Compliance with continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea among privately paying patients- a cross sectional study

Therapeutic adherence in patients with Obstructive Sleep Apnea Syndrome: a retrospective cohort study

INTRODUCTION

Obstructive Sleep Apnea Syndrome (OSAS) is a respiratory disorder characterized by repeated episodes of partial or complete airway obstruction. Continuous Positive Airway Pressure therapy (CPAP) is effective in improving sleep quality and daytime sleepiness. The aim of the study was to evaluate therapeutic adherence in a sample of patients with OSAS from the Pneumology ward of the "Cardinal Massaia" Hospital in Asti.

MATERIALS AND METHODS

A sample of 221 patients with OSAS were collected and retrospectively analyzed from January 2019 to December 2021. Ventilation hours during device titration (T1), possible second titration (T2) and one-year control (T3) were considered. The use of the CPAP device equal to or greater than 4 h/night was considered as therapeutic adherence. Age, gender, severity of OSAS, smoking, interface used and Epworth Sleepiness Scale (ESS) score were considered.

RESULTS

The analysis data showed that the percentage of adhesion during T1 was 84%. Only 9% needed T2, with 84% adherence. At T3 the adherence was 86%. Correlation studies showed that only smoking had a positive correlation with adherence, while OSAS severity, gender, ESS score, interface used and age had no statistically significant correlation.

CONCLUSION

It was important to understand that OSAS is a disease with prolonged treatment, which affects the life of the person and his family. Therefore, the concept of assistance network was born, which sees the healthcare operators, the person and his family as the main actors involved in a care process.

Modified biblock versus monoblock mandibular advancement appliances for treatment of obstructive sleep apnea: A randomized controlled trial

STATEMENT OF PROBLEM

The high prevalence of obstructive sleep apnea represents a serious public health problem. Oral appliances have gained wide acceptance among patients diagnosed with obstructive sleep apnea, who should wear them every night. A comfortable oral appliance is mandatory for successful treatment outcomes.

PURPOSE

The purpose of this randomized controlled trial was the assessment of the influence of 2 different designs of the mandibular advancement appliance (MAA), modified biblock and monoblock, for the management of obstructive sleep apnea.

MATERIAL AND METHODS

The study was designed as a prospective 2-arm randomized controlled clinical trial conducted in parallel. Twenty participants (aged 40 ±7.5 years) diagnosed with moderate obstructive sleep apnea were randomly assigned to a control group (n=10), receiving monoblock MAA, and a study group (n=10), receiving modified biblock MAA with elastics. Both appliances were fabricated by using computer-aided design and computer-aided manufacture (CAD-CAM) technology at different mandibular advancement levels (MALs): 50% and 75% of maximum MAL. A total of 60 cone beam computed tomography scans, 60 overnight full polysomnography sleep tests, 60 STOP-Bang questionnaires, and 40 Usability of Sleep Apnea Equipment-Oral Appliance (USE-OA) questionnaires were collected and analyzed blindly at baseline (initial visit), 50% MAL (3 months), and 75% MAL (6 months). The main outcome measures were the upper airway volume, linear anteroposterior and cross-sectional airway measurements, Apnea Hypopnea Index, Respiratory Disturbance Index, STOP-Bang questionnaire scoring, and USE-OA questionnaire scoring. Nonparametric statistical analysis was performed by using a statistical software program (α=.05). With a beta error accepted of up to 20%, the power of the study was 80%.

RESULTS

At 75% MAL, the percentage change in upper airway volumetric measurements showed a favorable increase: biblock group (115%) and monoblock group (42%), with a statistically significant difference (P=.001). The linear anteroposterior airway measurements and the percentage change in cross-sectional airway measurements were statistically similar: biblock group (80%) and (75%) monoblock group (60%), (54%) (P=.450, P=.151, respectively). The percentage change in the Apnea Hypopnea Index significantly decreased: biblock group (-89%) and monoblock group (-54%) (P<.001). The percentage change in the Respiratory Disturbance Index decreased: biblock group (-78%) and monoblock group (-62%) (P<.023). From the STOP-Bang questionnaire scoring, 100% of both groups showed low risk for obstructive sleep apnea at 75% MAL. From the satisfaction scoring on the USE-OA questionnaire, the biblock group was 100% strong satisfaction and the monoblock group was 50% satisfaction and 50% fairly satisfied.

CONCLUSIONS

The modified biblock MAA with elastics showed significant improvements in patients diagnosed with obstructive sleep apnea regarding upper airway measurements and full polysomnography vital parameters when compared with monoblock MAA.

Obstructive Sleep Apnea and Stroke: Determining the Mechanisms Behind their Association and Treatment Options

Sleep-disordered breathing (SDB) can be a sequela of stroke caused by vascular injury to vital respiratory centers, cerebral edema, and increased intracranial pressure of space-occupying lesions. Likewise, obstructive sleep apnea (OSA) contributes to increased stroke risk through local mechanisms such as impaired ischemic cerebrovascular response and systemic effects such as promoting atherosclerosis, hypercoagulability, cardiac arrhythmias, vascular-endothelial dysfunction, and metabolic syndrome. The impact of OSA on stroke outcomes has been established, yet it receives less attention in national guidelines on stroke management than hyperglycemia and blood pressure dysregulation. Furthermore, whether untreated OSA worsens stroke outcomes is not well-described in the literature. This scoping review provides an updated investigation of the correlation between OSA and stroke, including inter-relational pathophysiology. This review also highlights the importance of OSA treatment and its role in stroke outcomes. Knowledge of pathophysiology, the inter-relationship between these common disorders, and the impact of OSA therapy on outcomes affect the clinical management of patients with acute ischemic stroke. In addition, understanding the relationship between stroke outcomes and pre-existing OSA will allow clinicians to predict outcomes while treating acute stroke.

Personalized Medicine and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disease that is often under-diagnosed and under-treated in all ages. This is due to differences in morphology, diversity in clinical phenotypes, and differences in diagnosis and treatment of OSA in children and adults, even among individuals of the same age. Therefore, a personalized medicine approach to diagnosis and treatment of OSA is necessary for physicians in clinical practice. In children and adults without serious underlying medical conditions, polysomnography at sleep labs may be an inappropriate and inconvenient testing modality compared to home sleep apnea testing. In addition, the apnea-hypopnea index should not be considered as a single parameter for making treatment decisions. Thus, the treatment of OSA should be personalized and based on individual tolerance to sleep-quality-related parameters measured by the microarousal index, harmful effects of OSA on the cardiovascular system related to severe hypoxia, and patients' comorbidities. The current treatment options for OSA include lifestyle modification, continuous positive airway pressure (CPAP) therapy, oral appliance, surgery, and other alternative treatments. CPAP therapy has been recommended as a cornerstone treatment for moderate-to-severe OSA in adults. However, not all patients can afford or tolerate CPAP therapy. This narrative review seeks to describe the current concepts and relevant approaches towards personalized management of patients with OSA, according to pathophysiology, cluster analysis of clinical characteristics, adequate combined therapy, and the consideration of patients' expectations.

Mandibular Advancement Device (MAD) for Obstructive Sleep Apnea in an Edentulous Patient

Mandibular advancement devices have been efficiently used for the treatment of mild to moderate obstructive sleep apnea (OSA) by forward positioning of the tongue-mandible complex with a resultant increase in oropharyngeal volume. However, the literature on the treatment of edentulous patients is limited. This clinical report describes a clinical and laboratory method for the fabrication of a mandibular advancement device in a 75-year-old completely edentulous patient with mild OSA.

The Effect of Telemonitoring (TM) on Improving Adherence with Continuous Positive Airway Pressure (CPAP) in Obstructive Sleep Apnoea (OSA): A Service Improvement Project (SIP)

The benefits of CPAP demonstrated in clinical trials are difficult to deliver in real life due to the lack of adherence. We analysed the effect of a Telemonitoring (TM)-related intervention on adherence as part of a Service Improvement Project (SIP) analysed as a retrospective cohort study. The ‘historical control’ (HC) cohort (followed up in conventional clinics) included all patients who commenced on CPAP between 1 February and 30 April 2019 (n = 142). The ‘telemonitoring’ (TM) cohort included all patients who commenced on CPAP between 1 May and 31 July 2019 (n = 166). Adherence was checked at 30 days (baseline) and 73 days for both cohorts. Wilcoxon—Rank test was used for statistical analysis (results reported as mean ± SEM). Both cohorts had similar adherence at the 30-day baseline, compared to a significantly lower adherence in the HC-cohort at 73 days (55.7 ± 3.0 vs. 51.8 ± 3.2% of days ≥ 4 h: p = 0.0072, average usage 255 ± 12.8 vs. 236 ± 13.7 min: p = 0.0003). There was a significantly higher adherence in the TM-cohort at 73 days (50.8 ± 2.5 vs. 56.1 ± 2.9% of days ≥ 4 h: p = 0.0075; average usage 234 ± 10.4 vs. 252 ± 12.1 min: p = 0.0456). Telemonitoring-feedback is effective at improving adherence with CPAP, suggesting its potential beneficial role in the community setting, particularly in the post-COVID reality of increased remote consultations.

Management and Treatment of Patients With Obstructive Sleep Apnea Using an Intelligent Monitoring System Based on Machine Learning Aiming to Improve Continuous Positive Airway Pressure Treatment Compliance: Randomized Controlled Trial

Background

Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnea (OSA), but treatment compliance is often unsatisfactory.

Objective

The aim of this study was to assess the effectiveness and cost-effectiveness of an intelligent monitoring system for improving CPAP compliance.

Methods

This is a prospective, open label, parallel, randomized controlled trial including 60 newly diagnosed patients with OSA requiring CPAP (Apnea–Hypopnea Index [AHI] >15) from Lleida, Spain. Participants were randomized (1:1) to standard management or the MiSAOS intelligent monitoring system, involving (1) early compliance detection, thus providing measures of patient’s CPAP compliance from the very first days of usage; (2) machine learning–based prediction of midterm future CPAP compliance; and (3) rule-based recommendations for the patient (app) and care team. Clinical and anthropometric variables, daytime sleepiness, and quality of life were recorded at baseline and after 6 months, together with patient’s compliance, satisfaction, and health care costs.

Results

Randomized patients had a mean age of 57 (SD 11) years, mean AHI of 50 (SD 27), and 13% (8/60) were women. Patients in the intervention arm had a mean (95% CI) of 1.14 (0.04-2.23) hours/day higher adjusted CPAP compliance than controls (P=.047). Patients’ satisfaction was excellent in both arms, and up to 88% (15/17) of intervention patients reported willingness to keep using the MiSAOS app in the future. No significant differences were found in costs (control: mean €90.2 (SD 53.14) (US $105.76 [SD 62.31]); intervention: mean €96.2 (SD 62.13) (US $112.70 [SD 72.85]); P=.70; €1=US $1.17 was considered throughout). Overall costs combined with results on compliance demonstrated cost-effectiveness in a bootstrap-based simulation analysis.

Conclusions

A machine learning–based intelligent monitoring system increased daily compliance, reported excellent patient satisfaction similar to that reported in usual care, and did not incur in a substantial increase in costs, thus proving cost-effectiveness. This study supports the implementation of intelligent eHealth frameworks for the management of patients with CPAP-treated OSA and confirms the value of patients’ empowerment in the management of chronic diseases.

Trial Registration

ClinicalTrials.gov NCT03116958; https://clinicaltrials.gov/ct2/show/NCT03116958

Effects of telemedicine interventions in improving continuous positive airway pressure adherence in patients with obstructive sleep apnoea: a meta-analysis of randomised controlled trials

PURPOSE

This meta-analysis was conducted to assess the effects of telemedicine interventions on continuous positive airway pressure (CPAP) adherence in patients with obstructive sleep apnoea (OSA).

METHODS

The PubMed, Cochrane Library, OVID, Web of Science and EBSCO host databases were searched from January 2004 to February 2020 for randomised controlled trials (RCTs) that assessed the effects of telemedicine interventions on CPAP adherence in patients with OSA. The study inclusion criteria were RCTs that compared patients who received telemedicine interventions with a control group and reported a change in CPAP adherence. The primary outcome was the improvement in CPAP adherence.

RESULTS

In total, there were 11 RCTs (n = 1358) with quantitative analyses. Intervention times ranged from 1 to 6 months. Compared to controls, the telemedicine group exhibited better adherence to CPAP therapy (pooled mean difference (MD) = 0.57, 95% CI = 0.33 to 0.80, I² = 7%, p < 0.00001). We performed sensitivity analyses by the type of telemedicine intervention, comorbidity burden, and OSA severity to explore whether or not their effect sizes may have affected the time of CPAP application. We performed subgroup analyses by follow-up duration, age, and OSA Epworth sleepiness scale (ESS) symptoms to determine if their effect sizes may have affected the time of CPAP application. However, these analyses did not change the statistical significance of the pooled estimate.

CONCLUSIONS

The use of telemedicine for up to 6 months may enhance CPAP adherence in patients with OSA, when compared to no intervention. Our study was searched from January 2004 to February 2020 for randomised controlled trials (RCTs) that assessed the effects of telemedicine interventions on CPAP adherence in patients with OSA. Future studies can continue to search for articles after February 2020.

Efficacy of a Smart Antisnore Pillow in Patients with Obstructive Sleep Apnea Syndrome

Objective

Untreated obstructive sleep apnea syndrome (OSAS) increases the risk of cardiovascular, dementia, and motor vehicle accident events. However, continuous positive airway pressure (CPAP) which is the gold standard treatment is not acceptable for many patients with OSAS. Development of devices for the patients of nonadherence to CPAP is necessary.

Materials and Methods

We evaluated the effect of the smart antisnore pillow (SAP) in patients with OSAS in a prospective, noncontrolled, nonrandomized, pilot study. According to the apnea-hypopnea index (AHI), they were divided into two groups: mild-to-moderate OSAS group and severe OSAS group. Single-night polysomnography (PSG) with application of a SAP was performed. Thirty patients, 15 males and 15 females, 33–82 years old (mean age, 59.3 ± 12.9 years), completed the smart antisnore pillow therapy test. Among them, 23 patients had mild-to-moderate OSAS.

Results

The SAP significantly improved the snore number (p = 0.018), snore index (p = 0.013), oxygen denaturation index (p = 0.001), total AHI (p = 0.002), and supine AHI (p = 0.002) in the mild-to-moderate OSAS group, but there was no significant improvement in the severe OSAS group.

Conclusions

We concluded that the SAP is an effective positional therapy device for patients with OSAS of mild-to-moderate severity.

Proliferative Pathways of Vascular Smooth Muscle Cells in Response to Intermittent Hypoxia

Obstructive sleep apnea (OSA) is characterized by intermittent hypoxia (IH) and is a risk factor for cardiovascular diseases (e.g., atherosclerosis) and chronic inflammatory diseases (CID). The excessive proliferation of vascular smooth muscle cells (VSMCs) plays a pivotal role in the progression of atherosclerosis. Hypoxia-inducible factor-1 and nuclear factor-κB are thought to be the main factors involved in responses to IH and in regulating adaptations or inflammation pathways, however, further evidence is needed to demonstrate the underlying mechanisms of this process in VSMCs. Furthermore, few studies of IH have examined smooth muscle cell responses. Our previous studies demonstrated that increased interleukin (IL)-6, epidermal growth factor family ligands, and erbB2 receptor, some of which amplify inflammation and, consequently, induce CID, were induced by IH and were involved in the proliferation of VSMCs. Since IH increased IL-6 and epiregulin expression in VSMCs, the same phenomenon may also occur in other smooth muscle cells, and, consequently, may be related to the incidence or progression of several diseases. In the present review, we describe how IH can induce the excessive proliferation of VSMCs and we develop the suggestion that other CID may be related to the effects of IH on other smooth muscle cells.

Comparative analysis of predictive methods for early assessment of compliance with continuous positive airway pressure therapy

Background

Patients suffering obstructive sleep apnea are mainly treated with continuous positive airway pressure (CPAP). Although it is a highly effective treatment, compliance with this therapy is problematic to achieve with serious consequences for the patients’ health. Unfortunately, there is a clear lack of clinical analytical tools to support the early prediction of compliant patients.

Methods

This work intends to take a further step in this direction by building compliance classifiers with CPAP therapy at three different moments of the patient follow-up, before the therapy starts (baseline) and at months 1 and 3 after the baseline.

Results

Results of the clinical trial shows that month 3 was the time-point with the most accurate classifier reaching an f1-score of 87% and 84% in cross-validation and test. At month 1, performances were almost as high as in month 3 with 82% and 84% of f1-score. At baseline, where no information of patients’ CPAP use was given yet, the best classifier achieved 73% and 76% of f1-score in cross-validation and test set respectively. Subsequent analyzes carried out with the best classifiers of each time point revealed baseline factors (i.e. headaches, psychological symptoms, arterial hypertension and EuroQol visual analog scale) closely related to the prediction of compliance independently of the time-point. In addition, among the variables taken only during the follow-up of the patients, Epworth and the average nighttime hours were the most important to predict compliance with CPAP.

Conclusions

Best classifiers reported high performances after one month of treatment, being the third month when significant differences were achieved with respect to the baseline. Four baseline variables were reported relevant for the prediction of compliance with CPAP at each time-point. Two characteristics more were also highlighted for the prediction of compliance at months 1 and 3.

Trial registration

ClinicalTrials.gov Identifier, NCT03116958. Retrospectively registered on 17 April 2017.

Electronic supplementary material

The online version of this article (10.1186/s12911-018-0657-z) contains supplementary material, which is available to authorized users.

Adherence to Continuous Positive Airway Pressure therapy in Singaporean patients with Obstructive Sleep Apnea

PURPOSE

To investigate the rates of Continuous Positive Airway Pressure (CPAP) uptake and adherence amongst Singaporean patients diagnosed with Obstructive Sleep Apnea (OSA), and to evaluate factors correlated with CPAP uptake and adherence.

STUDY DESIGN

Retrospective review of medical records.

METHODS

Medical records were reviewed for baseline demographics, daytime sleepiness, presence of nasal symptoms and OSA severity, initial treatment choice, the rate of CPAP treatment uptake and CPAP adherence at 1 and 12 months.

RESULTS

2160 patients were diagnosed with OSA within the 5-year period (2011-2015). 463 (21.4%) had mild OSA, 583 (27.0%) had moderate OSA and 1114 (51.6%) had severe OSA. For initial therapy, 751 (34.8%) patients opted for a 1-month CPAP trial, 288 (13.3%) patients chose surgery upfront, 291 (13.5%) patients chose adjunctive treatments (weight loss, positional therapy, dental appliance, intranasal steroid spray for allergic rhinitis) and 830 (38.4%) patients rejected all forms of treatment. 337 out of 751 patients (44.9%) were adherent to CPAP therapy during the 1 month trial. 381 out of 751 (50.7%) patients took up CPAP therapy following the trial period, of which 299 out of 381 (78.5%) patients were adherent to CPAP therapy at 1 year. CPAP adherence during the 1-month trial was a predictor for eventual CPAP treatment uptake and CPAP adherence at 1 year (p < 0.001). Age (p < 0.001), BMI (p < 0.001) and normal ESS (p = 0.01) were predictors of treatment rejection. 24 patients underwent upper airway surgery during their first year of using CPAP. 21 out of the 24 patients (87.5%) were adherent to CPAP at 1 year after undergoing surgery. These patients had a higher rate of CPAP adherence compared to the overall cohort (87.5% versus 78.5%), but this was not statistically significant (p > 0.05).

CONCLUSION

Singaporean patients who accept CPAP therapy after an initial 1-month CPAP trial will generally be adherent to CPAP therapy. Initial patterns of CPAP usage are predictive of long term CPAP adherence. However, there is a high rate of CPAP treatment rejection both at the time of diagnosis and after the CPAP trial. Upper airway surgery in selected patients may improve CPAP adherence.

Obstructive Sleep Apnea is an Independent Risk Factor for Hospital Readmission

STUDY OBJECTIVES

Hospital readmissions are an important metric of quality and safety. This study seeks to characterize the relationship between readmissions and obstructive sleep apnea (OSA). A better understanding of this relationship could be utilized to develop preventative measures and reduce readmission rates.

METHODS

A retrospective review of patients discharged over a 24-month period to a Department of Defense hospital was conducted. Medical records review provided demographic data, presence of OSA and comorbid diseases, and whether readmission occurred within 30 days of discharge. Statistical analysis assessed risk factors for readmission, and multivariate analysis was performed. Next, 125 readmitted patients with OSA were randomly selected for detailed chart review and compared to a matched cohort that was not readmitted.

RESULTS

Of 22,261 unique patients discharged, 1,899 (8.5%) were readmitted. Patients with OSA had a readmission rate of 11.4% versus 7.6% for patients without OSA (P < .00001). Multivariable analysis revealed an odds ratio of 1.46 for readmission in patients with OSA (P < .0001). For the detailed chart review of 250 patients, length of hospital stay differed for the readmitted and non-readmitted groups (5.1 versus 3.6 days; P = .007). Apnea-hypopnea index (24.1 versus 27.2 events/h; P = .48) was similar between the groups. Also, inpatient (27.2% versus 26.4%) and outpatient (38.4% versus 37.6%) positive airway pressure (PAP) treatment rates were not different.

CONCLUSIONS

This study found OSA to be an independent risk factor for readmission within 30 days of discharge. PAP therapy appears to be underutilized in patients with known OSA. Additional studies are needed to define the relationship between OSA, PAP adherence, and hospital readmission.

Intermittent hypoxia-induced epiregulin expression by IL-6 production in human coronary artery smooth muscle cells

Patients with obstructive sleep apnea (OSA) experience repetitive episodes of desaturation and resaturation of blood oxygen (known as intermittent hypoxia or IH), during sleep. We showed previously that IH induced excessive proliferation of rat vascular smooth muscle cells through upregulation of members of the epidermal growth factor family, especially epiregulin (EREG), and the erbB2 receptor. In this study, we exposed human coronary artery smooth muscle cells to IH and found that IH significantly increased the expression of EREG. IH increased the production of interleukin‐6 (IL‐6) in smooth muscle cells, and the addition of IL‐6 induced EREG expression. Small interfering RNA for IL‐6 or IL‐6 receptor attenuated the IH‐induced increase in EREG. IL‐6 may play a pivotal role in EREG upregulation by IH and consequently OSA‐related atherosclerosis.

Suicidal ideation in patients with obstructive sleep apnoea and its relationship with disease severity, sleep-related problems and social support

We aimed to assess the prevalence of suicidal ideation and to examine the relationships between obstructive sleep apnoea severity, sleep-related problems, social support and suicidal ideation in obstructive sleep apnoea patients. We included 149 patients (68% male; mean age, 48.99 ± 9.57 years) with diagnosed obstructive sleep apnoea (Apnoea–Hypopnoea Index ⩾5) based on full-night polysomnography. The prevalence of suicidal ideation among obstructive sleep apnoea patients was 20.1 per cent. Structural equation modelling showed that suicidal ideation in obstructive sleep apnoea was strongly related to poor sleep quality and high fatigue levels. No relationship between social support and suicidal ideation in obstructive sleep apnoea patients was found.

Long-term prediction of adherence to continuous positive air pressure therapy for the treatment of moderate/severe obstructive sleep apnea syndrome

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is a highly effective treatment for obstructive sleep apnea syndrome (OSAS). However, poor adherence is a limiting factor, and a significant proportion of patients are unable to tolerate CPAP. The aim of this study was to determine predictors of long-term non-compliance with CPAP.

METHODS

CPAP treatment was prescribed to all consecutive patients with moderate or severe OSAS (AHI ≥15 events/h) (n = 295) who underwent a full-night CPAP titration study at home between February 1, 2002 and December 1, 2016. Adherence was defined as CPAP use for at least 4 h per night and five days per week. Subjects had periodical follow-up visits including clinical and biochemical evaluation and assessment of adherence to CPAP.

RESULTS

Median follow-up observation was 74.8 (24.2/110.9) months. The percentage of OSAS patients adhering to CPAP was 41.4% (42.3% in males and 37.0% in females), and prevalence was significantly higher in severe OSAS than in moderate (51.8% vs. 22.1%; p < 0.001; respectively). At multivariate analysis, lower severity of OSAS (HR = 0.66; CI 95 0.46-0.94) p < 0.023), cigarette smoking (HR = 1.72; CI 95 1.13-2.61); p = 0.011), and previous cardiovascular events (HR = 1.95; CI 95 1.03-3.70; p = 0.04) were the only independent predictors of long-term non-adherence to CPAP after controlling for age, gender, and metabolic syndrome.

CONCLUSIONS

In our cohort of patients with moderate/severe OSAS who were prescribed CPAP therapy, long-term compliance to treatment was present in less than half of the patients. Adherence was positively associated with OSAS severity and negatively associated with cigarette smoking and previous cardiovascular events at baseline.

Drug Induced Sleep Endoscopy in Obstructive Sleep Apnea

BACKGROUND

One of the main challenges of surgical treatment in Obstructive Sleep Apnea (OSA) is identifying the correct site of upper airway obstruction in an individual patient. Drug-Induced Sleep Endoscopy (DISE) in sedated patients with obstructive sleep apnea is the technique of choice for revealing anatomic and dynamic collapsible areas.

MATERIALS AND METHODS

In a prospective cross-sectional study adult patients with OSA documented by polysomnography were evaluated by sleep endoscopy. DISE had been done by an otolaryngologist in the setting of operating room during infusion of propofol and after the start of snoring. Endoscopic findings were recorded and evaluated from the aspect of obstruction level, severity, and multiplicity.

RESULTS

Twenty OSA patients (60% men) with mean±SD age of 38.9±9.26 years and mean Body Mass Index (BMI) of 26.57 kg/m2 were included in the study. OSA was severe in 11(55%) and moderate in 5(25%) subjects. Unilevel airway collapse was observed as retropalatal in 4(20%) and retrolingual in 3(15%) subjects. Multilevel collapse had been observed in the other 13(65%) patients. Most patients (65%) had multilevel obstruction especially those with BMI>30 (p<0.05). With increasing BMI, obstruction changed from unilevel to multilevel. None of the subjects showed complications with propofol or endoscopy procedure.

CONCLUSION

Our study showed DISE is safe, easy to perform, and informative in OSA patients. In particular, we observed a significant association between obesity and multilevel upper airway collapse.

Management of continuous positive airway pressure treatment compliance using telemonitoring in obstructive sleep apnoea

Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnoea (OSA), but treatment compliance is often unsatisfactory. This study investigated the efficacy and cost-effectiveness of telemonitoring for improving CPAP compliance.100 newly diagnosed OSA patients requiring CPAP (apnoea-hypopnoea index >15 events·h^-1) were randomised to standard management or a telemonitoring programme that collected daily information about compliance, air leaks and residual respiratory events, and initiated patient contact to resolve issues. Clinical/anthropometric variables, daytime sleepiness and quality of life were recorded at baseline and after 3 months. Patient satisfaction, additional visits/calls, side-effects and total costs were assessed.There were no significant differences between the standard and telemedicine groups in terms of CPAP compliance (4.9±2.2 versus 5.1±2.1 h·night^-1), symptoms, clinical variables, quality of life and unwanted effects. Telemedicine was less expensive than standard management (EUR123.65 versus EUR170.97; p=0.022) and was cost-effective (incremental cost-effectiveness ratio EUR17 358.65 per quality-adjusted life-year gained). Overall patient satisfaction was high, but significantly more patients rated satisfaction as high/very high in the standard management versus telemedicine group (96% versus 74%; p=0.034).Telemonitoring did not improve CPAP treatment compliance and was associated with lower patient satisfaction. However, it was more cost-effective than traditional follow-up.

Acceptance and Adherence to Continuous Positive Airway Pressure Therapy in patients with Obstructive Sleep Apnea (OSA) in a Southeast Asian privately funded healthcare system

BACKGROUND

There is limited data on long term Continuous Positive Airway Pressure (CPAP) adherence in Southeast Asian countries. This is a prospective study on CPAP adherence among Obstructive sleep apnea (OSA) patients in a Southeast Asian privately funded healthcare system.

METHODS

Patients with moderate-severe OSA who had been initiated on CPAP at least one year previously were contacted for a scripted telephone interview to assess compliance and factors associated with CPAP adherence.

RESULTS

Of 135 consecutive patients diagnosed to have moderate to severe OSA, 78 (57.8%) were initiated on CPAP treatment while 57 (42.2%) rejected CPAP upfront. 41 (52.6%) who initiated CPAP remained adherent at one year. OSA severity (AHI, ODI) and symptomatic improvement after CPAP were associated with better adherence. Presence of machine related side effects was associated with lower adherence. Inconvenience, cost and poor disease perception were reported as major barriers to uptake of CPAP therapy.

CONCLUSIONS

In this Southeast Asian privately funded healthcare system, almost half of all patients with significant OSA rejected CPAP treatment upfront, but adherence among those who started CPAP is comparable to other reports. Challenges with CPAP acceptance as well as CPAP adherence need to be addressed to improve outcomes.

When continuous positive airway pressure (CPAP) fails

Obstructive sleep apnoea (OSA) is increasingly prevalent, particularly in the context of the obesity epidemic, and is associated with a significant social, health and economic impact. The gold standard of treatment for moderate to severe OSA is continuous positive airway pressure (CPAP). However compliance rates can be low. Methodology to improve patient tolerance to CPAP alongside with alternative, non-surgical and surgical, management strategies are discussed. All patients that fail CPAP therapy would benefit from formal upper airway evaluation by the otolaryngologist to identify any obvious causes and consider site-specific surgical therapies. Patient selection is integral to ensuring successful outcomes. A multidisciplinary team is needed to manage these patients.

Obstructive Sleep Apnea and Vascular Diseases

Obstructive sleep apnea (OSA) affects a large proportion of adults, and is as an independent risk factor for cerebrovascular and cardiovascular disease. The repetitive airway obstruction that characterizes OSA results in intermittent hypoxia, intrathoracic pressure swings, and sleep fragmentation, which in turn lead to sympathetic activation, oxidative stress, inflammation, and endothelial dysfunction. This review outlines the associations between OSA and vascular diseases and describes basic mechanisms that may be responsible for this association, in both the micro- and macrocirculation. It also reports on interventional studies that aim to ameliorate OSA and thereby reduce vascular disease burden. © 2016 American Physiological Society. Compr Physiol 6:1519-1528, 2016.

Use of CPAP in patients with obstructive sleep apnea admitted to the general ward: effect on length of stay and readmission rate

BACKGROUND

Obstructive sleep apnea (OSA) has been associated with multiple cardiovascular comorbidities. Despite increased awareness of OSA and its treatments, the management of OSA in the hospital setting remains below expectations.

METHODS

We retrospectively reviewed the demographics, clinical characteristics, and hospital course on 413 consecutive patients with a history of OSA on domiciliary CPAP therapy admitted to the general medical ward and analyzed the prevalence of CPAP use and its effect on length of stay (LOS), 30-day readmission rate, and time-to-readmission in our tertiary care teaching hospital.

RESULTS

Of the 413 study participants, 264 (64.0 %) patients were receiving CPAP during their hospital admission. Patients who were receiving CPAP therapy during their hospitalization had a significantly higher body mass index (BMI) (41.4 vs. 36.8 kg/m(2), p < 0.001) and were more likely to be African-American (p = 0.01) and have congestive heart failure (CHF) (42.0 vs. 31.0 %, p = 0.038) peripheral vascular disease (PVD) (26.0 vs. 15.0 %, p = 0.013), and uncomplicated diabetes mellitus (p = 0.001) than those who were not. CPAP therapy in the hospital setting did not affect LOS (4.7 vs. 4.0 days, p = 0.291), readmission rate (11.0 % for both groups), or time-to-readmission (20.8 vs. 22.3 days, p = 0.762).

CONCLUSION

The majority of patients who are on domiciliary CPAP therapy were receiving CPAP therapy while admitted to the general medical ward of a tertiary care academic hospital. Presence of comorbid conditions such as obesity and certain cardiovascular diseases may have increased the likelihood of prescribing CPAP therapy while in the hospital. In-hospital CPAP therapy did not appear to significantly influence short-term outcomes such as hospital LOS, readmission rate, or time-to-readmission.

Cognitive deficits in adults with obstructive sleep apnea compared to children and adolescents

Obstructive sleep apnea (OSA) can negatively affect the patient's physical and psychological functioning, as well as their quality of life. A major consequence of OSA is impaired cognitive functioning. Indeed, several studies have shown that OSA mainly leads to deficits in executive functions, attention, and memory. As OSA can present in all age groups, these associated cognitive deficits have been observed in adults, as well as in children and adolescents. However, these cognitive deficits may have a different clinical picture in young patients compared to adults. In this review, we analyze the most affected cognitive domains in adults and children/adolescents with OSA, as evaluated by neuropsychological and neuroimaging studies. We found that deficits in working memory, attention, or executive functions cognitive domains are found in both adults and children with OSA. However, children with OSA also show changes in behavior and phonological processing necessary for proper development. Moreover, we examine the possible OSA treatments in children and adults that can have a positive influence on cognition, and therefore, improve patients' general functioning and quality of life.