Auto-titrating Continuous Positive Airway Pressure Research Articles

CPAP setup by mail: we're not there yet.

CPAP setup by mail: we're not there yet.

Factors associated with treatment outcomes after use of auto-titrating CPAP therapy in adults with obstructive sleep apnea.

To determine factors that are associated with OSA therapy outcomes with auto-titrating positive airway pressure (APAP). We sequentially grouped patients from a retrospective cohort based on APAP efficacy (sufficiently vs. insufficiently treated; insufficiently treatment defined as residual AHI of ≥ 5), therapy adherence (adherent vs. non-adherent, non-adherence defined as < 70% usage for ≥ 4h/night), and therapy outcomes (optimal vs. non-optimal and non-optimal outcomes defined as non-adherent and/or insufficiently treated). We subsequently compared each group. The insufficiently treated were older (68.4 ± 12.5 vs. 60.4 ± 13.1years, p < 0.01) and had lower BMI (31.9 ± 6.3 vs. 37.9 ± 9.1kg/m2, p < 0.01). They had higher baseline central apnea indices (CAI), longer leaks, higher peak pressures, and were less compliant. The non-adherent were younger (61.1 ± 12.6 vs. 65.5 ± 13.2years, p = 0.03) and comprised more females (56.1 vs. 43.9%, p = 0.04). The leak duration per usage hour was higher in the non-compliant (median: 1.5; IQR 7.9 vs. median: 0.3; IQR 1.9min/h; p < 0.01). The non-optimally treated had lower BMI, longer leaks, and less nightly usage. Multivariate analyses showed that leak duration was the common factor associated with treatment effectiveness and optimal therapy outcomes. Various demographic and clinical factors were associated with treatment efficacy and adherence. However, leak duration was the common factor related to treatment efficacy and overall optimal therapy outcomes.

The role of long-term continuous positive airway pressure in the progression of obstructive sleep apnoea: A longitudinal cohort study.

Recent evidence suggests that short-term obstructive sleep apnea (OSA) treatment could affect OSA pathogenesis such as ventilatory control. The aim of our present study was to identify the impact of long-term treatment on the change in pathogenesis and natural progression of OSA. In a longitudinal analysis of a non-obese cohort study, patients with OSA treated with either continuous positive airway pressure (CPAP) or an oral appliance (OA), interrupted their treatment for 1week and underwent a polysomnography (PSG) off treatment that was compared with their initial PSG taken 5years before treatment initiation. In all, 154 consecutive patients with OSA who were treated by CPAP using an auto-titrating continuous positive airway pressure device (CPAP-APAP) (n=112), or by OA (n=27) or were untreated (n=15), PSG was performed twice with a median (range) follow-up of 93(60-176)months. Multivariate logistic regression showed that reduction of body mass index (BMI) and good treatment adherence to be significant predictors of favourable OSA progression, as represented by an improved or unchanged apnea-hypopnea index (AHI) (odds ratios were 5.14 and 2.89, respectively). Amongst the patients with an unchanged BMI and good CPAP-APAP adherence (n=55), the improvement in AHI was significantly associated with the decrease in supine non-rapid eye movement-AHI and mixed apnoea index/apnoea index, which are generally recognised to be determinants of ventilator instability. These findings suggest that not only weight but also treatment adherence are determinants in the natural progression of OSA severity.

Paediatric CPAP in the digital age

ObjectivesAdherence to Continuous Positive Airway Pressure (CPAP) in children can be challenging. Advancements in CPAP technology have potential to influence adherence. The aim of this study was to compare adherence rates of children with obstructive sleep apnoea (OSA) initiated on autotitrating CPAP (APAP) with remote modem monitoring compared to a cohort started on fixed pressure CPAP alone. MethodsChildren aged over 3 years starting APAP at our centre between February 2017 and February 2020 were included. Therapy data was obtained for the initial 90 days. Data was compared to a cohort of children started on CPAP between July 2004 and September 2008. ResultsA total of 61 patients with a median age of 14.3 years formed the APAP group, and were significantly older than the CPAP group who had a median age of 8.6 years (p = 0.02). Co-morbid conditions were present in 51% compared with 69% in the earlier cohort (p = 0.11). No significant difference was found in any adherence parameters between the groups. The value closest to achieving a significant difference was hours used per day used, with an median of 5.2 h in the CPAP group compared with 7.0 h in the APAP group (p = 0.07). Two-way ANOVA including age group (above or below 13 years) showed that both age group and treatment group (CPAP vs APAP) were significantly associated with a difference in adherence (F = 4.41, p = 0.006), with mean hours used on days used being highest in the APAP group aged under 13 years. However no significant interaction was found between age and treatment group. ConclusionDespite the convenience for patients with outpatient initiation and ability to achieve optimal pressures quickly and remotely, our results show no improvement in adherence using APAP with remote monitoring, with the possible exception of children aged under 13 years. A large randomized controlled trial would be required to confirm these findings.

Initiation of therapy for obstructive sleep apnea syndrome: a randomized comparison of outcomes of telemetry-supported home-based vs. sleep lab-based therapy initiation

PurposeDiagnosis and treatment of obstructive sleep apnea are traditionally performed in sleep laboratories with polysomnography (PSG) and are associated with significant waiting times for patients and high cost. We investigated if initiation of auto-titrating CPAP (APAP) treatment at home in patients with obstructive sleep apnea (OSA) and subsequent telemonitoring by a homecare provider would be non-inferior to in-lab management with diagnostic PSG, subsequent in-lab APAP initiation, and standard follow-up regarding compliance and disease-specific quality of life.MethodsThis randomized, open-label, single-center study was conducted in Germany. Screening occurred between December 2013 and November 2015. Eligible patients with moderate-to-severe OSA documented by polygraphy (PG) were randomized to home management or standard care. All patients were managed by certified sleep physicians. The home management group received APAP therapy at home, followed by telemonitoring. The control group received a diagnostic PSG, followed by therapy initiation in the sleep laboratory. The primary endpoint was therapy compliance, measured as average APAP usage after 6 months.ResultsThe intention-to-treat population (ITT) included 224 patients (110 home therapy, 114 controls); the per-protocol population (PP) included 182 patients with 6-month device usage data (89 home therapy, 93 controls). In the PP analysis, mean APAP usage at 6 months was not different in the home therapy and control groups (4.38 ± 2.04 vs. 4.32 ± 2.28, p = 0.845). The pre-specified non-inferiority margin (NIM) of 0.3 h/day was not achieved (p = 0.130); statistical significance was achieved in a post hoc analysis when NIM was set at 0.5 h/day (p < 0.05). Time to APAP initiation was significantly shorter in the home therapy group (7.6 ± 7.2 vs. 46.1 ± 23.8 days; p < 0.0001).ConclusionUse of a home-based telemonitoring strategy for initiation of APAP in selected patients with OSA managed by sleep physicians is feasible, appears to be non-inferior to standard sleep laboratory procedures, and facilitates faster access to therapy.

565 Adherence to Auto-Titrating CPAP in Children with Trisomy 21 and Obstructive Sleep Apnea

Abstract Introduction Obstructive sleep apnea (OSA) is common in children with trisomy 21. The pathophysiology can be multifactorial and challenging to manage. Auto-titrating continuous positive airway pressure (autoCPAP) is an emerging tool for the treatment of pediatric OSA and few studies discuss adherence. This study compares autoCPAP adherence in children with and without trisomy 21 at our center. We hypothesized that autoCPAP adherence would not differ between the two groups. Methods A retrospective review of patients aged 0 to 18 years with a diagnosis of OSA as defined by the International Classification of Sleep Disorders Third Edition, and empirically prescribed autoCPAP between 2012 and 2020 was conducted. Patients without available polysomnography or adherence data were excluded. Data included patient demographics, baseline polysomnography characteristics, and autoCPAP usage. Adherence was defined as usage ≥ 4 hours/night on 70% of nights during a consecutive 30-day period as per the Centers for Medicare and Medicaid Services criteria. Descriptive statistics and non-parametric tests were utilized for analysis. Results There were 130 total patients included with a mean age of 12.5 years ± a standard deviation of 4.1 years. Seventeen children (13%) had trisomy 21. No statistically significant differences were observed between the trisomy 21 group (T21) and the non-trisomy 21 group (non-T21) with respect to the obstructive apnea hypopnea index (9.5 ± 11.2 in T21, 14.7 ± 22.3 in non-T21, p=0.61), or the oxygen saturation nadir (87.8% ± 4.2% in T21, 84.4% ± 10.8% in non-T21, p=0.57). The percentage of days used ≥ 4 hours in a 30-day period did not significantly differ (52.3% ± 42% in T21, and 49.5% ± 37.5% in non-T21, p=0.64). While 41% of T21 subsequently underwent a CPAP titration for a suboptimal response to autoCPAP (for reasons including intolerance, persistent snoring, or daytime sleepiness), this did not differ significantly from 23% in non-T21 (p=0.11). Conclusion Although limited by a small sample size, our data suggest that adherence to autoCPAP did not differ between the trisomy 21 and non-trisomy 21 groups of children with OSA. Empiric autoCPAP is a reasonable treatment option for children with OSA who are not surgical candidates, including those with trisomy 21. Support (if any):

411 REM predominance of OSA: Associated with supine position, but not with CPAP adherence

Abstract Introduction Obstructive sleep apnea (OSA) is a heterogeneous disease dependent on many factors including the sleep stage and the body position. OSA is often more severe during the rapid eye movement (REM) sleep stage, a phenomenon known as REM predominance. Prior studies suggested associations of higher REM predominance of OSA with younger age, higher obesity, and lower adherence to continuous positive airway pressure (CPAP) therapy, but these studies had small cohort sizes. Here we leverage home-based sleep tests (HST) that estimate REM sleep and measure body position to study REM predominance in a larger cohort of OSA patients. Methods We retrospectively reviewed patients who took HST at our clinic using devices based on peripheral arterial tonometry (WatchPAT, Itamar Medical). The HST results included estimated REM sleep periods and measured body positions. Auto-titrating CPAP therapy was prescribed for the majority of OSA patients diagnosed by the HST. Our inclusion criteria were: apnea-hypopnea index (AHI) above 5 /hour, estimated REM sleep time above 30 minutes, oxygen saturation below 90% (T90) for less than 10 minutes, and successful retrieval of CPAP usage data. CPAP adherence was defined as the percentage of nights with CPAP usage above four hours, and REM predominance as the ratio between REM AHI and non-REM AHI. Additionally, the percentage of estimated sleep time in supine position was calculated. Results Among 292 consecutive patients whose HST were reviewed, 113 patients met the inclusion criteria. The 25th-75th percentile ranges of age, body mass index (BMI), AHI, REM predominance, CPAP adherence and supine sleep percentage were 36–56 years, 28.1–38.4 kg/m2, 8.9–25.9 /hour, 1.27–2.89, 40%-97% and 28%-72%, respectively. REM predominance was not associated with CPAP adherence (P &amp;gt; 0.05), but was significantly associated with lower age, higher BMI, and higher supine sleep percentage (all P &amp;lt; 0.01). Conclusion We found that REM-predominant OSA is relatively more prevalent not only in young and obese patients, but in patients who sleep relatively more in the supine position. This association of REM predominance with body position is a novel finding to our knowledge. Contrary to prior studies, we did not find association of REM predominance with adherence to CPAP therapy. Support (if any):

Hospital screening for obstructive sleep apnea in patients admitted to a rural, tertiary care academic hospital with heart failure

ABSTRACT Background Rural communities represent a vulnerable population that would significantly benefit from hospital-based OSA screening given these areas tend to have significant health-care disparities and poor health outcomes. Although inpatient screening has been studied at urban hospitals, no study to date has assessed this approach in rural populations. Methods This study utilized the Electronic Medical Record (EMR) to generate a list of potential candidates by employing inclusion/exclusion criteria as screening. Subjects identified were then approached and offered information regarding the study. Screening for OSA entailed a tiered approach utilizing the sleep apnea clinical score (SAC) and portable sleep testing. Individuals identified as high risk (SAC ≥ 15) for OSA underwent evaluation with a portable sleep testing system while hospitalized. All participants with an apnea-hypopnea index (AHI) ≥5 events/h confirmed by a sleep medicine physician were considered screen positive for OSA. If approved/available, subjects screening positive for OSA were provided with an auto-titrating continuous positive airway pressure (PAP). Patient characteristics were analyzed using descriptive statistics. Categorical data were described using contingency tables, including counts and percentages. Continuously scaled measures were summarized by median with range. This study was registered with ClinicalTrials.gov. Identifier: NCT03056443. Results Nine hundred and fifty-eight potential subjects were identified. The three most common reasons for exclusion included previous OSA diagnosis or exposure to PAP therapy (n = 357), advanced illness (n = 380), and declined participation by the individual (n = 68). The remaining 31 subjects underwent further evaluation for obstructive sleep apnea. Twenty-three subjects had a high sleep apnea clinic score. Per our study protocol, 13 subjects who screened positive for OSA were initiated on APAP therapy. Conclusion: Our study provides important insight into the burden of sleep-disordered breathing (SDB) and unique challenges of hospital-based OSA screening/treatment in a rural setting. Our study identified barriers to successful screening in a rural population that may be well addressed by adapting previous research in hospital sleep medicine.

Auto-titrating CPAP for the treatment of obstructive sleep apnea in children.

In-laboratory titration polysomnography (PSG) is standard to determine optimal therapeutic continuous positive airway pressure (CPAP) in children with obstructive sleep apnea (OSA). The use of auto-titrating CPAP devices (autoCPAP) as an alternative to CPAP titration has not been well studied in children. We hypothesized that autoCPAP-derived pressures (PMEAN, PPEAKMEAN, P90) would be similar to titration PSG pressure (PPSG). This is a retrospective study of children with OSAS initiated on autoCPAP between 2007 and 2017, who used autoCPAP for at least 2 h/night and who had adequate titration PSG were included in the analysis. AutoCPAP-derived pressures were obtained from use downloads and compared with PPSG. PPSG predictive factors were analyzed by median regression. Nonparametric methods were used for analysis. Of 110 children initiated on autoCPAP, 44 satisfied the inclusion criteria. Age (median (interquartile range)) was 13.01 (9.98-16.72) years, and 63.6% were obese. PPSG median (interquartile range) was 8 (7-11) cmH₂O, mean autoCPAP-derived pressure (PMEAN) was 6.2 (5.6-7.6) cmH₂O, peak mean pressure (PPEAKMEAN) was 9.4 (7.7-11.1) cmH₂O, and average device pressure ≤ 90% of the time (P90) was 8.1 (7.2-9.7) cmH₂O. AutoCPAP-derived pressures correlated with PPSG (P < .05). PMEAN was lower than the other 3 pressures (P < .0002). Median regression analysis demonstrated that after adjusting for patient characteristics such as age, sex, and obesity status, autoCPAP-derived pressures remained significant predictors of PPSG (P < .05). There were no significant interactions between these patient characteristics and autoCPAP-derived pressures. This study demonstrates that autoCPAP-derived pressures correlate with the titration PSG-derived pressures. These results indicate that autoCPAP can be used in the pediatric population and can determine pressures that are close to the titration pressures.

Surgical management in a severe OSA patient diagnosed with Stickler syndrome

Stickler syndrome is a genetic disorder of connective tissue. One of the major symptoms associated with this disorder is an oro-facial malformation, which may cause a submucous cleft or a complete cleft of the hard palate. A 32-year-old man diagnosed with Stickler syndrome and a submucosal cleft palate (SMCP) visited our hospital with a chief complaint of excessive daytime sleepiness. The patient was diagnosed with severe obstructive sleep apnea (OSA), and administration of a polysomnography test revealed an apnea-hypopnea index (AHI) of 30.9 events/hour (h). Auto-titrating continuous positive airway pressure was initiated to control the OSA symptoms and subsequently the patient showed some improvement. However, due to continuous velopharyngeal insufficiency symptoms, intravelar veloplasty was performed. Three months after surgery, the AHI had decreased to 12.4 events/h. Recent studies have described a greater risk for OSA in individuals with cleft palate, than in the general population. The present case demonstrates surgical success in a patient with OSA and SMCP, suggesting that palatal surgery may be considered an optional surgical treatment for OSA patients with SMCP.

0902 The Use Of Auto-titrating Continuous Positive Airway Pressure (auto Cpap) For Obstructive Sleep Apnea In Children With Neurological Disorder

Abstract Introduction Multiple studies have demonstrated the effectiveness of auto-titrating continuous positive airway pressure (auto CPAP) in the adult population, but there is limited literature on the use of auto CPAP in the pediatric population. Specifically, the use of auto CPAP in children with neurological disorder(s) has not been established. Thus, we conducted a study to review the use of auto CPAP in children ages 18 years old and younger with Obstructive Sleep Apnea Syndrome (OSAS) and associated neurological disorder to document its effectiveness, adverse events and outcomes of its use. Methods A retrospective chart review was performed on patients 18 yo and younger diagnosed with OSAS and associated neurological disorder(s) who have good compliance with auto CPAP use. Good compliance was defined as &amp;gt;4 hours/night and &amp;gt;20/30 days of auto CPAP use. Compliance from the most recent 30 days was downloaded. Results 5 children met our criteria for inclusion, with a mean age of 11 years (6-18 years old). All had initial baseline sleep studies performed without PAP titration polysomnography. Associated neurological disorders were cerebral palsy, Arnold Chiari Malformation, seizure disorder and intellectual disability. The average length of use of auto CPAP was 4 months. Auto CPAP was used on average of 24/30 nights, with a mean of 7.35 hours/night. The mean baseline obstructive apnea-hypopnea (OAHI) index was 42 (8.2-94.4). The mean AHI on a 30 day download report showed a mean decrease in AHI to 2.9 (0.5-5.2) while on auto CPAP. Review of patient charts did not reveal any adverse outcomes associated with the use of auto CPAP in these patients. Conclusion This study showed that auto CPAP significantly improved the AHI in pediatric patients treated for OSA with associated neurological disorder. There were no reported adverse outcomes. Further research is needed to establish the effectiveness and safety of auto CPAP use in the pediatric population, specifically those with neurological disorder. The use of auto CPAP will help decrease the wait time for treatment in children with OSA. These patients can use auto CPAP while waiting for a titration study and for long term use. Support none

Automatic Derivation of Continuous Positive Airway Pressure Settings: Comparison with In-Laboratory Titration.

Background and PurposeThis study was designed to investigate differences in the final recommended pressure setting between that derived from an autotitrating continuous positive airway pressure (APAP) device and manual in-laboratory continuous positive airway pressure (CPAP) titration, as well as the factors that influence pressure differences in patients with obstructive sleep apnea (OSA).MethodsThis study enrolled 50 patients with OSA. All patients underwent both APAP titration and manual CPAP titration. We obtained the average device pressure ≤90% of the time (APAP90) from the downloaded manual for the APAP machine and the optimal pressure obtained by manual CPAP titration (CPAPmanual). We placed the subjects into three groups based on the pressure difference (ΔP) obtained by subtracting CPAPmanual from APAP90: 1) Prequal (ΔP=0), 2) CPAPmanual+ (ΔP ≤−1), and 3) APAP90+ (ΔP ≥1). Regression analysis was conducted to identify predictive factors associated with ΔP.ResultsThe values of APAP90 and CPAPmanual were 9.50±3.03 cmH2O and 9.48±2.71 cmH2O (mean±SD), respectively (p=0.95). The Prequal, CPAPmanual+, and APAP90+ groups comprised 9 (18%), 23 (46%), and 18 (36%) subjects, respectively. Regression analyses revealed that male sex [β=3.539, 95% confidence interval (CI)=0.040–7.039], body mass index (BMI) (β=0.186, 95% CI=0.020–0.352), and average usage per day (β=0.768, 95% CI=0.077–1.459) were associated with ΔP.ConclusionsWhile the mean pressure in the overall cohort did not differ significantly between APAP90 and CPAPmanual, there was a discordance majority showing different single pressures obtained when applying the two titration methods. Being Male, having an increased BMI, and having an increased average usage per day of APAP were significantly correlated with increased ΔP in this study.

Impact of CPAP treatment on leptin and adiponectin in adults with coronary artery disease and nonsleepy obstructive sleep apnoea in the RICCADSA trial

BackgroundIncreased leptin and decreased adiponectin levels are reported in coronary artery disease (CAD) as well as in obstructive sleep apnoea (OSA). Less is known regarding the impact of continuous positive airway pressure (CPAP) on these biomarkers. We aimed to determine variables associated with leptin and adiponectin in adults with CAD and nonsleepy OSA, and evaluate the effect of CPAP adjusted for confounding factors. MethodsThis was one of the secondary outcomes of the RICCADSA trial, conducted in Sweden between 2005 and 2013. From 244 revascularized CAD and OSA patients (apnoea–hypopnoea index >15/h) without excessive daytime sleepiness (Epworth Sleepiness Scale score <10), 196 with blood samples at baseline, after 3, and 12 months were included in the randomized controlled trial arm; of those, 98 were allocated to auto-titrating CPAP, and 98 to no-CPAP. ResultsNo significant changes in leptin and adiponectin levels were observed during follow-up, whereas Body-Mass-Index and waist circumference increased in both CPAP and no-CPAP groups with no significant between-group differences. Alterations in plasma leptin were determined by changes in waist circumference (beta coefficient 2.47; 95% confidence interval 0.77–4.40), whereas none of the analyzed parameters was predictive for changes in adiponectin levels. No association was found with CPAP adherence. ConclusionsCPAP had no significant effect on leptin and adiponectin in this cohort of nonsleepy OSA patients. An increase in waist circumference predicted an increase in plasma levels of leptin after 12 months, suggesting that lifestyle modifications should be given priority in adults with CAD and OSA regardless of CPAP treatment.

Retropharyngeal hematoma in the context of obstructive sleep apnea: a case report and review of the literature

BackgroundObstructive sleep apnea is related to increased systemic inflammation and arterial hypertension. We present a case of retropharyngeal hematoma without trauma und hypothesize that this could be caused by untreated obstructive sleep apnea.Case presentationA 47-year-old white woman with unilateral pharyngeal discomfort presented to our ear, nose, and throat clinic. She had no risk factors for the development of a spontaneous retropharyngeal hematoma, for example, hypertension or coagulation disorder. As she was overweight, the anamnesis included signs of obstructive sleep apnea such as snoring or breathing arrests during the night, which she denied. An endoscopic examination showed a submucosal hemorrhage of the posterior wall of her pharynx. Magnetic resonance imaging revealed a retropharyngeal hematoma without evidence of the injury of any blood vessel. A subsequent seven-channel polygraphy revealed a severe obstructive sleep apnea with an apnea-hypopnea index of 59.5 per hour. She was subsequently treated with auto-titrating continuous positive airway pressure resolving obstructive sleep apnea immediately. Two months after this episode she presented without any complaints.ConclusionIn consequence of this case we are convinced that an untreated obstructive sleep apnea can lead to retropharyngeal hematoma.

Worth the effort? Weighing up the benefit and burden of continuous positive airway pressure therapy for the treatment of obstructive sleep apnoea in chronic tetraplegia.

Mixed methods OBJECTIVES: Continuous positive airway pressure (CPAP) therapy is the recommended treatment for obstructive sleep apnoea (OSA). The aim of this study was to estimate CPAP adherence in people with tetraplegia and OSA, and to explore the barriers and facilitators to CPAP use. Hospital outpatient department in Melbourne, Australia METHODS: People with chronic tetraplegia and OSA were commenced with auto-titrating CPAP and supported for 1 month. Semi-structured interviews were conducted with participants at one month and analysed thematically. CPAP usage was measured at 1, 6 and 12 months, with "adherent" defined as achieving more than 4 h average per night. Sixteen participants completed the study (80% male; mean age 56 (SD = 15)). Mean nightly CPAP use at one month was 3.1 h (SD = 2.5; 38% adherent), and at 6 months and 12 months were 2.6 h (SD = 2.8; 25% adherent) and 2.1 h (SD = 3.2; 25% adherent). The perceived benefit/burden balance strongly influenced ongoing use. Burden attributed to CPAP use was common, and included mask discomfort, and physical and emotional problems. Adherent participants were motivated by the immediate daytime benefits to mood, alertness and sleepiness. There was a tendency to not recognise symptoms of OSA until after they were treated. CPAP use is challenging for people with tetraplegia, who experience substantial burden from using the device. When tolerated, the proximate benefits are substantial. People with tetraplegia need more intensive support for longer to help them overcome the burdens of CPAP and benefit from the treatment.

Abstract TMP45: An Intensive Multidisciplinary Protocol for Improving Adherence to CPAP Therapy During Inpatient Rehabilitation May Improve Recovery in Stroke Patients

Introduction: Obstructive sleep apnea (OSA) is associated with worse outcome after stroke. Treatment with continuous positive airway pressure (CPAP) may improve recovery after stroke but has been limited by poor adherence. Methods: In a single-arm ongoing study, adults with stroke underwent an intensive CPAP adherence protocol during inpatient rehabilitation, including motivational interviewing and help with CPAP by nurses and respiratory therapists. A 3-night run-in period of auto-titrating CPAP was used to test for tolerance and to diagnose OSA, based upon the apnea-hypopnea index and flow resistance. Qualifying patients were asked to continue CPAP for 3 months. The outcomes included CPAP adherence, defined as ≥ 4 hours of use on ≥ 70% of nights, and stroke recovery, measured by change in NIH Stroke scale (NIHSS) and Functional Independence Measure (FIM) over 3 months. Results: During the run-in, 39 of 60 (65%) patients had presumed OSA, 5 (8%) had no evidence of OSA, 4 (7%) had evidence of central sleep apnea, and 12 (20%) were intolerant of CPAP. Among the 34 of 39 patients who chose to continue CPAP after the run-in, the median use per night was 5.3 hours (IQR 4.1, 6.0) with 56% (n=19) adherent during rehabilitation. The median CPAP use per night for the 22 who completed the study was 5.1 hours (IQR 2.5, 6.4) with 54% (n=12) adherent over the 3-month period. Unadjusted for baseline factors, there was a significant change in the NIHSS in adherent patients (n=10) vs. non-adherent patients (n=10) [5 (SD 3) vs. 2 (SD 2), p =0.02]. Comparing adherent (n=7) to non-adherent patients (n=5), the change for total FIM trended towards significant [42 (SD 18) vs. 30 (SD 11), p =0.20] and the change for cognitive component of the FIM was significant [10 (SD 7) vs. 2 (SD 3), p =0.05]. Conclusion: After an intensive adherence intervention, over half of stroke patients with presumed OSA and CPAP tolerance were adherent over 3 months. CPAP adherent patients had greater improvement in NIHSS and the cognitive component of the FIM, although the associations may be confounded by patients’ characteristics influencing both adherence and outcomes. Future studies are needed to evaluate in a randomized trial if the intensive intervention will lead to long-term CPAP adherence and improved stroke recovery.

The prevention of delirium in elderly with obstructive sleep apnea (PODESA) study: protocol for a multi-centre prospective randomized, controlled trial

BackgroundDelirium is a common problem that occurs in 5–50% of elderly individuals following surgery. Patients who develop delirium after surgery are at increased risk for serious complications. Recent studies suggest that patients with obstructive sleep apnea (OSA), a sleep disorder characterized by repeated episodes of complete or partial blockage of the upper airway – are at greater risk to develop delirium. OSA is more common in elderly individuals but is often undiagnosed. Identification and treatment of unrecognized OSA may reduce the incidence of postoperative delirium. However, few studies have investigated the effect of perioperative treatment of OSA to prevent postoperative delirium.MethodsThis multi-centre randomized controlled trial will enrol 634 elderly patients undergoing elective hip/knee replacement surgery. The study has been approved by the Research Ethics Boards of the three participating institutions. Patients will be screened with the STOP-Bang questionnaire. Those with a score of 3 or greater will have a portable home sleep study using the ApneaLink™ Air device. Patients identified to have OSA will be randomized to 1) Auto-titrating continuous positive airway pressure (APAP) applied during sleep for 72 h after surgery or until discharge if they are discharged before 72 h or 2) Control group – routine care, no APAP. All patients will be evaluated for delirium for 72 h after surgery or until discharge if they are discharged before 72 h. The primary outcome is the occurrence of delirium – assessed twice daily using the Confusion Assessment Method for 72 h or until discharge if the hospital stay is <72 h.DiscussionDelirium is associated with increased morbidity and mortality, and higher healthcare costs. With the aging population, the incidence of postoperative delirium will likely increase as the number of elderly individuals undergoing surgery rises. The results of our study will be published in a peer-reviewed journal and presented at local and international medical conferences. Our study findings may lead to improved surgical outcomes, enhanced patient safety and reduced healthcare costs.Trial registrationThis study was retrospectively registered at clinicaltrials.gov NCT02954224 on November 3, 2016.

Comparison between the use of APAP and manual titration during split night polysomnography for diagnosis and treatment of OSA

Introduction Continuous positive airway pressure (CPAP) remains the gold standard treatment for obstructive sleep apnea (OSA). CPAP titration can be done using manual titration or using autotitrating continuous positive airway pressure (APAP) devices. Moreover, CPAP titration can be done using full-night or split-night protocol. The aim of the study was to compare between the use of APAP and manual titration to determine the needed CPAP pressure during split-night polysomnography for diagnosis and treatment of OSA. Patients and methods A total of 100 patients with severe OSA were enrolled after exclusion of patients with heart failure or respiratory failure. After diagnostic polysomnography, patients were divided into two groups: group 1 was offered manual CPAP titration and group 2 was offered APAP titration. The time for CPAP titration was at least 4 h in both groups. Results Both groups were matched regarding age, sex, BMI, sleep parameters, and apnea–hypopnea index (44.52±7.81/h in group 1 and 42.66±9.68/h in group 2 with no statistical significance). After CPAP titration, apnea–hypopnea index was significantly improved in both groups. The time needed to reach the therapeutic pressure was significantly lower in group 2 than in group 1. Moreover, attended technician was needed only in group 1. Conclusion The use of APAP was equal to manual titration in this group of patients with severe OSA, with decreased cost and lesser time to reach the therapeutic pressure. Large multicenter trials are needed to modify the guidelines in view of using APAP in split-night protocol for diagnosis and treatment of OSA.

Diagnosing and managing sleep apnea in patients with chronic cerebrovascular disease: a randomized trial of a home-based strategy

BackgroundObstructive sleep apnea is common and associated with poor outcomes after stroke or transient ischemic attack (TIA). We sought to determine whether the intervention strategy improved sleep apnea detection, obstructive sleep apnea (OSA) treatment, and hypertension control among patients with chronic cerebrovascular disease and hypertension.MethodsIn this randomized controlled strategy trial intervention, patients received unattended polysomnography at baseline, and patients with OSA (apnea-hypopnea index ≥5 events/h) received auto-titrating continuous positive airway pressure (CPAP) for up to 1 year. Control patients received usual care and unattended polysomnography at the end of the study, to identify undiagnosed OSA. Both groups received 24-h blood pressure assessments at baseline and end of the study. “Excellent” CPAP adherence was defined as cumulative use of ≥4 h/night for ≥70% of the nights.ResultsAmong 225 randomized patients (115 control; 110 intervention), 61.9% (120/194) had sleep apnea. The strategy successfully diagnosed sleep apnea with 97.1% (102/105) valid studies; 90.6% (48/53, 95% CI 82.7–98.4%) of sleep apnea was undiagnosed among control patients. The intervention improved long-term excellent CPAP use: 38.6% (22/57) intervention versus 0% (0/2) control (p < 0.0001). The intervention did not improve hypertension control in this population with well-controlled baseline blood pressure: intervention, 132.7 mmHg (±standard deviation, 14.1) versus control, 133.8 mmHg (±14.0) (adjusted difference, −1.1 mmHg, 95% CI (−4.2, 2.0)), p = 0.48).ConclusionsPatients with cerebrovascular disease and hypertension have a high prevalence of OSA. The use of portable polysomnography, and auto-titrating CPAP in the patients’ homes, improved both the diagnosis and the treatment for sleep apnea compared with usual care but did not lower blood pressure.

A randomised trial of peri‐operative positive airway pressure for postoperative delirium in patients at risk for obstructive sleep apnoea after regional anaesthesia with sedation or general anaesthesia for joint arthroplasty

Previous pilot work has established an association between obstructive sleep apnoea and the development of acute postoperative delirium , but it remains unclear to what extent this risk factor is modifiable in the 'real world' peri-operative setting. In a single-blind randomised controlled trial, 135 elderly surgical patients at risk for obstructive sleep apnoea were randomly assigned to receive peri-operative continuous positive airway pressure (CPAP) or routine care. Of the 114 patients who completed the study, 21 (18.4%) experienced delirium. Delirium was equally common in both groups: 21% (12 of 58 subjects) in the CPAP group and 16% (9 of 56 subjects) in the routine care group (OR = 1.36 [95%CI 0.52-3.54], p = 0.53). Delirious subjects were slightly older - mean (SD) age 68.9 (10.7) vs. 64.9 (8.2), p = 0.07 - but had nearly identical pre-operative STOP-Bang scores (4.19 (1.1) versus 4.27 (1.3), p = 0.79). Subjects in the CPAP group used their devices for a median (IQR [range]) of 3 (0.25-5 [0-12]) nights pre-operatively (2.9 (0.1-4.8 [0.0-12.7]) hours per night) and 1 (0-2 [0-2]) nights postoperatively (1.4 (0.0-5.1 [0.0-11.6]) hours per night). Among the CPAP subjects, the residual pre-operative apnoea-hypopnea index had a significant effect on delirium severity (p = 0.0002). Although we confirm that apnoea is associated with postoperative delirium, we did not find that providing a short-course of auto-titrating CPAP affected its likelihood or severity. Voluntary adherence to CPAP is particularly poor during the initiation of therapy.