High Adherence to CPAP Treatment Does Not Prevent the Continuation of Weight Gain among Severely Obese OSAS Patients

Comparative efficacy of non-pharmacological interventions for adults with sleep apnea: A systematic review and network meta-analysis

BACKGROUND

Sleep apnea is associated with cardiovascular risk, work productivity, occupational/traffic accidents, and quality-of-life (QoL); however uncertainty exists regarding optimal treatment. We performed a systematic review on the efficacy of non-pharmacological interventions for adults with sleep apnea.

METHOD

We searched MEDLINE, Scopus, Virtual-Health-Library and Web-of-Science through June 2023 for parallel/cross-over randomized trials on adults with sleep apnea (apnea-hypopnea-index>5 events/hour). Study selection, data extraction and risk-of-bias assessment were performed in duplicate, followed by frequentist network meta-analyses.

RESULTS

Ultimately, 197 unique trials were included (15,931 patients; mean age 51.4 years; 78.9 % male) assessing 25 treatments. Positive Airway Pressure (PAP) (alone or combined with health behaviour modification) consistently improved more apnea-hypopnea-index or daytime sleepiness and physical/mental QoL in obstructive sleep apnea (OSA) patients compared to all other interventions but was not always well-tolerated. Mandibular advancement devices (MAD) yielded the greatest improvement in depression, while also improving objective/subjective apnea-outcomes, and physical/mental QoL-albeit less than PAP and less for moderate/severe cases. Acupuncture, health behaviour modifications, surgical maxillomandibular advancement, minor oral surgery, oropharyngeal training, oxygen supplementation, or electrical neurostimulation might improve apnea-related outcomes, but weak evidence exists. Finally, electrical neurostimulation performed best for central sleep apnea and PAP performed best for positional OSA. Confidence in the network meta-analysis estimates was low due to non-adherence issues that was rarely directly assessed in included trials with objective measures.

CONCLUSION

PAP (alone or with co-interventions) performed best for the treatment of adult OSA patients regardless of disease severity. For patients not tolerating PAP, MADs might be a good alternative, but confer smaller improvements overall. However, adherence issues and the heterogenous response increase the complexity of OSA treatment.

Factors predictive of extensive use of CPAP treatment in obstructive sleep apnoea

AIM

In patients with obstructive sleep apnoea (OSA), the benefits of continuous positive airway pressure (CPAP) therapy are increased for every additional hour of daily CPAP usage. However, the data of predictors of extensive usage is scarce, if any. Therefore, we evaluated potential predictors affecting extensive treatment usage.

METHODS

In this retrospective study, we compiled an institutional cohort of consecutive patients diagnosed with who started CPAP therapy 1999-2022 and were included in a wireless telemonitoring system in May 2022 (N = 14,394). Patients using CPAP device ≥ 9 h/d were stratified into a younger (< 65 years; N = 124) and an older group (≥ 65 years; N = 131).

RESULTS

We found 255 patients (male 61%) eligible for our study, with a median age of 65 (interquartile range, IQR 55-73) years, and mean body mass index (BMI) of 36 ± 6.9 kg/m2. Median CPAP use was 10 h/d (IQR 10-11). BMI and depressive symptoms (DEPS) in the younger group were higher than in the older group (37.9 ± 7 vs. 34.6 ± 6.4 kg/m2, p < 0.001 and 11 (IQR 5-20) vs. 7 (IQR 5-14), p = 0.01, respectively). During follow-up, the BMI of the younger group increased (39.9 ± 12.5 kg/m2 vs. 37.9 ± 7 kg/m2, p = 0.009). DEPS values decreased in the younger group and became comparable between the groups. In multivariate models, the baseline BMI independently predicted extensive CPAP use among the younger age group, and the mask leak among the older group.

CONCLUSION

BMI at baseline in the younger and mask leak in the older group could be independent predictive factors for extensive use of CPAP.

Affecting factors and seasonal effects on the continuous positive airway pressure adherence of patients with obstructive sleep apnea

Continuous positive airway pressure (CPAP) is the preferred treatment for obstructive sleep apnea (OSA), but adherence remains challenging. This study identifies factors influencing CPAP adherence, including the impact of Korea's four distinct seasons. A retrospective study of 650 patients with OSA and prescribed with CPAP was conducted at a single institution from January 2018 to December 2020, and the patients' answers on various sleep questionnaires, demographic and polysomnographic data, and when and whether they returned the CPAP devices were collected and analyzed. The sample population was divided into when and whether the CPAP device was returned to the institution and the average daily use of the CPAP device. Results show that treatment failure is high in the first 12 weeks. Moreover, patients with more severe sleep apnea tended to have severe OSA-related clinical symptoms and are more likely to adhere to the treatment. In this study show that the seasons did not affect CPAP adherence because of indoor environmental factors. However, results show that other patient factors, such as BMI, AHI, RDI, daytime drowsiness, mood changes, and other OSA-related symptoms, have greater effects on CPAP adherence than seasonal change. Initial positive experience is important to adapt to the CPAP, and for this reason, more active intervention by sleep physicians during the initial CPAP adaptation is necessary.

Predictors of Adherence to Continuous Positive Airway Pressure in Older Adults With Apnea and Amnestic Mild Cognitive Impairment

BACKGROUND

Almost 60% of adults with amnestic mild cognitive impairment (aMCI) have obstructive sleep apnea (OSA). Treatment with continuous positive airway pressure (CPAP) may delay cognitive decline, but CPAP adherence is often suboptimal. In this study, we report predictors of CPAP adherence in older adults with aMCI who have increased odds of progressing to dementia, particularly due to Alzheimer's disease.

METHODS

The data are from Memories 2, "Changing the Trajectory of Mild Cognitive Impairment with CPAP Treatment of Obstructive Sleep Apnea." Participants had moderate to severe OSA, were CPAP naïve, and received a telehealth CPAP adherence intervention. Linear and logistic regression models examined predictors.

RESULTS

The 174 participants (mean age 67.08 years, 80 female, 38 Black persons) had a mean apnea-hypopnea index of 34.78, and 73.6% were adherent, defined as an average of ≥4 hours of CPAP use per night. Only 18 (47.4%) Black persons were CPAP adherent. In linear models, White race, moderate OSA, and participation in the tailored CPAP adherence intervention were significantly associated with higher CPAP use at 3 months. In logistic models, White persons had 9.94 times the odds of adhering to CPAP compared to Black persons. Age, sex, ethnicity, education, body mass index, nighttime sleep duration, daytime sleepiness, and cognitive status were not significant predictors.

CONCLUSIONS

Older patients with aMCI have high CPAP adherence, suggesting that age and cognitive impairment should not be a barrier to prescribing CPAP. Research is needed to improve adherence in Black patients, perhaps through culturally tailored interventions.

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.

Examining the relationship between obstructive sleep apnoea and eating behaviours and attitudes: A systematic review

BACKGROUND

Between 60 and 90% of adults with OSA are reported as overweight. The co-existence of obesity and OSA can greatly increase an individual's risk of type 2 diabetes, metabolic syndrome and cardiovascular disease. To better understand this relationship between OSA and weight, this review aimed to investigate if there is evidence of certain eating behaviours or eating attitudes that might be found in adults living with OSA.

METHODS

We searched four databases (MEDLINE, Embase, PsycInfo and Web of Science) on January 17th, 2022, to identify studies assessing the association between eating patterns and OSA in adults. Twenty-one studies met the inclusion criteria. A narrative synthesis was conducted on the included studies, following the vote-counting method.

RESULTS

There is preliminary evidence that the time of day when calories are consumed is associated with lower OSA severity. No other clear patterns of eating behaviours or attitudes were identified however this may be due to disparity within research studies and their reported results.

CONCLUSION

Further research is needed to examine the relationship between eating times and OSA severity. We recommend standardising the approach to examining the eating patterns of those living with OSA and the relationship that this might have on OSA symptoms as well as looking at attitudes towards food in this population. This may prove helpful in providing a better understanding of the relationship between OSA and persons with overweight and help in future intervention development.

Long-Term Weight Change and Glycemic Control in Patients With Type 2 Diabetes Mellitus and Treated vs. Untreated Sleep-Disordered Breathing-Analysis From the DIAbetes COhoRtE

Hypothesis: Positive airway pressure (PAP) is the standard treatment for sleep-disordered breathing (SDB), a prevalent condition in patients with type 2 diabetes mellitus (DM2). Recent studies showed that short-term PAP treatment may cause weight gain. However, long-term data for patients with DM2 are scarce. Therefore, the aim of the present analysis was to assess changes in weight and glycemic control in patients with DM2 and treated vs. untreated SDB.

Methods: The DIAbetes COhoRtE (DIACORE) study is a prospective population-based cohort study in patients with DM2. At baseline, patients of the DIACORE-SDB sub-study were tested for SDB [defined as apnea-hypopnea-index (AHI) ≥ 15/h] using a two-channel ambulatory SDB-monitoring device. In this observational study, PAP treatment was initiated in a subgroup of patients with SDB (SDB PAP) within clinical routine between the baseline and first follow-up visit [median observation period of 2.3 (2.2; 2.4) years], whereas the other patients with SDB did not receive PAP (SDB untreated). At baseline and first follow-up visit, weight and HbA1c were assessed.

Results: Of the 346 patients with SDB [mean age 68 years, 71% male, body-mass index (BMI) 31.9 kg/m²], 17% were in the SDB PAP and 83% in the SDB untreated group. Weight change within the observation period was similar in both groups (−0.2 and −0.9 kg; p = 0.322). The percentage of patients with severe weight gain (≥ 5 kg) within the observation period was significantly higher in the SDB PAP group compared to the SDB untreated group (15.0 vs. 5.6%; p = 0.011). Multivariable regression analysis, accounting for baseline HbA1c, insulin substitution, BMI, waist-to-hip ratio (WHR), physical activity, and AHI, showed that PAP treatment was significantly associated with a weight gain ≥ 5 kg [odds ratio (OR) = 3.497; 95% CI (1.343; 9.106); p = 0.010] and an increase in HbA1c [B = 2.410; 95% CI (0.118; 4.702); p = 0.039].

Conclusion: Median weight change was similar in patients with SDB with and without PAP treatment. However, patients with DM2 and PAP treatment have an increased risk of severe long-term weight gain and an increase in HbA1c.

Clinical Trial registration: DRKS00010498

Obesity and the Lung: What We Know Today

Obesity is becoming more and more prevalent especially in Western industrial nations. The understanding of adipose tissue as an endocrine organ as well as the detection of adipocytokines - hormones that are secreted from the adipose tissue - gave reason to examine the interactions between adipose tissue and target organs. These efforts have been intensified especially in the context of bariatric surgery as promising weight loss therapy. Interactions between the lung and adipose tissue have rarely been investigated and are not well understood. There are obvious mechanical effects of obesity on lung function explaining the associations between obesity and lung diseases, in particular obesity hypoventilation syndrome, obstructive sleep apnea syndrome, asthma, and chronic obstructive pulmonary disease. The rise in the prevalence of obesity affects the epidemiology of pulmonary diseases as well. The aim of this review is to summarize the current knowledge on interactions, associations, and consequences of obesity and weight loss on lung function and lung diseases. Based on these data, areas for future research are identified.

Long-Term Effects of Continuous Positive Airway Pressure (CPAP) Therapy on Obesity and Cardiovascular Comorbidities in Patients with Obstructive Sleep Apnea and Resistant Hypertension-An Observational Study

BACKGROUND

We sought to investigate whether long-term continuous positive airway pressure (CPAP) treatment in patients with obstructive sleep apnea (OSA) and resistant hypertension (RHTN) could attenuate the cardiovascular disease risk by lowering their body-mass index (BMI).

METHODS

This was a long-term observational study of RHTN patients diagnosed with OSA. Patients were evaluated with polysomnography initially and after a mean follow-up period of four years. The patients were divided into two groups based on their compliance to CPAP therapy.

RESULTS

33 patients (aged 54.67 ± 7.5, 18 men, 54.5%) were included in the study, of which 12 were compliant to CPAP therapy. A significant reduction in BMI at follow-up was noted in patients compliant to CPAP therapy (1.4 ± 3.5 vs. -1.6 ± 2.5, p = 0.006). We also noted a large effect size reduction in abdominal circumference at follow-up in the CPAP group. At follow-up evaluation, the mean heart rate (b/min) was lower in the CPAP group (58.6 ± 9.5 vs. 67.8 ± 7.8), while arrhythmia prevalence increased between initial (28.6%) and follow-up (42.9%) evaluation with an intermediate effect size in non-compliant patients.

CONCLUSIONS

In our cohort of OSA patients with RHTN, long-term adherence to CPAP therapy was associated with weight loss and improvement in cardiac rhythm outcomes.

Effects of continuous positive airway pressure (CPAP) therapy on neurological and functional rehabilitation in Basal Ganglia Stroke patients with obstructive sleep apnea: A prospective multicenter study

Obstructive sleep apnea (OSA) adversely affects neurological recovery. This study aimed to determine the impact of continuous positive airway pressure (CPAP) and/or rehabilitation in basal ganglia stroke patients with OSA.A prospective controlled trial was conducted in 2015-2018. The subjects received routine rehabilitation training for up to 2 years and were assigned to the intervention and control groups treated with CPAP or without, respectively. Then, treatment effects on sleep parameters, motor function, stroke severity, daily life activities, cognitive function, and psychological states were assessed at different time points.At 6 months, the CPAP group showed significantly lower mean apnea-hypopnea index (AHI), percentage of time with SpO2 at <90% (TS90%), micro-arousal index, and percentages of time in non-rapid eye movement (non-REM) stages 1-2 and REM stage in total sleeping time compared with the control group, and significantly higher mean minimum of peripheral oxygen saturation (L-SaO2%) and percentage of time in stage 3 (P < .001) sleep. The CPAP group showed significant improvements in average the National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer assessment scale (FMA), Barthel index (BI), Minimental state examination (MMSE), Hamilton anxiety scale (HAMA) and Hamilton depression rating scale for depression (HRSD) scores at different times versus the control group, respectively (P < .05). However, no difference in body mass index (BMI) management was observed (P > .05). Repeated-measures ANOVA revealed significant interactions between the two groups for change in FMA, MMSE, BI, HAMA, and HRSD scores from admission to 24 months (P < .001), but no significant was found for BMI (P = .582).Basal ganglia stroke patients with OSA tend to have significantly greater sleeping, neurological and functional recovery after CPAP, and rehabilitation over 2 years.

Gender-specific change in leptin concentrations during long-term CPAP therapy

Purpose

Nasal continuous positive airway pressure (CPAP) alleviates sleepiness in patients with obstructive sleep apnoea syndrome (OSAS), but part of OSAS patients keep gaining weight. Leptin and insulin-like growth factor-1 (IGF-1) interact with energy balance, and CPAP therapy has been suggested to influence these endocrine factors. We hypothesised that leptin would decrease during long-term CPAP therapy, and weight gain would associate with OSAS severity, lower CPAP adherence, lower IGF-1, and leptin concentrations.

Methods

Consecutive patients (n = 223) referred to sleep study with suspected OSAS were enrolled. Patients underwent cardiorespiratory polygraphy at baseline. Questionnaires were completed, and blood samples were drawn both at baseline and after 3 years. A total of 149 (67%; M 65, F 84) patients completed the follow-up. Plasma samples were available from 114 patients, 109 of which with CPAP adherence data (49 CPAP users, 60 non-users).

Results

At baseline, the CPAP users were more obese and had more severe OSAS than the non-users. Leptin concentrations did not differ. After follow-up, leptin concentrations were higher in CPAP users (30.2 ng/ml vs. 16.8 ng/ml; p = 0.001). In regression analysis, increase in leptin concentrations was independent of age, baseline body mass index (BMI), or the change in BMI. Leptin concentrations increased among females (− 8.9 vs. 12.7 ng/ml; p < 0.001); whereas in men, CPAP did not have an effect, if not opposed the natural decrease in leptin observed in men not using CPAP. Change in IGF-1 levels did not differ.

Conclusions

Our results suggest increase in leptin concentrations during long-term CPAP therapy among females.

Electronic supplementary material

The online version of this article (10.1007/s11325-019-01846-y) contains supplementary material, which is available to authorized users.

Adherence to Continuous Positive Airway Pressure in patients with Obstructive Sleep Apnoea. A ten year real life study

OBJECTIVE

To assess the predictive factors at 12 month and 10 year adherence to Continuous Positive Airway Pressure (CPAP) in patients with Obstructive Sleep Apnoea (OSA).

METHODS

Retrospective data analysis of patients starting CPAP between 2006 and 2009. After 12 months (T1) from start and during a 10 year follow up the following data were recorded: Body Mass Index (BMI), Time of night use, Epworth Sleepiness Scale (ESS) score.

RESULTS

Out of 315 patients, 147 fulfilled inclusion criteria and were evaluated. According to CPAP nighttime use during the first year, patients were divided into two groups: those using the device less < 4.5 h (Poor Adherence (PA): 61 patients), and those using ≥4.5 h: (Good Adherence (GA): 86 patients). Patients of PA group were significantly younger, had greater BMI and required more unscheduled visits during the first year. After 12 months, there were 11 (7.5%) dropouts, all in PA group. Patients using the nasal mask showed a greater prevalence among GA as compared to those using the oro-nasal mask (76.5% vs 57.8% respectively, p = 0.04). After 10 years 83 out of 147 (56.4%) patients were still under CPAP, 51 (59.3% of GA) and 32 (52.4% of PA group) respectively. Dropouts were significantly more frequent during the first 5 years (p = 0.04).

CONCLUSION

Ten years after prescription the majority of patients with OSA undergoing periodical controls, still perform CPAP independent of their adherence to therapy after one year of use. Use of nasal mask may be associate to better adherence.

Prolonged partial obstruction during sleep is a NREM phenomenon

OBJECTIVE

Prolonged partial obstruction (PPO) is a common finding in sleep studies. Although not verified, it seems to emerge in deep sleep. We study the effect of PPO on sleep architecture or sleep electroencephalography (EEG) frequency.

METHODS

Fifteen OSA patients, 15 PPO + OSA patients and 15 healthy subjects underwent a polysomnography. PPO was detected from Emfit mattress signal. Visual sleep parameters and median NREM sleep frequency of the EEG channels were evaluated.

RESULTS

The amount of deep sleep (N3) did not differ between the PPO + OSA and control groups (medians 11.8% and 13.8%). PPO + OSA-patients' N3 consisted mostly of PPO. PPO + OSA patients had lighter sleep than healthy controls in three brain areas (Fp2-A1, C4-A1, O1-A2, p-values < 0.05).

CONCLUSION

PPO evolved in NREM sleep and especially in N3 indicating that upper airway obstruction does not always ameliorate in deep sleep but changes the type. Even if PPO + OSA-patients had N3, their NREM sleep was lighter in three EEG locations. This might reflect impaired recovery function of sleep.

Therapeutic outcomes of mandibular advancement devices as an initial treatment modality for obstructive sleep apnea

Although continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA), there is a need for alternative treatment options, such as sleep surgeries and mandibular advancement devices (MADs), to overcome the limitations of CPAP.This study aimed to analyze the therapeutic outcomes of OSA subjects who were treated with a MAD, and to estimate the clinical impact of MAD as a first-line treatment for OSA.Forty-seven patients diagnosed with OSA received an adjustable MAD as an initial treatment. Drug-induced sleep endoscopic findings and sleep parameters (both pre-MAD and post-MAD treatment), such as apnea index, oxygen saturation, and degree of daytime sleepiness, were assessed retrospectively.The MAD treatment resulted in a significant reduction in apnea-hypopnea index, and also a significant elevation in lowest oxygen saturation. Satisfactory results of MAD treatment as a first treatment modality were observed in 27 patients, and a successful outcome was reached in approximately 72% of patients. The OSA patients who had lower body mass index and upper airway narrowing at the level of palate and tongue base showed relatively higher rates of a satisfactory outcome even in cases of moderate or severe OSA.These results suggest that the use of a MAD may be an alternative treatment option in OSA patients with retropalatal and retroglossal area narrowing regardless of disease severity. Additionally, MADs can be recommended as an initial treatment modality, and the effectiveness of MADs in achieving success may not be inferior to CPAP.

Prolonged partial upper airway obstruction during sleep - an underdiagnosed phenotype of sleep-disordered breathing

Obstructive sleep apnea syndrome (OSAS) is a well-recognized disorder conventionally diagnosed with an elevated apnea-hypopnea index. Prolonged partial upper airway obstruction is a common phenotype of sleep-disordered breathing (SDB), which however is still largely underreported. The major reasons for this are that cyclic breathing pattern coupled with arousals and arterial oxyhemoglobin saturation are easy to detect and considered more important than prolonged episodes of increased respiratory effort with increased levels of carbon dioxide in the absence of cycling breathing pattern and repetitive arousals. There is also a growing body of evidence that prolonged partial obstruction is a clinically significant form of SDB, which is associated with symptoms and co-morbidities which may partially differ from those associated with OSAS. Partial upper airway obstruction is most prevalent in women, and it is treatable with the nasal continuous positive pressure device with good adherence to therapy. This review describes the characteristics of prolonged partial upper airway obstruction during sleep in terms of diagnostics, pathophysiology, clinical presentation, and comorbidity to improve recognition of this phenotype and its timely and appropriate treatment.