Long-term prediction of adherence to continuous positive air pressure therapy for the treatment of moderate/severe obstructive sleep apnea syndrome

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.

Psychometric Properties of the Turkish Version of Self-Efficacy Measure for Sleep Apnea (SEMSA) Instrument

BACKGROUND

Determining the self-efficacy perceptions of obstructive sleep apnea (OSA) patients has a key role in health care practices. With further evaluation, the Self-Efficacy Measure for Sleep Apnea (SEMSA) could serve as a useful scale to develop specific interventions to increase self-efficacy in patients with OSA during the acceptance and maintenance of continuous positive airway pressure (CPAP) therapy.

OBJECTIVE

The aim of this study is to translate the SEMSA into Turkish and to evaluate the psychometric properties of the translation.

METHODS

This cross-sectional study was carried out with a sample of patients recently diagnosed with CPAP-naïve OSA. Linguistic and content validity of the scale were evaluated, while exploratory factor analysis and 2-level confirmatory factor analysis were used for validity. Internal consistency and test-retest methods were used in reliability analyses.

RESULTS

The mean (SD) age of the patients with OSA was 51.36 (11.29), and 68% were male. The item factor loads obtained as a result of the confirmatory factor analysis ranged from 0.44 to 0.94, confirming the three-factor structure of the instrument. The Cronbach's α coefficient of the scale was found to be 0.90. Measurements made within the scope of test-retest analysis were found to be related and consistent results were obtained in the intervening time (P < .01).

CONCLUSIONS

In this study, the Turkish version of SEMSA was found to be a valid and reliable tool and it could be used to evaluate the adherence-related cognition in Turkish patients with OSA on CPAP therapy.

Demographics of Adults With Obstructive Sleep Apnea Who Undergo Nasal Surgery

Objective

To assess the demographic characteristics between adult obstructive sleep apnea (OSA) patients who did and did not undergo nasal surgery (NS).

Study Design

Retrospective cohort study.

Setting

Kaiser Permanente Northern California clinical database.

Methods

Retrospective study of adult patients with ≥1 OSA diagnoses linked to clinical encounters from 2009 to 2016. Qualifying NS procedures performed on or after cohort entry through 2017 were ascertained. Demographic and clinical characteristics were compared; multivariable logistic regression examined associations of these characteristics with undergoing NS.

Results

A total of 174,821 patients had an OSA diagnosis. Among these, 3518 (2.0%) underwent NS, including septoplasty (61.9%), sinus-related (12.9%), turbinate (14.2%), and rhinoplasty (11.1%) procedures. Compared to the nonsurgery group, NS patients were more likely to be male (75.5% vs 62.1%), younger (48.2 ± 13.0 vs 54.7 ± 14.1), have lower body mass index (31.8 ± 6.4 vs 34.3 ± 8.1), and no comorbid conditions (63.1% vs 53.5%), P < .001. After adjusting for sex, age, body mass index (BMI), neighborhood deprivation, and comorbidities, black and Asian/Pacific Islander adults with OSA had 42% and 46% decreased odds of undergoing NS compared with non-Hispanic white patients (odds ratio, OR [95% confidence interval, CI]: 0.58 [0.50-0.67] and 0.54 [0.49-0.61]), while Hispanic patients had similar odds (OR [95% CI]: 1.02 [0.93-1.12]). Patients living in neighborhoods of highest deprivation had 18% lower odds of undergoing NS, compared with patients from neighborhoods corresponding to areas of lowest deprivation (adjusted odds ratio [95% CI]: 0.82 [0.75-0.91]).

Conclusion

These findings suggest that younger age, male sex, lower BMI, and higher SES may be associated with a higher likelihood of undergoing NS in OSA patients.

Concurrent laparoscopic sleeve gastrectomy with uvulopalatopharyngoplasty in the treatment of morbid obesity comorbid with severe obstructive sleep apnea: a retrospective cohort study

STUDY OBJECTIVES

This study aimed to evaluate the safety and short-term effect of contemporaneous surgeries (bariatric surgery plus uvulopalatopharyngoplasty [UPPP]) in the treatment of morbid obesity comorbid with severe obstructive sleep apnea (OSA).

METHODS

A retrospective cohort study was performed to identify patients with obesity and severe OSA who underwent laparoscopic sleeve gastrectomy (LSG) with or without UPPP surgeries between December 2019 and December 2021 in our center. Patients were divided into 2 groups according to different surgical methods (contemporaneous group [LSG with UPPP] vs LSG-only group). Data about surgical safety, OSA remission, and effectiveness of weight loss were collected and analyzed between the 2 groups before and 12 months after surgery.

RESULTS

A total of 101 patients were included in this study (contemporaneous group [LSG with UPPP], n = 42 vs LSG only group, n = 59). There was no significant difference in surgical safety between the 2 groups, and both OSA and obesity were significantly improved at 12.5 ± 2.1 months postoperative follow-up. The apnea-hypopnea index decreased from 68.7 ± 30.4 events/h to 10.2 ± 7.0 events/h in the contemporaneous group (P < .001) and from 64.7 ± 26.2 events/h to 18.9 ± 9.8 events/h in the LSG group (P < .001). Moreover, the apnea-hypopnea index decreased to below 5 events/h in 50% of patients (21/42) in the contemporaneous group but only in 13.5% of patients in the LSG group (P < .001). In the LSG group 20 (34%) patients achieved a reduction in apnea-hypopnea index < 15 events/h and resolution of daytime sleepiness.

CONCLUSIONS

Contemporaneous surgery (concurrent bariatric and UPPP surgeries) is feasible and an effective option for patients with obesity and severe OSA. However, our finding suggests that approximately a third of patients undergoing LSG with UPPP may not derive significant benefit from the UPPP portion of the contemporaneous surgical approach.

CITATION

Yang C, Yu W, Yao K, et al. Concurrent laparoscopic sleeve gastrectomy with uvulopalatopharyngoplasty in the treatment of morbid obesity comorbid with severe obstructive sleep apnea: a retrospective cohort study. J Clin Sleep Med. 2024;20(4):555-564.

Effects of chlorthalidone plus amiloride compared with amlodipine on short-term blood pressure variability in individuals with hypertension and obstructive sleep apnea: a randomized controlled trial

OBJECTIVE

To compare the effects of chlortalidone plus amiloride and amlodipine on blood pressure (BP) variability in patients with hypertension and obstructive sleep apnea syndrome (OSA).

METHODS

A randomized, controlled, double-blind trial enrolled men and women aged 40 years or older with a diagnosis of OSA (apnea-hypopnea index 10-40 apneas/h of sleep) confirmed by overnight laboratory polysomnography and systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg. Participants were randomized to receive chlortalidone 25 mg plus amiloride 5 mg daily or amlodipine 10 mg daily for 8 weeks. BP variability was calculated from 24-hour ambulatory BP monitoring at baseline and follow-up using the following indices: SD, coefficient of variation, average real variability (ARV), time-rate index, and variability independent of the mean (VIM).

RESULTS

The study included 65 patients, with 33 assigned to the chlortalidone plus amiloride group and 32 to the amlodipine group. Participants in both groups had similar baseline characteristics. Short-term BP variability decreased within groups for SD and ARV indexes for 24-hour systolic BP and daytime systolic BP, but statistically significant time*group interactions were found for sleep systolic SD and VIM, with greater reduction in patients treated with amlodipine.

CONCLUSION

In brief, our study has shown that the use of chlorthalidone in combination with amiloride and amlodipine produces comparable effects on short-term BP variability in patients with hypertension and OSA. Therefore, our findings suggest that BP variability may not be a significant factor when choosing between these medications for the treatment of hypertension and OSA.

The Beginning of the AI-Enabled Preventative PAP Therapy Era: A First-in-Human Proof of Concept Interventional Study

Positive Airway Pressure (PAP) therapy is the most common and efficacious treatment for Obstructive Sleep Apnea (OSA). However, it suffers from poor patient adherence due to discomfort and may not fully alleviate all adverse consequences of OSA. Identifying abnormal respiratory events before they have occurred may allow for improved management of PAP levels, leading to improved adherence and better patient outcomes. Our previous work has resulted in the successful development of a Machine-Learning (ML) algorithm for the prediction of future apneic events using existing airflow and air pressure sensors available internally to PAP devices. Although researchers have studied the use of ML for the prediction of apneas, research to date has focused primarily on using external polysomnography sensors that add to patient discomfort and has not investigated the use of internal-to-PAP sensors such as air pressure and airflow to predict and prevent respiratory events. We hypothesized that by using our predictive software, OSA events could be proactively prevented while maintaining patients' sleep quality. An intervention protocol was developed and applied to all patients to prevent OSA events. Although the protocol's cool-down period limited the number of prevention attempts, analysis of 11 participants revealed that our system improved many sleep parameters, which included a statistically significant 31.6% reduction in Apnea-Hypopnea Index, while maintaining sleep quality. Most importantly, our findings indicate the feasibility of unobtrusive identification and unique prevention of each respiratory event as well as paving the path to future truly personalized PAP therapy by further training of ML models on individual patients.

Management of hypertension in obstructive sleep apnea

Obstructive sleep apnea (OSA) plays an important role in the development of hypertension. Thus, this review summarizes pharmacological and non-pharmacological approaches to blood pressure (BP) control in patients with OSA. Current treatments for OSA, such as continuous positive airway pressure, are effective at lowering BP. However, they only provide a modest BP reduction, and pharmacological treatment remains important for achieving optimal BP control. Furthermore, current guidelines for the treatment of hypertension do not make specific recommendations on pharmacological treatment protocols for controlling BP in patients with OSA. Moreover, the BP-lowering effects of various classes of antihypertensives may be different in hypertensive patients with OSA than in those without OSA due to the underlying mechanisms that promote hypertension in OSA. The acute and chronic increase in sympathetic nerve activity in patients with OSA explain the effectiveness of beta blockers in controlling BP in these patients. As activation of the renin-angiotensin-aldosterone system may also promote hypertension in OSA, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers have generally been found effective for lowering BP in hypertensive patients with OSA. The aldosterone antagonist spironolactone also produces a good antihypertensive response in patients with OSA and resistant hypertension. However, there are limited data available that compare the effects of various classes of antihypertensive medication on BP control in those with OSA, and most data have been obtained from small-scale studies. This demonstrates the need for large-scale randomized controlled trials to evaluate a range of BP-lowering regimens in patients with OSA and hypertension.

Adherence to Continuous Positive Airway Pressure Therapy in Pediatric Patients with Obstructive Sleep Apnea: A Meta-Analysis

Introduction

Obstructive sleep apnea (OSA) is a public health problem that affects children. Although continuous positive airway pressure (CPAP) therapy is effective, the CPAP adherence rate in children is varied. This study aimed to evaluate the CPAP adherence rate and factors associated with CPAP adherence in children with OSA using a systematic review.

Methods

The inclusion criteria were observational studies conducted in children with OSA and assessed adherence of CPAP using objective evaluation. The literature search was performed in four databases. Meta-analysis using fixed-effect model was conducted to combine results among included studies.

Results

In all, 34 studies that evaluated adherence rate and predictors of CPAP adherence in children with OSA were included, representing 21,737 patients with an average adherence rate of 46.56%. There were 11 calculations of factors predictive of CPAP adherence: age, sex, ethnicity, body mass index, obesity, income, sleep efficiency, the apnea-hypopnea index (AHI), severity of OSA, residual AHI, and lowest oxygen saturation level. Three different factors were linked to children with adherence and non-adherence to CPAP: age, body mass index, and AHI.

Conclusion

The CPAP adherence rate in children with OSA was 46.56%. Young age, low body mass index, and high AHI were associated with acceptable CPAP adherence in children with OSA.

Homecare interventions as a Service model for Obstructive sleep Apnea: Delivering personalised phone call using patient profiling and adherence predictions

BACKGROUND AND OBJECTIVE

Obstructive Sleep Apnea (OSA) is a sleep disorder that leads to different pathologies like depression and cardiovascular problems. The first-line medical treatment for OSA is Continuous Positive Airway Pressure (CPAP) therapy. However, this therapy has the lowest adherence level when compared to other homecare therapies. Consequently, the main objective of this paper is to increase this adherence level with methods that can be replicated in a large number of patients.

METHODS

The Homecare Intervention as a Service model can build, verify, and deliver per-sonalised home care interventions. With the Homecare Intervention as a Service model, we build and provide on-demand personalised interventions according to the patient's needs. The 2 core components of this model are patient clustering and CPAP adherence predictions. To define the patient profiles and predict the adherence level, we apply the K-means and the Logistic Regression algorithm respectively. To support these algorithms, we use the CPAP monitoring data and qualitative data on the patients.

RESULTS

We demonstrate that there are 3 patient profiles (non-adherent, attempter, and adherent). We draw a comparison with multiple machine learning algorithms to predict CPAP adherence at 30, 60 and 90 days. In this case, the Logistic Regression gives the best results with a f1-score of 0.84 for30 days, 0.79 for 60 days and 0.76 for 90 days. These newly build profiles were to be used to deliver personalised phone call interventions. The phone call intervention shows an increase in adherence by 1.02 h/night for non-adherent patients and 0.69 h/night for attempter patients.

CONCLUSIONS

This is the first study in CPAP therapy that formalises the process of transforming raw data into effective home care interventions that can be delivered directly to the patients. In fact,it is the first time that both patient characterisation and predictions based on data are used to provide personalised patient management for CPAP therapy. Our model is flexible to be extended to new types of interventions and other homecare therapies.

Obstructive sleep apnea: a review for the orthodontist

INTRODUCTION

Obstructive sleep apnea (OSA) affects an important part of the population and is characterized by recurrent total or partial obstruction of the upper airway (UA) during sleep, negatively affecting the quality of life of patients in the short and long terms, and constituting an important public health problem for the society. The field of expertise of orthodontists is closely related to the UA, placing them in a strategic position to diagnose air passage failures and intervene when necessary. Orthodontists, as health professionals, must know how to recognize respiratory problems and manage them appropriately, when indicated.

OBJECTIVE

Thus, this paper aims to review and critically evaluate the related literature, to provide orthodontists with updated knowledge on the diagnosis and therapy related to OSA. Science and technology are constantly evolving; thus, the literature was also reviewed considering new technologies available in consumer-targeted applications and devices for the diagnosis, monitoring, and treatment of sleep-disordered breathing.

Therapieadhärenz drei Monate nach Einleitung einer nichtinvasiven CPAP-Therapie bei 1078 Patienten mit obstruktiver Schlafapnoe (OSA)

Einleitung Die nächtliche kontinuierliche positive Überdruckatmung (CPAP) gilt als therapeutischer Goldstandard einer obstruktiven Schlafapnoe (OSA). Die CPAP-Therapie stellt zumeist eine Dauertherapie mit geringen Nebenwirkungen dar. Trotzdem ist die Therapietreue unbefriedigend. In dieser Arbeit wurden die Therapietreue betrachtet und typische Probleme katalogisiert.

Methode 1078 OSA-Patienten wurden nach diagnostischer Polygrafie (PG) oder Polysomnografie (PSG) auf eine CPAP-Therapie eingestellt. Die Therapietreue wurde nach 3 Monaten nachverfolgt. Folgende Therapieadhärenz-Gruppen wurden festgelegt: 1. gute CPAP-Einstellung und Nutzung, 2. CPAP-Abbruch nach anfänglicher Nutzung, 3. mangelnde CPAP-Nutzung wegen Nebenwirkungen, 4. Abbruch aufgrund fehlender Motivation/geringem Leidensdruck, 5. Masken-Unverträglichkeit, 6. CPAP-Versagen aufgrund fehlenden Therapieeffekts, 7. Umstellung auf anderes Beatmungsverfahren, 8. keine Kontrolle erfolgt.

Ergebnisse Von 1078 CPAP-Patienten erschienen 830 Patienten (77 %) zur Therapiekontrolle. Hiervon waren 450 Patienten (54,2%) in Gruppe 1, 216 Patienten (26%) in Gruppe 2, 71 Patienten (8,5%) in Gruppe 3, 35 Patienten (4,2%) in Gruppe 4, 14 Patienten (1,7%) in Gruppe 5, 3 Patienten (0,4 %) in Gruppe 6 und 41 Patienten (4,9%) in Gruppe 7. Ein geringer obstruktiver Ereignisindex, niedriger CPAP-Druck und tendenziell auch ein geringer Epworth-Sleepiness-Score waren Prädiktoren für CPAP-Versagen. Für die Therapietreue konnten keine signifikanten Prädiktoren dargestellt werden.

Diskussion Eine effektive Therapienutzung von 54% nach 3 Monaten ist ein suboptimales Ergebnis. Prädiktoren für CPAP-Versagen waren Parameter, die vor Therapie auf geringen Leidensdruck der Patienten deuteten. Trotz großer Patientenkohorte konnten keine signifikanten CPAP-Adhärenz-Prädiktoren durch anthropometrische oder PSG-Daten dargestellt werden. Vielmehr könnten Erfahrungen in den ersten Therapietagen ausschlaggebend sein. CPAP-Geräte bieten Komforteinstellungen, die kenntnisgerecht auf den Patienten individualisiert werden müssen. Eine große Auswahl an unterschiedlichen Maskenformen erfordert Erfahrung und Training bei der patientenorientierten Maskenanpassung. Eine 3-monatige Wiedervorstellung erscheint zu lang, um Therapieprobleme zeitnah mit dem Patienten zu besprechen. Telemedizinische Möglichkeiten oder kurzfristige telefonische Beratungsoptionen sollten in Betracht gezogen werden.

Risk of Severe COVID-19 in Non-Adherent OSA Patients

Background

Patients with obstructive sleep apnoea (OSA) are at increased risk of severe course of COVID-19. Vaccination remains to be the most effective prevention of complicated courses of infection. The best contemporary conservative treatment of OSA is continuous positive airway pressure (CPAP) therapy.

Purpose

To compare vaccination acceptance and outcomes of COVID-19 infection between OSA patients adhering to the CPAP therapy and those who rejected CPAP and surgical therapy.

Patients and Methods

Subjects were divided into two groups: group A (N = 167) were individuals with sufficient CPAP adherence (more than 4 hours per night on average) over the last 10 years. Group B (N = 106) were individuals who did not use the CPAP therapy at all and had no indications to surgical therapy.

Results

Three patients in group B died, and one had a severe course of COVID-19. None of the patients in group A died or experienced a severe course of COVID-19. Group A had a significantly higher proportion of males (77.8% compared to 66% in group B) and all parameters of OSA severity. The vaccination status was similar among both groups, with a complete triple dose vaccination rate of 69.5% and 67.9% in groups A and B, respectively.

Conclusion

The results show that the patients with OSA adherent to CPAP therapy were less likely to experience a severe course of COVID-19 or death than the OSA patients non-compliant with therapy, despite the former group having more severe OSA. This result underlines the importance of adherence to CPAP therapy in OSA.

Study protocol of a randomized controlled trial of motivational interviewing-based intervention to improve adherence to continuous positive airway pressure in patients with obstructive sleep apnea syndrome: The MotivAir study

Objective

This study aims to evaluate the effectiveness of the MotivAir program-a phone-based intervention based on Motivational Interviewing (MI) principles and techniques-in enhancing adherence to Continuous Positive Airway Pressure (CPAP) therapy among patients with Obstructive Sleep Apnea Syndrome (OSAS).

Methods

A multicenter randomized controlled trial (RCT) design with random allocation at the level of the individual will be conducted to compare the impact of the experimental program (usual care plus MI) with a control group receiving usual care only in improving selected clinical and psychological parameters in the patients. A minimum sample of 80 participants (40 patients per group) will be recruited in each center according to the inclusion criteria. After the initial screening, participants will be randomly assigned to either the experimental group or the control condition. The program will last 180 days and will be delivered by a trained nurse. The impact of the MotivAir program on selected primary (adherence to CPAP in terms of average hours of usage per night and the Apnea-Hypopnea Index, AHI) and secondary (motivation, perceived competence, quality of life, sleepiness) outcomes will be measured at baseline, and after 1-, 3-, and 6-month from CPAP initiation.

Discussion

Participants are expected to show an increased level of adherence to CPAP and to acquire the skills and self-confidence necessary to deal with the psychological consequences of their chronic condition.

Pilot Study of a New Mandibular Advancement Device

This study was conducted to determine the efficacy of a customized mandibular advancement device (MAD) in the treatment of obstructive sleep apnea (OSA). Eight patients (M = 3; F = 5; mean age = 56.3 ± 9.4) with a diagnosis of OSA confirmed by polysomnography (PSG) were recruited on the basis of the following inclusion criteria: apnea-hypopnea index (AHI) > 5, age between 18 and 75 years, body mass index (BMI) < 25, and PSG data available at baseline (T0). All were treated with the new NOA® MAD by OrthoApnea (NOA®) for at least 3 months; PSG with NOA in situ was performed after 3 months of treatment (T1). The following parameters were calculated at T0 and T1: AHI, supine AHI, oxygen desaturation index (ODI), percentage of recording time spent with oxygen saturation <90% (SpO2 < 90%), and mean oxygen desaturation (MeanSpO2%). Data were submitted for statistical analysis. The baseline values were AHI = 21.33 ± 14.79, supine AHI = 35.64 ± 12.80, ODI = 17.51 ± 13.5, SpO2 < 90% = 7.82 ± 17.08, and MeanSpO2% = 93.45 ± 1.86. Four patients had mild OSA (5 > AHI < 15), one moderate OSA (15 > AHI < 30), and three severe OSA (AHI > 30). After treatment with NOA®, statistically significant improvements in AHI (8.6 ± 4.21) and supine AHI (11.21 ± 7.26) were recorded. OrthoApnea NOA® could be an effective alternative in the treatment of OSA: the device improved the PSG parameters assessed.

Telemetric Assessment of Continuous Positive Airways Pressure (CPAP) Effectiveness and Adherence in Obstructive Sleep Apnea during COVID-19 Pandemic

Obstructive sleep apnea is the most common sleep-related breathing disorder. In the pandemic times of the new coronavirus SARS-CoV-2, CPAP (Continuous Positive Airway Pressure) therapy of obstructive sleep apnea became even more challenging. After the pandemic outbreak in March 2020, most CPAP treatment recommendations changed because of rising concerns about CPAP usage safety for patients and their families. Therefore, we examined the effectiveness of CPAP and adherence to the therapy of 149 adults with obstructive sleep apnea in the period of two years from 4 March 2019 to 3 March 2021 (before pandemic breakout and during the first year of pandemic). Data on CPAP parameters and adherence to therapy were obtained via a telemetric system. Together, our results demonstrated that the COVID-19 pandemic had no significant impact on CPAP therapy parameters and adherence in whole study group. However, detailed analysis acknowledged that some demographic and clinical features influenced CPAP therapy. The results showed that across subgroups of patients differentiated on the basis of age, gender, co-existing diabetes mellitus, or hypertension, the COVID-19 pandemic seemed to affect CPAP effectiveness. Our results provide a good starting point for discussion on CPAP therapy recommendations during pandemic times.

Feasibility and Long-Term Compliance to Continuous Positive Airway Pressure Treatment in Adults With Down Syndrome, a Genetic Form of Alzheimer’s Disease

Background

Down syndrome (DS) is a genetic form of Alzheimer’s disease (AD) with a high prevalence of obstructive sleep apnea (OSA). These characteristics place the DS population as an optimal model to study the relationship between sleep and AD and to design clinical trials of preventive sleep therapies for AD. Regrettably, OSA treatment with continuous positive airway pressure (CPAP) is often neglected in adults with DS. In both clinical practice and research trials, it is usually presumed that these patients will not adapt to or tolerate the therapy.

Study Objective

We aimed to evaluate the feasibility and long-term CPAP compliance in this population and their capacity to be enrolled in CPAP research studies.

Methods

We prospectively compared the CPAP compliance of 17 OSA patients with DS and 19 age and sex matched OSA euploid patients. CPAP management and follow-up schedules were prescribed according to the habitual clinical practice. We compared group differences in tolerance, objective, and subjective hours of nightly CPAP usage at the 1st, 3rd, 6th, 12th, 24th, and 36th month visits. Good compliance was defined as at least 4 h use per night. We also investigated predictive factors of long-term CPAP compliance.

Results

The percentage of DS subjects with good CPAP compliance (81.2 vs. 78.9%) and the objective CPAP use (5 vs. 6 h, p = 0.92) did not differ from the control group (CG). Subjective CPAP compliance was significantly higher in OSA patients with DS than in controls in all the follow-up visits (8 vs. 6.75 h, p = 0.001). The DS group had a significantly higher number of visits (9 vs. 5; p = 0.021) and mask changes (2.5 vs. 2; p = 0.05) than controls. Objective hours of CPAP use at the first follow-up visit predicted long-term CPAP compliance (p &lt; 0.005).

Conclusion

CPAP treatment is feasible and has good long-term compliance in OSA patients with DS. It should be recommended to improve health and prevent comorbidities. The DS population is indeed suitable to participate in longitudinal preventive sleep clinical trials for AD.

Dropout and adherence of obstructive sleep apnoea patients to mandibular advancement device therapy: A systematic review of randomised controlled trials with meta-analysis and meta-regression

BACKGROUND

Mandibular advancement devices (MADs) are used as an alternative to continuous positive airways pressure to treat obstructive sleep apnoea (OSA) patients, but to date, specific data on the adherence to MAD therapy are lacking.

OBJECTIVES

The aim of the present systematic review was to investigate the dropout rate and adherence of OSA patients to different custom-made (CM) and non-custom-made (NCM) MAD therapies.

SEARCH METHODS

An electronic search was performed in MEDLINE, Cochrane Database of Systematic Reviews, Scopus, LILACS and Web of Science.

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing the compliance to customised and not customised MADs in the treatment of adult OSA patients were included.

DATA COLLECTION AND ANALYSIS

The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the risk of bias by the Cochrane Collaboration's tool for assessing risk of bias in RCT. The dropout rate of each study was computed and the adherence to MAD therapy in terms of hours per night and nights per week was extracted from each study.

RESULTS

Thirty-two RCTs were included. The risk of bias resulted low in most of the studies. The GRADE scores indicated that the quality of evidence was from very low to moderate. The meta-analyses showed that the mean dropout rate did not significantly differ between CM and NCM MADs: The overall mean dropout rate was 0.171 [0.128-0.213] with a mean follow-up of 4.1 months. The hours per night adherence was significantly higher for CM MADs (6.418 [6.033-6.803]) compared to NCM MADs (5.107 [4.324-5.890]. The meta-regression showed that the dropout rate increases significantly during time (p < .05).

CONCLUSIONS

There is a very low to moderate quality of evidence that the dropout rate of MAD therapy is similar among CM and NCM MADs, that the dropout rate increases significantly during time and that CM MADs have higher hours per night adherence compared with NCM MAD.

REGISTRATION

The study protocol was registered on PROSPERO (n. CRD42020199866).

[Adherence to CPAP Three Months after Starting Therapy in 1078 Patients with Obstructive Sleep Apnea (OSA)]

INTRODUCTION

 Nocturnal Continuous Positive Airway Pressure (CPAP) is considered the gold standard treatment for obstructive sleep apnoea (OSA). The CPAP therapy is a long-term treatment but does come with few possible side effects. The adherence to the therapy is frequently suboptimal. In this paper, adherence to therapy was assessed and typical problems were classified.

METHODS

 1078 OSA patients received CPAP therapy after a diagnostic polygraphy (PG) or polysomnography (PSG). Adherence to therapy was followed up three months after treatment induction. The following therapy adherence groups were defined: 1. correctly calibrated CPAP and good adherence, 2. CPAP non-acceptance, after initial use, 3. CPAP intolerance use due to side effects, 4. discontinuation due to lack of motivation/low rates of symptoms. 5. mask intolerance, 6. CPAP failure due to a lack of perceived treatment effect, 7. Change to another non-invasive ventilation method, 8. No control carried out.

RESULTS

 Out of 1078 OSA patients a therapy control was performed in 830 patients (77 %). Of these, 450 patients (54.2 %) were placed in group 1, 216 patients (26 %) in group 2, 71 patients (8.5 %) in group 3, 35 patients (4.2 %) in group 4, 14 patients (1.7 %) in group 5, 3 patients (0.4 %) in group 6 and 41 patients (4.9 %) in group 7. A mild obstructive index, low CPAP pressure and, as a trend, a low Epworth- Sleepiness score were predictors of CPAP failure. No significant predictors could be shown for adherence to therapy.

DISCUSSION

 An effective treatment use of 54 % after 3 months is a suboptimal result. Predictors of CPAP failure were parameters that indicated that the patient was less symptomatic prior to therapy. Despite a large patient cohort, neither anthropometric nor PSG-data provided any significant CPAP adherence predictors. Rather, experiences in the first nights of use could be decisive. CPAP devices offer comfort settings that have to be personalised to patients' needs and wants. A large selection of different mask shapes requires experience and training in patient-centred mask fitting. A three-month follow-up appointment seems too long to discuss therapy problems with the patient in a timely manner. Telemedical options or short-term telephone appointments should be considered.

Breathing irregularities before sleep onset on polysomnography in patients with heart diseases

PURPOSE

Severe cardiac dysfunction can manifest with diurnal breathing irregularity. However, it remains to be clarified whether or not diurnal breathing irregularity is observed in patients with heart diseases, including relatively mild chronic heart failure (CHF), compared to those without heart diseases.

METHODS

In this cross-sectional study, consecutive inpatients who were admitted for evaluation of sleep-disordered breathing were enrolled. We extracted 3.5 min of stable respiratory signals before sleep onset using polysomnography, analyzed the airflow data using fast Fourier transform, and quantified breathing irregularities using Shannon entropy S.

RESULTS

A total of 162 subjects were evaluated. Among these, 39 subjects had heart diseases, including ischemic heart disease (IHD), atrial fibrillation (Af), CHF, and a history of aortic dissection. The values of Shannon entropy S of airflow signals in subjects with heart diseases were significantly higher than in those without heart diseases (p < 0.001). After excluding CHF, the Shannon entropy S was also significantly higher in subjects with heart diseases than in those without heart diseases (p < 0.001). The values of Shannon entropy S were significantly correlated with plasma brain natriuretic peptide levels (r = 0.443, p < 0.001). Although the values were also significantly correlated with body mass index, the presence of heart diseases was independently associated with breathing irregularity in the multiple logistic analysis. Matching analysis revealed consistent differences between subjects with heart diseases and without heart diseases.

CONCLUSION

Breathing irregularity was observed before sleep onset in subjects with heart diseases who underwent polysomnography to diagnose sleep-disordered breathing.

The role of acetazolamide in sleep apnea at sea level: a systematic review and meta-analysis

STUDY OBJECTIVES

The recognition of specific endotypes as drivers of sleep apnea suggests the need of therapies targeting individual mechanisms. Acetazolamide is known to stabilize respiration at high altitude but benefits at sea level are less well understood.

METHODS

All controlled studies of acetazolamide in obstructive sleep apnea and/or central sleep apnea (CSA) were evaluated. The primary outcome was the apnea-hypopnea index.

RESULTS

Fifteen trials with a total of 256 patients were pooled in our systematic review. Acetazolamide reduced the overall apnea-hypopnea index (mean difference [MD] -15.82, 95% CI: -21.91 to -9.74, P < .00001) in central sleep apnea (MD -22.60, 95% CI: -29.11 to -16.09, P < .00001), but not in obstructive sleep apnea (MD -10.29, 95% CI: -33.34 to 12.77, P = .38). Acetazolamide reduced the respiratory related arousal index (MD -0.82, 95% CI: -1.56 to -0.08, P = .03), improved partial arterial of oxygen (MD 11.62, 95% CI: 9.13-14.11, P < .00001), mean oxygen saturation (MD 1.78, 95% CI: 0.53-3.04, P = .005), total sleep time (MD 25.74, 95% CI: 4.10-47.38, P = .02), N2 sleep (MD 3.34, 95% CI: 0.12-6.56, P = .04) and sleep efficiency (MD 4.83, 95% CI: 0.53-9.13, P = .03).

CONCLUSIONS

Acetazolamide improves the apnea-hypopnea index and several sleep metrics in central sleep apnea. The drug may be of clinical benefit in patients with high loop gain apnea of various etiologies and patterns. The existence of high heterogeneity is an important limitation in applicability of our analysis.

SYSTEMATIC REVIEW REGISTRATION

Registry: PROSPERO; Name: The effect of acetazolamide in patients with sleep apnea at sea level: a systematic review and meta analysis; URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020163316; Identifier: CRD42020163316.

Development and psychometric evaluation of the Motivation to Use CPAP Scale (MUC-S) using factorial structure and Rasch analysis among patients with obstructive sleep apnea before CPAP treatment is initiated

BACKGROUND

Continuous positive airway treatment (CPAP) is first-line treatment for obstructive sleep apnea (OSA), but adherence tends to be low. A clinical tool focusing on motivation to use CPAP is missing. The purpose was to develop a brief questionnaire to assess motivation to use CPAP that is psychometrically robust and suitable for use in clinical practice.

METHODS

A convenience sample including 193 treatment naive patients with OSA (67% men; mean age = 59.7 years, SD 11.5) from two CPAP clinics was used. Clinical assessments and full night polygraphy were performed. Questionnaires administered before CPAP treatment included the newly developed Motivation to Use CPAP Scale (MUC-S), Minimal Insomnia Symptoms Scale (MISS), Epworth Sleepiness Scale (ESS), and Attitude towards CPAP treatment Inventory (ACTI). The validity and reliability of the MUC-S were investigated using Rasch and exploratory factor analysis models. Measurement invariance, dimensionality and differential item functioning (i.e., across gender groups, excessive daytime sleepiness (ESS), insomnia (MISS) and attitude towards CPAP (ACTI) groups) were assessed.

RESULTS

The results supported a two-factor solution (autonomous motivation, 6 items, factor loadings between 0.61 and 0.85 and controlled motivation, 3 items, factor loadings between 0.79 and 0.88) explaining 60% of the total variance. The internal consistency was good with Cronbach's alpha of 0.88 and 0.86 for the two factors. No differential item functioning was found. A latent class analysis yielded three profiles of patients with high (n = 111), moderate (n = 60) and low (n = 22) motivation. Patients with high motivation were older, had higher daytime sleepiness scores, more insomnia symptoms and a more positive attitude towards CPAP.

CONCLUSIONS

The MUC-S seems to be a valid tool with robust psychometric properties suitable for use at CPAP clinics. Future studies should focus on how motivation changes over time and if MUC-S can predict objective long-term CPAP adherence.

Determinants of adherence to continuous positive airway pressure therapy in adults with obstructive sleep apnea

Objectives Adherence to continuous positive airway pressure (CPAP) devices in patients with obstructive sleep apnea (OSA) determines the effectiveness of the treat- ment. Likewise, the assessment of the control of the disease must consider the infor- mation referred by the patient, among other value-based health measures related to the satisfaction of the intervention. The objectives of this study were a) Determine the factors related to adherence to CPAP devices in subjects with OSA affiliated to an insurance company of the healthcare system in Colombia. b) Assess symptom control associated to the disease from the individual ́s perspective and his/her satisfaction with the treatment received. Materials and Methods 1,501 subjects with OSA were surveyed by telephone to explore: sociodemographic factors, habits and lifestyles, use of CPAP and its adverse events, control of the disease, comorbidities, access to care and therapy satisfaction. Using multilevel logistic regression techniques, the influence of the various factors on adherence to CPAP was analyzed, using Stata 13 software. Results Adherence to CPAP therapy was of 58% and the control of symptoms was of 41.7%. The factors that determined the use of CPAP were knowledge on how the device operates, and the disturbances during sleep due to the mask or nasal pad. The- rapy satisfaction was predominantly very good or good. Conclusion Even with moderate adherence values and a good experience with CPAP therapy, symptomatic control of the disease is poor. Many of the factors that affect the use of CPAP are modifiable with a proper approach by the devices ́ service provider.

Sleep Apnea and Insomnia: Emerging Evidence for Effective Clinical Management

Comorbid insomnia and sleep apnea (COMISA) are the most common co-occurring sleep disorders and present many challenges to clinicians. This review provides an overview of the clinical challenges in the management of patients with COMISA, with a focus on recent evidence regarding the evaluation and treatment of COMISA. Innovations in the assessment of COMISA have used profile analyses or dimensional approaches to examine symptom clusters or symptom severity that could be particularly useful in the assessment of COMISA. Recent randomized controlled trials have provided important evidence about the safety and effectiveness of a concomitant treatment approach to COMISA using cognitive-behavioral therapy for insomnia (CBT-I) with positive airway pressure (PAP). Furthermore, patient-centered considerations that integrate patient characteristics, treatment preferences, and accessibility to treatment in the context of COMISA are discussed as opportunities to improve patient care. Based on these recent advances and clinical perspectives, a model for using multidisciplinary, patient-centered care is recommended to optimize the clinical management of patients with COMISA.

Lower socioeconomic status and co-morbid conditions are associated with reduced continuous positive airway pressure adherence among older adult medicare beneficiaries with obstructive sleep apnea

STUDY OBJECTIVES

To examine rates of adherence to continuous positive airway pressure (CPAP) therapy among a representative sample of older adult Medicare beneficiaries with obstructive sleep apnea (OSA), and to identify demographic and health-related factors associated with CPAP adherence.

METHODS

Using a 5% sample of Medicare claims data, we utilized Medicare policy and CPAP machine charges as a proxy for CPAP adherence. A cumulative logit model was used to identify demographic, medical, and psychiatric predictors of CPAP adherence status.

RESULTS

Of beneficiaries who initiated CPAP (n = 3,229), 74.9% (n = 2,417) met the so-called "90-day Medicare adherence criteria," but only 58.8% of these individuals (n = 1,420) continued to use CPAP throughout the entire 13-month rent-to-own period. Anxiety, anemia, fibromyalgia, traumatic brain injury, and lower socioeconomic status (SES) were all associated with reduced CPAP adherence.

CONCLUSIONS

These results provide the first national estimates of CPAP adherence among older adult Medicare beneficiaries in the United States. In addition, findings highlight the salience of medical and psychiatric comorbidity, as well as SES, as important markers of CPAP adherence among older adults in the United States. Future studies should seek to evaluate interventions to improve CPAP adherence among older adults of lower SES.

Various Factors Affecting Short-Term Compliance Rates of CPAP in OSA Patients: in the Age of Insurance Coverage in Korea

Background and Objectives: Although many studies have explored the factors affecting compliance with continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA), the findings remain controversial. This study aimed to analyze CPAP compliance after insurance coverage began in Korea and to investigate what factors influenced CPAP compliance.Materials and Method: The subjects were 1,037 patients who were prescribed a CPAP after polysomnography at the Seoul Sleep Clinic; data were reviewed retrospectively. We classified those that used a CPAP for more than 4 hours per day for 70% or more days per month as into the good compliance group. We compared the ratio of good compliance by gender, position dependence, rapid eye movement (REM) dependence, telemonitoring of CPAP, pressure modification, and OSA severity.Results: There were no statistically significant differences in ratio of good compliance group according to gender, position dependence, REM dependence, or disease severity. When using a fixed CPAP (92.2%) rather than an auto PAP (88.4%), the ratio of patients in the good compliance group was significantly higher. Non-positioner and fixed CPAP users showed significantly longer average usage time.Conclusion: In a 3-month short-term follow-up study of CPAP compliance, the telemonitoring group and those using a fixed CPAP showed a higher ratio of good compliance. Average CPAP usage time was longer when using a fixed CPAP and in non-positioners. As age increased, CPAP usage time was longer, and the average compliance rate tended to increase.

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.

Mask side-effects in long-term CPAP-patients impact adherence and sleepiness: the InterfaceVent real-life study

Background

For some patients, Continuous Positive Airway Pressure (CPAP) remains an uncomfortable therapy despite the constant development of technological innovations. To date, no real life study has investigated the relationship between mask related side-effects (MRSEs) and CPAP-non-adherence (defined as < 4 h/day) or residual-excessive-sleepiness (RES, Epworth-Sleepiness-Scale (ESS) score ≥ 11) in the long-term.

Methods

The InterfaceVent-CPAP study is a prospective real-life cross-sectional study conducted in an apneic adult cohort undergoing at least 3 months of CPAP with unrestricted mask-access (34 different masks). MRSEs were evaluated using visual-analogue-scales, CPAP-data using CPAP-software, sleepiness using ESS.

Results

1484 patients were included in the analysis (72.2% male, median age 67 years (IQ_25–75: 60–74), initial Apnea–Hypopnea-Index (AHI) of 39 (31–56)/h, residual AHI_flow was 1.9 (0.9–4) events/h), CPAP-treatment lasted 4.4 (2.0–9.7) years, CPAP-usage was 6.8 (5.5–7.8) h/day, the prevalence of CPAP-non-adherence was 8.6%, and the prevalence of RES was 16.17%. Leak-related side-effects were the most prevalent side-effects (patient-reported leaks concerned 75.4% of responders and had no correlation with CPAP-reported-leaks). Multivariable logistic regression analyses evaluating explanatory-variable (demographic data, device/mask data and MRSEs) effects on variables-of-interest (CPAP-non-adherence and RES), indicated for patient-MRSEs significant associations between: (i) CPAP-non-adherence and dry-mouth (p = 0.004); (ii) RES and patient-reported leaks (p = 0.007), noisy mask (p < 0.001), dry nose (p < 0.001) and harness pain (p = 0.043).

Conclusion

In long-term CPAP-treated patients, leak-related side-effects remain the most prevalent side-effects, but patient-reported leaks cannot be predicted by CPAP-reported-leaks. Patient-MRSEs can be independently associated with CPAP-non-adherence and RES, thus implying a complementary role for MRSE questionnaires alongside CPAP-device-reported-data for patient monitoring.

Trial registration InterfaceVent is registered with ClinicalTrials.gov (NCT03013283).

Communication during the initial visit to a CPAP clinic Practitioners' experiences of facilitators and barriers when talking to patients with obstructive sleep apnea

Adherence to continuous positive airway pressure treatment for obstructive sleep apnea tends to be poor. Communication influences adherence but has not previously been investigated from a practitioner perspective, although shared decision‐making is known to be of great importance. The aim was to describe how practitioners experience communication with patients with obstructive sleep apnea during the initial visit at a continuous positive airway pressure treatment clinic, with focus on facilitators and barriers related to the 4 Habits Model, a communication model comprised of four types of interrelated skills to make encounters more patient‐centred: investing in the beginning; exploring the patient perspective; showing empathy; and investing in the end. A descriptive design with qualitative content analysis was used. A deductive analysis was carried out based on interviews with 24 strategically selected practitioners from seven continuous positive airway pressure treatment clinics. The 4 Habits Model was used as a framework for identifying facilitators and barriers to communication. Investments in the beginning was described as creating contact, showing the agenda and being adaptive, while explore the patient perspective included showing awareness, being explorative and creating a participating climate. Show empathy consisted of showing openness, being confirmative and creating acceptance, while showing a structured follow‐up plan, being open minded and invitational and creating motivation to build on were descriptions of invest in the end. Awareness of potential facilitators and barriers for patient‐centred communication during the beginning, middle and end of a continuous positive airway pressure treatment consultation can be used to improve contextual conditions and personal communication competences among practitioners working with continuous positive airway pressure treatment initiation.

Telemedicine for Continuous Positive Airway Pressure in Sleep Apnea. A Randomized, Controlled Study

Rationale: Continuous positive airway pressure (CPAP) is the standard treatment for the obstructive sleep apnea syndrome (OSAS), but long-term adherence remains a challenge. In a pilot study, we observed that telemedicine combined with telemetrically triggered interventions was associated with improved CPAP adherence in the first month of treatment.Objectives: In the current randomized, controlled phase III trial, we aimed to collect pivotal data for the use of telemedicine in CPAP treatment of patients with OSAS.Methods: Symptomatic patients with OSAS were randomized to a telemedicine or control arm and initiated CPAP treatment. Phone calls were triggered in the telemedicine group during the first month of treatment upon either poor use or excessive mask leakage. Patients were followed for 6 months. Measures of CPAP use at 6 months were the main study endpoints.Results: Among 240 patients enrolled, 71 (30%) discontinued CPAP treatment over the course of the study. The primary outcome measure, the proportion of nights with CPAP use greater than 1 hour, was not statistically different in the telemedicine group (92.0%) versus the control group (88.2%) (P = 0.565). The daily hours of CPAP use at 6 months also did not differ significantly between the telemedicine group (5.6 h) and the control group (4.8 h) (P = 0.663). However, in a post hoc analysis, telemedicine led to increased device use in a subgroup of patients with a mild form of disease (5.6 h vs. 3.4 h; P = 0.026). The telemedicine-based intervention had a positive impact on sleep-related quality of life as measured with the Quebec Sleep Questionnaire (5.55 vs. 5.49 at 1 mo [P = 0.020]; 5.61 vs. 5.46 at 6 mo [P = 0.013]).Conclusions: A telemetrically triggered intervention in the first month of treatment did not improve CPAP use in the study population overall, but it had positive effects in patients with a mild form of OSAS and led to an improvement in sleep-related quality of life.Clinical trial registered with www.clinicaltrials.gov (NCT01715194).

Acceptance of and six-month adherence to continuous positive airway pressure in patients with moderate to severe obstructive sleep apnea

BACKGROUND

Continuous positive airway pressure (CPAP) is the most effective treatment for moderate to severe obstructive sleep apnea (OSA). Acceptance of and adherence to CPAP are crucial for optimal treatment outcomes. The aim of this study was to investigate the factors influencing patients' acceptance of and adherence to CPAP treatment.

METHODS

One hundred eighty-eight patients with moderate to severe OSA who had received CPAP titration from October 2017 to September 2018 were recruited. They were interviewed at 2 weeks and at 6 months to assess CPAP use and barriers to acceptance and adherence.

RESULTS

One hundred fourteen patients (60.6%) accepted CPAP treatment. Disease severity, assessed by apnea-hypopnea index (AHI) (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.08), subjective satisfaction of titration (OR, 12.83; 95% CI, 3.83-42.99), initial intention of CPAP therapy (OR, 3.33; 95% CI, 1.05-10.51) and short-term home CPAP trial (OR, 9.40; 95% CI, 2.85-31.08) were associated with acceptance of CPAP treatment. Two-third of the 98 CPAP acceptors reported good CPAP adherence at 6 months follow-up. Average hours of CPAP use per day for the first 2 weeks (OR, 1.88; 95% CI, 1.28-3.04) and the global problems associated with CPAP use (OR, 0.82; 95% CI, 0.73-0.91) were independent predictors of the six-month CPAP adherence.

CONCLUSIONS

Nearly 40% of patients with moderate to severe OSA did not accept CPAP treatment, and one-third of those CPAP acceptors had poor adherence to CPAP treatment. Improvement in disease awareness, comfortable titration experience, short-term home CPAP trial may be of help to increase CPAP acceptance and early experience with CPAP is important for long-term adherence. The differences in predicting factors for CPAP acceptance and adherence highlight the importance of focusing on specific aspects during the whole process management of OSA.

A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study

STUDY OBJECTIVES

To investigate treatment models using cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) for people with obstructive sleep apnea (OSA) and comorbid insomnia.

METHODS

121 adults with OSA and comorbid insomnia were randomized to receive CBT-I followed by PAP, CBT-I concurrent with PAP, or PAP only. PAP was delivered following standard clinical procedures for in-lab titration and home setup and CBT-I was delivered in four individual sessions. The primary outcome measure was PAP adherence across the first 90 days, with regular PAP use (≥4 h on ≥70% of nights during a 30-day period) serving as the clinical endpoint. The secondary outcome measures were the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) with good sleeper (PSQI <5), remission (ISI <8), and response (ISI reduction from baseline >7) serving as the clinical endpoints.

RESULTS

No significant differences were found between the concomitant treatment arms and PAP only on PAP adherence measures, including the percentage of participants who met the clinical endpoint. Compared to PAP alone, the concomitant treatment arms reported a significantly greater reduction from baseline on the ISI (p = .0009) and had a greater percentage of participants who were good sleepers (p = .044) and remitters (p = .008). No significant differences were found between the sequential and concurrent treatment models on any outcome measure.

CONCLUSIONS

The findings from this study indicate that combining CBT-I with PAP is superior to PAP alone on insomnia outcomes but does not significantly improve adherence to PAP.

Benefits of Community-Based Approaches in Assessing and Addressing Sleep Health and Sleep-Related Cardiovascular Disease Risk: a Precision and Personalized Population Health Approach

PURPOSE OF REVIEW

In this current review, we describe the benefits of community-based and "precision and personalized population health" (P3H) approaches to assessing and addressing sleep health problems and sleep-related cardiovascular diseases (CVD) among vulnerable populations such as racial/ethnic minorities, the elderly, and the socioeconomically disadvantaged.

RECENT FINDINGS

Very few sleep health programs utilize a community-based or P3H approach, which may account for low estimates of sleep health problems, related CVD outcomes, and inadequate healthcare infrastructure to address sleep-related health outcomes at the community and population level. We describe community-based and P3H approaches and programs as solutions to accurately capture estimates of sleep health and reduce burden of sleep health problems and corollary CVD outcomes at the level of the community and population. Specifically, we describe seven critical steps needed to successfully implement a community-based and P3H approach to address sleep health problems. Community-based and P3H approaches are effective strategies to assessing and addressing sleep health problems and related health conditions.

Multidimensional Evaluation of Continuous Positive Airway Pressure (CPAP) Treatment for Sleep Apnea in Different Clusters of Couples

Continuous positive airway pressure (CPAP) is the most efficient treatment of obstructive sleep apnea (OSA). Little is known about the impact of spousal relationship profiles on CPAP adherence. We aimed to identify clusters of couples of OSA patients, and their association with CPAP adherence 120 days after CPAP initiation. In a multicenter prospective study, OSA patients recently prescribed CPAP were enrolled with their spouses. Data about spousal relationships were collected at inclusion and at day 120. Latent class analysis was performed to determine homogeneous groups of spousal relationships. The 290 participants were predominantly males (77%), median age was 53 years and interquartile range (IQR) 46–62, median body mass index (BMI) was 32 kg/m² (IQR: 28.6–35.9) and median apnea–hypopnea index: 43 events per hour (IQR: 33–58). Three couple clusters were identified: (1) older retired couples, (2) young working couples, and (3) mature active couples. Patients in the older retired couples cluster presented the highest CPAP adherence (p < 0.01) independently of initial complaints, OSA severity, and degree of improvement under CPAP. In a large cohort of OSA patients in whom clusters of couples were determined, there was a significant difference in CPAP adherence at day-120 after CPAP initiation.

Ten-year adherence to continuous positive airway pressure treatment in patients with moderate-to-severe obstructive sleep apnea

Purpose

This study aimed to evaluate the 10-year adherence to and identify the predictors of dropout from continuous positive airway pressure (CPAP) treatment for patients with moderate-to-severe obstructive sleep apnea (OSA).

Methods

We retrospectively analyzed the continuity, dropout, or other behaviors of 181 patients who initiated CPAP treatment at the Tokyo Dental College Ichikawa General Hospital from January 2003 to June 2005.

Results

Among a total of 181 patients, 56 (30.9%) dropped out of the treatment. Among the 125 patients who did not dropout, 54 continued CPAP treatment for > 10 years, 16 completed the treatment with OSA improvement, and 7 could not complete the treatment owing to unavoidable reasons such as death, dementia, hospitalization for serious illness, or migration to other countries. Further, 47 patients moved to another facility, whereas 1 patient purchased a CPAP device and stopped visiting our facility. Among the 56 patients who dropped out, approximately 50% of the patients dropped out within a year, and all dropped out within 76 months. Comparing demographics, OSA parameters, and CPAP parameters between the patients who did and did not drop out of the treatment, Cox regression analysis indicated that body mass index (BMI) and the first-month utilization rate were clinical variables that were independently associated with discontinuation of CPAP treatment.

Conclusion

The results of this study show that BMI and the first-month utilization rate of CPAP treatment are the predictors of the long-term adherence to this treatment.

Electronic supplementary material

The online version of this article (10.1007/s11325-020-02033-0) contains supplementary material, which is available to authorized users.

Maxillomandibular Advancement for the Treatment of Obstructive Sleep Apnea in Patients With Normal or Class I Malocclusion

BACKGROUND

Maxillomandibular advancement is an effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeleton. The authors sought to determine whether an advancement of 10 mm predicts surgical success and if any correlation existed between the magnitude of mandibular/maxillary advancement and improvement in polysomnography metrics using aggregated individual patient data from multiple studies.

METHODS

A search of the PubMed database was performed to identify relevant articles that included preoperative and postoperative polysomnography data and measurements of the advancement of both the maxillary and mandibular portions of the face in patients with normal or class I malocclusion. Each patient was stratified into "Success" or "Failure" groups based on criteria defining a "Success" as a 50% preoperative to post-operative decrease in AHI or RDI and a post-operative AHI or RDI <20.

RESULTS

A review of the PubMed database yielded 162 articles. Review of these resulted in 9 manuscripts and a total of 109 patients who met the inclusion criteria. There was no statistically significant difference in the amount of anterior advancement of either the mandible (P = 0.96) or the maxilla (P = 0.23) between the "Success" or "Failure" groups.

CONCLUSIONS

While there is a paucity of individual data available, the current data does not support an ideal amount of maxillary or mandibular advancement that is required to obtain a surgical success in the treatment of OSA. Until a multicenter, prospective, randomized trial is performed, surgical planning should be tailored to patient-specific anatomy to achieve the desired result.

Patient-reported reasons for and predictors of noncompliance with compression stockings in a randomized trial of stockings to prevent postthrombotic syndrome

INTRODUCTION

Elastic compression stockings (ECSs) are used to treat symptoms of venous insufficiency. However, lack of patient compliance can limit their effectiveness. In a secondary analysis of the SOX Trial, a randomized trial of active vs. placebo ECSs worn for 2 years to prevent postthrombotic syndrome after deep vein thrombosis, we aimed to describe patient-reported reasons for nondaily use of ECS and to identify predictors of noncompliance during follow-up.

METHODS

At each follow-up visit of the SOX Trial, patients were asked how many days per week they wore study stockings, and if not worn daily, to specify the reason(s). Reasons for nondaily use of ECSs were tabulated. Multiple logistic regression modeling was used to identify predictors of stocking noncompliance during follow-up (defined as use <3 days per week).

RESULTS

Among the 776 patients who attended at least 1 follow-up visit, daily use of stockings at each visit was similar in the active and placebo ECS groups. Reasons for nondaily use of stockings was most frequently related to aversive aspects of stockings (~three-fourths of patients) and less often related to patient behaviors (~one-fourth of patients). In multivariate analyses, behavior-related and aversive aspect-related reasons for nondaily use of ECSs at the 1-month visit were significant predictors of noncompliance during follow-up (odds ratio [OR] = 4.41 [95% confidence interval, 2.12-9.17] and OR = 3.99 [2.62-6.08], respectively).

CONCLUSIONS

Aversive aspects of ECSs and patient behaviors are important reasons for noncompliance. Improving the appeal and tolerability of ECS and education directed at modifying patient behaviors may improve compliance.

Association between Upper-airway Surgery and Ameliorative Risk Markers of Endothelial Function in Obstructive Sleep Apnea

The objective of our study was to evaluate the effects of upper-airway surgery on improvement of endothelial function-related markers in patients with obstructive sleep apnea (OSA). Subjects with moderate to severe OSA who underwent upper-airway surgery, with a follow-up duration of at least 6 months, were included. Pre- and postoperative polysomnographic variables and endothelial function-related markers were compared. Subgroup and correlation analyses were conducted to find possible indicators for better endothelial function-related markers after upper-airway surgery. In total, 44 patients with OSA were included. The mean follow-up duration was 1.72 ± 0.92 years. Serum VEGFA [-20.29 (CI: -35.27, -5.31), p < 0.05], Ang2 [-0.06 (CI: -0.16, 0.03), p < 0.05], E-selectin [-7.21 (CI: -11.01, -3.41), p < 0.001], VWF [-58.83 (CI: -103.93, -13.73), p < 0.05], VWFCP [-33.52 (CI: -66.34, -0.70), p < 0.05], and TM [-0.06 (CI: -0.09, -0.03), p < 0.05] were significantly lower after upper-airway surgery. However, other risk markers of endothelial function, such as Ang1, ICAM1, VEGFR1, and VCAM, did not change significantly. Correlations between improved endothelial function-related markers and ameliorated oxyhemoglobin saturation and glucolipid metabolism were established. Upper-airway surgery might be associated with an improvement in endothelial function in patients with OSA. These changes may be associated with improved oxygen saturation after upper-airway surgery.

Using the preoperative psychological evaluation to determine psychosocial risk factors for CPAP nonadherence among bariatric surgery candidates

BACKGROUND

Obstructive sleep apnea (OSA) is prevalent among bariatric surgery candidates and is associated with numerous adverse health conditions, both pre- and postoperatively. Continuous positive airway pressure therapy (CPAP) is the first-line treatment for OSA, but it requires significant behavioral changes. As such, CPAP adherence is a significant problem in OSA treatment. Information from the preoperative psychological evaluation may be used to identify psychosocial risk factors associated with CPAP nonadherence and inform the implementation of more specific and appropriate interventions.

OBJECTIVES

Examine the utility of Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) behavioral/externalizing dysfunction scale scores to determine personality and psychopathology associations with, and risk for, CPAP nonadherence.

SETTING

Academic medical center.

METHODS

Patients who underwent a preoperative psychological evaluation and were diagnosed with OSA (n = 358) were divided into 2 groups: CPAP adherent (n = 271) and CPAP nonadherent (n = 87). Independent samples t tests were computed to examine differences in average MMPI-2-RF scale scores between these groups. Relative risk ratios were computed using multiple MMPI-2-RF substantive scale score cut-offs to determine which MMPI-2-RF scales were associated with increased risk of CPAP nonadherence.

RESULTS

Higher scores on scales measuring behavioral/externalizing dysfunction and family problems were associated with and indicative of risk for CPAP nonadherence.

CONCLUSIONS

CPAP nonadherence is related to and may be affected by generally higher levels of behavioral/externalizing dysfunction. Using a broadband measure of personality and psychopathology, like the MMPI-2-RF, during the preoperative evaluation can provide important information about co-morbid symptoms that may interfere with CPAP adherence. Considering this information during preoperative treatment planning could increase the likelihood of preoperative CPAP adherence and reduce the likelihood of adverse postoperative outcomes.

An optimization method for surgical reduction of hypertrophied inferior turbinate

Surgical reductions of the hypertrophied inferior turbinate (HIT) can improve nasal obstruction. However, there is currently a lack of personalized and objective methods to guide surgical operations, which results in the excessive or inadequate resection of HIT. In this study, we proposed an optimizing method based on homotopy deformation to determine the resected amount and shape of the tissue by matching the flow resistance in the two nasal passageways. The simulation results obtained using computational fluid dynamics showed that after such an optimization procedure, the most obstructed nasal side could have a similar air flux as the less obstructed side. A 35% and a 56% less tissue resection in the optimizing operation compared to that in the total turbinectomy could well balance the air flow between the two nasal cavities in the simulations for patients 1 and 2 with unilateral nasal obstruction respectively. Compared with the optimization operation, the total turbinectomy made a more aggressive resection of HIT, which could worsen the air conditioning capacity of the nose. A sensitivity test indicated that in the optimization operation, the most constricted region in the nasal cavity should be adequately enlarged. However, more tissue resection than is required for the optimization operation did not improve the flow in the obstructed side strikingly. Simulations of the optimization operation in both nasal cavities for a patient with bilateral nasal obstruction were also performed. The flow rate could reach the normal level and be well balanced in the two sides after such an optimization procedure.

Positional sleep disordered breathing in patients with arrhythmia. Should we advise our patients to avoid supine position during sleep?

BACKGROUND

Sleep disordered breathing [SDB] is a well-known problem in patients with cardiovascular diseases. Around 50% of pts. with SDB present positional sleep disordered breathing [PSDB].

AIMS

The aim of this study was the investigation of the frequency of PSDB in patients with different forms of arrhythmias.

METHODS

We analyzed the presence of SDB in 53 pts. with diagnosed atrial fibrillation (paroxysmal or persistent), 88 pts. before ablation of ventricular ectopy and 110 pts. that had Holter monitoring due to the symptoms suggesting arrhythmia.

RESULTS

Finally, we could collect all the data in 243 pts. - 150 men 93 women. AHI < 15 was recorded in 136 (56%) pts., AHI > 15 in 107 (44%) pts. Moderate sleep disordered breathing was diagnosed in 59 (24%) pts. (AHI 15-30), severe sleep disordered breathing (AHI > 30) was recognized in 48 (20%) pts. In all of the analyzed groups, AHI in supine position was significantly higher than in nonsupine position. PSDB was recorded in 55% of pts. with AHI > 15 and in 29% of pts. (n = 14) with AHI > 30. Percentage of time in supine position was an independent factor related with the presence of at least moderate or severe sleep disordered breathing.

CONCLUSION

1. Moderate or severe SDB is recorded in 44% of pts. with arrhythmias, almost 50% of them have positional SDB. 2. Percent of time of sleeping in supine position has an important independent impact on the presence of SDB. 3. Big studies should be conducted to verify if avoidance of sleeping in supine position may improve clinical outcome.

CONDENSED ABSTRACT

Sleep disordered breathing SDB is a frequent problem of pts. with cardiovascular diseases. It may influence the prognosis. Moderate or severe SDB is recorded in 44% of pts. with arrhythmias, almost 50% of them have positional SDB. Percent of time of sleeping in supine position has an important independent impact on the presence of SDB. 3. Big studies should be conducted to verify if avoidance of sleeping in supine position may improve clinical outcome. What is new?

Predictors of long-term adherence to continuous positive airway pressure in patients with obstructive sleep apnea and cardiovascular disease

Study Objectives

Poor adherence to continuous positive airway pressure (CPAP) commonly affects therapeutic response in obstructive sleep apnea (OSA). We aimed to determine predictors of adherence to CPAP among participants of the Sleep Apnea and cardioVascular Endpoints (SAVE) trial.

Methods

SAVE was an international, randomized, open trial of CPAP plus usual care versus usual care (UC) alone in participants (45–75 years) with co-occurring moderate-to-severe OSA (≥12 episodes/h of ≥4% oxygen desaturation) and established cardiovascular (CV) disease. Baseline sociodemographic, health and lifestyle factors, OSA symptoms, and 1-month change in daytime sleepiness, as well as CPAP side effects and adherence (during sham screening, titration week, and in the first month), were entered in univariate linear regression analyses to identify predictors of CPAP adherence at 24 months. Variables with p <0.2 were assessed for inclusion in a multivariate linear mixed model with country, age, and sex included a priori and site as a random effect.

Results

Significant univariate predictors of adherence at 24 months in 1,121 participants included: early adherence measures, improvement in daytime sleepiness at 1 month, fixed CPAP pressure, some measures of OSA severity, cardiovascular disease history, breathing pauses, and very loud snoring. While observed adherence varied between countries, adherence during sham screening, initial titration, and the first month of treatment retained independent predictive value in the multivariate model along with fixed CPAP pressure and very loud snoring.

Conclusions

Early CPAP adherence had the greatest predictive value for identifying those at highest risk of non-adherence to long-term CPAP therapy.

Clinical Trial Registration

SAVE is registered with clinicaltrials.gov (NCT00738179).

Psychometric properties of the Ethos Brief Index (EBI) using factorial structure and Rasch Analysis among patients with obstructive sleep apnea before and after CPAP treatment is initiated

BACKGROUND

Continuous positive airway treatment (CPAP) is the recommended treatment for patients with obstructive sleep apnea (OSA). Outcome measures often focus on clinical and/or self-rated variables related to the medical condition. However, a brief validated instrument focusing on the whole life situation (i.e., ethos) suitable for clinical practice is missing. The aim of this study was to investigate factorial structure, categorical functioning of the response scale, and differential item functioning across sub-populations of the Ethos Brief Index (EBI) among patients with obstructive sleep apnea (OSA) before and after initiation of continuous positive airway pressure (CPAP).

METHODS

A prospective design, including 193 patients with OSA (68% men, 59.66 years, SD 11.51) from two CPAP clinics, was used. Clinical assessment and overnight respiratory polygraphy were used to diagnose patients. Questionnaires administered before and after 6 months of CPAP treatment included EBI, Epworth Sleepiness Scale (ESS), Hospital Anxiety and Depression Scale, and global perceived health (initial item in SF-36). The validity and reliability of the EBI were investigated using Rasch and confirmatory factor analysis models. Measurement invariance, unidimensionality, and differential item functioning across gender groups, Apnea-Hypopnea Index, and ESS groups were assessed.

RESULTS

The reliability of the EBI was confirmed using composite reliability and Cronbach's alpha. The results supported unidimensionality of the EBI in confirmatory factor analysis and the Rasch model. No differential item functioning was found. A latent profile analysis yielded two profiles of patients with low (n = 42) and high (n = 151) ethos. Patients in the low ethos group were younger and had higher depression scores, lower perceived health, and higher body mass index.

CONCLUSIONS

The EBI is a valid tool with robust psychometric properties suitable for use among patients with OSA before and after treatment with CPAP is initiated. Future studies should focus on its predictive validity.

Long-term Efficacy of Uvulopalatopharyngoplasty among Adult Patients with Obstructive Sleep Apnea: A Systematic Review and Meta-analysis

OBJECTIVES

To evaluate the long-term efficacy and potential predictors of uvulopalatopharyngoplasty (UPPP) among adult patients with obstructive sleep apnea (OSA).

DATA SOURCES

A systematic search was conducted through PubMed/Medline, Embase, Web of Science, and the Cochrane Library until December 2018.

REVIEW METHODS

Full-text articles were selected that studied adult patients who underwent single-level UPPP or its modification for OSA and had a long-term follow-up (at least 34 months) with objective sleep study results. Studies that had no objective outcomes or performed other surgical procedures for OSA were excluded.

RESULTS

Of 2600 studies, 11 were included. Meta-analysis comparing long-term post- and preoperative outcomes showed significant improvements, with an 15.4 event/h (46.1%) decrease of apnea-hypopnea index. Compared with the short-term outcomes (3-12 months), the long-term outcomes were less effective, with apnea-hypopnea index increasing 12.3 events/h (63.8%) and the surgical response decreasing from 67.3% to 44.35%. Subanalysis of individual patient data showed significant correlations of baseline body mass index, lowest arterial oxygen saturation, and proportion of sleep time with oxygen saturation <90% with long-term surgical response.

CONCLUSIONS

Despite the surgical efficacy decreasing over time, UPPP and its modification are an effective surgical method for adult OSA in both the short term and the long term after the surgery. Baseline body mass index, lowest arterial oxygen saturation, and proportion of sleep time with oxygen saturation <90% were potentially predictive for long-term surgical response. Case-control studies of the long-term surgical effect of OSA are needed.