Decisive Situations Affecting Partners’ Support to Continuous Positive Airway Pressure–Treated Patients With Obstructive Sleep Apnea Syndrome: A Critical Incident Technique Analysis of the Initial Treatment Phase

Nocturnal positive pressure ventilation improves relationship satisfaction of patients with OSA and their partners

OBJECTIVE

Continuous positive airway pressure (CPAP) ventilation is considered the therapeutic standard for obstructed sleep apnea (OSA). Therapy success may also be affected by the patient's bed partner. A questionnaire was developed and tested that measures the attitude of the bed partner towards CPAP therapy and relationship effects.

METHODS

A new questionnaire to capture bed partners' attitude towards CPAP mask therapy was used with an anonymous sample of 508 bed partners. Possible constructs underlying the attitude of the bed partner towards mask appearance have been investigated by means of a Principal Components Analysis.

RESULTS

The survey revealed bed partners' positive attitude towards their partner's CPAP therapy (over 90% of bed partners were happy with the therapy, over 75% would recommend the therapy). Importantly, the bed partners' satisfaction with the relationship increased significantly during CPAP therapy (before therapy: 49% were satisfied, after therapy initiation: 70%; p<.001). There was a strong correlation between support for CPAP therapy and improved sleep quality of bed partners (r = 0.352, p>.001). Furthermore, the validation of the questionnaire through principal components analysis revealed three major factors: Attitude (of the bed partner towards CPAP therapy), Looks (of the mask perceived by the bed partner), Intimacy (effect of CPAP therapy on relationship and intimacy).

CONCLUSION

Both, the OSA patient and the bed partner benefit from CPAP therapy. This is the first bed partner questionnaire - interviewing the bed partner alone and anonymously - that showed that CPAP therapy also positively influences the relationship. We recommend that the bed partner be involved in the CPAP treatment from the start of therapy.

"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.

Factors affecting obstructive sleep apnea patients' use of upper airway stimulation treatment

STUDY OBJECTIVES

Upper airway stimulation (UAS) is an alternative treatment for obstructive sleep apnea that must be activated nightly. Although the implanted device offsets the mask- or pressure-related side effects often associated with continuous positive airway pressure therapy, some UAS recipients do not use the therapy consistently. This study qualitatively explored factors associated with UAS usage in obstructive sleep apnea patients.

METHODS

Semistructured interviews were conducted with 24 obstructive sleep apnea patients who received UAS treatment. Twelve patients were categorized as high users with mean usage of ≥ 4 hours/night and 12 were categorized as low users with < 4 hours/night or nonuse. Interviews explored patients' experiences regarding barriers and facilitators to UAS use and their advice for new UAS recipients. Demographic and clinical data including the Insomnia Severity Index and Generalized Anxiety Disorder Scale were collected.

RESULTS

Compared to high users, low users had higher levels of insomnia (mean Insomnia Severity Index: 3.6 vs 15.2, respectively) and anxiety (mean Generalized Anxiety Disorder Scale: 3.4 vs 6.9). High users reported more positive experiences with UAS treatment, such as improvements in symptoms and convenience of treatment, as facilitators of use. Low users tended to focus on the negative aspects of treatment, particularly stimulation-related discomfort and associated sleep disturbance.

CONCLUSIONS

Insomnia with or without anxiety contributes to differing patient-reported experiences in high vs low user groups, with increased insomnia symptoms among low users. Improved understanding of the specific barrier and facilitators of UAS adherence may drive better long-term use and more personalized management strategies, including concomitant insomnia treatment.

CLINICAL TRIALS REGISTRATION

Registry: ClinicalTrials.gov; Name: Stimulation Therapy for Apnea: Reporting Thoughts (START); URL: https://clinicaltrials.gov/ct2/show/NCT04768543; Identifier: NCT04768543.

CITATION

Luyster FS, Ni Q, Lee K, et al. Factors affecting obstructive sleep apnea patients' use of upper airway stimulation treatment. J Clin Sleep Med. 2022;18(9):2207-2215.

Obstructive Sleep Apnea and Adherence to Continuous Positive Airway Pressure (CPAP) Treatment: Let's Talk about Partners!

BACKGROUND

Continuous positive airway pressure (CPAP) is the gold standard treatment for obstructive sleep apnea (OSA). The benefits of this therapy were studied and analyzed over time; patient adherence is often poor, as many factors negatively influence it. A topic that needs clarification is whether adherence to CPAP treatment in a patient with OSA is influenced by the behavior of a partner or spouse.

METHODS

A scoping review was conducted to evaluate the role of partner involvement in the CPAP treatment management in a patient with OSA. The research project was performed between August and September 2021 by consulting the main biomedical databases: CINHAL, Embase, PsycINFO, and PubMed.

RESULTS

Among 21 articles considered valid for our aim, 15 are qualitative studies, 5 are quantitative and 1 presents a mixed method. We identified several thematic areas and "key" elements, which are prevalent in the studies evaluated.

CONCLUSIONS

The presence of a partner promotes adherence to CPAP therapy in patients with OSA, resulting in ameliorating their overall quality of life. To increase CPAP adherence, a trained nurse could represent a reference figure to technically and emotionally support couples during the adaptation period and in the long term.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The relationship between attachment, treatment compliance and treatment outcomes in patients with obstructive sleep apnea

OBJECTIVE

Obstructive sleep apnea (OSA) is a common condition with numerous health and psychological consequences. While treatment with Continuous Positive Airway Pressure (CPAP) is highly effective, it seems to be impacted by interpersonal aspects of the patient. The current study explores the role of two major interpersonal descriptors (attachment and relationship satisfaction) on treatment initiation and compliance with CPAP. The benefit of CPAP treatment on sleep measures and psychological functioning is also examined.

METHODS

Participants in stable relationships, diagnosed with OSA following an inpatient polysomnography test (N = 83), were recruited. Participants were appraised on their decision to initiate treatment and completed interpersonal measures (couples' satisfaction, attachment dimensions) as well as sleep measures and mental health measures. Participants were invited to repeat the measures after 3 months (N = 31 agreed). Associations between interpersonal measures and CPAP initiation and compliance as well as the impact of CPAP on sleep and all psychological measures was assessed.

RESULTS

Individuals with high attachment anxiety pursued OSA treatment based on a mutual decision with the partner, while individuals with lower attachment anxiety made the decision themselves. Couples' satisfaction was positively associated with CPAP compliance over 3 months. CPAP compliance significantly improved sleep measures, mood and anxiety symptoms.

CONCLUSION

The study brings evidence for a positive role of interpersonal factors in the initiation and compliance with OSA treatment as well as longitudinal benefits on sleep, mood and anxiety levels. The results can inform clinical approaches meant to increase treatment engagement and adherence in OSA patients through psychoeducation.

Semistructured Motivational Interviews of Patients and Caregivers to Improve CPAP Adherence: A Qualitative Analysis

STUDY OBJECTIVES

The aim of this qualitative analysis was to identify obstructive sleep apnea (OSA) patients' preferences, partner experiences, barriers and facilitators to positive airway pressure (PAP) adherence, and to assess understanding of the educational content delivered and satisfaction with the multidimensionally structured intervention.

METHODS

A qualitative analysis was conducted on 28 interventional arm patients with a new diagnosis of OSA. They received a one-on-two semistructured motivational interview as the last part of a 60- to 90-minute in-person educational group intervention. The 10- to 15-minute interview with the patient and caregiver was patient-centered and focused on obtaining the personal and emotional history and providing support. We also assessed understanding of the OSA training plan, their commitment to it, and their goals for it.

RESULTS

We identified four themes: OSA symptom and diagnosis, using the PAP machine, perceptions about the group visit, and factors that determine adherence to PAP. Patients experienced positive, negative, or mixed emotions during the journey from symptoms of OSA to PAP adherence.

CONCLUSIONS

Our findings suggest that patients' and caregivers' positive experiences of PAP could be enhanced by a patient-centered interaction and that it was important to explicitly address their fears and concerns to further enhance use of PAP. Not only could caregiver support play a role in improving PAP adherence but also the peer coaching session has the potential of providing a socially supportive environment in motivating adherence to PAP treatment.

Impact of Obstructive Sleep Apnea and Its Treatments on Partners: A Literature Review

STUDY OBJECTIVES

Many adults sleep with a significant other; thus, sleep disorder symptoms and treatments of one partner are likely to impact the other partner's health. A literature review was conducted to examine the impact of obstructive sleep apnea (OSA) and OSA treatments on partner-assessed sleep and daytime functioning and partner involvement in OSA treatment.

METHODS

MEDLINE, EMBASE, and CINAHL searches yielded 38 pertinent quantitative and qualitative studies that described sleep and/or daytime functioning assessed in partners of patients with untreated OSA, sleep and/or daytime functioning assessed in partners who were referred for OSA treatment, including continuous positive airway pressure (CPAP) therapy, oral appliance (OA), or surgery, and/or associations between partner involvement and OSA treatment use.

RESULTS

The majority of studies found untreated OSA to have a negative impact on partners' objective and subjective sleep and daytime functioning, in particular mood, quality of life, and relationship quality. Improvements in partner-assessed sleep quality were reported for CPAP, OA, and surgery. Conflicting results were reported for partners' mood, quality of life, daytime sleepiness, and relationship quality. Perceived partner support was associated with greater CPAP use.

CONCLUSIONS

Symptoms associated with OSA can negatively impact partners' sleep and daytime functioning. Treatment of OSA with CPAP, OA, or surgery can have health benefits for not only patients but also partners. Collaborative partner involvement may be a useful strategy for interventions promoting CPAP adherence.

Patient and Partner Experiences With Obstructive Sleep Apnea and CPAP Treatment: A Qualitative Analysis

Few studies have investigated factors associated with continuous positive airway pressure (CPAP) treatment for sleep apnea from the patients' and their partners' perspective. This qualitative research study explored patients' and partners' experiences of CPAP and facilitators and barriers to CPAP use, and elicited suggestions for a first-time CPAP user program. Data from 27 participants were collected via four sleep apnea patient and four partner focus groups. Qualitative content analysis identified five themes: knowledge of sleep apnea, effects of sleep apnea, effects of CPAP, barriers and facilitators of CPAP, and ideas for a new user support program. Patients and partners emphasized the importance of partner involvement in the early CPAP treatment period. These data suggest consideration of a couple-oriented approach to improving CPAP adherence.

Spousal involvement and CPAP adherence: a dyadic perspective

Poor adherence to continuous positive airway pressure (CPAP) treatment is associated with substantial health care costs, morbidity and mortality, and has been a leading obstacle in the effective management of obstructive sleep apnea (OSA). Successful interventions to improve CPAP adherence may ultimately include a variety of components. For patients living with spouses (refers to all domestic partners), the spouse will likely be an integral component to any successful intervention. Developing understanding of the role of spouses in adherence to CPAP has been identified to be a critical research need. This review expands the investigation of CPAP adherence to a broader context, from an exclusive focus on individual patients to a dyadic perspective encompassing both patients and their spouses. A conceptual framework based on social support and social control theories is proposed to understand spousal involvement in CPAP adherence. Methodologies for future investigations are discussed, along with implications for developing interventions that engage both patients and their spouses to improve CPAP use.

Validation of the CPAP Habit Index-5: A Tool to Understand Adherence to CPAP Treatment in Patients with Obstructive Sleep Apnea

Long-term adherence to continuous positive airway pressure (CPAP) is low among patients with obstructive sleep apnea (OSA). The potential role of “habit” in sustaining adherence to CPAP use has not been studied. This study aimed to establish the relevance of habit to CPAP adherence, via validation of an adaptation of the Self-Report Habit Index (the CPAP Habit Index-5; CHI-5). Analyses focused on the homogeneity, reliability, and factor structure of the CHI-5 and, in line with theoretical predictions, its utility as a predictor of long-term CPAP adherence in middle-aged patients with OSA. A prospective longitudinal design was used. 117 patients with objectively verified OSA intended for CPAP treatment were recruited. Data was collected via clinical examinations, respiratory recordings, questionnaires, and CPAP devices at baseline, 2 weeks, 6 months, and 12 months. The CHI-5 showed satisfactory homogeneity interitem correlations (0.42–0.93), item-total correlations (0.58–0.91), and reliability (α = 0.92). CHI-5 data at 6 months showed a one-factor solution and predicted 63% of variance in total CPAP use hours after 12 months. Based on the satisfactory measurement properties and the high amount of CPAP use variance it explained, the CHI-5 can be seen as a useful tool in clinical practice.