CPAP adherence after ambulatory and in-hospital management in patients aged 65 years and older

OBJECTIVES

The aims of this study are to evaluate the early adherence to CPAP treatment in patients aged 65 years and older and to compare ambulatory (ACPAP) and in-hospital (HCPAP) management in starting CPAP treatment.

METHODS

Adherence to CPAP therapy at 3 months was retrospectively studied in patients on whom CPAP therapy was initiated between 1 January 2020 and 31 December 2021. Patients in the ACPAP group were selected based on the current Belgian reimbursement criteria (OAHI ≥30/h and few comorbidities).

RESULTS

146 patients were studied (median OAHI 43.35/h [32.02; 57.40]; median age 69 [67.0; 73.0]): 116 (79.5%) patients in the HCPAP and 30 (20.5%) in the ACPAP group. Based on an adherence threshold of average CPAP use of ≥ 4 hours per day, 120 (82%) patients were adherent to the treatment; 94 (81%) patients in the HCPAP and 26 (86.7%) in the ACPAP group. The median CPAP use for the total population was 6.4 h/day [4.89; 7.34], reaching 6.3 h/d [4.79; 7.15] for the HCPAP group and 6.8 h/d [6.21; 8.06] for the ACPAP group (p = 0.019). Insomnia was a significant risk factor for non-adherence (OR 5.16 [1.64; 16.08], p = 0.0043) but the ACPAP method was not (OR 0.66 [0.18; 1.91], p = 0.4748).

CONCLUSION

Early CPAP adherence in patients ≥ 65 years old was good in terms of average use per day and proportion of adherent patients. ACPAP method was not a risk factor for lower CPAP adherence in patients presenting severe OSAS (OAHI ≥30/h) and few comorbidities.

The Influence of CPAP Therapy on Basal Metabolic Rate and Physical Activity in Obese Patients with Obstructive Sleep Apnea

BACKGROUND

Energy balance in Obstructive Sleep Apnea (OSA), a disease closely related to obesity, is disturbed, and physical activity levels are impaired. The role of Continuous Positive Airway Pressure treatment (CPAP) in alleviating the disruptions mentioned above is questioned. The objective of this study is to explore changes in energy expenditure (EE) and physical activity (PA) in obese patients with OSA after CPAP treatment.

METHODS

An assessment of Basal Metabolic Rate (BMR) via indirect calorimetry (IC) was performed on 24 obese patients (male in the majority (87.5%), mean age of 52.4 ± 9.8 years), newly diagnosed with moderate-severe OSA by polysomnography, at 4-time points: at baseline, at CPAP titration, at the 1-month and the 3-month follow up. Physical activity levels were subjectively estimated using the International Questionnaire of Physical Activity (IPAQ) before and after 3 months of adherent CPAP application.

RESULTS

BMR significantly decreased after CPAP treatment (1926 ± 537.8 kcal/d at baseline, 1790 ± 493.7 kcal/d at CPAP initiation, 1680.3 ± 600.8 kcal/d at 1 month, and 1581.3 ± 478.9 kcal/d at 3 months follow up (p < 0.001)). No significant changes in IPAQ were observed over time: baseline median IPAQ: 3894 (1487.5-11,755.5) total MET·min·wk-1, 3-month median IPAQ: 3900 (1512-11,824.5) total MET·min·wk-1.

CONCLUSIONS

CPAP has an appreciable time effect on the BMR of obese patients with moderate-severe OSA. However, this change is not accompanied by a significant increase in physical activity levels.

Cognitive Functions, Depressive and Anxiety Symptoms After One Year of CPAP Treatment in Obstructive Sleep Apnea

Objective

The study worked with depressive symptoms, anxiety score and cognitive functions in obstructive sleep apnea (OSA) patients treated with CPAP.

Methods

Eighty-one subjects with OSA and without psychiatric comorbidity were treated with CPAP for one year and completed the following scales and cognitive tests: Trail Making Test, Verbal Fluency Test, d2 Test, Beck Depression Inventory-II and Beck Anxiety Inventory. MINI ruled out psychiatric disorder. At the two months check-up, subjects were re-evaluated for depressive and anxiety symptoms, and after one year of CPAP treatment, subjects repeated cognitive tests and scales. Data about therapy adherence and effectiveness were obtained from the patient's CPAP machines.

Results

The study was completed by 59 CPAP adherent patients and eight non-adherent patients. CPAP therapy effectiveness was verified in all patients by decreasing the apnea-hypopnoea index below 5 and/or 10% of baseline values. The adherent patients significantly improved depressive and anxiety symptoms. There was also an improvement in overall performance in the attention test; however, performance in many individual items did not change. The adherent patients also improved verbal fluency and in the Part B of the Trail making test. The non-adherent group significantly increased the number of mistakes made in the d2 test; other results were non-significant.

Conclusion

According to our results, OSA patients' mood, anxiety and certain cognitive domains improved during the one-year therapy with CPAP.

Trial Registration Number

NCT03866161.

Impact of continuous positive airway pressure ventilation on cardiovascular outcomes among patients with obstructive sleep apnea: A meta-analysis of randomized trials

Background

The impact of continuous positive airway pressure (CPAP) on cardiovascular outcomes among patients with obstructive sleep apnea (OSA) is controversial.

Objective

To evaluate the impact of CPAP on reducing cardiovascular outcomes in patients with OSA.

Methods

We performed a computerized search of MEDLINE, EMBASE and COCHRANE databases through April 2021 for randomized trials evaluating the impact of CPAP versus control on cardiovascular outcomes in patients with OSA. Summary estimates were reported using both fixed and random effects model. The main study outcome was major adverse cardiac events (MACE).

Results

The final analysis included 8 randomized trials with total of 5684 patients. The weighted mean follow-up was 42.6 months. There was no difference between the CPAP and control groups in the risk of MACE (14.4% versus 14.8%, risk ratio [RR]: 0.97; 95% confidence interval [CI]: 0.85 to 1.10; p = 0.60; I2 = 21%). Subgroup analysis suggested that CPAP was associated with lower MACE (by 36%) in CPAP-adherent patients (≥4 h/night) (Pinteraction = 0.08). There was no difference between the CPAP and control groups in the risk of all-cause mortality, cardiovascular mortality, acute stroke, acute myocardium infarction or hospitalizations for angina.

Conclusions and relevance

CPAP use might not be associated with lower cardiovascular events among patients with OSA. However, patients adherent to CPAP (≥4 h/night) might derive a benefit on cardiovascular outcomes. Future studies are warranted to evaluate the impact of CPAP in reducing cardiovascular events among patients with severe OSA and with optimal adherence rates to CPAP therapy.

Alternative Procedure to Individual Nasal Pressure Titration for Sleep Apnea

In the treatment of obstructive sleep apnea (OSA), the current standard of "CPAP titration" in the laboratory or at home is a resource demanding and costly approach that, in developed economies, markedly augments healthcare costs and in low resource economies precludes access to care altogether. Here, we discuss that current guidelines for titration of CPAP could be obviated by taking a different route that in many ways is similar to the institution of treatment in many other medical conditions. To this effect, we present novel population based data from 16,780 patients, showing that after individualized and labor-intensive and expensive CPAP titration, 86.4% of OSA patients are treated with nasal pressure settings within the range of 9 ± 2 cmH₂O, and review the literature to justify the potential adoption of a standard therapeutic CPAP setting as the initial intervention which would be subsequently followed by any necessary adjustments in only a minority of patients who would not derive the necessary benefit from such standardized intervention. Assuming an 80-85% success rate as derived from our analyses, our personal view if extensively adopted could radically reduce healthcare costs and enable markedly improve access to diagnostics.

Use of the WatchPAT to detect occult residual sleep-disordered breathing in patients on CPAP for obstructive sleep apnea

STUDY OBJECTIVES

To determine the accuracy of the apnea-hypopnea index (AHI) as measured by continuous positive airway pressure (CPAP) machines by simultaneously employing a home sleep apnea testing device (WatchPAT 200, Itamar Medical, Israel [WPAT]) in patients suspected of having residual sleep-disordered breathing (SDB).

METHODS

Patients with new, recurrent, or worsening signs, symptoms, or comorbidities associated with obstructive sleep apnea underwent home sleep apnea testing using WPAT while simultaneously using CPAP at their usual prescribed settings. CPAP AHI and WPAT AHI, respiratory disturbance index, and oximetry readings were then compared.

RESULTS

We identified an elevated AHI with WPAT testing in nearly half of patients with clinically suspected residual SDB and a normal CPAP AHI. WPAT detected additional respiratory events as well, including rapid eye movement-related apneas, respiratory effort-related arousals, and hypoxemia.

CONCLUSIONS

WPAT AHI was significantly higher than simultaneous CPAP AHI in nearly half of those patients with clinically suspected residual SDB being treated with CPAP. Additional respiratory disturbances, including rapid eye movement-related respiratory events, respiratory effort-related arousals, and hypoxemia, were elucidated only with the use of the WPAT. Residual SDB may have potential clinical consequences, including reduced CPAP adherence, ongoing hypersomnolence, and other health-related sequelae. Simultaneous WPAT testing of patients with a normal CPAP AHI may represent a valuable tool to detect clinically suspected residual SDB or to ensure adequate treatment in high-risk patients with obstructive sleep apnea in general.

Comparison of the effect of weight change, simulated computational continuous positive airway pressure treatment and positional therapy on severity of sleep apnea

Weight loss, continuous positive airway pressure (CPAP) and positional therapy (PT) are important treatments in obstructive sleep apnea (OSA). Although all of these reduce the apnea-hypopnea index (AHI) effectively, the benefits of these treatments have not been thoroughly investigated in a patient-specific manner. Therefore, clinicians do not have objective means to choose an optimal treatment for each patient. We aim to provide clinicians the possibility for treatment optimization in a patient-specific manner by introducing a computational simulation approach. The effect of actual weight change, computationally simulated CPAP treatment and PT and their combinations on the AHI were compared in 54 OSA patients divided into three equally sized groups (weight loss > 7%, weight loss 0%-7%, and weight gain) after a 5-year follow-up with lifestyle intervention. Weight loss reduced the AHI by 43.5% (p < .05) and 18%, simulated CPAP treatment with 3.3-hr adherence by 42.4% (p < .05) and 35.5% (p < .05), and simulated PT by 13.5% (p < .05) and 30.7% (p < .05) in > 7% and 0%-7% weight loss groups, respectively. Simulated CPAP treatment and PT were able to compensate for the increase in the AHI caused by weight gain. A developed simulation approach could help clinicians to estimate treatment success in advance in order to prescribe the most optimal patient-specific treatment to reduce OSA-related health risks.

Quality of life of obstructive sleep apnoea patients receiving continuous positive airway pressure treatment: A systematic review and meta-analysis

BACKGROUND

Previous studies have shown conflicting results on the effect of continuous positive airway pressure (CPAP) on quality of life (QoL) in obstructive sleep apnoea (OSA) patients.

OBJECTIVES

To evaluate the effect of CPAP on QoL in OSA patients compared to sham CPAP, placebo pills, and conservative treatment.

METHODS

Studies were identified via Web of Knowledge, PubMed, PsychInfo, CINAHL, EMBASE, OpenGrey, and the Cochrane Library. Subgroup analyses and sensitivity analyses were conducted to assess the robustness of the findings.

RESULTS

Meta-analysis of 13 randomised controlled trials showed no significant differences in overall and psychological QoL comparing values of CPAP treated patients with controls; however, physical QoL improved. CPAP significantly affected the overall QoL in studies with controls receiving sham CPAP, parallel design, low risk of bias, and mild OSA patients.

CONCLUSION

CPAP treatment may help to improve physical symptoms of OSA, whereas impaired psychological QoL still cannot be alleviated.

Intra- and Inter-Physician Agreement in Therapeutic Decision for Sleep Apnea Syndrome

BACKGROUND

Large variation in diagnostic procedures and treatment recommendations may hinder the management of obstructive sleep apnea (OSA) and also compromise correct interpretation of the results of multicenter clinical trials, especially in subjects with non-severe OSA. The aim of this study was to analyze the therapeutic decision-making between different sleep physicians in patients with AHI<40events/h.

METHODS

Six experienced senior sleep specialists from different sleep centers of Spain were asked to make a therapeutic decision (CPAP treatment) based on anonymized recordings of patients with suspected OSA that has previously performed a sleep study. The clinical data was shown in an online database and included anthropometric features, clinical questionnaires, comorbidities, physical examination and sleep study results. Intra- and inter-observer decision-making were analyzed by the Fleiss' Kappa statistics (Kappa).

RESULTS

A total of 720 medical decisions were taken to analyze the agreement between sleep professionals. Overall intra-observer evaluation reliability was almost perfect (Kappa=0.83, 95% CI, 0.75-0.90, p<0.001). However, overall inter-observer concordance decreased to moderate agreement (Kappa=0.46, 95% CI, 0.42-0.51, p<0.001). Nevertheless, it was especially low when considering AHI<15events/h.

CONCLUSIONS

This study demonstrates a good intra-observer concordance in the therapeutic decision-making of different sleep physicians treating patients with low/moderate OSA. However, when analyzing inter-observer agreement the results were considerably worse. These findings underline the importance of developing improved consensus management protocols.

Role of Positive Airway Pressure Therapy for Obstructive Sleep Apnea in Patients With Stroke: A Randomized Controlled Trial

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is an independent risk factor for stroke. The objective of this study was to assess the effect of continuous positive airway pressure (CPAP) treatment on prevention of new vascular events among patients with stroke and OSA.

METHODS

Consecutive conscious patients presenting with first imaging-confirmed arterial stroke were included, 6 weeks or more after ictus. All patients underwent clinical and polysomnography (PSG) testing. Patients with an apnea-hypopnea index (AHI) of > 15 events/h were randomized to posttitration nightly CPAP treatment and non-CPAP (received best medical treatment) groups. On follow-up at 3, 6, and 12 months from randomization, evaluation was carried out for any new vascular events as the primary outcome measure, and for clinical stroke outcomes (using the Barthel Index and modified Rankin scale) and neuropsychological parameters as the secondary outcome measures.

RESULTS

Among the 679 patients with stroke who were screened, 116 reported for PSG, 83 had AHI > 15 events/h, and 70 (34 in CPAP and 36 in non-CPAP) were randomized. Thirteen patients could not be randomized because of a lack of CPAP devices. Four patients crossed over from the CPAP to the non-CPAP group. Age (mean age 53.41 ± 9.85 in CPAP versus 52.69 ± 13.23 years in non-CPAP, P = .81) and sex distribution (24 males in CPAP versus 33 males in non-CPAP, P = .79) were similar in both groups. At 12-month follow-up, there was 1 vascular event (3.33%) in the CPAP group and 6 events (15%) in the non-CPAP group (P = .23). Modified Rankin scale score improvement by ≥ 1 at 12-month follow-up was found in significantly more patients in the CPAP group than in the non-CPAP group (53% versus 27%).

CONCLUSIONS

These findings suggest significantly better stroke outcomes and statistically nonsignificant favorable outcomes in terms of recurrence of vascular events for patients with stroke and OSA who use CPAP treatment.

CLINICAL TRIAL REGISTRATION

Registry: Clinical Trials Registry - India, CTRI Registration No: CTRI/2016/07.007104, Title: Sleep Disordered Breathing in stroke patients: Effect of treatment trial, URL: http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=8682&EncHid=&userName=sleep%20disordered%20breathing.

Pressure-Relief Features of Fixed and Autotitrating Continuous Positive Airway Pressure May Impair Their Efficacy: Evaluation with a Respiratory Bench Model

STUDY OBJECTIVES

Pressure-relief features are aimed at improving the patient's comfort during continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea. The objective of this study was to determine the effect of these therapy features on fixed CPAP and autotitrating CPAP (APAP) treatment efficacy.

METHODS

Seven pressure-relief features applied by three CPAP devices were included in our study (Remstar Auto: C-Flex 3, C-Flex+ 3, A-Flex 3, P-Flex; AirSense 10: EPR 3; Prisma 20A: SoftPAP 2 and 3). In fixed CPAP, the devices were subjected to a 10-min bench-simulated obstructive apnea sequence (initial apnea-hypopnea index, AHI = 60/h) with and without pressure-relief features. In APAP, the sequence was lengthened to 4.2 h (initial AHI = 58.6/h). The residual AHI and mean/median pressure were compared with and without pressure-relief features.

RESULTS

Compared to conventional CPAP, where pressure was adjusted to be just sufficient to control the simulated obstructive events, C-Flex+ 3, P-Flex, and EPR 3 failed to normalize the breathing flow and did not reduce the AHI. The mean pressures with the three features, respectively, were 1.8, 2.6, and 2.6 cmH2O lower than the conventional CPAP. Compared to conventional APAP, similar levels of control were observed with pressure-relief features, apart from P-Flex where the delivered mean pressure was lower and residual AHI greater. The device-reported mean/median pressures in APAP with A-Flex 3, P-Flex, EPR 3, and SoftPAP 3 were higher than that measured on the bench.

CONCLUSIONS

Pressure-relief features may attenuate CPAP efficacy if not adjusted for at the time of their introduction. In clinical practice, efficacy can be ensured by increasing the therapeutic pressure delivered by fixed CPAP or by enabling the pressure-relief features prior to initial pressure titration. Device-reported pressures in APAP devices with pressure relief activated may overstate delivered pressures.

The association between continuous positive airway pressure therapy and liver disease development in obstructive sleep apnea/hypopnea syndrome patients: a nationwide population-based cohort study in Taiwan

PURPOSE

Studies on the association between continuous positive airway pressure (CPAP) treatment and liver diseases such as non-alcoholic fatty liver disease (NAFLD) and cirrhosis in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS) are limited. To the best of our knowledge, none exists that makes use of a national database in an Asian population. This study aims to evaluate the effects of CPAP treatment on patients with these two disorders in a retrospective, population-based study in Taiwan.

METHODS

Using the Taiwan National Health Insurance claims database, this study collected the data of OSAHS patients diagnosed between 2000 and 2008 and divided them into CPAP treatment and non-CPAP treatment groups. All subjects were followed up until 2010. Liver disease incidence and risk were calculated.

RESULTS

The CPAP group had a lower cumulative incidence rate of developing liver disease than the non-CPAP group within the observation periods (p < 0.001). After adjusting for age, gender, urbanization level, and comorbidities, the CPAP treatment group showed a lower risk of developing liver disease compared with the non-CPAP treatment group (sub-aHR of 0.66 (95% CI 0.55-0.80), p < 0.001).

CONCLUSIONS

Our observations suggest that CPAP treatment may play an important role to delay the progression of liver disease in OSAHS patients and decreases the incidence of liver disease among OSAHS patients. Thus, CPAP therapy may be a feasible way to decrease the risk of liver disease among patients with OSAHS.

Protective Effect of Long-Term CPAP Therapy on Cognitive Performance in Elderly Patients with Severe OSA: The PROOF Study

OBJECTIVE

Obstructive sleep apnea syndrome (OSA) leads to a deterioration in cognitive functions, with regard to memory and executive functions. However, few studies have investigated the impact of treatment on these cognitive functions in elderly subjects.

METHODS

The study was conducted in a large cohort of subjects aged 65 years or older (the PROOF cohort). Subjects were not diagnosed or treated for OSA. Subjects underwent a polygraphic recording. Cognitive performance was assessed in all OSA subjects at baseline and 10 years later, whether or not they were receiving continuous positive airway pressure (CPAP) therapy.

RESULTS

A group of 126 patients were analyzed. Only 26% of them were treated, with therapy initiated at the discretion of the primary care physician. Among treated subjects, self-reported compliance with therapy was good (> 6 h/night on average), and 66% of them reported an improvement in their quality of life. Patients receiving CPAP treatment had a higher apneahypopnea index (p = 0.006), a higher oxygen desaturation index (p < 0.001), and experienced more pronounced daytime repercussions (p = 0.004). These patients showed a statistically significant improvement in mental agility (similarities test; p < 0.0001) and memory performance (Grober and Buschke delayed free recall; p = 0.02).

CONCLUSION

CPAP treatment is associated with the maintenance of memory performance over time.

Continuous positive airway pressure in severe obstructive sleep apnea reduces pain sensitivity

STUDY OBJECTIVE

To evaluate effects of CPAP on pain sensitivity in severe OSA patients.

DESIGN

Within-subject treatment study.

SETTING

Hospital-based sleep disorders center.

PATIENTS

Twelve severe OSA patients (7 men, 5 women), 50.2 ± 12.5 years, with no pain.

INTERVENTIONS

The morning after a diagnostic nocturnal polysomnogram (NPSG), patients underwent a training session of finger withdrawal latency (FWL) testing to a radiant heat stimulus, a validated human behavioral model of thermal nociception. Baseline FWL in seconds was obtained after the training session. CPAP pressure was titrated on a second night in the laboratory. Two nights after titration, patients returned to sleep in the laboratory on CPAP. FWL was tested in the morning after awakening, after 6-8 wks of CPAP use, and finally (within 6-8 weeks) after 2 nights of discontinuation of CPAP. Mean FWL in seconds (sec) was compared using MANOVAs with nights as the within subject variable.

RESULTS

Apnea-hypopnea index (AHI) decreased from 50.9 ± 14.5 to 1.4 ± 1.0 with CPAP, and sleep continuity improved. In parallel, FWL increased significantly from a mean baseline of 9.8 ± 1.3 sec to 13.7 ± 5.1 sec (P = 0.01) and with continued CPAP use (5.1 ± 2.3 h nightly) for 6-8 weeks FWL remained elevated (21.1 ± 16.2 sec). After the 2-night CPAP discontinuation, apnea/hypopneas returned and sleep was fragmented (AHI = 32.6 ± 19.8). FWL decreased to 11.6 ± 5.9 sec relative to intermediate-term CPAP use (P = 0.03).

CONCLUSION

CPAP treatment reduces pain sensitivity in OSA patients. Future studies will focus on patients with OSA and chronic pain and identify mediating mechanisms.