PAP Adherence Research Articles

Effect of melatonin on insomnia and daytime sleepiness, in patients with obstructive sleep apnea and insomnia (COMISA): A randomized double-blinded placebo-controlled trial

BackgroundCOMISA is a common disorder that results in nighttime awakenings ,daytime sleepiness and PAP intolerance. Cognitive behavioral therapy for insomnia is used to improve PAP adherence and no medication has been evaluated in such population yet. Melatonin with its chronobiotic and antioxidant effects may have potential benefits on COMISA consequences at the appropriate dose and time. This study aimed to evaluate the effect of melatonin on sleep quality, daytime sleepiness and PAP Compliance in patients with COMISA.MethodsThis double-blind placebo trial randomly assigned eligible OSA patients who suffered from insomnia despite using PAP for over a month to receive either melatonin 10 mg or placebo. The primary outcomes were measured by changes in the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire (FOSQ-10) over one month. Adherence to PAP was measured by the results of the PAP device reports on the average length of time and number of nights that the device was used.ResultsThirty patients were enrolled in the study after randomization. The melatonin arm showed significant improvement in all four primary outcomes compared to the placebo arm. The PSQI score was 3.836±1.839 in the melatonin arm versus 10.522±3.626 in the placebo arm (Pvalue<0.001). The ISI score was 8.476±3.568 in the melatonin arm versus 14.47±4.50 in the placebo arm (Pvalue<0.001). The ESS score was 6.854±4.334 in the melatonin arm versus 13.298±5.119 in the placebo arm (Pvalue<0.001). The FOSQ-10 score was 24.93±5.02 in the melatonin arm versus 19.87±4.24 in the placebo arm (Pvalue= 0.006). Additionally, nighttime consequences such as sleep latency and awakenings showed significant improvement in the melatonin arm. PAP devices results revealed improvement in duration of PAP use overnight. ConclusionsAdministering melatonin has been shown to improve self-reported sleep quality and PAP adherence in patients with COMISA.Trial registrationRegistration number IRCT20220105053635N1 was issued by the Iranian Registry of Clinical Trials (IRCT).

0570 Impact of a Sleep Apnea Management Group Clinic on PAP Adherence and PROs: A Randomized Controlled Trial

0570 Impact of a Sleep Apnea Management Group Clinic on PAP Adherence and PROs: A Randomized Controlled Trial

0567 Utilizing Machine Learning Based on Multi-Modal Data to Predict PAP Adherence in Patients with OSA

0567 Utilizing Machine Learning Based on Multi-Modal Data to Predict PAP Adherence in Patients with OSA

0537 Enhancing PAP Adherence in Black and Hispanic Patients Utilizing an Automated Telemonitoring Intervention

0537 Enhancing PAP Adherence in Black and Hispanic Patients Utilizing an Automated Telemonitoring Intervention

0565 Utilization of Pap Titration as Indicator for Prediction of Pap Adherence

0565 Utilization of Pap Titration as Indicator for Prediction of Pap Adherence

0562 Evaluation of Habitual Sleep Duration and PAP Adherence to Quantify Effective AHI Reduction at Home in Older Adults

0562 Evaluation of Habitual Sleep Duration and PAP Adherence to Quantify Effective AHI Reduction at Home in Older Adults

Exploring the efficacy of the multi-theory model (MTM) in understanding the intention for PAP adherence among recently diagnosed sleep apnea patients

Exploring the efficacy of the multi-theory model (MTM) in understanding the intention for PAP adherence among recently diagnosed sleep apnea patients

Performance of Claims-Based Algorithms for Adherence to Positive Airway Pressure Therapy in Commercially Insured Patients With OSA

BackgroundPositive airway pressure (PAP) therapy is first line therapy for obstructive sleep apnea (OSA), but consistent use is required for it to be effective. Previous studies have used Medicare fee-for-service claims data (e.g., device and equipment charges) as a proxy for PAP adherence to assess its effects. However, this approach has not been validated in a United States (US) commercially insured population, where coverage rules are not standardized. Research QuestionIn a commercially insured population in the US, how well do claims-based algorithms for defining PAP adherence correspond with objective PAP device usage? Study Design and MethodsDe-identified administrative claims data of commercially insured patients (18-64 years) with OSA were linked to objective PAP therapy usage data from cloud-connected devices. Adherence was defined based on device use (using an extension of Centers for Medicare and Medicaid Services 90-day compliance criteria) and from claims-based algorithms to compare usage metrics and identify potential misclassifications. ResultsThe final sample included 213,341 patients. Based on device usage, 48% were adherent in the first year. Based on claims, between 10 and 84% of patients were identified as adherent (accuracy, sensitivity, specificity ranges: 53-68%, 12-95%, 26-92%, respectively). Relative to claims-adherent patients, device-adherent patients had consistently higher usage across all metrics (mean: 339.9 vs. 260.0-290.0 days of use; 6.6 vs. 5.1-5.6 days per week; 6.4 vs. 4.6-5.2 hours per day). Consistent PAP users were frequently identified by claims-based algorithms as non-adherent, while many inconsistent users were classified by claims-based algorithms as adherent. InterpretationIn aggregate US commercial data with non-standardized PAP coverage rules, concordance between existing claims-based definitions and objective PAP use was low. Caution is warranted when applying existing claims-based algorithms to commercial populations. Clinical Trials Registration NumberNot applicable

Pediatric pulmonology year in review 2022: Sleep medicine.

Pediatric pulmonology publishes original research, review articles, and case reports on a wide variety of pediatric respiratory disorders. In this article, we summarized the past year's publications in sleep medicine and reviewed selected literature from other journals in this field. We focused on original research articles exploring aspects of sleep-disordered breathing in patients with underlying conditions such as asthma, neuromuscular disorders, and Down syndrome. We also explored sleep-disordered breathing risk factors, monitoring, diagnosis, and treatment; and included recent recommendations for drug-induced sleep endoscopy and ways to monitor and improve PAP adherence remotely.

Moroccan Women's Attitudes Regarding Pap Smear Test and Adherence to Cervical Cancer Screening.

In Morocco, cervical cancer is the second most common cancer affecting women after breast cancer. Encouraging more women to practice cervical cancer screening remains a major public health concern. There is a lack of data on awareness and of data concerning the determinants of the acceptability of Pap smear test in Morocco. To fill this gap, our study aims to assess the level of awareness of cervical cancer and human papillomavirus (HPV) infection among Moroccan women and to understand the determinants of the acceptability of Pap smear test. We conducted a cross-sectional study including 857 women in the following three Moroccan regions: Casablanca-settat, Marrakech-Safi, and Tanger-Tetouan-Al Hoceima, by using a structured interviewer-administered questionnaire between November 2019 and February 2020. Out of the total sample, 83.9% of participants were aware of cervical cancer, 87.2% of participants were unaware of HPV, and 51.8% of participants were aware of Pap smear test. The rate of women who had ever had a Pap smear test in our population was only 19.36%. Moreover, our study revealed that more than 78% of participants were willing to undergo Pap smear test regularly in the future. The study revealed parity, age, educational level, risk perception, and the belief that early screening improves the chances of successful treatment, as determinants of acceptability of Pap smear test. Our results have shown that there is an urgent need to implement a strategy to sensitize women on the prevention of cervical cancer. Furthermore, the results of this study should be taken into account in the development of strategic and action plans for the prevention of cervical cancer.

0447 Study of PAP response and compliance in patients with ILD and OSA: A case-control single center cohort

Abstract Introduction Interstitial lung disease (ILD) is a heterogenous group of parenchymal lung disorders with multiple etiologies. ILD often affects the quality of life and survival of patients. OSA is commonly diagnosed among ILD patients with reported prevalences of 50-90%, and a prevalence of moderate to severe OSA as high as 65%. There is also concern that patients with ILD may be less tolerant of PAP therapies. We aim to identify differences in PAP treatment response and adherence in patients with ILD and OSA compared with a group of matched OSA controls. Methods A retrospective cohort analysis was conducted on patients ≥ 18 years-old that were evaluated at Mayo Clinic Center for Sleep Medicine between July 2012 to June 2022. Inclusion criteria were patients with a diagnosis of ILD per ATS criteria also diagnosed with OSA by HSAT or PSG. Control OSA patients were matched to ILD/OSA patients by age, BMI, and AHI ranges. Exclusion criteria included comorbid conditions of asthma or COPD. Patients with early non-adherence to CPAP or those who didn't have sleep follow up were also excluded. Follow-up sleep visits were assessed to determine CPAP adherence, change in PAP pressure, addition of oxygen, and change in Epworth sleepiness scale. Results We compared 51 patients with ILD/OSA and 51 OSA matched-controls. Twenty-five ILD/OSA patients were diagnosed by PSG and 26 by HSAT. Median treatment follow-up for the ILD group was 7 months (IQR of 3 to 18 months). Baseline characteristics, including oxygen desaturation index (ODI), oxygen saturation, time spent below 89% during overnight oximetry, and baseline Epworth scale, were similar between ILD/OSA and non-ILD OSA patients. Importantly, there was no statistically significant difference in PAP adherence, median PAP levels, PAP pressure change, residual AHI, or change in Epworth after treatment Conclusion There was no significant difference in baseline OSA characteristics, treatment response, and PAP adherence in ILD patients with OSA compared with matched non-ILD OSA controls. Outcome assessment may be limited by sample size and the shorter follow-up period. Future studies should include longer-term follow-up with a larger ILD cohort to assess the impact of ILD progression on PAP adherence over time. Support (if any)

0516 Biopsychosocial intervention using virtual multidisciplinary group with improved PAP adherence after 1 year post intervention

Abstract Introduction Prevalence of untreated sleep apnea among veterans is 22.2 %. Untreated patients are at risk for multiple adverse outcomes including chronic sleep deprivation, excessive day time sleepiness, chronic fatigue, depression, and cardiovascular complications including hypertension, coronary artery disease, cerebrovascular accidents, pulmonary hypertension as result of increased sympathetic activity during apnea episodes. Nonadherence to PAP therapy within the first week of treatment are up to 50 % of patients who use PAP device during the first week between 12-25 % discontinue by PAP use by year 3. Barriers to PAP use include physical problems with PAP hardware, knowledge gaps, and psychological issues. Methods Veterans from sleep medicine and sleep apnea clinics as well as multiple primary care clinics participated in the PAP adherence group following 6 weeks biopsychosocial model. The intervention included weekly synchronized video encounters of behavior sleep specialist, respiratory therapist and sleep clinic nurse with the targeted group of veterans with sleep apnea and poor PAP adherence. This approach has multiple benefits, including being patient centered, cost effective and efficient with ability to help veterans at various motivational levels, assist 6-10 veterans virtually in 6 one-hour group sessions and easy care coordination. Results A total of 21 veterans with sleep apnea participated in virtual multidisciplinary group to improve PAP adherence between September 2020 and January 2021. Patients PAP adherence before intervention, post intervention and 1year after intervention was evaluated. Percent of patients using PAP &amp;gt;2 hours before intervention was 5 %, immediately after intervention it increased to 20 %, and there was further increase up to 33% after 1 year post. Conclusion A structured multidisciplinary biopsychosocial intervention demonstrated statistically significant improvement in PAP adherence which persisted up till 1 year post intervention. In fact additional improvement of &amp;gt;2 hours of PAP usage was noted in this patient group suggesting possible long term benefit of psychosocial multidisciplinary intervention on PAP adherence. This study also demonstrated efficiency of utilization of virtual/telemedicine platform for psychosocial intervention and brief behavioral therapy. Support (if any)

0552 Predictive Characteristics of Run-In Period Adherence in a Randomized Controlled Trial

Abstract Introduction The run-in period has been used in randomized controlled trials in obstructive sleep apnea (OSA) to assess continuous positive airway pressure (CPAP) adherence. We hypothesize that there are differences in participant characteristics and PAP adherence between those excluded after the run-in period and those included in the final analytic sample of the Sleep Apnea Stress Study (SASS, NCT00607893), a trial designed to examine effect of PAP treatment on intermediate cardiovascular outcomes. Methods The SASS trial was designed to include a 2-week run-in period with a 1-month wash-out period. Patients with CPAP adherence &amp;gt;4 hours of CPAP use for 70% of run-in period nights were randomized. Demographic factors were compared among groups using analysis of variance (ANOVA) or Kruskal-Wallis test in continuous variables, Pearson’s chi-square test or Fisher’s exact test was used for categorical variables. Bonferroni correction was applied for pairwise comparisons. SAS version 9.4 (The SAS Institute Cary, NC) was used to perform all analyses. Results Fifty-nine participants(30.8%) who did not meet PAP adherence threshold were excluded after run-in period and compared to Sham and CPAP treatment group(n=74 in each group). Results are presented as excluded vs sham treatment vs CPAP treatment. Participants excluded after the run-in period were more likely to be female than those who proceeded to randomization: 66% vs. 47% vs. 45%,p=0.031 and of Black race:73% vs. 42% vs. 47%, p=0.002. Participants excluded after the run-in period and those non-adherent to treatment in sham and CPAP were younger than adherent participants: excluded: 48.9±12.0, sham non-adherent 49.7±12.3, CPAP non-adherent 47.7 ± 13.2, sham adherent 58.3±9.3, CPAP non-adherent 54.3 ± 9.4, p=0.014. In the run-in period, participants who were excluded had the median of number of days using the device 12 (IQR 7-15), mean of average daily use 2.8±2.1 hours and median percent of days with 4+ hours use 18.2% (IQR 0-57.1%). Conclusion We identify that age and race are predictors of run-in period non-adherence to PAP therapy underscoring the need to develop pre-randomization PAP adherence optimization strategies specific to these subgroups to ensure representation in the trial. Support (if any) This work was supported by NIH HL079114-02.

0565 The Obstructive Sleep Apnea CPAP Therapy Compliance; Progressions, Challenges and Interventions

Abstract Introduction Obstructive sleep apnea (OSA) is a common sleep disorder affecting 26% of the United States adult population and is associated with adverse health outcomes. Despite the advent of an array of treatment options, PAP remains the primary treatment modality for OSA since the approach was introduced in 1981. The objective of this systematic review is to determine how we can increase compliance to PAP therapy as the gold standard of OSA treatment. Methods A systematic review was conducted to study meta-analyses performed to determine the clinical significance of using PAP in several modalities, PAP initiation strategies, educational and behavioral interventions, tele monitoring, humidification, level of AHI, different mask interfaces, and flexible or modified pressure profile PAP to treat OSA in adults. Results Data demonstrated a clinically significant improvement in PAP adherence with the use of educational, behavioral, troubleshooting, and telemonitoring interventions. Also systematic reviews show that nasal interfaces compared to oronasal interfaces have improved adherence and slightly greater reductions in OSA severity, heated humidification compared to no humidification reduces some continuous PAP-related side effects. Finally, AHI level of 15 and above but not demographic variables payed a role in compliance. Conclusion All medical therapies have challenges with patient adherence. PAP therapy for OSA has unique challenges as available data indicate that optimal benefit is derived from continued use throughout the patient's sleeping period while clinical trials continue to demonstrate suboptimal group adherence ranging from 3–5 h/night. Given this, substantial work remains to be done to determine the optimal combination of strategies to maximize adherence. All researches on increasing adherence has evaluated outcomes at 3 months or less, despite evidence that usage continues to wane over time long-term. Evaluation of strategies to maintain adherence long term is a critical research priority. Other fields to focus are strategies for identification of patient-factors that place them at risk for nonadherence prior to PAP use, and the development and validation of specific algorithms to utilize with telemonitoring to identify nonadherent patients early after initiation of PAP. Comparative effectiveness studies will be needed to develop a comprehensive adherence program that can be deployed into routine clinical care. Support (if any)

0529 Efficacy of a Novel Acceptance-Based Approach in Improving PAP Adherence in Women Veterans

Abstract Introduction Sleep disordered breathing (SDB) is associated with a myriad of health conditions yet is often underrecognized in women. Positive airway pressure (PAP) therapy is first line therapy for SDB; however, adherence rates are low, with women in the U.S. having lower PAP adherence than men. In studies of veterans, published research has not evaluated interventions specifically for women with SDB. Acceptance and Commitment Therapy (ACT) is a technique that utilizes individuals’ values, commitment to change, and mindfulness techniques to promote behavioral change and may be an effective technique in improving PAP adherence among women veterans. Methods We analyzed data from women veterans newly diagnosed with SDB who agreed to try PAP therapy (mean age=53.2 years [range 26-80], 30% African American, 28% Hispanic; n=90) who participated in a randomized controlled trial comparing an ACT-based intervention (Acceptance and Behavioral Changes to treat Sleep Apnea - ABC-SA; n=44) to a PAP educational control (n=46). Remote monitoring was used to determine days of PAP usage, days PAP used &amp;gt; 4 hours (main outcome), and hours of PAP used per month for the first 3 months of use. We used mixed models to compare changes in PAP adherence measures between groups over the first 3 months of use. Results In the ABC-SA group, mean nights of use were 20.9, 14.9, and 11.5 for months 1, 2, and 3 respectively, versus 16.9, 11.0, and 8.7 in the control group, with a non-significant trend towards more nights of use in the ABC-SA group in month 1 (p=0.056). There were no significant differences between ABC-SA and control in other PAP use outcomes in months 1, 2 or 3. Conclusion An ACT-based approach did not improve PAP adherence in women veterans over the first three months compared to education alone. Future studies are needed to evaluate whether subgroups may benefit from more intensive interventions such as ABC-SA and to evaluate interventions for improving PAP use long-term. Support (if any) This research was supported by the VA HSR&amp;D IIR 16-244. Dr. Martin was supported by VA HSR&amp;D RCS 20-191 and NIH/NHLBI K24 HL143055.

Potential and future challenges for Cheyne-Stokes breathing telemonitoring from continuous positive airway pressure devices.

Subscription RequiredCommentariesPotential and future challenges for Cheyne-Stokes breathing telemonitoring from continuous positive airway pressure devices Kimimasa Saito, MD, PhD Kimimasa Saito, MD, PhD Saito Naika Kokyukika, Mie Sleep Clinic, Ise-shi, Japan Search for more papers by this author Published Online:January 3, 2023https://doi.org/10.5664/jcsm.10456

Pediatric pulmonary year in review 2021: Sleep medicine

Pediatric pulmonology publishes original research, review articles, and case reports on a wide variety of pediatric respiratory disorders. In this article, we summarized the past year's publications in sleep medicine and reviewed selected literature from other journals in this field. We focused on original research articles exploring aspects of sleep-disordered breathing in patients with underlying conditions such as cystic fibrosis, asthma, and sickle cell disease. We also explored sleep-disordered breathing risk factors, monitoring, diagnosis, and treatment; and included recent recommendations for drug-induced sleep endoscopy and ways to monitor and improve PAP adherence remotely.

0767 Clinical implementation of a program to improve PAP acceptance and adherence for sleep disordered breathing among Veterans: Preliminary results

Abstract Introduction Positive airway pressure (PAP) is the gold standard in treating sleep disordered breathing (SDB); however, consistent use of this therapy has challenges such as comfort and equipment optimization. Despite various educational, technological, psychosocial and pharmacological strategies, the average adherence rate of 34% have changed very little over the past 20 years. A recent study of 3013 US veterans determined a baseline average PAP adherence rate of 50%. We developed and implemented a novel PAP readiness education program (PREP) for veterans newly diagnosed with SDB in a Veterans Administration sleep clinic to promote greater PAP acceptance and adherence. Methods Patients (N=63, Mean age 62.2±12.4 years) with newly diagnosed SDB were offered a 1-hour telehealth session prior to initiating PAP therapy that included psychoeducation about SDB and PAP treatment expectations, with troubleshooting techniques (i.e. scheduled practice, mindfulness). A 1-week follow-up call was conducted to communicate PAP data and address treatment barriers. PAP use reports were downloaded and analyzed at 1-7 days (first week), 1-30 days (first month), and 31-60 days (60-days) post-PAP initiation. PAP acceptance was defined as ≥1 day of use and adherence as ≥4 hours of use at each timepoint. Results Among 63 Veterans offered PREP, 66.6% (n=42) participated in PREP. Among participants, acceptance of PAP was as follows: 57.1% used ≥1 day in the first week, 64.3% used ≥1 day in the first month, and 45.2% used ≥1 day at 60-days post-PAP initiation. Percent of days with use ≥4 hours was 28.9% ±30.4 in the first week and 24.9% ±30.0 in the first month. PAP adherence at 60-days post-PAP initiation was 34.3% ±38.5 at 60-days. Conclusion Implementation of a 1-session plus 1-week follow-up call PAP readiness education program within a sleep medicine clinic was well received by patients and resulted in PAP acceptance by 2/3 of veterans in the first month post-PAP initiation. PAP adherence results may have reflected the impact of a nationwide PAP device recall that occurred during the study period. Further work is needed to test this intervention in a clinical population and to identify predictors of PAP acceptance and adherence in real-world clinical settings. Support (If Any) AASM Foundation #211-FP-19, VAGLAHS GRECC and CSHIIP

0360 PAP Adherence, Follow-Up, and Telehealth During the COVID-19 Pandemic

Abstract Introduction Positive airway pressure (PAP) is the gold standard therapy for OSA. However, patient follow-up and adherence to PAP therapy remains variable. With the onset of the COVID-19 pandemic, many sleep centers shifted towards telemedicine. In order to evaluate the impact of telehealth, we assessed the rates of follow-up and PAP adherence among patients newly diagnosed with OSA prior to and after the onset of the COVID-19 pandemic. Methods Patients aged 18-75 years enrolled in our military sleep center who met eligibility criteria were divided into a pre-pandemic group and a pandemic group. For the pre-pandemic group, initial and follow-up clinic appointments occurred via face-to-face encounters. For the pandemic group, these clinic appointments occurred via telephone encounters. PAP follow-up was defined as a clinic appointment occurring within 6 months of the initial OSA diagnosis and the onset of PAP therapy. Adequate PAP adherence was defined as usage of the device ≥ 4 hours per night on ≥ 70% of nights during a consecutive 30-day period. Differences among the two groups regarding PAP follow-up, PAP adherence, and demographic data were analyzed. Results Eligible patients (n=234) were divided into a pre-pandemic group (n=117) and a pandemic group (n=117). Demographic data for the pre-pandemic group vs. pandemic group included the following: mean age 42.2 vs. 40.3 years; 78.6% vs. 88.0% male; 60.7% vs. 76.9% active duty military, mean BMI 30.1 vs. 30.1; mean AHI 28.5/hr vs. 27.7/hr; mean Epworth Sleepiness Scale score 11.7 vs. 12.0; mean Insomnia Severity Index 16.9 vs. 16.8. The rates of PAP follow-up were 59.0% (pre-pandemic group) vs. 41.0% (pandemic group). The rates of adequate PAP adherence were 34.8% (pre-pandemic group) vs. 25.0% (pandemic group). Conclusion There were higher rates of PAP follow-up and PAP adherence among patients seen via face-to-face encounters occurring prior to the onset of the COVID-19 pandemic. While utilization of telehealth in our center did not result in improved outcomes, there may still be utility in offering telehealth to the sleep patient population. Additional studies are needed to identify effective interventions that can be implemented to improve rates of PAP follow-up and PAP adherence. Support (If Any) There were higher rates of PAP follow-up and PAP adherence among patients seen via face-to-face encounters occurring prior to the onset of the COVID-19 pandemic. While utilization of telehealth in our center did not result in improved outcomes, there may still be utility in offering telehealth to the sleep patient population. Additional studies are needed to identify effective interventions that can be implemented to improve rates of PAP follow-up and PAP adherence.

0540 First Year PAP Trajectories among Treatment-Naive Youth with Sleep Disordered Breathing

Abstract Introduction Little is known about the time course for youth adjusting to and achieving optimal PAP adherence. Methods This retrospective study identified 12-month PAP trajectories and treatment persistence following treatment initiation in youth. Participants were first-time PAP initiators receiving care at Cincinnati Children’s Hospital from 07/2017-12/2019. Electronic downloads provided monthly PAP use. Adherence indicators were frequency (percentage of nights PAP used each month) and duration of use (average usage hours on nights used each month). Persistence of group-level adherence (frequency and duration) was measured via descriptive statistics in SPSS. Adherence sub-groups were identified using longitudinal mixed models in MPlus. Results The sample was 169 youth ages 2-22yrs started on PAP. Within the first month, 55% of participants were using PAP &amp;gt;50% of nights and 43% were using for &amp;gt;4 hours/night. Adherence (frequency and duration, respectively) decreased by month as follows: month 3 - 48% and 42%; month 6 - 41% and 41%; month 12 - 36% and 32%. Longitudinal mixed models identified 5 trajectories for frequency of use (based on the model of best fit using BIC index): “starts high, stays high” (34% of sample); “starts high, slowly decreasing” (7%); “starts high, rapidly decreasing” (12%); “starts low, slowly increasing” (8%); “starts low, stays low” (39%). Two trajectories were identified for duration (average hours worn on nights used, also based on model of best fit) and included: “starts high, slowly increasing” (40%) and “starts low, stays low” (60%). Conclusion At the group level, PAP adherence was sub-optimal in the first month of use (around half of participants using PAP &amp;gt;50% of nights or for &amp;gt;4 hours) and declined over the subsequent 11 months. However, mixed models identified distinct adherence subgroups, with about 40% of the sample falling into subgroups with relatively high adherence by month 12. This suggests acclimation to PAP takes time in a pediatric population. Findings may help clinicians/policy makers set realistic expectations around time to achieve optimal PAP adherence among youth, and highlights the need for further PAP adherence promotion interventions. Support (If Any) First, and fourth authors’ time supported by NIH post-doctoral training grants (T32 DK063929 and T32HD068223, respectively).