Challenges and motivating factors related to positive airway pressure therapy for post-TIA and stroke patients

"The terrible dryness woke me up, I had some trouble breathing"-Critical situations related to oral health as described by CPAP-treated persons with obstructive sleep apnea

Continuous positive airway pressure is a common and effective treatment for obstructive sleep apnea, but adherence remains an issue. Both obstructive sleep apnea and oral diseases are associated with cardiovascular diseases, and as oral dryness contributes to treatment abandonment, oral health is of importance for this patient group. The aim was therefore to explore how persons with continuous positive airway pressure-treated obstructive sleep apnea experience situations associated with their oral health, and which actions they take to manage these. An explorative and descriptive design was adopted using the critical incident technique. Based on a purposeful selection, 18 adults with long-term experience of continuous positive airway pressure-treatment were interviewed using a semi-structured interview guide. Both negative and positive situations were described. Negative situations consisted of challenges with breathing, including mouth-breathing, choking sensations, problems with night-time and daytime oral dryness, changes in the saliva composition, and deteriorating oral health. Positive situations included experiences of reduced mouth-breathing and oral dryness. The situations were often successfully managed by mimicking daytime movements, changing sleeping position, adjusting the CPAP-device and mask, increasing oral hygiene efforts, drinking water, using a humidifier or chinstrap, or contacting their oral healthcare clinic. Long-term experience of persons with continuous positive airway pressure-treated obstructive sleep apnea regard situations and actions from everyday life. Successful management can contribute to long-term adherence and decrease negative effects on oral health. More interdisciplinary collaborations could enable identification and adequate recommendations for persons who experience negative situations during their continuous positive airway pressure treatment.

Sleep and Stroke: New Updates on Epidemiology, Pathophysiology, Assessment, and Treatment

PURPOSE OF REVIEW

This review aims to discuss the most recent data on sleep disorders and stroke, highlighting relevant findings for the practicing neurologist or health providers who encounter patients with sleep disorders and stroke.

RECENT FINDINGS

Sleep apnea and abnormal sleep duration have the strongest association with stroke risk. Possible mechanisms include non-dipping of blood pressure during sleep, hypoxemia or reoxygenation leading to sympathetic activation, hypertension, atrial fibrillation and impaired cerebral hemodynamics. Treatment studies suggest that continuous positive airway pressure (CPAP) for sleep apnea could improve primary prevention of stroke, but data is equivocal for secondary prevention. However, CPAP could improve functional outcomes after stroke.

SUMMARY

Sleep disorders present an opportunity to improve stroke risk and functional outcomes. However, new strategies are needed to determine the patients at high-risk who would most likely benefit from targeted care. Novel methods for phenotyping sleep disorders could provide personalized stroke care to improve clinical outcomes and public health strategies.

Adapting Continuous Positive Airway Pressure Therapy to Where Patients Live: A Comparative Case Study

Objectives

Continuous positive airway pressure (CPAP) therapy has been demonstrated to effectively reverse the abnormal physiology of sleep apnea and improve a variety of patient outcomes, yet helping patients adapt and adhere to CPAP has proven to be a challenging issue in the effective treatment of obstructive sleep apnea (OSA). As a home-based intervention trial, the “Sleep Apnea in Transient Ischemic Attack and Stroke: Reducing Cardiovascular Risk with Positive Airway Pressure” (“sleep tight”) study was uniquely positioned to capture and evaluate challenges faced by patients over time during their introduction to CPAP therapy. 

Methods

A comparative case study design was used to better understand the process whereby patients adapted CPAP therapy in order to fit their own personal set of circumstances. Cases were identified from patients enrolled in the “enhanced intervention” group of the sleep tight trial. 

Results

These comparative case studies illustrated how adherence to CPAP therapy is an adaptive process where personal context matters. The case studies also demonstrated how some patients overcame challenges and barriers by themselves to integrate CPAP therapy into their own lives, while others required help from study staff to overcome these barriers and some were never able to successfully adapt CPAP therapy in order to fit their personal contexts, despite study staffs’ best efforts. 

Conclusions

A major opportunity to improve CPAP adherence appears to exist in placing greater emphasis on supporting patients in adapting CPAP therapy for “where they live.” 

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.

Sleep Apnea and Stroke

Stroke is the second leading cause of death worldwide and often has devastating consequences for affected individuals in terms of chronic disability. Traditional risk factors such as age, male sex, ethnicity, hypertension, and atrial fibrillation explain 60%-80% of the risk of stroke. Obstructive sleep apnea (OSA) is highly prevalent in individuals who have had a stroke and its emerging role as a potential modifiable risk factor for stroke has been recognized in the most recent American Heart Association stroke guidelines, which recommend consideration of screening for and treatment of OSA in this regard. In this article we provide an overview of the current evidence-based knowledge related to stroke and sleep apnea. The main focus of this article is key pathophysiological mechanisms by which OSA might increase the risk for stroke. The effect of OSA on stroke outcomes and the efficacy of treatment of OSA on these outcomes is also discussed.