Impact of Mask Type on the Effectiveness of and Adherence to Unattended Home-Based CPAP Titration

Performance of the NOSE Questionnaire in Mask Selection for Home CPAP Titration

Introduction  Many patients abandon CPAP treatment because they find the mask uncomfortable. Therefore, specialists may benefit from the predictive value of airway assessment tools. Objective  To identify nasal ventilation failure through the Nasal Obstruction Symptom Evaluation (NOSE) scale in patients with obstructive sleep apnea (OSA) who undergo home-based auto-adjusting CPAP titration and to determine whether there is a correlation between NOSE score and the type of mask selected. Materials and Methods  In this prospective correlational study, the NOSE scale was used in terms of mask selection and titration indicators. Patients were classified based on their NOSE score: > or < 50. Results  We included 303 patients; 226 men (74.5%), BMI: 33.2 ± 6.1 kg/m 2 , neck circumference (cm): 42.8 ± 3.6 and Epworth (ESS) score: 9.2 ± 5.6, mild OSA: 12 (3.9%), moderate OSA: 127 (41.9%), and severe OSA: 164 (54.1%). The mean NOSE score was 24.3 ± 22.8 and 42 patients (13.8%) had NOSE scores > 50. Indicators for both groups were: compliance (5.9 ± 1.3 vs. 5.8 ± 1.4 hours) p: 0.41, therapeutic pressure (9.1 ± 2.0 vs. 8.8 ± 1.6 cm of H 2 O) p: 0.23, residual AHI (2.3 ± 1.8 vs. 2.8 ± 2.6 events/hour) p: 0.25, and leaks (20.5 ± 10.6 vs. 21.3 ± 10.7 liters/minute) p: 0.64. According to adjusted multiple regression, a NOSE of > 50 was not a predictor of mask selection. Conclusions  A > 50 NOSE score was not a predictor of mask selection, and it was not correlated to titration performance.

Nasal pillow vs. standard nasal mask for treatment of OSA: a systematic review and meta-analysis

PURPOSE

The purpose of this study was to compare the effectiveness of nasal pillows with standard nasal masks in the treatment of patients with obstructive sleep apnea (OSA).

METHODS

A digitalized search was carried out in four different databases including PubMed, Scopus, EMBASE, and CENTRAL using relevant keywords along with a manual search in relevant journals. All comparative studies comparing outcomes of using a nasal pillow with the use of standard nasal masks for continuous positive airway pressure (CPAP) treatment in patients with OSA were included. The qualitative analysis was carried out by tabulating the demographic data. The quantitative data were subjected to meta-analysis. The quality of comparative studies (both retrospective and prospective cohorts) was evaluated using New-castle Ottawa scale (NOS).

RESULTS

A total of 14 studies (eight prospective and six retrospective) were included in the review. Of them, five studies were randomized and were of cross-over study design. No significant differences were observed in achieved CPAP and residual apnea-hypopnea index (AHI) levels between the nasal pillow and nasal mask with SMD - 0.05 95% CI [- 0.18, 0.09], p = 0.50 and SMD - 0.13 95% CI [- 0.28, 0.03], p = 0.12, respectively. However, nasal pillow usage was associated with better CPAP adherence with a difference of only + 0.29 min/night as compared to a standard nasal mask, with SMD 0.29 95% CI [0.07, 0.50], p = 0.009.

CONCLUSION

Nasal pillow and standard nasal mask were equally effective in terms of residual AHI level and achieved similar therapeutic CPAP pressures. However, the difference in CPAP adherence between groups, though statistically significant, is of questionable clinical significance.

Development and initial validation of a questionnaire to measure patient experience with oral appliance therapy

STUDY OBJECTIVES

To develop and validate a questionnaire to measure patient experience with oral appliance therapy.

METHODS

The AMEE Guide No. 87 was followed in the development and validation of a patient questionnaire to assess patient experience with oral appliance therapy.

RESULTS

Our search identified 522 articles; 5 of these articles described the use and/or validation of questionnaires to measure changes in symptoms and patient-reported outcomes in the treatment of obstructive sleep apnea. A total of 27 questions were developed. Five patients participated in pilot testing. A final review of the questionnaire was conducted by an expert panel.

CONCLUSIONS

The creation and validation of a questionnaire to assess patient experience with oral appliance therapy may provide new methods for advancing research in the field of dental sleep medicine.

CITATION

Ng ET, Perez-Garcia A, Lagravère-Vich MO. Development and initial validation of a questionnaire to measure patient experience with oral appliance therapy. J Clin Sleep Med. 2023;19(8):1437-1445.

In search of a better CPAP interface: A network meta-analysis comparing nasal masks, nasal pillows and oronasal masks

Until now, no study has directly network meta-analysed the impact of nasal masks, nasal pillows and oronasal masks on continuous positive airway pressure therapy in patients with obstructive sleep apnea. This study aimed to meta-analyse the impact of three kinds of nasal interfaces with both network meta-analysis and pairwise comparison. PubMed, EMBASE, CENTRAL and ClinicalTrials.gov were systematically searched from inception to December 2020 for studies that compared the three types of nasal interfaces for treating obstructive sleep apnea with continuous positive airway pressure. The outcomes were residual apnea-hypopnea index, continuous positive airway pressure, and nightly average usage. The network meta-analysis was conducted using multivariate random-effects in a frequentist framework where three interfaces were ranked with the surface under the cumulative ranking probabilities. The pairwise comparison was conducted using random-effects meta-analysis. Twenty-nine articles comprising 6378 participants were included. The pairwise comparison showed both nasal masks and nasal pillows were associated with lower residual apnea-hypopnea index, lower continuous positive airway pressure, and higher continuous positive airway pressure adherence compared with oronasal masks. The surface under the cumulative ranking confirmed that nasal masks were associated with the lowest residual apnea-hypopnea index and highest adherence, while pillows were associated with the lowest continuous positive airway pressure. The meta-regression identified that lower pretreatment apnea-hypopnea index and continuous positive airway pressure determined during continuous positive airway pressure titration (versus determined during continuous positive airway pressure therapy) was associated with lower continuous positive airway pressure with nasal masks and nasal pillows. In conclusion, compared with oronasal masks, nasal masks and nasal pillows are better interfaces, especially in patients with lower pretreatment apnea-hypopnea index and those with the therapeutic pressure determined during continuous positive airway pressure titration.

Analysis of risk factors for air leakage in auto-titrating positive airway pressure users: a single-center study

STUDY OBJECTIVES

Because air leakage from masks is known as a common cause of low adherence to continuous positive airway pressure therapy, we analyzed the risk factors for air leakage related to parameters associated with auto-titrating positive airway pressure, polysomnography, InBody Test, and rhinomanometry.

METHODS

Usage data and medical records of 120 auto-titrating positive airway pressure users were reviewed retrospectively. All patients used a nasal or pillow mask and were carefully monitored at scheduled follow-ups.

RESULTS

Use of a pillow mask, sex (male), age, and abdominal fat percentage were significantly associated with high average air leakage. The higher the auto-titrating positive airway pressure average and mean pressure, the more likely patients exhibited high rates of air leakage. The percentage of patients with high average air leakage increased over time (up to 6 months of follow-up).

CONCLUSIONS

Older male patients using a pillow mask and those with a high abdominal fat percentage and high auto-titrating positive airway pressure may require close follow-up and continuous monitoring for air leakage. Because air leakage from a mask can change over time, mask-sealing capacity should be reassessed and masks should be changed regularly.

CITATION

Kang YJ, Cho J-H, Park C-S. Analysis of risk factors for air leakage in auto-titrating positive airway pressure users: a single-center study. J Clin Sleep Med. 2022;18(1):75-88.

Evaluation of CPAP mask performance during 3 years of mask usage: time for reconsideration of renewal policies?

Background

Continuous positive airway pressure (CPAP) mask renewal policies vary inside and between countries. There are no independent studies on the optimal mask renewal frequency. We aimed to evaluate CPAP mask function over time in a real-life clinical setting, and to compare the results against current renewal policies.

Methods

Daily performance data of 1846 CPAP masks (65% nasal, 22% nasal pillows, 12% oronasal) were recorded from 450 participants (68% male, mean age 59 years) with obstructive sleep apnoea. The unintentional leak, Apnoea-Hypopnoea Index (CPAP-AHI) and usage data were exported from the CPAP device.

Results

Of 656 324 nights of CPAP usage, the mean renewal time was 497 days (SD 327), mean leak 5.7 L/min (SD 8.1) and CPAP-AHI 3.8 events/h (SD 3.6). The difference in mean leak between one (5.2 L/min, SD 7.5), 12 (6.0 L/min, SD 10.2) and 24 months (5.8 L/min, SD 7.5) was minimal (p=0.59). Mean CPAP-AHI remained normal and unchanged in nasal masks and pillows up to 30 months, and was highest in oronasal masks. Different mask manufacturers performed similarly. Masks’ daily or total usage did not affect the results. Shifting the mask renewal policy to 24 months could reduce the mask-related cost up to 50%–88%.

Conclusions

Nasal masks and pillows could be used at least 2 years without significant changes in unintentional leak and CPAP-AHI. We suggest updating the mask renewal policies of nasal masks and pillows; results on oronasal masks and other manufacturers CPAP devices need further verification.

Effect of healthcare benefits on short-term adherence of positive airway pressure therapy

PURPOSE

The objective of this study was to assess the impact of healthcare benefits on adherence to positive airway pressure (PAP) therapy in obstructive sleep apnea (OSA) patients.

METHODS

Medical records of OSA patients at the Veterans Health Service Medical Center were retrospectively reviewed. OSA patients were assigned to two groups as the date of prescribing PAP: after (=Group A) and before (=Group B) July 1, 2018 when PAP therapy starts to be included in healthcare insurance coverage for OSA patients in South Korea. PAP adherence was compared over a 3-month period between the two groups; subjective improvement after therapy was evaluated using the Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index scores. In addition, we evaluated a number of OSA patients who chose to start PAP therapy without healthcare benefit (from July 2018 to December 2018).

RESULTS

Each of the 50 patients in the Group A and B exhibited PAP adherence rates of 82% and 26%, respectively (P < .001). Age did not affect PAP adherence in the Group A. The mean apnea-hypopnea index (from 36.7 to 1.34, P < .001) and ESS (from 7.6 to 5.6, P = .004) scores of patients in the Group A had significantly improved within the first three months. Twenty-three (23 out of 334, 6.9%) OSA patients did not have any healthcare insurance, but they medically needed PAP therapy. However, only one of the 23 patients began PAP treatment.

CONCLUSION

Short-term PAP adherence significantly improved after PAP therapy was included in healthcare insurance coverage.