Mean Continuous Positive Airway Pressure Use Research Articles

O004 The effect of treating OSA with CPAP on mood and sleepiness

Abstract Introduction Excessive sleepiness and symptoms of depression and anxiety are highly prevalent in individuals with obstructive sleep apnoea (OSA). The aim of this study was to determine the effect of treating OSA with continuous positive airway pressure (CPAP) on mood and daytime sleepiness. Methods Seventy-eight participants (mean age 51.3±12.2 years; 41% female) with previously diagnosed OSA were randomised to either treatment as usual (TAU CPAP, n=43) or to a waitlist control group (WL, n=35). Participants in the TAU CPAP group were implemented with CPAP via an in-laboratory sleep study at the Austin Health sleep laboratory. CPAP initiation was delayed for participants in the WL group by 4 months. Sleepiness and depression, anxiety and stress symptoms, were measured at baseline and 4 months follow-up and compared between groups. CPAP use was measured in the TAU CPAP group. Results Participants in both groups reported mild symptoms of depression at baseline. Daytime sleepiness (p<.001) improved in the TAU CPAP group compared to the WL group, but not symptoms of depression, anxiety and stress. Baseline stress symptoms in females improved in the TAU CPAP group compared to the WL group (p<.007). Mean CPAP use was 3.5(2.9) h/night in the TAU CPAP group. Discussion Daytime sleepiness was improved with 4 months of CPAP use compared to no treatment. Mood did not improve with 4 months of CPAP therapy. Developing an OSA-specific tool to measure mood symptoms may be beneficial, and future studies should carefully consider recruitment criteria to include participants with mood symptoms at baseline.

Effectiveness and feasibility of continuous positive airway pressure in patients with stroke and sleep apnea: a meta-analysis of randomized trials.

This meta-analysis aimed to investigate the feasibility and effectiveness of continuous positive airway pressure (CPAP) treatment in stroke patients with sleep apnea. PubMed, EMBASE, and the Cochrane Library were searched from inception until July 28, 2022, for randomized controlled trials comparing the use of CPAP and usual treatment in patients with stroke or transient ischemic attack and sleep apnea. The primary outcome measures were the feasibility of CPAP therapy, neurological function, and functional status. After screening 5,747 studies, 14 studies with 1,065 patients were included in this meta-analysis. Overall, 8 of the 14 studies recorded CPAP use, and the mean CPAP use was 4.47 hours per night (95% confidence interval [CI]: 3.85-5.09). The risk ratio of discontinuing CPAP was 1.50 (95% CI: 0.76-2.94; P = .24). Analysis of the neurofunctional scales showed that CPAP treatment improved neurological function (standardized mean difference: 0.28; 95% CI: 0.02-0.53), but there was substantial heterogeneity (I2 = 57%, P = .03) across the studies. CPAP treatment had no significant effect on functional status vs the control (standardized mean difference: 0.25; 95% CI: -0.01 to 0.51), but the studies also had substantial heterogeneity (I2 = 55%, P = .06). CPAP treatment is feasible in patients with stroke and sleep apnea and may improve neurological outcomes in these patients. However, this finding should be interpreted with caution because of the substantial heterogeneity of current trials. Fu S, Peng X, Li Y, Yang L, Yu H. Effectiveness and feasibility of continuous positive airway pressure in patients with stroke and sleep apnea: a meta-analysis of randomized trials. J Clin Sleep Med. 2023;19(9):1685-1696.

Associations of self-efficacy and outcome expectancy with adherence to continuous positive airway pressure therapy in Japanese patients with obstructive sleep apnea.

To examine the associations of self-efficacy and outcome expectancy with adherence to continuous positive airway pressure (CPAP) therapy among Japanese men with obstructive sleep apnea (OSA) using objective adherence data for CPAP therapy. We conducted a retrospective study of 497 Japanese men with OSA who were receiving CPAP therapy. Good adherence was defined as CPAP use of ≥4 hours per night for ≥70% of nights. Logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the associations of good adherence to CPAP therapy with self-efficacy and outcome expectancy (measured with the CPAP Self-Efficacy Questionnaire for Sleep Apnea in Japanese). The models were adjusted for age, duration of CPAP therapy, body mass index, apnea-hypopnea index, Epworth Sleepiness Scale score, and comorbidities (diabetes mellitus and hypertension). In total, 53.5% of participants had good adherence to CPAP therapy. The mean CPAP use was 5.18±1.53 hours/night. After adjusting for related factors, we found significant associations of good adherence to CPAP therapy with self-efficacy scores (OR, 1.10; 95% CI, 1.05-1.13; p<0.001) and outcome expectancy scores (OR, 1.10; 95% CI, 1.02-1.15; p=0.007). Our results indicate that self-efficacy and outcome expectancy are associated with good adherence to CPAP therapy among Japanese men with OSA.

Impact of an Extended Telemonitoring and Coaching Program on Continuous Positive Airway Pressure Adherence.

Rationale: The benefits of continuous positive airway pressure (CPAP) therapy in obstructive sleep apnea are limited by adherence. Telemonitoring and coaching have been demonstrated to increase adherence, but the ideal duration of such support is unclear. Objectives: To compare the impact of a 12-month versus a 3-month behavioral support program on CPAP adherence. Methods: We evaluated real-world CPAP adherence data from all patients initiating CPAP between July 1, 2018, and April 1, 2020, by any durable medical equipment (DME) providers who had used a 12-month commercially available telemonitoring/coaching program (Long Term Adherence Management, Philips Respironics) in this timeframe. Patients receiving either 12 months or 3 months of support (Patient Adherence Management Service) were compared with those initiated on CPAP without support. Mean CPAP adherence was computed monthly over the initial 18 months. Missing usage was imputed as zero use. All analyses were adjusted for age, sex, and DME provider. Results: The nine DME providers using the 12-month telemonitoring/coaching service cared for a total of 26,489 patients (3,264 receiving 12-month support, 15,424 receiving 3-month support, and 7,801 receiving no support) in the timeframe under study. In adjusted analyses, mean CPAP use in the 3-month support group was greater than the no support group in Month 3 (4.6 h vs. 4.3 h; P < 0.001) but subsequently, usage declined to match the no support group at both Month 12 and Month 18. In contrast, mean CPAP use was greater in the 12-month support group than in the no support group at Month 3 (4.6 h vs. 4.3 h; P < 0.001), Month 12 (4.0 h vs. 3.6 h; P < 0.001), and Month 18 (3.3 h vs. 3.2 h; P = 0.02). Conclusions: A 3-month telemonitoring/coaching program increases CPAP use in the short term but does not lead to sustained improvements. In contrast, a 12-month program leads to sustained improvements but results still diminish once coaching ceases. Implementation of longer-term telemonitoring and coaching programs may be vital to obtaining long-term benefits from CPAP therapy.

Treatment outcomes among rural and urban patients with obstructive sleep apnea: a prospective cohort study.

To determine whether adherence to continuous positive airway pressure (CPAP) in adults with uncomplicated obstructive sleep apnea differs by rural vs urban residential address. In this prospective cohort study, we recruited adults who initiated CPAP for uncomplicated obstructive sleep apnea that was diagnosed by a physician using sleep specialist-interpreted diagnostic testing. Participants were classified as urban (community size > 100,000) or rural (community size < 100,000) by translating residential postal code into geographic census area. The primary outcome was mean daily hours of CPAP use compared between rural and urban patients. Secondary outcomes included the proportion of patients who were adherent to CPAP, change in Epworth Sleepiness Scale score, change in EuroQOL-5D visual analog score, and Visit-Specific Satisfaction Instrument score. All outcomes were measured 3 months after CPAP initiation. We enrolled 242 patients (100 rural) with a mean (standard deviation) age of 51 (13) years and a respiratory event index of 24 (18) events/h. The mean (95% confidence interval) CPAP use was 3.19 (2.8-3.58) hours/night and 35% were CPAP-adherent, with no difference between urban and rural patients. Among the 65% of patients who were using CPAP at 3 months, the mean CPAP use was 4.89 (4.51-5.28) hours/night and was not different between rural and urban patients. Improvement in the Epworth Sleepiness Scale score and patient satisfaction was similar between groups, but the EuroQOL-5D score improved to a greater extent in rural patients. Urban or rural residence was not associated with CPAP adherence according to multivariable regression analysis. Rural vs urban residence was not associated with differences in CPAP adherence among patients with uncomplicated OSA diagnosed by a physician using specialist-interpreted sleep diagnostic testing. Corrigan J, Tsai WH, Ip-Buting A, etal. Treatment outcomes among rural and urban patients with obstructive sleep apnea: a prospective cohort study. J Clin Sleep Med. 2022;18(4):1013-1020.

Mindfulness may be a novel factor associated with CPAP adherence in OSAHS patients.

Poor adherence to continuous positive airway pressure (CPAP) remains the greatest obstacle to effective treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS). The purpose of the present study was to identify if mindfulness is associated with CPAP adherence of OSAHS patients. Newly diagnosed patients with OSAHS completed questionnaires including the Epworth Sleepiness Scale (ESS), the Mindful Attention Awareness Scale (MAAS), and the Hospital Anxiety and Depression Scale (HADS) and had experienced an overnight CPAP titration. Participants returned to the sleep center for a scheduled research visit after 30-day CPAP treatment at home. Demographics, disease severity, and device-related variables were collected. Multiple linear regression analysis was performed to build a multivariate predictive model for the outcome variable, mean daily CPAP use over 30days. Mean CPAP use was 4.7 ±2.4h/night for the study sample of 100 patients and 67% were classified as CPAP adherent. MAAS scale was 45.2 ± 18.8, whereas only 13% of patients expressed anxiety or depression. MAAS scales were significantly higher in the CPAP adherent group compared to the non-adherent group (49.5 ± 14.5 vs 40.8 ± 14.2, p< 0.001) with mean hours of daily CPAP use over 30days for the adherent group (5.7 ±1.4h/night) compared to the non-adherence group (3.0 ±1.7h/night). There were differences between the two groups in HADS depression, AHI, lowest SaO2, optimal CPAP pressure, residual AHI, mean days over 30days, and mean daily CPAP use in the first week. Univariate analyses identified an unadjusted association between mean daily CPAP use over 30days and HADS depression, MAAS, AHI, lowest SaO2, optimal pressure, and mean daily CPAP use in the first week. Multiple linear regression analysis demonstrated only MAAS and AHI were associated (p< 0.05) with mean daily CPAP use. MAAS and AHI uniquely explained 10.1% (p< 0.001) and 8.7% (p< 0.001) of mean daily CPAP use respectively. This study found a significant independent association of dispositional mindfulness with CPAP adherence. As a novel factor, mindfulness may play an important role in CPAP adherence.

A French update on the Self-Efficacy Measure for Sleep Apnea (SEMSA) to assess continuous positive airway pressure (CPAP) use.

The Self-Efficacy Measure for Sleep Apnea (SEMSA) is a 26-item self-questionnaire composed of three factors: risk perception of obstructive sleep apnea syndrome (OSAS), benefit of continuous positive airway pressure (CPAP), and self-efficacy (the confidence to engage in CPAP use). It is used to evaluate health beliefs about OSAS and CPAP in order to optimize CPAP use. The purpose of this study was to design and validate a French version of the SEMSA. A forward-backward translation of the SEMSA was performed. Subjects with OSAS treated by CPAP and followed by our sleep clinic were invited to complete the questionnaire. The psychometric properties of the French SEMSA version were analyzed in terms of its construct validity (with confirmatory factor analysis, CFA), internal structural validity (Cronbach's alpha coefficient), and external validity (Pearson's correlation between SEMSA score and duration of CPAP use). Two hundred eighty-eight subjects filled in the questionnaire. The mean age was 63.16 ± 12.73years. The number of years since the beginning of CPAP treatment was 6.58 ± 6.03years. The mean CPAP use duration was 6.19 ± 2.03h/night. CFA was unsatisfactory (RMSEA = 0.066 and CFI = 0.88). The exploratory factor analysis revealed a fourth factor named "cardiovascular risk" factor. Cronbach's alpha coefficient was 0.886. The correlation between the "self-efficacy" factor and the duration of CPAP use was significant (r = 0.26, p≤ 0.001). The French version of the SEMSA is a psychometrically acceptable self-report questionnaire for measuring health beliefs and behavior in French patients with OSAS treated with CPAP. Such translation and validation should lead to the adoption of validated psychosocial methods for improving CPAP use.

Change in Cognition and Other Non-Motor Symptoms With Obstructive Sleep Apnea Treatment in Parkinson Disease.

Parkinson disease (PD) non-motor symptoms are associated with sleep disorders and impair quality of life. Our objective was to assess the effect of obstructive sleep apnea (OSA) treatment using continuous positive airway pressure (CPAP) on PD non-motor symptoms. In this prospective observational study, 67 patients with idiopathic PD underwent polysomnography. Those with moderate-severe OSA were offered CPAP therapy. Subjects were divided into those without OSA (OSA-), and those with OSA (OSA+). Analyses were conducted for 6 and 12 months' follow-up data. At 6 months, those who had used CPAP at home for at least 1 month were considered CPAP users (OSA+CPAP+), whereas those who did not try it, or declined further treatment following a short trial were considered non-users (OSA+CPAP-). For the 12-month analysis, only those still actively using CPAP at 12 months were included in the OSA+CPAP+ group. Non-motor symptom measurements were: Epworth Sleepiness Scale, Montreal Cognitive Assessment (MoCA), Unified Parkinson's Disease Rating Scale part 1 (UPDRS1), Parkinson's Disease Sleep Scale (PDSS), Fatigue Severity Scale, Apathy Scale, Beck Depression Inventory, and Hospital Anxiety and Depression Scale (HADS). Sixty-five participants were re-assessed at least once. At 6 months, 30 participants were categorized as OSA+CPAP+, 11 OSA+CPAP-, and 18 OSA-. At 12 months, 21 were categorized as OSA+CPAP+, 21 OSA+CPAP-, and 17 OSA-. The UPDRS1 and PDSS improved from baseline in OSA+CPAP+ at 6 months (-2.7, standard deviation [SD] 4.0, P = .001, and 7.9, SD 19.0, P = .03, respectively) and 12 months (-4.1, SD 5.4, P = .002, and 11.4, SD 24.4, P = .04, respectively), but not in other groups. The MoCA and HADS-A improved in OSA+CPAP+ at 12 months (1.7, SD 3.5, P = .04, and -2.1, SD 3.8, P = .02, respectively). The MoCA improved in those with low baseline MoCA and those with REM sleep behavior disorder. Mean CPAP use in users at 12 months was 3 hours 36 minutes per night. CPAP treatment of OSA in PD is associated with improved overall non-motor symptoms, sleep quality, anxiety, and global cognitive function over a 12-month period.

CPAP as treatment of sleep apnea after stroke: A meta-analysis of randomized trials.

To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) examining the effectiveness of continuous positive airway pressure (CPAP) in stroke patients with sleep disordered breathing (SDB). In a systematic literature search of electronic databases (MEDLINE, Embase, and the Cochrane Library) from 1980 to November 2016, we identified RCTs that assessed CPAP compared to standard care or sham CPAP in adult patients with stroke or TIA with SDB. Mean CPAP use, odds ratios (ORs), and standardized mean differences (SMDs) were calculated. The prespecified outcomes were adherence to CPAP, neurologic improvement, adverse events, new vascular events, and death. Ten RCTs (564 participants) with CPAP as intervention were included. Two studies compared CPAP with sham CPAP; 8 compared CPAP with usual care. Mean CPAP use across the trials was 4.53 hours per night (95% confidence interval [CI] 3.97-5.08). The OR of dropping out with CPAP was 1.83 (95% CI 1.05-3.21, p = 0.033). The combined analysis of the neurofunctional scales (NIH Stroke Scale and Canadian Neurological Scale) showed an overall neurofunctional improvement with CPAP (SMD 0.5406, 95% CI 0.0263-1.0548) but with a considerable heterogeneity (I2 = 78.9%, p = 0.0394) across the studies. Long-term survival was improved with CPAP in 1 trial. CPAP use after stroke is acceptable once the treatment is tolerated. The data indicate that CPAP might be beneficial for neurologic recovery, which justifies larger RCTs.

Comorbid insomnia symptoms predict lower 6-month adherence to CPAP in US veterans with obstructive sleep apnea.

There is limited information on the association between pre-treatment insomnia symptoms and dysfunctional sleep beliefs with continuous positive airway pressure (CPAP) adherence in veterans with obstructive sleep apnea (OSA). Our aims were to describe demographic and sleep characteristics of veterans with and without comorbid insomnia and determine whether pre-treatment insomnia symptoms and dysfunctional sleep beliefs predict CPAP use after 6months of therapy. Hispanic veterans attending the Miami VA sleep clinic were recruited and completed the insomnia severity index, the dysfunctional sleep belief and attitude scale (DBAS), and other questionnaires. Participants were asked to return after 7days and 1 and 6months to repeat questionnaires and for objective CPAP adherence download. Hierarchical regression models were performed to determine adjusted associations of pre-treatment insomnia symptoms and DBAS sub-scores on 6-month mean daily CPAP use. Fifty-three participants completed the 6-month follow-up visit with a mean CPAP use of 3.4 ± 1.9h. Veterans with comorbid insomnia had lower mean daily CPAP use (168 ± 125 vs 237 ± 108min, p = 0.04) and lower percent daily CPAP use ≥ 4h (32 ± 32 vs 51 ± 32%, p = 0.05) compared to participants without insomnia. In adjusted analyses, pre-treatment insomnia symptoms (early, late, and aggregated nocturnal symptoms) and sleep dissatisfaction were predictive of lower CPAP use at 6months. Pre-treatment dysfunctional sleep beliefs were not associated with CPAP adherence. Pre-treatment nocturnal insomnia symptoms and sleep dissatisfaction predicted poorer 6- month CPAP use. Insomnia treatment preceding or concurrent with CPAP initiation may eliminate a barrier to regular use.

Adherence to continuous positive airway pressure in adults with an intellectual disability

Study objectivesThis retrospective study evaluated the feasibility of continuous positive airway pressure (CPAP) therapy in adults with intellectual disabilities (ID). MethodsCPAP therapy of 24 obstructive sleep apnea syndrome (OSA) patients with ID were compared to age- and sex-matched adults with normal cognitive functioning. All ID patients received an intensive in-hospital training protocol to stimulate adherence. Good adherence was defined as a use of >70% of the nights and >4 h/night. Influencing factors were assessed. ResultsBaseline apnea-hypopnea index (AHI) was significantly higher in ID patients compared to controls (median 34/h (range 6–101) versus 17/h (range 5–50), p = 0.013). The required average duration of in-hospital training was four nights (range 1–8 days). At six weeks, 60% of the ID patients showed good adherence and 65% at six months, compared to 71% and 50% respectively in the control group. Mean CPAP use per night was equal in both groups both at six weeks (5 h in both groups) and six months (ID 6:30 h vs control 5 h (p = 0.18)). CPAP adherence correlated with baseline AHI in the control patients, but not in ID patients. There was no correlation between CPAP adherence and the level of ID or the degree of support at home. ConclusionsUsing an intensive training protocol it is very well feasible to apply CPAP therapy in OSA patients with any degree of ID. CPAP adherence in ID patients was comparable to the control patients in this study as well as to previously published adherence numbers.

CPAP vs Mandibular Advancement Devices and Blood Pressure in Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-analysis.

Obstructive sleep apnea is associated with higher levels of blood pressure (BP), which can lead to increased cardiovascular risk. To compare the association of continuous positive airway pressure (CPAP), mandibular advancement devices (MADs), and inactive control groups (placebo or no treatment) with changes in systolic BP (SBP) and diastolic BP (DBP) in patients with obstructive sleep apnea. The databases of MEDLINE, EMBASE, and the Cochrane Library were searched up to the end of August 2015 and study bibliographies were reviewed. Randomized clinical trials comparing the effect of CPAP or MADs (vs each other or an inactive control) on BP in patients with obstructive sleep apnea were selected by consensus. Of 872 studies initially identified, 51 were selected for analysis. Data were extracted by one reviewer and checked by another reviewer. A network meta-analysis using multivariate random-effects meta-regression was used to estimate pooled differences between each intervention. Meta-regression was used to assess the association between trial characteristics and the reported effects of CPAP vs inactive control. Absolute change in SBP and DBP from baseline to follow-up. Of the 51 studies included in the analysis (4888 patients), 44 compared CPAP with an inactive control, 3 compared MADs with an inactive control, 1 compared CPAP with an MAD, and 3 compared CPAP, MADs, and an inactive control. Compared with an inactive control, CPAP was associated with a reduction in SBP of 2.5 mm Hg (95% CI, 1.5 to 3.5 mm Hg; P < .001) and in DBP of 2.0 mm Hg (95% CI, 1.3 to 2.7 mm Hg; P < .001). A 1-hour-per-night increase in mean CPAP use was associated with an additional reduction in SBP of 1.5 mm Hg (95% CI, 0.8 to 2.3 mm Hg; P < .001) and an additional reduction in DBP of 0.9 mm Hg (95% CI, 0.3 to 1.4 mm Hg; P = .001). Compared with an inactive control, MADs were associated with a reduction in SBP of 2.1 mm Hg (95% CI, 0.8 to 3.4 mm Hg; P = .002) and in DBP of 1.9 mm Hg (95% CI, 0.5 to 3.2 mm Hg; P = .008). There was no significant difference between CPAP and MADs in their association with change in SBP (-0.5 mm Hg [95% CI, -2.0 to 1.0 mm Hg]; P = .55) or in DBP (-0.2 mm Hg [95% CI, -1.6 to 1.3 mm Hg]; P = .82). Among patients with obstructive sleep apnea, both CPAP and MADs were associated with reductions in BP. Network meta-analysis did not identify a statistically significant difference between the BP outcomes associated with these therapies.

Urinary proteomic profiling in severe obesity and obstructive sleep apnoea with CPAP treatment

IntroductionObstructive sleep apnoea (OSA) is common in obesity and is associated with cardiovascular and metabolic complications. Continuous positive airway pressure (CPAP) in OSA may lead to physiological changes reflected in the urinary proteome. The aim of this study was to characterise the urinary proteome in severely obese adult subjects with OSA who were receiving CPAP compared with severely obese subjects without OSA. MethodsSeverely obese subjects with and without OSA were recruited. Subjects with OSA were receiving CPAP. Body composition and blood pressure measurements were recorded. Urinary samples were analysed by Capillary Electrophoresis–Mass Spectrometry (CE–MS). ResultsTwenty-seven subjects with OSA-on-CPAP (age 49±7years, BMI 43±7kg/m2) and 25 controls without OSA (age 52±9years, BMI 39±4kg/m2) were studied. Age and BMI were not significantly different between groups. Mean CPAP use for OSA patients was 14.5±1.0 months. Metabolic syndrome was present in 14(52%) of those with OSA compared with 6(24%) of controls (p=0.039). A urinary proteome comprising 15 peptides was identified showing differential expression between the groups (p<0.01). Although correction for multiple testing did not reach significance, sequences were determined for 8 peptides demonstrating origins from collagens, fibrinogen beta chain and T-cadherin that may be associated with underlying cardiovascular disease mechanisms in OSA. ConclusionsThe urinary proteome is compared in OSA with CPAP and without OSA in severe obesity. The effects of CPAP on OSA may lead to changes in the urinary peptides but further research work is needed to investigate the potential role for urinary proteomics in characterising urinary peptide profiles in OSA.

Polygraphic respiratory events during sleep in children treated with home continuous positive airway pressure: description and clinical consequences

ObjectiveData are scarce on respiratory events during sleep for children treated at home with continuous positive airway pressure (CPAP). The present study aimed to characterize the respiratory events with CPAP during sleep and to analyze their clinical consequences. Patients/MethodsConsecutive polygraphies (PG) performed on stable children treated with CPAP were analyzed and scored using SomnoNIV Group definitions. For every respiratory event, the presence of a 3% oxygen desaturation and/or an autonomic arousal was systematically searched. Nocturnal gas exchange was assessed using summary data of oximetry and transcutaneous carbon dioxide pressure recordings. ResultsTwenty-nine consecutive polygraphies, performed on 26 children (mean age 7.8 ± 6.2 years, mean CPAP use 10.6 ± 14.4 months), were analyzed. The index of total respiratory events was low (median value 1.4/h, range 0–34). The mean number of different types of respiratory events per PG was 2 ± 1 (range 0–4), with always a predominant event. Partial or total upper airway obstruction without a decrease in ventilatory drive was the most frequent event and was the most frequently associated with an oxygen desaturation (in 30% of the events) and an autonomic arousal (in 55% of the events). Weak correlations were observed between nocturnal oximetry and PG results. ConclusionsThe index of respiratory events during CPAP treatment for stable children is low. As these events may be associated with an oxygen desaturation or an autonomic arousal, and as nocturnal gas exchange cannot predict PG results, a systematic sleep study seems justified for the routine follow-up of children treated with CPAP.

The association of age, insomnia, and self-efficacy with continuous positive airway pressure adherence in black, white, and Hispanic U.S. Veterans.

Studies of continuous positive airway pressure (CPAP) adherence in multi-ethnic samples are lacking. This study explores previously described factors associated with therapeutic CPAP use in South Florida veterans with obstructive sleep apnea-hypopnea syndrome (OSAHS). We performed a retrospective, cross-sectional analysis of CPAP adherence comparing white, black, and Hispanic veterans returning to the Miami VA sleep clinic over a 4-month period. Participants had CPAP use download and completed questionnaires on demographics, sleepiness, insomnia, and social cognitive measures related to adherence. Linear regression modeling was used to explore the impact of measured variables and potential interactions with race-ethnicity on mean daily CPAP use. Participants (N = 248) were 94% male with mean age of 59 ± 11 years and included 95 blacks (38%), 91 whites (37%), and 62 Hispanic (25%) veterans. Blacks had less mean daily CPAP use than whites (-1.6 h, p < 0.001) and Hispanics (-1.3 h, p < 0.01). Blacks reported worse sleep onset insomnia symptoms compared to whites. In the final multivariable regression model, black race-ethnicity (p < 0.01), insomnia symptoms (p < 0.001), and self-efficacy (p < 0.001) were significantly associated with mean daily CPAP use. In addition, the black race by age interaction term showed a trend towards significance (p = 0.10). In agreement with recent studies, we found that mean daily CPAP use in blacks was 1 hour less than whites after adjusting for covariates. No CPAP adherence differences were noted between whites and Hispanics. Further investigations exploring sociocultural barriers to regular CPAP use in minority individuals with OSAHS are needed.

Determinants of continuous positive airway pressure adherence in a sleep clinic cohort of South Florida Hispanic veterans

There are little existing data on continuous positive airway pressure (CPAP) adherence in US Hispanic veterans with obstructive sleep apnea (OSA). Our aim was to describe determinants of 1-month adherence in a sleep clinic cohort of South Florida Hispanic veterans. Hispanic veterans referred to the Miami VA sleep clinic were recruited and completed questionnaires about sleep apnea risk, sleep quality, insomnia symptoms, sleepiness, depression/anxiety, acculturation, personality traits, and cognitions about OSA and CPAP. Individuals at risk for OSA were scheduled for baseline polysomnography (PSG), followed by in-lab CPAP titration or a trial of auto-CPAP. Participants with OSA accepting CPAP therapy were asked to return after 7 and 30days of treatment for adherence verification and to repeat questionnaires. One hundred twenty-four participants (94% men) were enrolled with 114 completing overnight PSG. Eighty-six out of 95 participants (91%) with sleep apnea syndrome or moderate to severe OSA accepted CPAP treatment. Fifty-nine participants completed both follow-up visits with a mean CPAP use at 30days of 3.6 ± 2.0h. The only independent predictor of 7-day mean daily CPAP use was the baseline Insomnia Severity Index while the best predictor of 30-day mean daily CPAP use was the 7-day mean daily use. Our study suggests that South Florida Hispanic veterans with OSA evaluated in a sleep clinic show poor CPAP adherence. Insomnia and poor early use predicted poor adherence overall. Larger prospective studies with other race-ethnic groups are needed to determine the role of ethnicity and race in CPAP adherence among US veterans with OSA.

Randomized Controlled Trial of Variable-Pressure Versus Fixed-Pressure Continuous Positive Airway Pressure (CPAP) Treatment for Patients with Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS)

To determine whether fixed-pressure or variable-pressure CPAP was preferred by patients and gave better outcomes in patients with the obstructive sleep apnea/hypopnea syndrome (OSAHS). Randomized blinded cross-over trial with 6 weeks of fixed and 6 weeks of variable-pressure CPAP. Sleep center. 200 consecutive consenting CPAP naïve patients with daytime sleepiness and > 15 apneas + hypopneas/h after an attended auto-CPAP titration night. CPAP therapy using the same device (Autoset Spirit) set for 6 weeks in fixed pressure mode and for 6 weeks in variable pressure mode, the order of therapies being randomized. All measurements were recorded at the end of each limb by a researcher blind to treatment. These included symptoms, Epworth Score, CPAP usage, objective sleepiness by modified Osler test, vigilance and health related quality of life. A total of 181 of 200 patients completed the study. At the end of the study, patients expressed no significant difference in the primary outcome, patient preference, 72 patients preferring fixed and 69 preferring variable-pressure CPAP. Epworth score was lower on variable (9.5, SEM 0.4) than fixed-pressure CPAP (10.0, SEM 0.3; P = 0.031). Mean CPAP use was higher on variable (4.2, SEM 0.2 h/night) than fixed-pressure CPAP (4.0, SEM 0.2 h/night; P = 0.047). There were no other significant differences between treatments. CONCLUSIONS This study shows no difference in patient preference and only a marginal benefit of variable over fixed-pressure CPAP in OSAHS in terms of subjective sleepiness and CPAP use. The clinical value of this difference remains to be determined. Variable-pressure versus fixed-pressure continuous positive airway pressure (CPAP) treatment for patients with obstructive sleep apnoea/hypopnoea syndrome (OSAHS); Registration # ISRCTN43085025.http://www.controlled-trials.com//SRCTN43085025.

Long-Term Effect of Continuous Positive Airway Pressure Therapy on Inflammation Markers of Patients with Obstructive Sleep Apnea Syndrome

Several lines of evidence suggest immune system derangement in obstructive sleep apnea syndrome (OSAS) patients. However, no data exist on the long-term effect of continuous positive airway pressure (CPAP) treatment on systemic immunity. Hence, we sought to evaluate this effect on various immunological parameters in OSAS patients. Prospective case series. Sleep unit of a general hospital. Newly-diagnosed, nonsmoking, otherwise healthy OSAS male patients (n = 52) were evaluated on diagnosis and 6 months after CPAP treatment. According to compliance to CPAP use at 6-month follow-up, they were divided into 2 groups: group A (n = 32): good compliance (mean CPAP use > or = 4 h/night); and group B (n = 20): poor compliance (mean CPAP use < 4 h/night). N/A. Blood samples were obtained at baseline and at the 6-month follow-up. Percentage and absolute count of lymphocyte subsets (by flow cytometry), serum TNF-alpha, IL-6, and uric acid levels were measured. No differences were recorded regarding the baseline anthropometric or sleep characteristics of the 2 groups. In group A, a significant decrease in the absolute count of total lymphocytes (P = 0.003), and of CD4+ cells (P = 0.001), and a decrease in TNF-alpha levels (P = 0.001) and uric acid levels (P < 0.001) was observed after CPAP application. On the contrary, no alterations occurred in any of the tested parameters in group B patients. The selective reduction of soluble and cellular immune response factors only in those OSAS patients who exhibited good compliance to CPAP therapy provides further evidence for an ongoing systemic immune process in OSAS.

Long-term Effect of Continuous Positive Airway Pressure on BP in Patients With Hypertension and Sleep Apnea

To analyze the long-term effect of continuous positive airway pressure (CPAP) on ambulatory BP in patients with obstructive sleep apnea (OSA) and hypertension, and to identify subgroups of patients for whom CPAP could be more effective. We conducted a prospective, long-term follow-up trial (24 months) in 55 patients with OSA and hypertension (mean CPAP use, 5.3 +/- 1.9 h/d [+/- SD]). Twenty-four-hour ambulatory BP monitoring (ABPM) was measured at baseline and after intervention with CPAP on an intention-to-treat basis. In addition, the correlation between the changes in 24-h mean arterial pressure (24hMAP) and CPAP compliance, OSA severity, and baseline ABPM was assessed. At the end of follow-up, a significant decrease was shown only in diastolic BP (- 2.2 mm Hg; 95% confidence interval [CI], - 4.2 to - 0.1; p = 0.03) but not in 24hMAP or other ABPM parameters. However, a correlation between changes in 24hMAP and baseline systolic BP (r = - 0.43, p = 0.001), diastolic BP (r = - 0.38, p = 0.004), and hours of use of CPAP (r = - 0.30, p = 0.02) was observed. A significant decrease in the 24hMAP was achieved in a subgroup of patients with incompletely controlled hypertension at entry (- 4.4 mm Hg; 95% CI, - 7.9 to - 0.9 mm Hg; p = 0.01), as well as in those with CPAP compliance > 5.3 h/d (- 5.3 mm Hg; 95% CI, - 9.5 to - 1.2 mm Hg; p = 0.01). Linear regression analysis showed that baseline systolic BP and hours of CPAP were independent predictors of reductions in BP with CPAP. Long-term CPAP reduced BP modestly in the whole sample. However, patients with higher BP at entry and good CPAP compliance achieved significant reductions in BP.

Continuous positive airway pressure for sleep apnoea/hypopnoea syndrome: usefulness of a 2 week trial to identify factors associated with long term use

BACKGROUNDThe sleep apnoea/hypopnoea syndrome (SAHS) is common and treatment with continuous positive airway pressure (CPAP) is effective. However, not all patients can cope with the demands of using mask positive pressure. Compliance can be improved with an intensive educational programme and patient support, but this is not practical in most centres given the large numbers of patients coming forward for treatment. Several studies have evaluated correlations between various parameters at diagnosis in order to anticipate patients' behaviour and to avoid the social and health implications of undertreated SAHS. We have evaluated the use of additional data derived during a 2 week home CPAP trial to identify factors associated with longer term use of CPAP and compliance.METHODSFollowing a diagnostic study, 209 patients were offered a CPAP machine for a 2 week home trial. After completing the trial, patients were reassessed and scored their overall satisfaction with CPAP treatment on a five point scale ranging from “much worse” to “much better” and an Epworth score relating to the loan period. Machine run time was recorded from the integral clock. These data were added to those available at diagnosis to construct models indicative of continuing CPAP and average nightly use at 1 year.RESULTS209 patients were offered the 2 week loan at least a year before June 1999 (90.9% men, mean (SD) age 51.0 (10.6) years, body mass index (BMI) 34.6 (7.7) kg/m2, Epworth score 15 (IQR 11–18), apnoea/hypopnoea index (AHI) 38.1 (22.9) events/h). 153 patients (73.2%) opted to continue CPAP and 56 declined. One year later data were available for 187 patients; 128 (68.5% on an intention to treat analysis) continued to use the machine with a mean use of 5.0 (2.4) hours/night. A logistic regression model indicated that mean CPAP use during the loan period and the overall satisfaction score accurately defined continuing CPAP and “satisfactory” CPAP use at 1 year. For patients with low machine use and no symptomatic improvement during the loan period, the addition of baseline AHI, baseline Epworth score, and the Epworth score at the end of the loan to the equation identifying factors associated with “satisfactory” CPAP use (mean &gt;2 hours/night) improved the value of the model.CONCLUSIONData derived from a 2 week CPAP trial are useful in identifying patients who will comply with CPAP treatment to 1 year. It can be used to identify patients with significant symptomatic disease who will struggle with CPAP and may benefit from additional education and support. High mean hourly use and a high degree of overall satisfaction during the loan period identified patients likely to use CPAP and be compliant with it at 1 year.