvement; familiarity with medical treatments; understanding of nocturnal hypoventilation and its consequences; family and health-care team support; and early adaptation to treatments. Factors associated with poor bilevel NIV adherence included previous negative experiences with therapy, negative attitude towards therapy; difficulty adapting; perceived lack of support from family or health-care team; fear/embarrassment regarding treatment; caregivers not being health-minded; technical issues; side effects; and a lack of subjective symptom improvement.

CONCLUSIONS

The dimensions which most affect adherence to bilevel NIV are those which contribute to youths' conception of feeling "well" or "unwell." Adherence to treatment may hinge largely on the way in which NIV is initially experienced and framed.

COMMENTARY

A commentary on this article appears in this issue on page 1355.

Effect of beta-blocker therapy on heart rate response in patients with hypertension and newly diagnosed untreated obstructive sleep apnea syndrome

BACKGROUND

Beta1-receptor antagonists (BBs) are commonly administered in the treatment of cardiovascular disease (CVD). The reported benefits of BB use in CVD patients with concomitant obstructive sleep apnea (OSA) may be limited by their impact on apnea-induced bradycardias. Therefore the aim of the study was to test the influence of BBs on periapneic heart rate (HR) fluctuations in hypertensive patients with newly-detected and untreated OSA.

METHODS

We studied 88 hypertensive patients (56 on BBs and 32 BB naive) with newly-diagnosed moderate-to-severe OSA who were free of major pulmonary comorbidities and did not require antiarrhythmic therapy. ECGs recorded during sleep were investigated for heart rate (HR) responses to apneas allowing to compare extreme HR accelerations and decelerations between the groups.

RESULTS

Average sleep-time HR was comparable in BB-naive (BB-) and BB-treated (BB+) patients. Direct comparisons showed that HR decelerations were also similar in the two subgroups (53.8±9.6 vs. 54.4±7.8 bpm; P=0.78, for BB- and BB+, respectively) however, BBs blunted the OSA-induced HR accelerations (82.3±12.2 vs. 74.3±10.0; P=0.003). After adjusting for baseline HR and magnitude of desaturations, HR decelerations were more evident in BB-naive group whereas tachycardic responses remained blunted in the BB+ group. The incidence of ectopies and conduction abnormalities were comparable across two groups.

CONCLUSIONS

Beta-blockers do not potentiate apnea-induced HR decelerations, attenuate apnea-induced increases in heart rate and do not influence incidence of ectopies and conduction abnormalities in patients with hypertension and moderate-to-severe, untreated OSA.

Obstructive sleep apnea: acute effects of CPAP on polyssonographic variables

Introduction The use of non-invasive ventilation in the form of continuous positive airway pressure (CPAP) is among the main therapeutic options for patients with obstructive sleep apnea (OSA). Yet the effects of CPAP obtained on the first night of use are underreported. Objective To evaluate the acute effects of CPAP on polysomnographic variables in patients with OSA. Materials and methods This study is a case series with 31 patients (55.8 ± 11.4 years; 22 men) in the initial phase of CPAP treatment. The subjects were evaluated by means of polysomnography with and without CPAP (10.2 ± 3.1 cmH2O) and without CPAP, on different days, by means of the following variables: sleep stages 1, 2 and 3 (N1, N2 and N3), rapid eye movement (REM) sleep, apnea and hypopnea index (AHI), AHI in REM sleep (AHIREM) and the micro-arousal index (MAI). Results The use of CPAP resulted in a reduction of N2 (p < 0.001), AHI (p < 0.001), AHIREM (p < 0.001) and MAI (p = 0.001). There was an increase in N3 (p = 0.006) and REM sleep (p < 0.001) during the night with use of CPAP. Conclusion This study demonstrated that, from the first night of use by patients with OSA, CPAP promotes greater balance between sleep phases, and improves sleep quality. These results should be presented to patients and their families in order to encourage greater adherence in the initial phase of treatment with CPAP.

Validation of the CPAP Habit Index-5: A Tool to Understand Adherence to CPAP Treatment in Patients with Obstructive Sleep Apnea

Long-term adherence to continuous positive airway pressure (CPAP) is low among patients with obstructive sleep apnea (OSA). The potential role of “habit” in sustaining adherence to CPAP use has not been studied. This study aimed to establish the relevance of habit to CPAP adherence, via validation of an adaptation of the Self-Report Habit Index (the CPAP Habit Index-5; CHI-5). Analyses focused on the homogeneity, reliability, and factor structure of the CHI-5 and, in line with theoretical predictions, its utility as a predictor of long-term CPAP adherence in middle-aged patients with OSA. A prospective longitudinal design was used. 117 patients with objectively verified OSA intended for CPAP treatment were recruited. Data was collected via clinical examinations, respiratory recordings, questionnaires, and CPAP devices at baseline, 2 weeks, 6 months, and 12 months. The CHI-5 showed satisfactory homogeneity interitem correlations (0.42–0.93), item-total correlations (0.58–0.91), and reliability (α = 0.92). CHI-5 data at 6 months showed a one-factor solution and predicted 63% of variance in total CPAP use hours after 12 months. Based on the satisfactory measurement properties and the high amount of CPAP use variance it explained, the CHI-5 can be seen as a useful tool in clinical practice.

Depression may reduce adherence during CPAP titration trial

STUDY OBJECTIVES

Depression is a risk factor for medication non-compliance. We aimed to identify if depression is associated with poorer adherence during home-based autotitrating continuous positive airway pressure (autoPAP) titration.

DESIGN

Mixed retrospective-observational study.

SETTING

Academic center.

PARTICIPANTS

Two-hundred forty continuous positive airway pressure-naïve obstructive sleep apnea (OSA) patients.

MEASUREMENTS

Patients underwent approximately 1 week of home-based autoPAP titration with adherence data downloaded from the device. Electronic hospital records were reviewed in a consecutive manner for inclusion. Three areas of potential predictors were examined: (i) demographics and clinical factors, (ii) disease severity, and (iii) device-related variables. Depression and anxiety were assessed using the Hospital Anxiety and Depression Scale (HADS). Scores on the subscales were categorized as normal or clinical diagnoses of depression (≥ 8) and anxiety (≥ 11). The primary outcome variable was the mean hours of autoPAP used per night.

RESULTS

Patients were diagnosed with OSA by either attended polysomnography (n = 73, AHI 25.5[15.1-41.5]) or unattended home oximetry (n = 167, ODI3 34.0[22.4-57.4]) and had home-based autoPAP titration over 6.2 ± 1.2 nights. Mean autoPAP use was 4.5 ± 2.4 hours per night. Multiple linear regression analysis revealed that depression and lower 95(th) percentile pressures significantly predicted lesser hours of autoPAP use (R(2) = 0.19, p < 0.001). Significantly milder OSA in those requiring lower pressures may have confounded the relationship between 95(th) percentile pressure and autoPAP use.

CONCLUSION

Depression was independently associated with poorer adherence during home-based autoPAP titration. Depression may be a potential target for clinicians and future research aimed at enhancing adherence to autoPAP therapy.

Type of mask may impact on continuous positive airway pressure adherence in apneic patients

RATIONALE

In obstructive sleep apnea patients (OSA), continuous positive airway pressure (CPAP) adherence is crucial to improve symptoms and cardiometabolic outcomes. The choice of mask may influence CPAP adherence but this issue has never been addressed properly.

OBJECTIVE

To evaluate the impact of nasal pillows, nasal and oronasal masks on CPAP adherence in a cohort of OSA.

METHODS

Newly CPAP treated OSA participating in "Observatoire Sommeil de la Fédération de Pneumologie", a French national prospective cohort, were included between March 2009 and December 2011. Anthropometric data, medical history, OSA severity, sleepiness, depressive status, treatment modalities (auto-CPAP versus fixed pressure, pressure level, interface type, use of humidifiers) and CPAP-related side effects were included in multivariate analysis to determine independent variables associated with CPAP adherence.

RESULTS

2311 OSA (age = 57(12) years, apnea+hypopnea index = 41(21)/h, 29% female) were included. Nasal masks, oronasal masks and nasal pillows were used by 62.4, 26.2 and 11.4% of the patients, respectively. In univariate analysis, oronasal masks and nasal pillows were associated with higher risk of CPAP non-adherence. CPAP non-adherence was also associated with younger age, female gender, mild OSA, gastroesophageal reflux, depression status, low effective pressure and CPAP-related side effects. In multivariate analysis, CPAP non-adherence was associated with the use of oronasal masks (OR = 2.0; 95%CI = 1.6; 2.5), depression, low effective pressure, and side effects.

CONCLUSION

As oronasal masks negatively impact on CPAP adherence, a nasal mask should be preferred as the first option. Patients on oronasal masks should be carefully followed.

Efficacy and compliance in treatment of sleep apnea with Herbst mandibular advancement splints (OHA version)

The benefits of the Herbst thermoformed advancement splint in the treatment of obstructive breathing disorders during sleep have been assessed in numerous studies. Unfortunately, like all other mandibular advancement devices, patients fail to wear it regularly in the long-term. Injuries, discomfort or pain caused by errors in manufacture or adjustment are generally blamed for this. After a critical review of the literature, some solutions are proposed to improve production of the orthesis and patient management.