Nonattended home automated continuous positive airway pressure titration: comparison with polysomnography

Comparison of 3-months treatment adherence and estimating residual apnea hypopnea index between home versus in-laboratory auto-titrating positive airway pressure titration

PURPOSE

We aimed to assess the accuracy of home titration in estimating apnea hypopnea index (AHI) and optimal pressure values and to compare improvements in subjective daytime sleepiness, sleep quality and quality of life, along with 3-months treatment adherence of patients that received at-home versus in-laboratory auto-titrating positive airway pressure (APAP) titration.

MATERIALS AND METHODS

In patients with a diagnosis of obstructive sleep apnea syndrome (OSAS), a study arm of laboratory attended APAP titration was compared with a study arm of home titration using an APAP device for three days. Subjective questionnaires were evaluated before and after 3 months of treatment.

RESULTS

Fifty-three patients with newly diagnosed OSAS were enrolled. There was a significant positive correlation between PSG AHI and APAP AHI (r_s  = 0.43, P = 0.003) and the fixed pressure for the APAP arm was positively correlated with the APAP PSG arm of the study (r_s  = 0.71, P < 0.001). When the Bland-Altman graphs were compared, it was seen that the measurements obtained by the APAP AHI method were 0.3 units higher than the PSG AHI measurements, and that the mean of the measurement differences between the two methods was not different than 0 (P [H₀ : Mean = 0] = 0.551). After 3 months of treatment, average nightly use was slightly higher in the APAP arm (P = 0.387).

CONCLUSIONS

The results indicate that both titration methods were not clinically inferior in terms of a fixed optimal pressure, residual events, 3-months treatment adherence and change in subjective sleepiness, sleep quality and quality of life after treatment.

Apnea burden: efficacy versus effectiveness in patients using positive airway pressure

BACKGROUND

Modern continuous positive airway pressure (PAP) machines track hours of use and residual respiratory events while on treatment. A substantial portion of sleep apnea patients are partially compliant, emphasizing the need to distinguish between PAP efficacy and PAP effectiveness in chronic management of patients with sleep apnea.

METHODS

We used a combination of three data sources to estimate the sleep apnea burden in a convenience cohort of PAP users from our clinics that were compliant based on Medicare criteria: self-reported habitual total sleep time, and PAP usage times with residual apnea-hypopnea index (AHI) from compliance downloads.

RESULTS

Assuming that the off-PAP time consists of baseline AHI severity, an estimated apnea burden was calculated to estimate PAP effectiveness. Whereas 70% of patients in our cohort showed machine AHI values <5/h, the apnea burden calculations revealed that only one-third of patients are predicted to have an effective AHI <5.

CONCLUSION

Estimating PAP effectiveness through the concept of apnea burden has implications for clinical care as well as research trials.

Does home sleep testing impair continuous positive airway pressure adherence in patients with obstructive sleep apnea?

BACKGROUND

The increasing recognition of obstructive sleep apnea (OSA) and demand for polysomnography has created a need for home sleep testing (HST) using unattended diagnostic and titration studies. Although these studies increase access to care and reduce cost, the limited interaction with sleep laboratories may negatively affect positive airway pressure (PAP) adherence. We sought to determine the difference in PAP use between HST and traditional in-laboratory studies.

METHODS

This observational cohort study included 210 patients with OSA classified into three equal groups. Following preestablished guidelines, group 1 underwent unattended, type III home diagnostic and unattended home auto-adjustable PAP (APAP) titrations; group 2 underwent in-laboratory, type I diagnostic and continuous PAP titration studies; group 3 underwent type I diagnostic and APAP titration studies. Group 1 was primarily managed and educated in a primary care clinic, whereas groups 2 and 3 received extensive education in an academic sleep medicine center. Objective measures of PAP use during the first 4 to 6 weeks of therapy were compared between groups.

RESULTS

Type of study and location of care did not affect PAP adherence. PAP was used for 70%, 73%, and 72% of nights in groups 1, 2, and 3, respectively (P = .94). Mean hours of nightly use (4.4 ± 2.0 h, 4.7 ± 1.5 h, and 4.6 ± 1.5 h; P = .98) was also similar. Regular use was observed in 54%, 51%, and 50% of subjects (P = .84). Discontinuation rates were similar between groups.

CONCLUSIONS

PAP usage did not differ between those undergoing HST vs in-laboratory studies. HST offers a more accessible and cost-effective alternative without compromising therapeutic adherence.

APAP impact on metabolic syndrome in obstructive sleep apnea patients

PURPOSE

Prevalence of metabolic syndrome (MS) in obstructive sleep apnea (OSA) patients is high. The effect of autoadjusting positive airway pressure (APAP) on MS remains unclear. This study aimed to determine the prevalence of MS in OSA patients before and 6 months after APAP, and to identify potential determinants of metabolic status change.

METHODS

Seventy-four male patients with moderate to severe OSA were enrolled. MS diagnosis was established according to the National Cholesterol Education Program/Adult Treatment Panel III. APAP was prescribed to all patients.

RESULTS

In the studied population, mean age was 55.9 years (SD 10.7 years), median body mass index (BMI), Epworth sleepiness scale (ESS), and respiratory disturbance index (RDI) were 33.4 kg/m(2) (interquartile range (IQR) 8.4 kg/m(2)), 12.0 (IQR 8.0), and 46.9/h (IQR 33.6/h), respectively. Prevalence of MS before and 6 months after APAP was 63.5% and 47.3%, respectively, and this difference was statistically significant (p = 0.004). In the subgroup of patients with MS at baseline (n = 47), 14 did not present MS after APAP. In these patients, a significant negative association with RDI (p = 0.016) and a positive association with percent of total days of usage (p = 0.014) were found. Blood pressure (p = 0.018) and serum triglycerides (p = 0.001) had a statistically significant reduction during this period. In patients that still had MS, 22.2% presented a reduction of the number of MS criteria.

CONCLUSIONS

After 6 months, APAP reduced the prevalence of MS, mainly in patients with less severe OSA and with a better therapeutic compliance. Blood pressure and serum triglycerides reduction contributed to this metabolic status change.

[Practical aspects of the management of patients treated by continuous positive airway pressure]

The therapeutic follow-up is a decisive factor of the success of a long course treatment by continuous positive airway pressure (CPAP). The effectiveness of this treatment on both symptoms and complications must be regularly verified. Polysomnography with CPAP could be necessary in order to check out the efficacy of this treatment and/or to find an associated diagnosis when symptoms persist, particularly a diurnal drowsiness, which is the main therapeutic target in obstructive sleep apnea syndrome (OSAS). The secondary effects that are likely to compromise the compliance of CPAP treatment must be resolved, particularly the nasal intolerance, which are enhanced by mask leakages and often corrected by using heated humidity with CPAP delivery systems. The efficacy of CPAP on both diurnal drowsiness and hypertension is related to the compliance of this treatment which must be regularly verified, at the same time that the clinical evaluation. The data obtained from the device's memory give information concerning the number of hours day to day, in which the CPAP device was running at the prescribed pressure. The first months with CPAP are decisive to avoid a failure of the treatment at long term. This period must be closely monitored by both the physician and the home care provider. Patients should use the CPAP at least 3-4 h by night and all possible means should be used to obtain a maximal compliance. Therapeutic educational programs could help to reach this goal.