Early CPAP use after anterior skull base surgery: A cautionary tale of postoperative CSF leak case report.

Obstructive sleep apnea (OSA) is a common pediatric condition characterized by recurrent partial or complete cessation of airflow during sleep, typically due to inadequate upper airway patency. Continuous positive airway pressure (CPAP) is a therapeutic option that reduces morbidity. Despite efforts to promote use, CPAP adherence is poor in both pediatric and adult populations. We sought to determine whether demographics, insurance status, OSA severity, therapeutic pressure, or comorbid conditions were associated with pediatric CPAP adherence. A retrospective review of adherence download data was performed on all pediatric patients with initiation or adjustment of CPAP treatment over a one-year period with documented in-laboratory CPAP titration. Patients were grouped as CPAP adherent or non-adherent, where adherence was defined as > 70% nightly use and average usage ≥ 4 hours per night. Differences between the groups were analyzed by χ(2) test. Overall, nearly half of participants were CPAP adherent (49%, 69/140). Of the demographic data collected (age, ethnicity, sex, insurance status), only female sex was associated with better adherence (60.9% vs 39.5% of males adherent; odds ratio [OR] = 2.41, 95%CI = 1.20-4.85; p = 0.01). Severity of OSA (diagnostic apnea-hypopnea index [AHI] and degree of hypoxemia), therapeutic pressure, and residual AHI did not impact CPAP adherence (p > 0.05). Patients with developmental delay (DD) were more likely to be adherent with CPAP than those without a DD diagnosis (OR = 2.55, 95%CI = 1.27-5.13; p = 0.007). Female patients with trisomy 21 tended to be more adherent, but this did not reach significance or account for the overall increased adherence associated with female sex. Our study demonstrates that adherence to CPAP therapy is poor but suggests that female sex and developmental delay are associated with better adherence. These findings support efforts to understand the pathophysiology of and to develop adherence-promoting and alternative interventions for pediatric OSA.

Endoscopic skull base surgery continues to evolve in its indications, techniques, instrumentation, and postoperative care. As surgery of the skull base will often violate dura, intraoperative and postoperative cerebrospinal fluid (CSF) leak is not uncommon and represents a potential conduit for air and bacterial contamination. Patients with obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) therapy undergoing skull base surgery represent a challenging group. However, there appears to be a paucity of consensus regarding the postoperative management of this patient population. The objective of this study is to examine practice patterns and expert opinion on the use of postoperative CPAP and nasal saline in patients with OSA. A 14-item survey was generated by consensus among expert authors and distributed online to members of the North American Skull Base society and other international skull base community members. Data were analyzed for median, mean, and standard deviation variables. Subgroup analysis was completed between surgeons from different geographical locations and operative experience. SPSS22 was utilized for all complex statistical analysis and figures. Seventy-one responses were collected from skull base surgeons. In patients with OSA, respondents would resume patients' CPAP therapy after a mean of 10.1 days (median, 7; standard deviation [SD], 10.2), without a CSF leak. In the presence of a small CSF leak, the mean duration would increase to 14.3 days (median, 14; SD, 9.8) and to 20.7 days (median, 21; SD, 11.8) in the presence of a larger leak. A surgeon's choice to attribute the relationship between delaying the start of nasal saline and CPAP after the endoscopic skull base surgery with progressively more challenging skull base repair was found to be statistically significant ( P < .001). Saline and CPAP therapies are initiated after the endoscopic skull base surgical repairs by surgeons at an increasing temporal delay in relation to the degree and complexity of the skull base defect repaired.

To determine if the type of continuous positive airway pressure (CPAP) mask interface influences CPAP treatment efficacy, adherence, side effects, comfort and sleep quality in patients with moderate-severe obstructive sleep apnea (OSA). This took place in a hospital-based tertiary sleep disorders unit. It is a prospective, randomized, crossover trial comparing three CPAP interfaces: nasal mask (NM), nasal mask plus chinstrap (NM-CS) and oronasal mask (ONM) each tried in random order, for 4 weeks. After each 4-week period, patient outcomes were assessed. Participants had a new diagnosis of obstructive sleep apneas. Forty-eight patients with moderate-severe OSA (32 males, mean ± standard deviation apnea-hypopnea index (AHI) 55.6 ± 21.1 events/h, age 54.9 ± 13.1 years, body mass index 35.8 ± 7.2 kg/m2) were randomized. Thirty-five participants completed the full study, with complete data available for 34 patients. There was no statistically significant difference in CPAP adherence; however, residual AHI was higher with ONM than NM and NM-CS (residual AHI 7.1 ± 7.7, 4.0 ± 3.1, 4.2 ± 3.7 events/h respectively, main effect P = .001). Patient satisfaction and quality of sleep were higher with the NM and NM-CS than the ONM. Fewer leak and mask fit problems were reported with NM (all chi-square P < .05), which patients preferred over the NM-CS and ONM options (n = 22, 9 and 4 respectively, P = .001). The CPAP adherence did not differ between the three different mask interfaces but the residual AHI was lower with NM than ONM and patients reported greater mask comfort, better sleep, and overall preference for a NM. A nasal mask with or without chinstrap should be the first choice for patients with OSA referred for CPAP treatment. Registry: Australian and New Zealand Clinical Trials Registry, URL: https://www.anzctr.org.au, title: A comparison of continuous positive airway pressure (CPAP) interface in the control of leak, patient compliance and patient preference: nasal CPAP mask and chinstrap versus full face mask in patients with obstructive sleep apnoea (OSA), identifier: ACTRN12609000029291.

Introduction Continuous Positive Airway Pressure (CPAP) therapy is a common and effective treatment for obstructive sleep apnea (OSA). Among patients with stroke and OSA, CPAP therapy is associated with reduced stroke risk and improved recovery but is limited by generally poor adherence. We aimed to explore the association between clinical factors and the first 3 months of CPAP use within a stroke rehabilitation population who were provided with enhanced CPAP support. Methods Stroke patients admitted to inpatient rehabilitation (IPR) were enrolled and tested for OSA with a portable sleep apnea test. Eligible participants were provided CPAP for 3 months along with a multicomponent CPAP adherence intervention, including technical support, motivational interviewing, and mobile health interventions. Associations between demographics, stroke severity, and OSA-related factors and average CPAP use over 3 months were evaluated using t-tests. Results Thirty-three of 36 participants met criteria for OSA [mean age= 58 ± 11 years, 67% male, 52% non-Hispanic white (NHW)]. The mean respiratory event index (REI) was 21/hour and mean NIH Stroke Scale score was 6. Three participants withdrew from the study during IPR. Among the 30 remaining participants, mean nightly CPAP use over 3 months was 3.1 hours. Mean nightly CPAP use during IPR (3.3 ± 0.9 hours over a mean of 12.6 ± 2.4 days) was predictive of mean CPAP use after IPR (3.0 ± 1.1 hours), p = 0.01 (linear model). Mean nightly CPAP use was 4.8 hours among those with REI ≥ 30 compared to 2.4 hours among participants with REI&amp;lt; 30 (p=0.04). Mean CPAP use did not differ by stroke severity, oxygen desaturation index, age, gender or obesity. Conclusion In this study of enhanced CPAP support initiated during stroke IPR, OSA severity, but not stroke severity, was associated with CPAP use over a 3-month period. CPAP use during IPR was associated with CPAP use after IPR. Further investigations regarding the relationships of stroke, sleep apnea, and CPAP adherence are warranted to improve outcomes for patients with these common, and often comorbid, conditions. Support (if any)

Clinical and Polysomnographic Predictors of Short-Term Continuous Positive Airway Pressure Compliance

Patients with severe OSA consume greater amounts of cholesterol, protein, and fat as well as have greater caloric expenditure. However, it is not known whether their activity levels or diet change after treatment with CPAP. To investigate this issue, serial assessments of activity and dietary intake were performed in the Apnea Positive Pressure Long-term Efficacy Study (APPLES); a 6-month randomized controlled study of CPAP vs. sham CPAP on neurocognitive outcomes. Subjects were recruited into APPLES at 5 sites through clinic encounters or public advertisement. After undergoing a diagnostic polysomnogram, subjects were randomized to CPAP or sham if their AHI was ≥ 10. Adherence was assessed using data cards from the devices. At the Tucson and Walla Walla sites, subjects were asked to complete validated activity and food frequency questionnaires at baseline and their 4-month visit. Activity and diet data were available at baseline and after 4 months treatment with CPAP or sham in up to 231 subjects (117 CPAP, 114 Sham). Mean age, AHI, BMI, and Epworth Sleepiness Score (ESS) for this cohort were 55 ± 13 [SD] years, 44 ± 27 /h, 33 ± 7.8 kg/m(2), and 10 ± 4, respectively. The participants lacking activity and diet data were younger, had lower AHI and arousal index, and had better sleep efficiency (p < 0.05). The BMI was higher among women in both CPAP and Sham groups. However, compared to women, men had higher AHI only in the CPAP group (50 vs. 34). Similarly, the arousal index was higher among men in CPAP group. Level of adherence defined as hours of device usage per night at 4 months was significantly higher among men in CPAP group (4.0 ± 2.9 vs. 2.6 ± 2.6). No changes in consumption of total calories, protein, carbohydrate or fat were noted after 4 months. Except for a modest increase in recreational activity in women (268 ± 85 vs. 170 ± 47 calories, p < 0.05), there also were no changes in activity patterns. Except for a modest increase in recreational activity in women, OSA patients treated with CPAP do not substantially change their diet or physical activity habits after treatment. .

Duration of positive airway pressure adherence: how much PAP is enough?

CPAP for excessive sleepiness in elderly patients

Resistant Hypertension in Obstructive Sleep Apnea: Is Continuous Positive Airway Pressure the Next Step?

Central sleep apnea (CSA) may occasionally occur in patients with obstructive sleep apnea during titration with a continuous positive airway pressure (CPAP) device. To determine the prevalence and the natural history of CPAP-emergent CSA. This is a retrospective study of 1286 patients with a diagnosis of OSAwho underwent titration with a positive airway device during a 1-year period. Patients were seen in consultation and underwent full-night attended polysomnography followed by full-night attended CPAP titration. Four weeks after CPAP therapy, patients returned to the clinic for follow-up, and objective adherence to CPAP was recorded. In patients who had CSA on CPAP, a second full-night attended CPAP titration was recommended. Eighty-four of the 1286 patients developed a central apnea index (CAI) of 5 or greater per hour while on CPAP. The incidence of CSA varied from 3% to 10% monthly, with an overall incidence of 6.5%. Forty-two of the 84 patients returned for a second CPAP titration. In 33 patients, CSA was eliminated. In each of the remaining 9 patients, the CAI remained at 5 or greater per hour, with an average of 13 per hour. These patients characteristically had the most severe OSA, and 5 had a CAI of 5 or more per hour at baseline. Two of the 9 patients were on opioids In this large retrospective study of 1286 patients with a diagnosis of OSA, 6.5% had CPAP-emergent or persistent CSA. However, CPAP-emergent CSA was generally transitory and was eliminated within 8 weeks after CPAP therapy. The prevalence of CPAP-persistent CSA was about 1.5%. Severity of OSA, a CAI of 5 or greater per hour, and use of opioids were potential risk factors.

Noninvasive Ventilation and Exogenous Surfactant in Times of Ever Decreasing Gestational Age: How Do We Make the Most of These Tools?

Excessive daytime sleepiness is a frequent symptom of obstructive sleep apnea (OSA) and has been proposed as a motivator for adherence to continuous positive airway pressure (CPAP) therapy. However, excessive daytime sleepiness is absent in many patients with coronary artery disease (CAD) and concomitant OSA. We evaluated long-term use of CPAP and predictors of CPAP use in nonsleepy and sleepy OSA patients from a CAD cohort. Long-term CPAP use is lower in CAD patients with nonsleepy OSA vs sleepy OSA. Nonsleepy (Epworth Sleepiness Scale [ESS] score < 10) OSA patients randomized to CPAP (n = 122) and sleepy (ESS ≥10) OSA patients offered CPAP (n = 155) in the RICCADSA trial in Sweden were included in this substudy. The median follow-up was 4.8 years for the main trial, with a predefined minimum follow-up of 2 years. The probability of remaining on CPAP at 2 years was 60% in nonsleepy patients and 77% in sleepy patients. Multivariate analyses indicated that age and hours of CPAP use per night at 1 month were independently associated with long-term CPAP use in nonsleepy patients. In the sleepy phenotype, body mass index, acute myocardial infarction at baseline, and hours of CPAP use per night at 1 month were predictors of long-term CPAP use. Long-term use of CPAP is likely to be challenging for CAD patients with nonsleepy OSA. Early CPAP use is an important predictor of continued long-term use of CPAP, so optimizing patients' initial experience with CPAP could promote adherence.

Introduction While studies support the beneficial short-term role of continuous positive airway pressure (CPAP) therapy on cardiometabolic risk in adults with obstructive sleep apnea (OSA), its sustained effect on cardiovascular disease (CVD) risk is unknown. CPAP use data linked to electronic health records (EHR) offer opportunities to understand the role of OSA treatment for preventing CVD. We evaluated the association between CPAP use and CVD incidence in patients referred to a sleep study at a large health system. Methods We included adult patients with available apnea-hypopnea index (AHI) between 01/2018-02/2020 in Kaiser Permanente Southern California. At baseline, eligible participants had &amp;gt;1 year of continuous insurance coverage allowing gaps &amp;lt;90 days and were free of CVD 1 year prior to OSA diagnosis. Participants were distributed into three groups: no OSA (AHI&amp;lt;5), OSA (AHI≥5) with any CPAP use (median[IQR] 2.5[0.7–5.0] h/day) and OSA without evidence of CPAP use. CVD incidence was defined as first occurrence of myocardial infarction, stroke, unstable angina, heart failure or CVD death, based on validated EHR algorithms. We used Cox proportional hazards models to assess the association between OSA with or without CPAP use and CVD incidence, adjusted for baseline age, sex, body mass index, race/ethnicity, Charlson comorbidity index, and use of anti-hypertensives and lipid-lowering medications. Stratified analyses were conducted based on OSA severity. Results We included 11,145 patients without OSA, 13,898 with OSA and CPAP use, and 20,884 patients without CPAP use. Median follow-up was 262 days (IQR=129–409). CVD incidence rates were, respectively, 0.26%, 0.45% and 0.56%. In adjusted models, moderate-severe OSA (AHI≥15) without CPAP use was associated with increased CVD incidence when compared to no OSA (HR=1.71; 95%CI=1.11–2.64; p=0.016). OSA with any CPAP use was associated with lower CVD incidence (HR=0.68; 95%CI=0.50–0.93; p=0.016) when compared to OSA patients with no CPAP use. Stronger effects were observed when restricting the sample to moderate-severe OSA (HR=0.56; 95%CI=0.39–0.81; p=0.002). Conclusion Our analysis in a large observational clinical sample suggests that moderate-severe OSA with no CPAP use is associated with increased CVD incidence. Moreover, OSA with CPAP use was associated with decreased CVD incidence relative to no CPAP use. Support (if any) AASM Foundation (194-SR-18;205-SR-19); AHA (20CDA35310360).

A randomized controlled trial of a multi-dimensional intervention to improve CPAP use and self-efficacy

Effect of nasal continuous positive airway pressure in uncontrolled nocturnal asthmatic patients with obstructive sleep apnea syndrome