Night-to-night variability in CPAP use over the first three months of treatment

Atomoxetine and spironolactone combine to reduce obstructive sleep apnea severity and blood pressure in hypertensive patients

BACKGROUND

Norepinephrine reuptake inhibitors such as atomoxetine (ato) can improve OSA by increasing pharyngeal muscle activity. Mineralocorticoid antagonists such as spironolactone, may potentiate the reduction of OSA severity and reduce blood pressure. We evaluated whether adding spironolactone to atomoxetine (ato-spiro) improved responses in hypertensive OSA patients.

METHODS

Twenty-one patients with an apnea-hypopnea index (AHI) between 10 and 50 events/h and a history of hypertension were recruited and crossed-over in random order to ato 80 mg and ato-spiro 80/50 mg for 1 week after a 3-day low dose run-in period. Two dropped out due to drug related side effects. Polysomnography and 24-hour blood pressure (BP) monitoring were performed at baseline and after each treatment period.

RESULTS

AHI decreased on both ato and ato-spiro from a baseline median(IQR) of 20.3(18.8 to 28.5) to 8.2(7 to 13.1) and 6.2(5.7 to 14.1), respectively (p < 0.001 for both). Systolic BP (mmHg) fell by mean(95%CI) -4.5(-13.8 to 4.8, p = 0.33) on ato and - 10.3(-19.2 to -1.5, p = 0.02) on ato-spiro, and diastolic BP dropped by -3.0(-8.0 to 2.0, p = 0.23) on ato and - 5.0(-9.1 to -0.9; p = 0.02) on ato-spiro. Both ato and ato-spiro led to a significant shift from apnea to hypopnea predominance (p < 0.001), and significant reductions in hypoxic burden (p ≤ 0.001) and REM sleep (p ≤ 0.001).

CONCLUSIONS

Both ato-spiro and ato alone decreased OSA severity similarly, but ato-spiro led to even greater, statistically significant and clinically meaningful falls in systolic and diastolic BP. BP reductions were likely due to ato-related improvements in upper airway patency and hypoxemia, and to spiro-related reduced fluid retention. These findings show promise for ato-spiro as an oral treatment for hypertensive OSA patients. REGISTERED AT CLINICALTRIALS.GOV: NCT04905979.

Mandibular device treatment in obstructive sleep apnea -A structured therapy adjustment considering night-to-night variability night-to-night variability in mandibular devices

BACKGROUND

Mandibular advancement devices (MAD) are a well-established treatment option for obstructive sleep apnea (OSA). MAD are considered preferably for patients with mild to moderate OSA presenting with a elevated night-to-night variability (NNV). This study aimed to determine the treatment effect of MAD on NNV considering different protrusion distances and patient related outcome (PRO).

METHODS

We conducted a prospective cohort analysis of patients before MAD with 60% and 80% of the maximum protrusion. OSA severity was assessed using a home-sleep test for two consecutive nights. PRO contained the Epworth Sleepiness Scale (ESS) and sleep related quality of life (FOSQ).

RESULTS

Twenty patients with a median overweight body-mass-index of 27.1 (interquartile range (IQR) 16.3 kg/m²), with a mainly mild to moderate OSA with an apnea -hypopnea index (AHI) of 18.3 / h (IQR 17.7) and elevated ESS of 12.5 (IQR 8.0) were included. As opposed to 80%, 60% protrusion significantly but not 80% relevantly reduced AHI (60%%: 11.2 (IQR 5.5)/h, p = 0.01; 80%: 12.9 (IQR18,0)/h, p = 0.32) and improved the ESS (60%: 8.0 (IQR 10,0); 80%: 10 (IQR 9.0)), with therapy settings. No correlation could be detected between NNV and ESS, and FOSQ changes. Higher baseline NNV was associated with severe OSA (p = 0.02) but not with gender, overweight, or status post-tonsillectomy.

CONCLUSIONS

OSA improvement is associated with lower NNV; both OSA and NNV are connected to the degree of protrusion. Therefore, higher NNV does not justify the exclusion of candidates for MAD treatment. PRO changes are not visibly affected by NNV but by general OSA changes. These findings may help to define and optimize future study designs for the primary outcome decision between objective OSA parameters and PRO.

Telemedicine for long-term continuous positive airway pressure therapy: A six-month follow-up study in Japan using propensity score matching

BACKGROUND

During the coronavirus disease (COVID-19) pandemic, Japan's health insurance system allowed continuous positive airway pressure (CPAP) telephone consultations to extend clinic visit intervals. This study aimed to determine whether 6-month CPAP adherence in the telemedicine (TM) group was inferior to that in the standard care group.

METHODS

Patients receiving long-term CPAP therapy for at least 6 months for obstructive sleep apnea (OSA) from two clinics in Japan were recruited between May and July 2020. The TM group consisted of patients who had not visited the clinic in person for 6 months, with physicians providing telephone consultations every 1-2 months. The standard care group included patients who visited the clinic monthly for physician consultation. In both groups, physicians reviewed CPAP usage data via telemonitoring. Patients were classified into three groups according to change in adherence: ≤ -5%, > -5 to <5%, and ≥5%. The primary outcome was the number of patients with worsened CPAP adherence (≤-5%).

RESULTS

Of the 479 patients in the TM group and 146 in the standard care group, 120 were matched using propensity score 1:1 nearest neighbor matching and selected from both groups. Adherence worsened in 41 (34.2%) and 32 (26.7 %) patients in the TM and standard care groups, respectively. The TM group was not inferior to the standard care group in terms of the proportion of patients with worsened CPAP adherence (χ2 = 1.81, df = 1, P = 0.178).

CONCLUSIONS

This study found no significant difference in the 6-month CPAP adherence between the TM and standard care groups.

Factors Affecting CPAP Adherence in an OSA Population during the First Two Years of the COVID-19 Pandemic

Background: Obstructive sleep apnea (OSA) is a common disorder associated with major cardiovascular and neurocognitive sequelae. Continuous positive airway pressure (CPAP) is the standard treatment for OSA. The aim of this study was to investigate the prevalence and associations of long-term CPAP adherence in newly diagnosed OSA patients. Methods: We enrolled patients who were diagnosed with OSA during the COVID-19 pandemic. Adherence was defined as CPAP use ≥4 h per night on ≥70% of nights over 30 consecutive days. Patient demographics were retrieved from medical records, and CPAP adherence at 6 months and 1 year after initiation was monitored. Results: Overall, 107 patients were included in the analysis. A number of 73 (68%) and 63 (59%) patients were adherent to CPAP treatment at 6 months and 12 months accordingly. Among the factors examined and analyzed (age, gender, BMI, Apnea-Hypopnea Index (AHI)), no significant correlation was found. Further analysis revealed the potential role of comorbidities. CPAP compliance at 6 months was shown to be associated with better CPAP adherence at 12 months. Conclusions: CPAP adherence at 6 months is correlated to long-term adherence to treatment. Therefore, early close follow-up is important. Further prospective studies are needed to identify other potential predictors.

The short Thai version of functional outcomes of sleep questionnaire (FOSQ-10T): reliability and validity in patients with sleep-disordered breathing

PURPOSE

The study is to evaluate reliability and validity of the short Thai version of Functional Outcome of Sleep Questionnaire (FOSQ-10T), in patients with sleep disordered breathing (SDB).

METHODS

Inclusion criteria were Thai patients with SDB age ≥ 18 years old who had polysomnography results available. Exclusion criteria were patients unable to complete questionnaire for any reason, patients with a history of continuous antidepressant or alcohol use, and underlying disorders including unstable cardiovascular, pulmonary, or neurological conditions. All participants were asked to complete the FOSQ-10 T and Epworth sleepiness scales (ESS). Of these, 38 patients were required to retake FOSQ-10 T at 2-4 weeks later to assess test-retest reliability, and 19 OSA patients treated with CPAP were asked to do so at 4 weeks following therapy to assess questionnaire's responsiveness to treatment.

RESULTS

There were 42 participants (24 men, 18 women), with a mean age of 48.3 years. The internal consistency of the FOSQ-10T was good, as indicated by Cronbach's alpha coefficient of 0.85. The test-retest reliability was good, as indicated by intraclass correlation coefficient of 0.77. The correlation between the FOSQ-10T and ESS scores (concurrent validity) was moderate (r =  - 0.41). The scores of FOSQ-10T significantly increased after receiving adequate CPAP therapy, showing an excellent responsiveness to treatment. However, there was no significant association between FOSQ-10T scores and OSA severity measured by apnea-hypopnea index.

CONCLUSIONS

The FOSQ-10T has good reliability and validity to use as a tool to assess QOL in Thai patients with SDB. It is convenient and potentially useful in both clinical and research settings.

Telemedicine management of obstructive sleep apnea disorder in China: a randomized, controlled, non-inferiority trial

PURPOSE

Previous studies assessed different components of telemedicine management pathway for OSA instead of the whole pathway. This randomized, controlled, and non-inferiority trial aimed to assess whether telemedicine management is clinically inferior to in-person care in China.

METHODS

Adults suspected of OSA were randomized to telemedicine (web-based questionnaires, self-administered home sleep apnea test [HSAT], automatically adjusting positive airway pressure [APAP], and video-conference visits) or in-person management (paper questionnaires, in-person HSAT set-up, APAP, and face-to-face visits). Participants with an apnea-hypopnea index (AHI) ≥ 15 events/hour received APAP for 3 months. The non-inferiority analysis was based on the change in Functional Outcomes of Sleep Questionnaire (FOSQ) score and APAP adherence. Cost-effectiveness analysis was performed.

RESULTS

In the modified intent-to-treat analysis set (n = 111 telemedicine, 111 in-person), FOSQ scores improved 1.73 (95% confidence interval [CI], 1.31-2.14) points with telemedicine and 2.05 (1.64-2.46) points with in-person care. The lower bound of the one-sided 95% non-inferiority CI for the difference in change between groups of - 0.812 was larger than the non-inferiority threshold of - 1. APAP adherence at 3 months was 243.3 (223.1-263.5) minutes/night for telemedicine and 241.6 (221.3-261.8) minutes/night for in-person care. The lower bound of the one-sided 95% non-inferiority CI of - 22.2 min/night was higher than the non-inferiority delta of - 45 min/night. Telemedicine had lower total costs than in-person management (CNY 1482.7 ± 377.2 vs. 1912.6 ± 681.3; p < 0.0001), driven by patient costs, but no significant difference in QALYs.

CONCLUSIONS

Functional outcomes and adherence were not clinically inferior in patients managed by a comprehensive telemedicine approach compared to those receiving in-person care in China.

CLINICAL TRIAL REGISTRATION

https://www.chictr.org.cn , Registration number ChiCTR2000030546. Retrospectively registered on March 06, 2020.

Obstructive Sleep Apnea Treatment and the Evaluation of Clinical Effectiveness of Uniquely Designed Oral Appliance Therapy Device

BACKGROUND

 Continuous positive airway pressure (CPAP) has been considered first-line therapy for patients with obstructive sleep apnea (OSA); however, adherence to the therapy is suboptimal. Oral appliance therapy (OAT) is an alternative to CPAP that may lend to better patient adherence, quality of life, and overall patients' effectiveness of therapy.

METHODS

This was a prospective, single-site, non-randomized study to evaluate the clinical effectiveness of a uniquely designed OAT device with an embedded adherence tracking chip in the treatment of mild and moderate OSA patients over three months. The effectiveness of OAT therapy was defined as the numerical product of efficacy and adherence. The efficacy of the device was defined as the change from baseline in the apnea-hypopnea index (AHI). Adherence was based on usage for a minimum of 4 hours/night of use, for at least five out of seven nights a week.

RESULTS

45 participants fitted with the OAT device completed at least one follow-up visit and had recordable objective data. Average patient wearing time was 7 hours/night and a reduction of the AHI from 16.4 events/hour to 5.7 events/hour after three months of use. Mean disease alleviation (MDA), which serves as a measure of the overall therapeutic effectiveness, was 62% when looking at 4 hours/night of usage. As the comfort of the device is related to wearing time, subjective data indicated the optimum first-time fit of the device.

CONCLUSION

The study OAT device was well tolerated throughout the study. When both efficacy and adherence are considered, OAT can be a clinically effective tool to treat OSA.

High Monocyte-to-Lymphocyte Ratio is Associated with Obstructive Sleep Apnea Hypopnea Syndrome

Objective

This study aims to explore the correlation between serum monocyte-to-lymphocyte ratio (MLR) and other inflammatory parameters with the occurrence of obstructive sleep apnea-hypopnea syndrome (OSAHS) in patients.

Methods

This study included 310 patients who underwent polysomnography monitoring at our hospital between January 2021 and January 2023. Routine blood inflammatory parameters and polysomnography (PSG) results were also evaluated. The differences in inflammatory markers between the OSAHS and normal groups were compared, and OSAHS independent related factors were screened.

Results

The MLR of OSAHS group was significantly higher than that of control group, and the difference was statistically significant. Multivariate logistic regression analysis suggested that MLR is an independent risk factor for OSAHS.

Conclusion

High MLR was correlated with OSAHS. The diagnostic value of MLR was better than that of the other inflammatory parameters.

Comparative Effectiveness of Supine Avoidance versus Continuous Positive Airway Pressure for Treating Supine-isolated Sleep Apnea: A Clinical Trial

Rationale: About 20-35% of patients with obstructive sleep apnea (OSA) have supine-isolated OSA, for which supine sleep avoidance could be an effective therapy. However, traditional supine discomfort-based methods show poor tolerance and compliance to treatment and so cannot be recommended. Supine alarm devices show promise, but evidence to support favorable adherence to treatment and effectiveness at reducing excessive daytime sleepiness compared with continuous positive airway pressure (CPAP) remains limited. Objectives: To establish if alarm-based supine-avoidance treatment in patients with supine-isolated OSA is noninferior to CPAP in reducing daytime sleepiness. Methods: After baseline questionnaire administration and in-home supine-time and polysomnography assessments, patients with supine-isolated OSA and Epworth Sleepiness Scale scores ⩾8 were randomized to ⩾6 weeks of supine-avoidance or CPAP treatment, followed by crossover to the remaining treatment with repeat assessments. Noninferiority was assessed from change in Epworth Sleepiness Scale with supine avoidance compared with CPAP using a prespecified noninferiority margin of 1.5. Average nightly treatment use over all nights and treatment efficacy and effectiveness at reducing respiratory disturbances were also compared between treatments. Results: The reduction in sleepiness score with supine avoidance (mean [95% confidence interval], -1.9 [-2.8 to -1.0]) was noninferior to that with CPAP (-2.4 [-3.3 to -1.4]) (supine avoidance-CPAP difference, -0.4 [-1.3 to 0.6]), and the lower confidence limit did not cross the noninferiority margin of 1.5 (P = 0.021). Average treatment use was higher with supine avoidance compared with CPAP (mean ± standard deviation, 5.7 ± 2.4 vs. 3.9 ± 2.7 h/night; P < 0.001). Conclusions: In patients with supine-isolated OSA, vibrotactile supine alarm device therapy is noninferior to CPAP for reducing sleepiness and shows superior treatment adherence. Clinical trial registered with www.anzctr.org.au (ACTRN 12613001242718).

A randomized controlled trial of a multi-dimensional intervention to improve CPAP use and self-efficacy

OBJECTIVES

To assess the utility of a tailored intervention program to improve continuous positive airway pressure (CPAP) use and self-efficacy in individuals with obstructive sleep apnea (OSA).

METHODS

81 participants (mean age 52.1 ± 11.6 years; 35 females) with OSA were randomized to either a multi-dimensional intervention (PSY CPAP, n = 38) or treatment as usual (TAU CPAP, n = 43). The intervention included a psychoeducation session prior to CPAP initiation, a booster psychoeducation session in the first weeks of commencing CPAP, follow-up phone calls on days 1 and 7, and a review appointment on day 14. CPAP use was compared between the PSY CPAP and TAU CPAP groups at 1 week, 1 month, and 4 months. Self-efficacy scores (risk perception, outcome expectancies, and CPAP self-efficacy) were compared between groups following the initial psychoeducation session and again at 1 month and 4 months.

RESULTS

CPAP use was higher in the PSY CPAP group compared to the TAU CPAP group for all time points (p = .02). Outcome expectancies improved significantly over time in PSY CPAP participants (p = .007). Change in risk perception was associated with CPAP use at 1 week (p = .02) for PSY CPAP participants. However, risk perception did not mediate the effect between group and CPAP use at 1 week.

CONCLUSIONS

Interventions designed to increase self-efficacy and administered prior to CPAP initiation, repeated in the early stages of CPAP therapy, and combined with a comprehensive follow-up regime are likely to improve CPAP use. Sustained improvement in CPAP use is the ultimate goal but remains to be investigated.

Improvement of sleep parameters by titration polysomnography could predict adherence to positive airway pressure therapy in obstructive sleep apnea

STUDY OBJECTIVES

Poor adherence to continuous positive airway pressure (CPAP) has been a critical issue in treating obstructive sleep apnea. Because long-term CPAP adherence may be established shortly after treatment begins, early intervention is essential. This study aimed to identify the potential factors affecting CPAP therapy adherence during diagnostic polysomnography and auto CPAP titration polysomnography.

METHODS

This retrospective observational study included 463 patients with obstructive sleep apnea who underwent consecutive diagnostic polysomnography and titration polysomnography. We recorded their demographic, anthropometric, and lifestyle factors and obtained self-reported comments regarding their sleep status following both polysomnography evaluations. CPAP adherence was evaluated following 3 months of treatment.

RESULTS

A total of 312 patients (67.4%) fulfilled the criteria for good adherence. Each patient's CPAP adherence was categorized as "poor" (< 4 hours/night or <70% of nights), "good" (≥ 4 hours/night and ≥ 70% of nights), or "excellent" (≥ 6 hours/night and ≥ 80% of nights). There were no significant differences in arterial oxyhemoglobin saturation measured by pulse oximetry and apnea-hypopnea index during diagnostic polysomnography among 3 groups. The polysomnographic evaluations indicated that patients with better adherence displayed more significant improvements in sleep parameters, including apnea-hypopnea index, sleep efficacy, sleep latency, and sleep architecture, which were correlated with an improvement in self-reported sleep quality.

CONCLUSIONS

Polysomnographic evaluations enabled CPAP adherence prediction and a comparison of self-reported sleep quality with and without CPAP; CPAP adherence led to improvements in polysomnographic parameters. Our findings suggest that titration polysomnography and self-reported sleep improvement with CPAP could be used for adherence prediction in clinical practice.

CITATION

Shirahata T, Uchida Y, Uchida T, et al. Improvement of sleep parameters by titration polysomnography could predict adherence to positive airway pressure therapy in obstructive sleep apnea. J Clin Sleep Med. 2023;19(8):1465-1473.

Beyond CPAP: modifying upper airway output for the treatment of OSA

Obstructive Sleep Apnea (OSA) is exceedingly common but often under-treated. Continuous positive airway pressure (CPAP) has long been considered the gold standard of OSA therapy. Limitations to CPAP therapy include adherence and availability. The 2021 global CPAP shortage highlighted the need to tailor patient treatments beyond CPAP alone. Common CPAP alternative approaches include positional therapy, mandibular advancement devices, and upper airway surgery. Upper airway training consists of a variety of therapies, including exercise regimens, external neuromuscular electrical stimulation, and woodwind instruments. More invasive approaches include hypoglossal nerve stimulation devices. This review will focus on the approaches for modifying upper airway muscle behavior as a therapeutic modality in OSA.

Acceptance of and adherence with long-term positive airway pressure treatment in adults with chronic obstructive pulmonary disease: A systematic review protocol

BACKGROUND

Long-term noninvasive positive airway pressure (PAP) treatment is effective treatment for sleep-related breathing disorders and chronic hypercarbic respiratory failure secondary to chronic obstructive pulmonary disease (COPD). PAP treatment may be delivered as continuous positive airway pressure or noninvasive ventilation. Success in initiating PAP treatment and barriers to its use in adult patients with COPD are largely unknown. This systematic review aims to identify the acceptance of and adherence to PAP treatment prescribed for long-term use in adult patients with COPD and to summarize variables associated with these measures.

METHODS

Seven online electronic databases will be searched by an experienced medical librarian to identify records containing the concepts "obstructive airways disease" and "noninvasive positive airway pressure" and "acceptance" or "adherence". Randomized and non-randomized studies of interventions will be included. Citation lists from relevant articles will be reviewed, and experts will be contacted regarding unpublished studies. Abstracts from key conferences between 2018-2023 and Google Scholar search results will be reviewed for inclusion. Titles, abstracts and full texts will be reviewed independently for inclusion by two reviewers. Data extraction will be completed by one author using a pre-established form and primary outcomes confirmed by a second author. Methodological quality will be evaluated. If sufficient data are available for meta-analysis, a pooled summary statistic for the primary outcome will be calculated using a random-effects generic inverse-variance meta-analysis, weighted proportion or weighted medians-based approach. Subgroup analysis will explore clinically meaningful sources of heterogeneity. Variables that are associated with acceptance and adherence will be described.

DISCUSSION

Long-term PAP treatment is a complex intervention prescribed to patients with COPD for several indications. Synthesis of the evidence on success with PAP treatment and variables associated with acceptance or adherence will inform program and policy development for supporting patients with COPD who are prescribed this therapy.

TRIAL REGISTRATION

Systematic review registration: This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on July 13, 2021 (registration number CRD42021259262), with revisions submitted on April 17, 2023.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Impact of a telerehabilitation programme combined with continuous positive airway pressure on symptoms and cardiometabolic risk factors in obstructive sleep apnea patients

Background

Obstructive sleep apnea syndrome is a common sleep-breathing disorder associated with adverse health outcomes including excessive daytime sleepiness, impaired quality of life and is well-established as a cardiovascular risk factor. Continuous positive airway pressure is the reference treatment, but its cardiovascular and metabolic benefits are still debated. Combined interventions aiming at improving patient's lifestyle behaviours are recommended in guidelines management of obstructive sleep apnea syndrome but adherence decreases over time and access to rehabilitation programmes is limited. Telerehabilitation is a promising approach to address these issues, but data are scarce on obstructive sleep apnea syndrome.

Methods

The aim of this study is to assess the potential benefits of a telerehabilitation programme implemented at continuous positive airway pressure initiation, compared to continuous positive airway pressure alone and usual care, on symptoms and cardiometabolic risk factors of obstructive sleep apnea syndrome. This study is a 6-months multicentre randomized, parallel controlled trial during which 180 obese patients with severe obstructive sleep apnea syndrome will be included. We will use a sequential hierarchical criterion for major endpoints including sleepiness, quality of life, nocturnal systolic blood pressure and inflammation biological parameters.

Discussion

m-Rehab obstructive sleep apnea syndrome is the first multicentre randomized controlled trial to examine the effectiveness of a telerehabilitation lifestyle programme in obstructive sleep apnea syndrome. We hypothesize that a telerehabilitation lifestyle intervention associated with continuous positive airway pressure for 6 months will be more efficient than continuous positive airway pressure alone on symptoms, quality of life and cardiometabolic risk profile. Main secondary outcomes include continuous positive airway pressure adherence, usability and satisfaction with the telerehabilitation platform and medico-economic evaluation.

Trial registration

Clinicaltrials.gov Identifier: NCT05049928. Registration data: 20 September 2021.

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

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

Developing OurSleepKit: A Couple-focused mHealth Tool to Support Adherence to Positive Airway Pressure Treatment

BACKGROUND AND AIM

Existing interventions promoting positive airway pressure (PAP) adherence focus only on the diagnosed individual, despite the fact that partners are often the most impacted by obstructive sleep apnea (OSA), and are delivered mostly by health professionals, with limited success. The goal of this work is to develop a prototype of OurSleepKit, a couple-focused mobile health (mHealth) tool to coach mutual engagement and promote adherence to PAP treatment.

METHODS

We used an iterative participatory approach working with future end users of OurSleepKit to support the development of this prototype. We conducted a total of 14 semi-structured in-depth open-ended dyadic interviews with OSA patients and their partners. Phase 1 of the development was to inform key functions of an engaging tool. Phase 2 focused on developing functions to engage positive conversation in the dyad and obtained feedback for this initial prototype.

RESULTS

The OurSleepKit prototype was developed and demonstrated high acceptability and engagement. Three key functions included periodic assessments based on developmental stages of PAP treatment, a Coaching Board which provides customized and dynamically updated support content - primarily brief story-telling videos featuring real-life couples' experiences - and timely tailored prompts (for action, learning, and conversation) through push notifications in the evening to facilitate positive conversation in the dyad and offer in-the-moment support for PAP use.

CONCLUSIONS

Going beyond the traditional and prevailing view of PAP use as an individual phenomenon, OurSleepKit is a novel mHealth intervention engaging both the patient and partner holding great promise to promote PAP adherence.

Hypoglossal nerve stimulator patient usage: Patterns and trends over time

Objective

Hypoglossal nerve stimulation (HNS) is an effective treatment for obstructive sleep apnea (OSA) patients intolerant of continuous positive airway pressure but is only effective if used regularly. Usage patterns have not been studied in detail. In this study, we aimed to characterize granular HNS usage patterns.

Methods

Patients implanted by a single surgeon at an academic medical center from August 2016 to January 2021 were identified from a prospective database, which was merged with the Inspire Cloud usage database. Patient, OSA, and usage characteristics were summarized, and patient- and OSA-related characteristics were associated with usage characteristics by Wilcoxon rank-sum analyses. Usage trends over time were summarized in the overall cohort and stratified by initial usage.

Results

Fifty patients were included. Median usage was 94% of nights (interquartile range [IQR]: 82%-98%) for 5.8 h per night (IQR: 4.9-6.4). Higher post-operative apnea-hypopnea index predicted fewer nights used (92% [IQR: 82%-97%] vs. 96% [IQR: 91%-99%]). No other characteristics examined were significantly associated with usage. Median hours used per night decreased from 6.80 h (IQR: 5.32-7.94) on Day 1 to 5.76 (IQR: 1.81-7.13) on Day 361. This decrease was most pronounced in the quartile with the lowest initial usage.

Conclusion

This study found that most patient and OSA characteristics were not associated with HNS usage, and that usage generally decreased over time. This decrease in usage over time was most pronounced in patients with the lowest initial usage. Further work should identify interventions to improve usage patterns to optimize clinical outcomes. Level of Evidence: 4.

Obstructive sleep apnea: personalizing CPAP alternative therapies to individual physiology

Introduction The recent continuous positive airway pressure (CPAP) crisis has highlighted the need for alternative obstructive sleep apnea (OSA) therapies. This article serves to review OSA pathophysiology and how sleep apnea mechanisms may be utilized to individualize alternative treatment options.Areas covered: The research highlighted below focuses on 1) mechanisms of OSA pathogenesis and 2) CPAP alternative therapies based on mechanism of disease. We reviewed PubMed from inception to July 2022 for relevant articles pertaining to OSA pathogenesis, sleep apnea surgery, as well as sleep apnea alternative therapies.Expert opinion: Although the field of individualized OSA treatment is still in its infancy, much has been learned about OSA traits and how they may be targeted based on a patient's physiology and preferences. While CPAP remains the gold-standard for OSA management, several novel alternatives are emerging. CPAP is a universal treatment approach for all severities of OSA. We believe that a personalized approach to OSA treatment beyond CPAP lies ahead. Additional research is needed with respect to implementation and combination of therapies longitudinally, but we are enthusiastic about the future of OSA treatment based on the data presented here.

Telemedicine compared to standard face-to-face care for CPAP treatment: real-world Australian experience

STUDY OBJECTIVES

We tested a telemedicine model of care to initiate continuous positive airway pressure (CPAP) for patients with obstructive sleep apnea (OSA) living in remote Western Australia.

METHODS

A prospective study comparing telemedicine for CPAP initiation in a remote population versus standard face-to-face CPAP initiation in a metropolitan population. The primary outcome was average nightly CPAP use in the final week of a CPAP trial.

RESULTS

A total of 186 participants were allocated to either telemedicine (n=56) or standard care (n=130). The average distance from the study centre for the telemedicine group was 979 km (±792km) compared to 19km (±14km) for the standard care group. The CPAP trial duration in the standard care group was less than the telemedicine group (37.6 vs 69.9 days, p<0.001). CPAP adherence in the telemedicine group was not inferior to standard care (Standard 4.7±0.2 hours, Telemedicine 4.7±0.3 hours, p=0.86). No differences were found between groups in residual apnea-hypopnea index, symptom response, sleep specific quality of life at the end of the trial and continued CPAP use (3 to 6 months). Participant satisfaction was high in both groups. Total health care costs of the telemedicine model were less than the standard model of care. An estimated A$4,538 per participant in travel costs was saved within the telemedicine group by reducing the need to travel to the sleep center for in-person management.

CONCLUSIONS

In remote dwelling adults starting CPAP for the treatment of OSA, outcomes using telemedicine were comparable to in-person management in a metropolitan setting.

Preferred Attributes of Care Pathways for Obstructive Sleep Apnoea from the Perspective of Diagnosed Patients and High-Risk Individuals: A Discrete Choice Experiment

BACKGROUND

The current healthcare system is challenged with a large and rising demand for obstructive sleep apnoea (OSA) services. A paradigm shift in OSA management is required to incorporate the preferences of diagnosed patients and individuals at high risk of OSA.

OBJECTIVES

This study aimed to provide empirical evidence of the values and preferences of individuals diagnosed with OSA and high-risk populations regarding distinct OSA care pathway features.

METHODS

A discrete choice experiment was undertaken in two groups: those with a formal diagnosis of OSA (n = 421) and those undiagnosed but at high risk of having OSA (n = 1033). Participants were recruited from a large cross-sectional survey in Australia. The discrete choice experiment approach used mixed-logit regression models to determine preferences relating to eight salient features of the OSA management pathway, i.e. initial assessment provider, sleep study setting, diagnosis costs, waiting times, results interpretation, treatment options, provider of ongoing care and frequency of follow-up visits.

RESULTS

The findings indicate that all eight attributes investigated were statistically significant factors for respondents. Generally, both groups preferred low diagnostic costs, fewer follow-up visits, minimum waiting time for sleep study results and sleep specialists to recommend treatment. Management of OSA in primary care was acceptable to both groups and was the most preferred option by the high-risk group for the initial assessment, sleep study testing and ongoing care provision.

CONCLUSIONS

The discrete choice experiment results offer a promising approach for systematic incorporation of patient and high-risk group preferences into the future design and delivery of care pathways for OSA management.

The impact of daytime transoral neuromuscular stimulation on upper airway physiology - A mechanistic clinical investigation

There is a need for alternatives to positive airway pressure for the treatment of obstructive sleep apnea and snoring. Improving upper airway dilator function might alleviate upper airway obstruction. We hypothesized that transoral neuromuscular stimulation would reduce upper airway collapse in concert with improvement in genioglossal muscle function. Subjects with simple snoring and mild OSA (AHI < 15/h on screening) underwent in-laboratory polysomnography with concurrent genioglossal electromyography (EMGgg) before and after 4-6 weeks of twice-daily transoral neuromuscular stimulation. Twenty patients completed the study: Sixteen males, mean ± SD age 40 ± 13 years, and BMI 26.3 ± 3.8 kg/m² . Although there was no change in non-rapid eye movement EMGgg phasic (p = 0.66) or tonic activity (p = 0.83), and no decrease in snoring or flow limitation, treatment was associated with improvements in tongue endurance, sleep quality, and sleep efficiency. In this protocol, transoral neurostimulation did not result in changes in genioglossal activity or upper airway collapse, but other beneficial effects were noted suggesting a need for additional mechanistic investigation.

Transoral awake state neuromuscular electrical stimulation therapy for mild obstructive sleep apnea

Introduction

Obstructive sleep apnea (OSA) is a common disorder with major neurocognitive and cardiovascular sequelae. The treatment of symptomatic patients with mild OSA remains controversial given that adherence to positive airway pressure (PAP) has historically been suboptimal. With this notion in mind, we assessed a daily transoral neuromuscular electrical stimulation (NMES) device for individuals with mild OSA.

Methods

The sample represents a subset of participants with a baseline AHI 5–14.9 events/hour, drawn from a parent study which also included participants with primary snoring. Outcome measures for the current study included changes in apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI) and snoring levels before and after use of the NMES. 

Results

Among 65 participants (68% men) with median age of 49 years (range 24 to 79) and median BMI of 27.7 kg/m2 (range 20 to 34), the NMES device was used daily for 6 weeks. We observed a significant improvement in the AHI from 10.2 to 6.8 events/hour among all participants and from 10.4 to 5.0 events/h among responders. Statistically significant improvements in the ESS, PSQI, objectively measured snoring, and bed partner-reported snoring were observed. Adherence among all participants was 85%.

Discussion

This NMES device has the benefit of being a treatment modality of daytime therapy which confers a high level of tolerability and patient acceptance. It alleviates the need for an in situ device during sleep and leads to improvements in OSA severity, snoring, and subjective sleep metrics, potentially crucial in mild OSA. Further studies are needed to define which individuals may benefit most from the device across the wider spectrum of OSA severity and assess long-term therapeutic outcomes.

Trial registration

ClinicalTrials.gov Identifier: NCT03829956.

Effectiveness of Surgical Mandibular Advancement in Improving Airway Dimensions in Nongrowing Skeletal Class II Patients With Obstructive Sleep Apnea—A CBCT Study

Background:

Skeletal nongrowing class II patients with retrognathic mandible are often at risk of developing obstructive sleep apnea (OSA). This skeletal discrepancy, when severe enough, is often addressed by surgical mandibular advancement which not only achieves aesthetics, structural balance, and functional efficiency but also improves the airway function.

Objective:

The aim of the study was to evaluate the effectiveness of surgical mandibular advancement on airway dimensions, in nongrowing skeletal class II patients with mandibular retrognathism associated with OSA.

Materials and Methods:

The sample consisted of 8 patients with skeletal class II due to retrognathic mandible associated with OSA. Screening was done with functional outcomes of sleep questionnaire (FOSQ) score and confirmed with polysomnography. Pretreatment and posttreatment airway dimensions/volume were assessed and calculated on cone beam computed tomography (CBCT). Three months post surgery, oxygen saturation was recorded.

Results:

A statistically significant improvement in mean oxygen saturation level was observed from 87.62 ± 7.70 to 97.75 ± 0.46 and mean increase in airway volume was from 48.60 ± 7.17 to 69.48 ± 26.22. The smallest cross section increased from 137 ± 74.37 to 253.75 ± 76.67. Anteroposterior dimensions increased significantly from 6.17 ± 1.78 to 9.33 ± 2.07 and transversed from 24.56 ± 6.41 to 30.14 ± 3.35. FOSQ score improved from 9.37 ± 2.61 to 15.25 ± 0.88.

Conclusion:

Surgical mandibular advancement is an effective treatment option in improving airway dimensions in nongrowing skeletal class II patients with mandibular retrognathism associated with OSA.

Early objective adherence to hypoglossal nerve stimulation therapy

STUDY OBJECTIVES

To assess early adherence to therapy with hypoglossal nerve stimulation therapy.

METHODS

This is a prospective study of consecutive patients with moderate to severe obstructive sleep apnea who underwent implantation of hypoglossal nerve stimulation therapy within a single academic practice and attended a follow-up appointment after greater than 30 days of therapy use. Objective adherence data were extracted from an objective monitoring database and compared to patient characteristics.

RESULTS

The study population was 79 participants who were 29.1% female with a mean age of 58.7 ± 12.8 years old, body mass index of 28.9 ± 3.4 kg/m², and baseline apnea-hypopnea index of 33.8 ± 17.6 events/h. In the first 7 days after device activation, average use was 7.8 h/night, with 91.9% of nights with greater than 4 hours of therapy use and an average of 0.2 pauses in therapy per night. These figures remained stable after 30 days of use: 7.7 h/night, 91.0% of nights longer than 4 hours, and 0.3 pauses per night. Objective evidence of difficulty with acclimatization was associated with age less than 60 years (odds ratio 2.8, 95% confidence interval 1.1-7.1, P = .03) and a history of prior upper airway surgery (3.9, 1.2-11.9, P = .015). Insomnia was present in 31 patients and was not associated with objective evidence of difficulty tolerating therapy.

CONCLUSIONS

Early adherence to hypoglossal nerve stimulation is excellent (92.4% >4 hours on >70% of nights), suggesting that the acclimatization period is straightforward in most. Younger age and a history of prior upper airway surgery appear to be associated with an increased risk of difficulty with acclimatization.

CITATION

Huyett P. Early objective adherence to hypoglossal nerve stimulation therapy. J Clin Sleep Med. 2022;18(2):631-636.

An overview of noninvasive ventilation in cystic fibrosis

Noninvasive ventilation (NIV) use was initially reported in cystic fibrosis (CF) in 1991 as a bridge to lung transplantation, and over the decades, the use of NIV has increased in the CF population. Individuals with CF are prone to various physiologic changes as lung function worsens, and they benefit from NIV for advanced lung disease. As life expectancy in CF has been increasing due to advances such as highly effective modulator therapy, people with CF may also benefit from NIV for other diagnosis beyond advanced lung disease. NIV can improve gas exchange, quality of sleep, exercise tolerance, and augment airway clearance in CF. CF providers can readily become comfortable with this therapeutic modality. In this review, we will summarize the physiologic basis for NIV use in CF, describe indications for initiation, and discuss how to order and monitor patients on NIV. We will discuss aspects unique to people with CF and the use of NIV, as well as suggestions on how to reduce risks such as infection. We hope that this serves as a resource for CF providers, in particular those who do not have dedicated training in sleep medicine as we all continue to care for the CF patient population.

Longitudinal Analysis Evaluating Self-Reported CPAP Use for OSA during the COVID-19 Pandemic

Continuous positive airway pressure therapy (CPAP) is a highly effective treatment for obstructive sleep apnea (OSA), but CPAP adherence remains suboptimal. The COVID-19 pandemic significantly altered sleep medicine services and aspects of daily living for sleep medicine patients, which may further compromise CPAP adherence. Sleep medicine patients were distributed an online survey at baseline and six months later (January–May 2021). Participants answered questions regarding CPAP use (any changes in CPAP use, sleep quality with CPAP use, CPAP use as advised, and changes in daily habits). Eighty-one adults completed the baseline survey, and 54 adults completed the follow-up survey. Twenty-seven participants reported a diagnosis of OSA and were prescribed CPAP (mean age 58 ± 18.2 years, 48% female, 67% Caucasian). Longitudinal analysis with chi-square association testing showed significant changes in CPAP use as advised and significant improvements in sleep quality with CPAP use when comparing the baseline to six-month follow-up survey. Additionally, logistic regression was performed to determine if pre-pandemic sleep study results (apnea-hypopnea index and respiratory disturbance index) predicted self-reported CPAP use during the pandemic, though no association was found. Throughout the pandemic, sleep medicine patients improved their CPAP use as advised and reported significant improvements in sleep quality with CPAP use.

Elevated serum matrix metalloproteinase-2 levels in heart failure patients with reduced ejection fraction and Cheyne-Stokes respiration

STUDY OBJECTIVES

Cheyne-Stokes respiration (CSR), a kind of central sleep apnea (CSA), is referred to as a poor prognostic factor in heart failure patients with reduced ejection fraction (HFrEF). Matrix metalloproteinase (MMP) and B-type natriuretic peptide (BNP) play important roles in HFrEF patients and are markers of poor prognosis. However, there is no literature mentioning the changes in MMP and BNP in HFrEF patients with CSR.

METHODS

From June 2018 to June 2019, 41 adult patients with stable heart failure and left ventricular ejection fraction (LVEF) <50% were enrolled from the cardiology clinic. After history taking and medication review to exclude possible central nervous system or medication related CSA, an overnight polysomnography study was performed, and CSR was identified. The morning serum MMP-2, MMP-9 and BNP levels were determined using enzyme-linked immunosorbent assay and fluorescence immunoassay techniques. A positive airway pressure (PAP) device was applied to 7 patients for 3 months.

RESULTS

The serum MMP-2 and BNP levels were significantly higher in HFrEF patients with CSR than in patients without CSR. In addition, elevated serum MMP-2 levels correlated well with the severity of sleep apnea and intermittent hypoxia, which were represented as the apnea-hypopnea index and the oxygen-desaturation index. No positive correlation was found between those markers and LVEF. Finally, the treatment of sleep apnea with CPAP for 3 months tended to reduce the elevated serum MMP-2 levels.

CONCLUSIONS

Higher serum MMP-2 and BNP levels were found in HFrEF patients with CSR. Elevated MMP-2 levels were correlated with the severity of sleep apnea and intermittent hypoxia.

Effects of TORS-OSA Surgery on Lower Urinary Tract Symptoms, Overactive Bladder Symptoms, and Nocturia in Male Patients with Obstructive Sleep Apnea/Hypopnea Syndrome

OBJECTIVE

To determine the presence of lower urinary tract symptoms (LUTS), and overactive bladder (OAB) symptoms in men with obstructive sleep apnea/hypopnea syndrome (OSA) and the effects of transoral robotic surgery (TORS) for the treatment of OSA on these conditions.

MATERIALS AND METHODS

One hundred twenty-three patients with a diagnosis of OSA were prospectively enrolled. The evaluations of LUTS and OAB symptoms were based on self-administered questionnaires containing international prostate symptom score (IPSS) and OAB symptom score (OABSS), respectively. Men with an OABSS urgency score of ≥2 and sum score of ≥3 were considered to have OAB. The therapeutic outcomes were assessed at baseline, and 12 weeks after TORS-OSA Surgery.

RESULTS

There were significant differences in IPSS, and OABSS according to OSA severity. After TORS-OSA surgery, significant improvements on OSA severity, daytime quality of life (QoL) and nighttime sleep quality were observed. TORS-OSA surgery was also associated with a statistically significant improvement of LUTS, LUTS QoL score, and OAB symptoms (IPSS 22.1% decrease; IPSS QoL score 21.1% decrease; OABSS17.4% decrease) at post-operative 3 months' follow-up. The presence of OAB, and severe nocturia was significantly reduced from 22.8% to 11.4% (p=0.001), 5.7% to 0.8% (p=0.031) after TORS-OSA surgery. There were no patients who had acute airway compromise or massive bleeding peri- or post-operatively.

CONCLUSION

TORS upper airway surgery could improve LUTS and OAB symptoms on male patients with OSA in addition to improvement of major parameters of sleep study and sleep-related QoL.

A multidisciplinary perspective on the complex interactions between sleep, circadian, and metabolic disruption in cancer patients

Sleep is a basic need that is frequently set aside in modern societies. This leads to profound but complex physiological maladaptations in the body commonly referred to as circadian disruption, which recently has been characterized as a carcinogenic factor and reason for poor treatment outcomes, shortened survival, and reduced quality of life in cancer patients. As sleep and circadian physiology in cancer patients spans several disciplines including nursing science, neurology, oncology, molecular biology and medical technology, there is a lack of comprehensive and integrated approaches to deal with this serious and growing issue and at best a fractionated understanding of only part of the problem among researchers within each of these segments. Here, we take a multidisciplinary approach to comprehensively review the diagnosis and impact of sleep and circadian disruption in cancer patients. We discuss recent discoveries on molecular regulation of the circadian clock in healthy and malignant cells, the neurological and endocrine pathways controlling sleep and circadian rhythmicity, and their inputs to and outputs from the organism. The benefits and drawbacks of the various technologies, devices, and instruments used to assess sleep and circadian function, as well as the known consequences of sleep disruption and how sleep can be corrected in cancer patients, will be analyzed. We will throughout the review highlight the extensive crosstalk between sleep, circadian rhythms, and metabolic pathways involved in malignancy and identify current knowledge gaps and barriers for addressing the issue of sleep and circadian disruption in cancer patients. By addressing these issues, we hope to provide a foundation for further research as well as better and more effective care for the patients in the future.

Dose response relationship between positive airway pressure therapy and excessive daytime sleepiness: the HomePAP study

STUDY OBJECTIVES

Clinical benefits of PAP therapy for OSA are assumed to require adherent PAP usage, as defined by CMS as ≥ 4 hours of use ≥ 70% of nights. However, this is based on early data and does not necessarily capture improvements at subthreshold adherence. We explored dose-response relationships between PAP adherence measures and EDS from the HomePAP RCT.

METHODS

Participants ≥18 years with apnea hypopnea index ≥ 15 and baseline sleepiness (Epworth Sleepiness Scale (ESS) ≥ 12) received PAP therapy. Data were collected at baseline, 1-month, and 3-months follow-up. Regression models and receiver operating characteristic curves evaluated PAP measures as predictors of ESS change and normalization (ESS < 10).

RESULTS

In 119 participants (age 49.4 ± 12.6 years, 66.4% male, 72.3% white), > 50% were PAP non-adherent per CMS criteria at 3 months. Percent of nights with PAP use ≥ 4 hours predicted ESS change (p = 0.023), but not when controlling for AHI. Percent of nights with ≥ 4 hours and average PAP use provided the best discrimination for predicting ESS normalization; each 10% increase in PAP use ≥ 4 hours increased the odds of ESS normalization by 22% (p = 0.007); those using PAP ≥ 4 hours had nearly 3-fold greater odds of ESS normalization (p = 0.025). At least 4 hours and 70% of nights provided the best balance between specificity (0.50) and sensitivity (0.73).

CONCLUSIONS

Although sub-adherent PAP usage may still confer some benefit for OSA patients, adherence to current criteria confers the highest likelihood for ESS change and normalization.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: Portable Monitoring for Diagnosis and Management of Sleep Apnea (HomePAP); Identifier: NCT00642486; URL: http://clinicaltrials.gov/show/NCT00642486.

A latent-class heteroskedastic hurdle trajectory model: patterns of adherence in obstructive sleep apnea patients on CPAP therapy

BACKGROUND

Sleep apnea patients on CPAP therapy exhibit differences in how they adhere to the therapy. Previous studies have demonstrated the benefit of describing adherence in terms of discernible longitudinal patterns. However, these analyses have been done on a limited number of patients, and did not properly represent the temporal characteristics and heterogeneity of adherence.

METHODS

We illustrate the potential of identifying patterns of adherence with a latent-class heteroskedastic hurdle trajectory approach using generalized additive modeling. The model represents the adherence trajectories on three aspects over time: the daily hurdle of using the therapy, the daily time spent on therapy, and the day-to-day variability. The combination of these three characteristics has not been studied before.

RESULTS

Applying the proposed model to a dataset of 10,000 patients in their first three months of therapy resulted in nine adherence groups, among which 49% of patients exhibited a change in adherence over time. The identified group trajectories revealed a non-linear association between the change in the daily hurdle of using the therapy, and the average time on therapy. The largest difference between groups was observed in the patient motivation score. The adherence patterns were also associated with different levels of high residual AHI, and day-to-day variability in leakage.

CONCLUSION

The inclusion of the hurdle model and the heteroskedastic model into the mixture model enabled the discovery of additional adherence patterns, and a more descriptive representation of patient behavior over time. Therapy adherence was mostly affected by a lack of attempts over time, suggesting that encouraging these patients to attempt therapy on a daily basis, irrespective of the number of hours used, could drive adherence. We believe the methodology is applicable to other domains of therapy or medication adherence.

Influence of apnea vs hypopnea predominance in predicting mean therapeutic positive airway pressures among patients with obstructive sleep apnea

STUDY OBJECTIVES

Lower therapeutic positive airway pressure (PAP) levels are associated with improved response to non-PAP therapies in the treatment of obstructive sleep apnea. The aim of this study was to evaluate the prevailing notion that patients with apnea-predominant obstructive sleep apnea require higher therapeutic PAP levels compared to patients with hypopnea-predominant obstructive sleep apnea.

METHODS

An institutional review board-approved retrospective review was performed using strict inclusion criteria: presence of type I or III sleep study, apnea-hypopnea index > 10 events/h, and adherence to auto-adjusting continuous positive airway pressure. Patients were stratified by apnea (> 50% apneas) or hypopnea (≤ 50% apneas) predominance, and PAP data were compared. Statistical analyses were performed using Student's t test and linear regression modeling.

RESULTS

Between January 1, 2018 and January 1, 2020, 500 patients met inclusion criteria. Two hundred twenty-one (44.1%) patients were apnea-predominant and 279 (55.8%) were hypopnea-predominant. Apnea-predominant patients had a slightly greater mean PAP (9.01 vs 8.36, P = .002) than hypopnea-predominant patients. Univariable and multivariable linear regression of 7 variables (obstructive apnea percentage, age, sex, body mass index, apnea-hypopnea index, O₂ nadir, mask type) showed obstructive apnea percentage was the weakest predictor of therapeutic PAP levels.

CONCLUSIONS

Apnea-predominant individuals demonstrated a clinically insignificant difference in PAP level compared to hypopnea-predominant individuals; moreover, obstructive apnea percentage was not a strong predictor of therapeutic PAP levels. Of the modeled variables, the strongest predictor of PAP level was apnea-hypopnea index. Further studies are needed to explore these relationships as well as additional variables that may contribute to predicting therapeutic PAP levels.

CITATION

Yu JL, Liu Y, Tangutur A, et al. Influence of apnea vs hypopnea predominance in predicting mean therapeutic positive airway pressures among patients with obstructive sleep apnea. J Clin Sleep Med. 2021;17(11):2171-2178.

A Method for Identifying Ground Truth Labels in Regression Problems using Annotator Precision

We propose a novel method for deriving ground truth labels for regression problems that considers the precision of annotators separately for each label. This method ensures that higher performing annotators contribute more to the final landmark position which is in contrast to conventional methods that assume all annotators are equally accurate in completing the set task. In addition to describing the novel method, a set of preliminary experimental results is also provided, comparing the performance of the precision method to that of the global mean.

Short-Term Effects of a Multidisciplinary Residential Rehabilitation Program on Perceived Risks, Confidence Toward Continuous Positive Airway Pressure Treatment, and Self-Efficacy in a Sample of Individuals Affected by Obstructive Sleep Apnea Syndrome

Continuous positive airway pressure (CPAP) therapy is the standard treatment for obstructive sleep apnea (OSA) syndrome. However, optimizing adherence to CPAP therapy of individuals remains very challenging for clinicians because of the role played by the psychological components. In this study, we verified the changes in cognitions and beliefs of individuals after a four-week multidisciplinary residential rehabilitation program targeting the adaptation to CPAP therapy for OSA syndrome. We assessed the components of perceived risks, confidence toward the treatment, and self-efficacy through the self-report questionnaire, namely the Self-Efficacy Measure for Sleep Apnea (SEMSA) questionnaire. We also explored the role played by the temperamental traits on the changes registered in these components after the treatment. Forty-five participants completed the rehabilitation program, showing a higher level of adherence to the treatment. Significant changes were observed in terms of confidence toward the treatment, although no change was reported in terms of perceived risks and self-efficacy. Moreover, those individuals with a higher persistent temperamental trait reported a significant improvement in perceived risks, in the absence of other significant results. After the rehabilitation treatment, our participants were more prone to consider the effect of CPAP treatment on health outcomes. This was in line with the educational aim of the rehabilitation treatment. The temperament seemed to play only a marginal role in the global changes reported by our participants. We discussed the need for behavioral interventions, in addition to education, in improving self-efficacy.

The Importance of Mask Selection on Continuous Positive Airway Pressure Outcomes for Obstructive Sleep Apnea. An Official American Thoracic Society Workshop Report

Continuous positive airway pressure (CPAP) remains the major treatment option for obstructive sleep apnea (OSA). The American Thoracic Society organized a workshop to discuss the importance of mask selection for OSA treatment with CPAP. In this workshop report, we summarize available evidence about the breathing route during nasal and oronasal CPAP and the importance of nasal symptoms for CPAP outcomes. We explore the mechanisms of air leaks during CPAP treatment and possible alternatives for leak control. The impact of nasal and oronasal CPAP on adherence, residual apnea-hypopnea index, unintentional leaks, and pressure requirements are also compared. Finally, recommendations for patient and partner involvement in mask selection are presented, and future directions to promote personalized mask selection are discussed.

Predictors of weight loss in obese patients with obstructive sleep apnea

PURPOSE

Consistent predictors of weight loss outcomes with very low-energy diets (VLEDs) in obstructive sleep apnea (OSA) have not been identified. This study aimed to identify variables predictive of weight loss success in obese patients with OSA undertaking an intensive weight loss programme.

METHODS

We analysed biological, psychological, and behavioural variables as potential predictors of weight loss in obese patients with OSA after a 2-month VLED followed by one of two 10-month weight loss maintenance diets. Actigraphy, in-lab polysomnography, urinary catecholamines, and various psychological and behavioural variables were measured at baseline, 2, and 12 months. Spearman's correlations analysed baseline variables with 2-month weight loss, and 2-month variables with 2-12 month-weight change.

RESULTS

Forty-two patients completed the VLED and thirty-eight completed the maintenance diets. Actigraphy data revealed that late bedtime (r_s =  - 0.45, p =  < 0.01) was correlated with 2-month weight loss. The change in the time that participants got out of bed (rise-time) from baseline to two months was also correlated with 2-month weight loss (r_s = 0.36, p = 0.03). The Impact of Weight on Quality of Life-Lite questionnaire (IWQOL) Public Distress domain (r_s =  - 0.54, p =  < 0.01) and total (r_s =  - 0.38, p = 0.02) scores were correlated with weight loss maintenance from 2 to 12 months.

CONCLUSIONS

Results from this small patient sample reveal correlations between actigraphy characteristics and weight loss in obese patients with OSA. We suggest the IWQOL may also be a useful clinical tool to identify OSA patients at risk of weight regain after initial weight loss.

CLINICAL TRIAL REGISTRATION

This clinical trial was prospectively registered on 18/02/2013 with the Australia and New Zealand Clinical Trials Registry (ACTRN12613000191796).

PUBLIC REGISTRY TITLE

Sleep, Lifestyle, Energy, Eating, Exercise Program for the management of sleep apnea patients indicated for weight loss treatment: A randomised, controlled pilot study. URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363680.

Telemedicine in Sleep-Disordered Breathing: Expanding the Horizons

Interest in telemedicine has increased exponentially. There is a growing body of published evidence on the use of telemedicine for patients using continuous positive airway pressure. Telemedicine-ready devices can support the transmission on use time, apnea-hypopnea index, and leakage. This approach enables early activation of troubleshooting. Automated, personalized feedback for patients and patient access to their own data provide unprecedented opportunities for integrating comanagement approaches, multiactor interactions, and patient empowerment. Telemedicine is likely cost effective, but requires better evidence. Notwithstanding barriers for implementation that remain, telemedicine has to be embraced, leaving the physician and patient to accept it or not.

Racial disparities in positive airway pressure therapy adherence among veterans with obstructive sleep apnea

STUDY OBJECTIVES

Black individuals are disproportionately affected by diabetes, cardiovascular disease, obesity, and OSA. Adherence to PAP therapy has been reported to be lower among black individuals. This study seeks to examine associations between black race and PAP adherence among veterans with OSA.

METHODS

This was a retrospective study. Veterans newly diagnosed with OSA at a single Department of Veterans Affairs sleep center who were prescribed a modem-enabled PAP device between January 2015 and November 2017 were enrolled. PAP adherence was defined as ≥ 4 hours nightly usage for at least 70% of nights measured at 30 days from PAP setup. We examined the relationship between race and adherence, controlling for sex, marital status, age, socioeconomic status, residual apnea-hypopnea index), and mask leak.

RESULTS

Of 3013 patients identified with OSA, 2571 (85%) were newly started on PAP therapy (95% male, aged 59 years ± 14 years, 45% married, 8% with neighborhood socioeconomic disadvantage). Twenty-five percent of participants were black, and 57% were white. PAP adherence at 30 days was 50% overall (42% among blacks, 53% among nonblacks). Black race was associated with reduced 30-day PAP adherence in unadjusted (P < .001) and adjusted logistic regression models (odds ratio = 0.64; 95% CI, 0.53 - 0.78; P < .001).

CONCLUSIONS

Among veterans with OSA, black race was associated with reduced PAP adherence. These findings suggest health inequality among black individuals in the treatment of OSA.

Multimodality assessment of sleep outcomes in people living with HIV performed using validated sleep questionnaires

Studies conducted in people living with HIV (PLHIV) report high rates of sleep disturbance, without a clear explanation as to cause or effect. Therefore, we proposed use of multiple validated questionnaires that would allow a more comprehensive evaluation of sleep quality in PLHIV. We administered eight validated sleep and wellbeing questionnaires, recording different aspects of sleep in order to provide a comprehensive description of sleep quality, quantity, daytime functioning, wakefulness, and general wellbeing. Associations with demographics and clinical data were analyzed by univariable/multivariable analyses. Of 254 subjects 99% were male (98% men who have sex with men), 88% white, mean age 41 (SD ± 9.9) years, HIV duration eight years (SD ± 6.3), 94% were on antiretroviral therapy, mean CD4 cell count was 724 cells/mm³, 81% had HIV RNA<40 copies/ml, 72% were university educated, and 60% used 'chemsex' drugs. Almost half (45%) reported poor sleep quality, 22% insomnia, 21% daytime sleepiness, and 33% fatigue. As individual factors, HIV duration ≥10 years, anxiety, depression, and recreational drug use were associated with poor quality sleep, fatigue, and poorer functional outcomes (p ≤ 0.05). The prevalence of sleep disturbance was high in our cohort of PLHIV. Sleep disturbance was associated with longer duration of HIV infection, depression, anxiety, and recreational drug use.

Video Consultation as an Adequate Alternative to Face-to-Face Consultation in Continuous Positive Airway Pressure Use for Newly Diagnosed Patients With Obstructive Sleep Apnea: Randomized Controlled Trial

Background

The effectiveness of continuous positive airway pressure (CPAP) is dependent on the degree of use, so adherence is essential. Cognitive components (eg, self-efficacy) and support during treatment have been found to be important in CPAP use. Video consultation may be useful to support patients during treatment. So far, video consultation has rarely been evaluated in thorough controlled research, with only a limited number of outcomes assessed.

Objective

The aim of the study was to evaluate the superiority of video consultation over face-to-face consultation for patients with obstructive sleep apnea (OSA) on CPAP use (minutes per night), adherence, self-efficacy, risk outcomes, outcome expectancies, expectations and experiences with video consultation, and satisfaction of patients and nurses.

Methods

A randomized controlled trial was conducted with an intervention (video consultation) and a usual care group (face-to-face consultation). Patients with confirmed OSA (apnea-hypopnea index >15), requiring CPAP treatment, no history of CPAP treatment, having access to a tablet or smartphone, and proficient in the Dutch language were recruited from a large teaching hospital. CPAP use was monitored remotely, with short-term (weeks 1 to 4) and long-term (week 4, week 12, and week 24) assessments. Questionnaires were completed at baseline and after 4 weeks on self-efficacy, risk perception, outcome expectancies (Self-Efficacy Measure for Sleep Apnea), expectations and experiences with video consultation (covering constructs of the unified theory of acceptance and use of technology), and satisfaction. Nurse satisfaction was evaluated using questionnaires.

Results

A total of 140 patients were randomized (1:1 allocation). The use of video consultation for OSA patients does not lead to superior results on CPAP use and adherence compared with face-to-face consultation. A significant difference in change over time was found between groups for short-term (P-interaction=.008) but not long-term (P-interaction=.68) CPAP use. CPAP use decreased in the long term (P=.008), but no significant difference was found between groups (P=.09). Change over time for adherence was not significantly different in the short term (P-interaction=.17) or long term (P-interaction=.51). A relation was found between CPAP use and self-efficacy (P=.001), regardless of the intervention arm (P=.25). No significant difference between groups was found for outcome expectancies (P=.64), self-efficacy (P=.41), and risk perception (P=.30). The experiences were positive, and 95% (60/63) intended to keep using video consultation. Patients in both groups rated the consultations on average with an 8.4. Overall, nurses (n=3) were satisfied with the video consultation system.

Conclusions

Support of OSA patients with video consultation does not lead to superior results on CPAP use and adherence compared with face-to-face consultation. The findings of this research suggest that self-efficacy is an important factor in improving CPAP use and that video consultation may be a feasible way to support patients starting CPAP. Future research should focus on blended care approaches in which self-efficacy receives greater emphasis.

Trial Registration

Clinicaltrials.gov NCT04563169; https://clinicaltrials.gov/show/NCT04563169

Daytime Neuromuscular Electrical Therapy of Tongue Muscles in Improving Snoring in Individuals with Primary Snoring and Mild Obstructive Sleep Apnea

Study Objectives: Evaluating daytime neuromuscular electrical training (NMES) of tongue muscles in individuals with Primary Snoring and Mild Obstructive Sleep Apnea (OSA). Methods: A multicenter prospective study was undertaken in patients with primary snoring and mild sleep apnea where daytime NMES (eXciteOSA^® Signifier Medical Technologies Ltd., London W6 0LG, UK) was used for 20 min once daily for 6 weeks. Change in percentage time spent snoring was analyzed using a two-night sleep study before and after therapy. Participants and their bed partners completed sleep quality questionnaires: Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI), and the bed partners reported on the nighttime snoring using a Visual Analogue Scale (VAS). Results: Of 125 patients recruited, 115 patients completed the trial. Ninety percent of the study population had some reduction in objective snoring with the mean reduction in the study population of 41% (p < 0.001). Bed partner-reported snoring reduced significantly by 39% (p < 0.001). ESS and total PSQI scores reduced significantly (p < 0.001) as well as bed partner PSQI (p = 0.017). No serious adverse events were reported. Conclusions: Daytime NMES (eXciteOSA^®) is demonstrated to be effective at reducing objective and subjective snoring. It is associated with effective improvement in patient and bed partner sleep quality and patient daytime somnolence. Both objective and subjective measures demonstrated a consistent improvement. Daytime NMES was well tolerated and had minimal transient side effects.

Adherence with positive airway pressure therapy for obstructive sleep apnea in developing vs. developed countries: a big data study

STUDY OBJECTIVES

Minimal focus has been placed on variations in health care delivery for obstructive sleep apnea (OSA). This study compared positive airway pressure usage in developing countries (Brazil and Mexico) vs. a developed country (United States) and investigated the impact of a patient engagement tool (myAir; ResMed, San Diego, CA) on adherence.

METHODS

Deidentified data from the AirView database (ResMed) for patients receiving positive airway pressure therapy with wirelessly connected Air10 (AirSense and AirCurve) devices in Brazil, Mexico, and the United States were analyzed. Adherence was defined using US Center for Medicare and Medicaid Services (CMS) criteria (usage ≥ 4 h/night on ≥ 70% of nights in the first 90 days).

RESULTS

The analysis included 4,181,490 patients (Brazil: 31,672; Mexico 16,934; United States: 4,132,884). CMS adherence over 90 days was slightly lower in Latin America vs. the United States (Brazil: 71.7%; Mexico: 66.4%; United States: 74.0%). Significantly fewer patients were using the patient engagement tool in Brazil (8.1%) and Mexico (2.8%) vs. the United States (26%; both P < .001). Patients registered to use an engagement tool had a higher rate of CMS adherence and were twice as likely to achieve CMS adherence. Average daily usage and days with usage > 4 hours in the first week were the strongest predictors of CMS adherence. Across all countries, > 80% of patients meeting CMS criteria at 3 months were still using positive airway pressure therapy at 1 year, with 1-year adherences rates of > 75%.

CONCLUSIONS

Short-term and long-term positive airway pressure adherence rates in Brazil and Mexico were similar to those achieved in the United States. Patients who registered to use an engagement tool consistently had better adherence than those who did not.