What is known about the experiences of using CPAP for OSA from the users' perspective? A systematic integrative literature review

Patient experience of the use of continuous positive airway pressure for the treatment of obstructive sleep apnea with or without telemedicine during COVID-19: a qualitative approach

STUDY OBJECTIVES

Continuous positive airway pressure (CPAP) is considered effective treatment for moderate-severe obstructive sleep apnea (OSA). Clinicians measure adherence to treatment by the number of hours CPAP is used per 24 hours. There have been very few studies examining the patients' lived experience of CPAP and the barriers to use. This study examined the patients' experience of OSA, CPAP use and treatment during COVID-19.

METHODS

This CPAP patient experience qualitative study was part of a larger project. The overarching study was a 3-armed nonblinded randomized controlled trial of patients on CPAP for treatment of OSA using standard care or 1 of 2 telemedicine interventions. Patients who had completed the randomized controlled trial study were invited to be interviewed via telephone, about their OSA diagnosis, CPAP experiences, their experience of using telemedicine, and the impact of SARS-CoV-2 (COVID-19).

RESULTS

Fifteen patients (5 from each arm of the trial) took part in a semistructured interview. Thematic analysis identified 3 themes: day to day living, standard hospital care vs telemedicine management, and living through COVID-19 with CPAP.

CONCLUSIONS

All participants described significant symptoms caused by their OSA before diagnosis. Although CPAP treatment was often described as challenging, patients discussed the improvement in their symptoms with treatment. There were differing opinions on virtual appointments; however, the consensus was the use of telemedicine to support CPAP treatment was well received. COVID-19 appeared to have little effect on the patient experience.

CITATION

Jones TA, Roddis J, Stores R. Patient experience of the use of continuous positive airway pressure for the treatment of obstructive sleep apnea with or without telemedicine during COVID-19: a qualitative approach. J Clin Sleep Med. 2024;20(11):1739-1748.

Factors associated with treatment adherence to mandibular advancement devices: a scoping review

PURPOSE

Obstructive sleep apnea (OSA) is frequently treated with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs). For various reasons, both treatment options are often affected by low adherence. While factors associated with low CPAP adherence are described in the literature extensively, less is known about adherence to MAD therapy. This scoping review aimed to synthesize the body of literature on the factors associated with adherence to MAD treatment.

METHODS

A systematic literature search was conducted using bibliographic databases PubMed, Embase.com , Web of Science, and the Cochrane Library (Wiley) to identify relevant studies that described factors associated with adherence to MAD in the treatment of OSA or snoring combined with OSA in adults.

RESULTS

The literature search yielded a total of 694 references. Forty studies were found eligible for inclusion. The literature showed that factors with a possible negative influence on the adherence to MAD treatment are personality aspects; failing effectiveness of MAD; side effects during MAD therapy; using a thermoplastic MAD; dental treatments during MAD therapy; and a poor first experience with the MAD with inadequate guidance by professionals. Factors that may have a positive effect on MAD adherence include effectiveness of therapy, custom-made MAD, good communication skills of the practitioner, early recognition of side effects, stepwise titration of the MAD, and positive first experience with MAD.

CONCLUSIONS

The knowledge of factors associated with MAD adherence can be used to provide further insight into individual adherence to OSA treatments.

Examining the relationship between obstructive sleep apnoea and eating behaviours and attitudes: A systematic review

BACKGROUND

Between 60 and 90% of adults with OSA are reported as overweight. The co-existence of obesity and OSA can greatly increase an individual's risk of type 2 diabetes, metabolic syndrome and cardiovascular disease. To better understand this relationship between OSA and weight, this review aimed to investigate if there is evidence of certain eating behaviours or eating attitudes that might be found in adults living with OSA.

METHODS

We searched four databases (MEDLINE, Embase, PsycInfo and Web of Science) on January 17th, 2022, to identify studies assessing the association between eating patterns and OSA in adults. Twenty-one studies met the inclusion criteria. A narrative synthesis was conducted on the included studies, following the vote-counting method.

RESULTS

There is preliminary evidence that the time of day when calories are consumed is associated with lower OSA severity. No other clear patterns of eating behaviours or attitudes were identified however this may be due to disparity within research studies and their reported results.

CONCLUSION

Further research is needed to examine the relationship between eating times and OSA severity. We recommend standardising the approach to examining the eating patterns of those living with OSA and the relationship that this might have on OSA symptoms as well as looking at attitudes towards food in this population. This may prove helpful in providing a better understanding of the relationship between OSA and persons with overweight and help in future intervention development.

What is Known About Critical Congenital Heart Disease Diagnosis and Management Experiences from the Perspectives of Family and Healthcare Providers? A Systematic Integrative Literature Review

The experience of diagnosis, decision-making and management in critical congenital heart disease is layered with complexity for both families and clinicians. We synthesise the current evidence regarding the family and healthcare provider experience of critical congenital heart disease diagnosis and management. A systematic integrative literature review was conducted by keyword search of online databases, MEDLINE (Ovid), PsycINFO, Cochrane, cumulative index to nursing and allied health literature (CINAHL Plus) and two journals, the Journal of Indigenous Research and Midwifery Journal from 1990. Inclusion and exclusion criteria were applied to search results with citation mining of final included papers to ensure completeness. Two researchers assessed study quality combining three tools. A third researcher reviewed papers where no consensus was reached. Data was coded and analysed in four phases resulting in final refined themes to summarise the findings. Of 1817 unique papers, 22 met the inclusion criteria. The overall quality of the included studies was generally good, apart from three of fair quality. There is little information on the experience of the healthcare provider. Thematic analysis identified three themes relating to the family experience: (1) The diagnosis and treatment of a critical congenital heart disease child significantly impacts parental health and wellbeing. (2) The way that healthcare and information is provided influences parental response and adaptation, and (3) parental responses and adaptation can be influenced by how and when support occurs. The experience of diagnosis and management of a critical congenital heart disease child is stressful and life-changing for families. Further research is needed into the experience of minority and socially deprived families, and of the healthcare provider, to inform potential interventions at the healthcare provider and institutional levels to improve family experience and support.

Correlations of Obstructive Sleep Apnea Syndrome and Daytime Sleepiness with the Risk of Car Accidents in Adult Working Population: A Systematic Review and Meta-Analysis with a Gender-Based Approach

Obstructive sleep apnea syndrome (OSAS) is an under-recognized clinical condition and is correlated with sleepiness and impaired cognitive function. Objectives: The primary aim of this systematic review, developed within the Sleep@OSA project, was to determine the correlations of obstructive sleep apnea syndrome, daytime sleepiness and sleep-disordered breathing with the risk of car accidents in adult working populations; a secondary aim was to analyze the epidemiologic data with a gender-based approach to identify differences between women and men in the data and in associated risk factors. Methods: Clinical trials and studies reporting data on the frequency of car accidents involving adult working population with daytime sleepiness and/or OSAS compared with a control group of participants were included. Literature searches of free text and MeSH terms were performed using PubMed, Google Scholar, the Cochrane Library and Scopus from 1952 to 3 May 2021. Results and Conclusions: The search strategy identified 2138 potential articles. Of these, 49 papers were included in the qualitative synthesis, and 30 were included in the meta-analysis. Compared with controls, the odds of car accidents were found to be more than double in subjects with OSAS (OR = 2.36; 95% CI 1.92−2.91; p < 0.001), with a similar risk between commercial motor vehicle drivers (OR = 2.80; 95% CI 1.82−4.31) and noncommercial motor vehicle drivers (OR = 2.32; 95% CI 1.84−2.34). No significant correlation was found between sleepiness and car crashes, but subjects with sleep-disordered breathing were at increased risk of car accidents (OR = 1.81; 95% CI 1.42−2.31; p < 0.001). To our surprise, although epidemiological studies on the risk of road accidents in the adult population with OSAS and daytime sleepiness are currently very abundant, specific data on the female population are not available.

Validation of the French Cues to CPAP Use Questionnaire in patients with OSAS: A step forward for evaluating cues to CPAP use in order to predict treatment adherence

PURPOSE

The cues to starting CPAP are important in patients with Obstructive Sleep Apnea Syndrome (OSAS) to predict CPAP use and behavioral change. The Cues to CPAP Use Questionnaire (CCUQ) is a short practical self-reported scale to evaluate such cues to action. This study sought to examine the psychometric reliability and validity of the French version.

METHODS

A forward-backward translation of the CCUQ was performed. Principal research tools were CCUQ, SEMSA and ESS. Subjects with OSAS were invited to complete the CCUQ just before CPAP initiation and 10 days after CPAP initiation. The ESS was completed just before CPAP initiation and one month after CPAP initiation. The SEMSA was completed just before CPAP initiation. Statistical analyses methods aim to evaluate the psychometric properties of the French CCUQ version in terms of its construct validity, internal structural validity, test-retest and external validity. Mean CPAP use on the previous month was recorded at one, six and twelve months after CPAP initiation.

RESULTS

A total of 140 patients with OSAS were included with 61.4% of men and a mean age of 55.3 (±12.9), BMI of 29.8 (±4.9), initial ESS of 11.97 (±5.68), and initial AHI 37.2/h (±19.3). Factor analysis confirmed the three-factor structure of the CCUQ. Cronbach's alpha coefficient was 0.64. Test-retest reliability (at t-0 and at 10 days) of the CCUQ was satisfactory. External validity shown significant correlation of the CCUQ with SEMSA and of the dimension "Partner cues" of the CCUQ with mean CPAP use at one month.

CONCLUSION

The French CCUQ scale is a reliable and valid tool for measuring cues to action in adults with OSAS initiating CPAP treatment. Further studies are necessary to confirm the predictive value of cues to action and self-efficacy for CPAP use and adherence. Such investigations would underpin public health CPAP interventions in accordance with models of behavioral change.

Oral health problems linked to obstructive sleep apnea are not always recognized within dental care-As described by dental professionals

Objectives

Obstructive sleep apnea (OSA) has an impact on an individual's quality of life and general health, and can also affect their oral health. The patient's experiences, together with intraoral signs and symptoms could indicate the presence of OSA. Knowledge that the patient has, or is at high risk for having OSA can help the dental healthcare provider maintain the oral health and general health for these patients. The purpose was to explore dentists and dental hygienists' experiences when encountering adult patients with potential, untreated and treated OSA.

Methods

A qualitative inductive approach was used. Experienced dentists and dental hygienists working within Swedish Public Dental Service were strategically selected. Semi‐structured face‐to‐face interviews were performed followed by qualitative content analysis.

Results

Interviews from 13 participants, seven dental hygienist and six dentists, led to three areas describing varied experience: Importance of the patient encounter and identifying intraoral signs both of which describe experiences related to the importance of the initial unstructured conversation and focused clinical assessments, and strategies for nurturing care which point to interest about care, treatment, and collaborations with medical health care providers.

Conclusions

Dental professionals are not able to consistently recognize patients who have, or are at high risk for OSA. During the patient encounter, is it important to determine if a patient is at risk for, or has oral signs of OSA.

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.

Experiences of Using Positive Airway Pressure for Treatment of Obstructive Sleep Apnoea: A Systematic Review and Thematic Synthesis

STUDY OBJECTIVES

Sub-optimal use of positive airway pressure (PAP) to treat obstructive sleep apnoea (OSA) continues to be a major challenge to effective treatment. Meanwhile, the individual and societal impacts of untreated OSA make effective treatment a priority. Although extensive research has been conducted into factors that impact PAP use, it is estimated that at least half of users do not use it as prescribed. However, the voice of users is notably minimal in the literature. A systematic review and qualitative metasynthesis of PAP user experience was conducted to contribute to understandings of how PAP is experienced and to inform how usage could be improved.

METHODS

PsycINFO, MEDLINE, CINAHL and EMBASE databases were systematically searched. Primary research findings of adult experiences using PAP that had been inductively analysed were included. Papers were critically appraised using the CASP qualitative checklist to generate a "hierarchy of evidence". Thematic synthesis was then conducted to generate analytical themes. Results were presented in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).

RESULTS

25 papers reporting on over 398 people's experiences were analysed to generate 4 themes: Journey to PAP, Discomfort from and around PAP, Adapting to and using PAP, and Benefits from PAP. Author reflexivity and vulnerability to bias is acknowledged.

CONCLUSIONS

The findings highlight the applicability of a biopsychosocial understanding to PAP use. This metasynthesis gave voice to user experiences, revealing barriers to PAP use at a healthcare service level across the world, and suggests ways services can address these barriers.

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.

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.

Noninvasive Ventilation and Spinal Cord Injury

Individuals with spinal cord injury (SCI) are at increased risk of respiratory complications during wake and sleep. Sleep-disordered breathing (SDB) is commonly associated with SCI and requires an individualized approach to its management. Respiratory control plays a key role in the pathogenesis of SDB in cervical SCI. Noninvasive ventilation plays an important role in the management of respiratory complications in individuals with SCI acutely and in chronic phases. Positive airway pressure treatment may be effective in eliminating SDB and improving sleepiness symptoms, but adherence to treatment is poor and effect on long-term outcomes is questionable.

Tailored Approach to Sleep Health Education (TASHE): a randomized controlled trial of a web-based application

STUDY OBJECTIVES

In a randomized controlled trial, we compared the effect of the Tailored Approach to Sleep Health Education (TASHE) on obstructive sleep apnea (OSA) self-efficacy among community-dwelling blacks in New York City.

METHODS

Study participants were 194 blacks at high risk for OSA based on the Apnea Risk Evaluation System. TASHE intervention was delivered via a Wi-Fi-enabled tablet, programmed to provide online access to culturally and linguistically tailored information designed to address unique barriers to OSA care among blacks. Blacks in the attention-controlled arm received standard sleep information via the National Sleep Foundation website. Blacks in both arms accessed online sleep information for 2 months. Outcomes (OSA health literacy, self-efficacy, knowledge and beliefs, and sleep hygiene) were assessed at baseline, at 2 months, and at 6 months.

RESULTS

We compared outcomes in both arms based on intention-to-treat analysis using adjusted Generalized Linear Mixed Modeling. TASHE exposure significantly increased OSA self-efficacy (OSA outcome expectation [β = .5; 95% CI: .1-.9] and OSA treatment efficacy [β = 0.4; 95% CI: .0-.8]) at 2 months but not at 6 months. Additionally, TASHE exposure improved sleep hygiene at 6 months (β = 6.7; 95% CI: 2.2-11.3) but not at 2 months.

CONCLUSIONS

Community-dwelling blacks exposed to TASHE materials reported increased OSA self-efficacy compared with standard sleep health education. Stakeholder-engaged, theory-based approaches, as demonstrated in the TASHE intervention, can be used successfully to deliver effective sleep health messages.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; URL: https://clinicaltrials.gov/ct2/show/NCT02507089; Identifier: NCT02507089.

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.

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.

Devoted or negotiated routes of adherence: Narratives of patients with obstructive sleep apnoea using a continuous positive airway pressure device

AIMS

To explore the narratives of patients about receiving a diagnosis of obstructive sleep apnoea and using a continuous positive airway pressure device.

DESIGN

A qualitative design with a narrative approach.

METHODS

Participants with personal experience of using a continuous positive airway pressure device were recruited through purposive sampling. Two women and five men were interviewed in 2017. The data material was subjected to a narrative analysis.

RESULTS

Two storylines portraying two different trajectories of continuous positive airway pressure use were identified: "A route of devotion" reflects patients experiencing immediate health benefits, which lead to committed use. "A route of negotiations" is characterized by more irregular use, and the perceived benefits were less evident than for those displaying a devoted route. Individuals adjust to a continuous positive airway pressure device differently based on their prior and present life situation and whether use of the device is experienced as an opportunity to regain ordinary life or as an obstacle to maintaining ordinary life.

Worth the effort? Weighing up the benefit and burden of continuous positive airway pressure therapy for the treatment of obstructive sleep apnoea in chronic tetraplegia

STUDY DESIGN

Mixed methods OBJECTIVES: Continuous positive airway pressure (CPAP) therapy is the recommended treatment for obstructive sleep apnoea (OSA). The aim of this study was to estimate CPAP adherence in people with tetraplegia and OSA, and to explore the barriers and facilitators to CPAP use.

SETTING

Hospital outpatient department in Melbourne, Australia METHODS: People with chronic tetraplegia and OSA were commenced with auto-titrating CPAP and supported for 1 month. Semi-structured interviews were conducted with participants at one month and analysed thematically. CPAP usage was measured at 1, 6 and 12 months, with "adherent" defined as achieving more than 4 h average per night.

RESULTS

Sixteen participants completed the study (80% male; mean age 56 (SD = 15)). Mean nightly CPAP use at one month was 3.1 h (SD = 2.5; 38% adherent), and at 6 months and 12 months were 2.6 h (SD = 2.8; 25% adherent) and 2.1 h (SD = 3.2; 25% adherent). The perceived benefit/burden balance strongly influenced ongoing use. Burden attributed to CPAP use was common, and included mask discomfort, and physical and emotional problems. Adherent participants were motivated by the immediate daytime benefits to mood, alertness and sleepiness. There was a tendency to not recognise symptoms of OSA until after they were treated.

CONCLUSION

CPAP use is challenging for people with tetraplegia, who experience substantial burden from using the device. When tolerated, the proximate benefits are substantial. People with tetraplegia need more intensive support for longer to help them overcome the burdens of CPAP and benefit from the treatment.

Promoting CPAP adherence in clinical practice: A survey of Swedish and Norwegian CPAP practitioners' beliefs and practices

The benefits of continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea are well established, but adherence tends to be low. Research exploring CPAP practitioners' beliefs around determinants of CPAP adherence, and the actions they use in clinical practice to promote CPAP adherence is lacking. This study aimed to: (i) develop and validate a questionnaire to assess beliefs and current practices among CPAP practitioners; (ii) explore practitioners' beliefs regarding the main determinants of patient adherence, and the actions practitioners most commonly use to promote CPAP adherence; and (iii) explore the associations between perceived determinants and adherence-promotion actions. One-hundred and forty-two CPAP practitioners in Sweden and Norway, representing 93% of all Swedish and 62% of all Norwegian CPAP centres, were surveyed via a questionnaire exploring potential determinants (18 items) and adherence-promotion actions (20 items). Confirmatory factor analysis and second-order structural equational modelling were used to identify patterns of beliefs, and potential associations with adherence-promotion actions. Patients' knowledge, motivation and attitudes were perceived by practitioners to be the main determinants of CPAP adherence, and educating patients about effects, management and treatment adjustments were the most common practices. Knowledge was shown to predict educational and informational actions (e.g. education about obstructive sleep apnea and CPAP). Educational and informational actions were associated with medical actions (e.g. treatment adjustment), but knowledge, attitude and support had no association with medical actions. These findings indicate that a wide variety of determinants and actions are considered important, though the only relationship observed between beliefs and actions was found for knowledge and educational and informational actions.

Ambivalent Adherence and Nonadherence to Continuous Positive Airway Pressure Devices: A Qualitative Study

STUDY OBJECTIVES

Continuous positive airway pressure (CPAP) therapy is considered the front-line treatment for moderate-severe obstructive sleep apnea (OSA). However, nonuse rates are very high, such that adherence to CPAP has become a major concern. Although the literature on CPAP use is vast, further research is required to understand patients' experiences of CPAP use and nonuse. This is the goal of this study.

METHODS

This study draws on in-depth interviews with 61 Jewish-Israeli patients with OSA who received a recommendation to use a CPAP device. The sample includes both patients who started using CPAP devices as well as patients who rejected this course of treatment. It follows principles of constructivist-grounded theory in both sampling and analysis.

RESULTS

The study shows that regardless of patients' status of adherence, their attitudes toward CPAP devices are characterized by ambivalence. Users of CPAP expressed ambivalent adherence, pondering whether they should stop using the device; and patients who rejected the CPAP expressed ambivalent nonadherence, wondering whether they should give the CPAP another chance. This study identifies the experiences involved in using, as well as not using, CPAP devices that produce patients' ambivalence.

CONCLUSIONS

Both adherence and nonadherence to CPAP are dynamic processes that are characterized by patients' ambivalence and contingent upon diverse factors. These findings have practical implications as they suggest that all patients, regardless of their initial adherence status, would benefit from a close follow-up.

Perioperative management of the obese surgical patient

INTRODUCTION

The escalation in the prevalence of obesity throughout the world has led to an upsurge in the number of obese surgical patients to whom perioperative care needs to be delivered.

SOURCES OF DATA

After determining the scope of the review, the authors used PubMed with select phrases encompassing the words in the scope. Both preclinical and clinical reports were considered.

AREAS OF AGREEMENT

There were no controversies regarding preoperative management and the intraoperative care of the obese surgical patient.

AREAS OF CONTROVERSY

Is there a healthy obese state that gives rise to the obesity paradox regarding postoperative complications?

GROWING POINTS

This review considers how to prepare for and manage the obese surgical patient through the entire spectrum, from preoperative assessment to possible postoperative intensive care.

AREAS TIMELY FOR DEVELOPING RESEARCH

What results in an obese patient developing 'unhealthy' obesity?

Balancing task focus and relationship building: asking sleepy patients about traffic risk in treatment initiation consultations

BACKGROUND

The use of traffic risk assessment questions is an understudied area in nursing research. Obstructive sleep apnoea is associated with an increased risk of traffic accidents. Therefore, traffic safety authorities demand adherent continuous positive airway pressure use. Nurses act as coaches to achieve treatment adherence, but they are also obliged to act as state agents by prohibiting obstructive sleep apnoea patients from drowsy driving.

OBJECTIVE

To examine how nurses and obstructive sleep apnoea patients manage traffic risk assessment questions in the relation-building context of treatment initiation consultations.

METHODS

To study, in detail, the actual practice of risk assessment, we used conversation analysis of 19 video-recorded initial treatment consultations with nurses and recently diagnosed obstructive sleep apnoea patients.

ETHICS

The study received ethical approval from the Central Ethical Review Board in Linköping (registration number 214/231-32) and follows the ethical guidelines for qualitative research.

RESULTS

Patients influence how nurses phrase questions about traffic risk by taking a stance to daytime sleepiness prior to the risk question. Nurses ask traffic risk questions in a way that assumes that driving is unproblematic if patients have not previously indicated problems. It may pose a significant problem when nurses, by accepting patients' prior stance when asking about traffic risk, orient to relationship building rather than task focus.

CONCLUSION

To clarify the difference between their two potentially conflicting roles, nurses need to refer to existing laws and official guidelines when they raise the issue of risk in treatment initiation consultations. Nurses should also ask risk assessment questions in a problem-oriented communicative environment. Traffic risk assessment is sensitive yet important, as obstructive sleep apnoea is a highly prevalent problem causing excessive sleepiness. It is essential to acknowledge nurses' double roles with regard to coaching continuous positive airway pressure treatment and assessing traffic risk.

Patient-centered care in obstructive sleep apnea: A vision for the future

Obstructive sleep apnea is a common condition, with multiple potential neurocognitive, cardiovascular, and metabolic consequences. Efficacious treatment is available, but patient engagement is typically required for treatment to be effective. Patients with sleep apnea are phenotypically diverse and have individual needs, preferences, and values that impact treatment decisions. There has been a shift in obstructive sleep apnea management from diagnosis to chronic care management. Making treatment decisions that incorporate an individual patient's values and preferences and are personalized for that patient's biology has the potential to improve patient outcomes. A patient-centered care approach in obstructive sleep apnea is reviewed including 1) determining patient-specific needs to guide treatment decisions, 2) understanding patient values, preferences, and other factors impacting treatment decisions and using shared decision-making, 3) enhancing patient education and support to improve treatment adherence, 4) promoting patient engagement, 5) optimizing care coordination, continuity of care, and access to care, and 6) determining and assessing patient-centered outcomes.

Communication between patients with obstructive sleep apnoea syndrome and healthcare personnel during the initial visit to a continuous positive airway pressure clinic

AIMS AND OBJECTIVES

To describe facilitators and barriers from a patient perspective in communications between patients with obstructive sleep apnoea syndrome and healthcare personnel during the first meeting when continuous positive airway pressure is initiated.

BACKGROUND

Adherence to continuous positive airway pressure treatment tends to be poor, especially at the initial phase of treatment. Communication between the patient and healthcare personnel has not been studied from the patient perspective, as either a barrier or facilitator for adherence.

METHODS

A descriptive design using qualitative content analysis was used. Interviews with 25 patients with obstructive sleep apnoea syndrome took place after their initial visit at four continuous positive airway pressure clinics. A deductive analysis based on The 4 Habits Model (i.e. emphasise the importance of investing in the beginning of the consultation, elicit the patient's perspective, demonstrate empathy and invest in the end of the consultation) was conducted.

RESULTS

Building confidence (i.e. structure building, information transfer, commitment) or hindering confidence (i.e. organisational insufficiency, stress behaviour, interaction deficit) was associated with investing in the beginning. Motivating (i.e. situational insight, knowledge transfer, practical training) or demotivating (i.e. expectations, dominance and power asymmetry, barriers) was associated with eliciting the patient's perspective. Building hope (i.e. awareness, sensitivity, demonstration of understanding) or hindering hope (i.e. unprepared, uncommitted, incomprehension) was associated with showing empathy. Agreement (i.e. confirmation, responsibilities, comprehensive information) or disagreement (i.e. structural obscurity, irresponsibility, absent-mindedness) was associated with investing in the end.

CONCLUSIONS

Understanding of facilitators and barriers, as described by patients, can be used to improve contextual conditions and communication skills among healthcare personnel.

RELEVANCE TO CLINICAL PRACTICE

A patient-centred communication technique should be used in relation to all stages of The 4 Habits Model to facilitate shared decision-making and improve adherence to continuous positive airway pressure treatment.

The role of nasal treatments in snoring and obstructive sleep apnoea

PURPOSE OF REVIEW

This review highlights recent advances and views on the role of the nose in snoring and obstructive sleep apnoea.

RECENT FINDINGS

Recent reviews and past randomized controlled trials generally agree that nasal surgery may improve quality of life in snoring and obstructive sleep apnoea. There have been no published randomized controlled trials regarding nasal treatments in snoring or obstructive sleep apnoea in the past year.

SUMMARY

Snoring and obstructive sleep apnoea are upper airway disorders in which the role of the nose has been well researched. Studies support that nasal surgery improves quality of life in snoring, but it may not lead to resolution of snoring. Likewise, nasal treatments for obstructive sleep apnoea increase the quality of life and treatment compliance in some patients. Further stratification of patients who may benefit from nasal intervention may clarify the role of nasal surgery.