PAP Adherence Research Articles

Novel Nasal Pillow Mask Designed to Meet CPAP Efficacy and Improve Comfort

SESSION TITLE: Aftermath of OSA and Its Treatment SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 27, 2015 at 08:45 AM - 10:00 AM PURPOSE: Despite transformative benefits for CPAP in OSA, adherence is quite variable. Complaints include skin irritation, eye puffiness, belching, headache/sinus problems and aesthetic/social complaints. Unlike standard CPAP masks, we are testing a new mask and technology (FRESCA) which delivers low levels of airflow while providing intrapharyngeal pressure hypothesized to maintain upper airway patency. During inhalation, FRESCA entrains room-air minimizing the need for a humidifier. We sought to test FRESCA vs standard CPAP in terms of efficacy. METHODS: To test the viability of this approach we are performing a single-blinded randomized crossover study using standard sleep software. To date, 30 subjects have been enrolled, 25 yielding data from 7 sites. Compliant nasal CPAP users were provided 8 hours sleep opportunity, one night on standard CPAP mask at prescribed pressure and one night on FRESCA mask, same pressure. A blinded RPSGT scored the studies using Medicare criteria (≥4% desaturation). Primary outcomes are Apnea Hypopnea Index(AHI) and Oxygen Desaturation Index(ODI). RESULTS: 25 subjects (17M) are presented with age 53.7±10.1years, and BMI 30.0±3.0kg/m2. In 3 subjects a third night was necessary (one due to sleep<4hrs and two due to high leak). Of the 25 subjects, baseline AHI was 23.8±15.3/h. All enrolled subjects had CPAP levels ranging from 4-14cmH2O. As blinding is maintained we present primary outcomes (AHI and ODI) for Treatment X and Treatment Y. On Treatment Y, the median AHI and ODI respectively were 1/h[0.2,4.6], 0.3/hr[0.2, 3.5]. On Treatment X the median AHI and ODI respectively were 0.7/h[0.2, 2.6] and 0.1/hr[0.0,0.2]. CONCLUSIONS: Thus far, FRESCA has comparable efficacy to standard CPAP. Further efforts will be required to determine whether this new technology will improve comfort while maintaining PAP efficacy for Obstructive Sleep Apnea. CLINICAL IMPLICATIONS: This new mask may play a role in improving PAP adherence. DISCLOSURE: The following authors have nothing to disclose: Pamela DeYoung, Erik Smales, Gary Zammit, Richard Bogan, Delmer Henninger, Wesley Fleming, David Seiden, Imran Sharief, Bret Sherman, Robert Owens, Atul Malhotra No Product/Research Disclosure Information

Is Traumatic Brain Injury Associated with PAP Adherence in Obstructive Sleep Apnea: A Pilot Study. (P7.318)

Is Traumatic Brain Injury Associated with PAP Adherence in Obstructive Sleep Apnea: A Pilot Study. (P7.318)

Upper Airway Obstruction during Noninvasive Ventilation Induced by the Use of an Oronasal Mask

In patients with neuromuscular disorders, no randomized studies have been performed whether nasal or oronasal masks should be preferred. Oronasal masks are often used in acute respiratory failure, while nasal masks are preferred in patients with chronic respiratory failure. However, the use of nasal masks can result in mouth leaks with implications on sleep quality. To reduce these leaks, oronasal masks have been applied during home noninvasive ventilation (NIV). Until now, upper airway obstruction during NIV has been thought to be induced by nasal obstruction, pharyngeal collapse, and/or glottis closure. We report a case indicating another cause of upper airway obstruction: use of an oronasal mask can induce obstructive events in the upper airways, possibly resulting in sleep fragmentation and decreased efficiency of NIV.

Effect of addition of chin strap on PAP compliance, nightly duration of use, and other factors.

A chinstrap is potentially useful to reduce unintentional air leak by preventing mouth opening during PAP treatment. This study examines whether the addition of a chinstrap to PAP therapy has any effect on adherence, nightly duration of use, air leak, and residual AHI. This was a retrospective study performed at an AASM-accredited VAMC sleep center. Clinical sleep data of veterans (n = 124) prescribed PAP therapy for sleep apnea was evaluated, and the effect of chinstrap use vs non-use on the above parameters was assessed. Chinstrap users had significantly greater PAP adherence, longer nightly duration of PAP use, lower residual AHI and lower leak compared to chinstrap non-users at first follow up visit. The addition of a chin strap to PAP therapy is a simple and inexpensive method of increasing PAP adherence.

The Future is Here

Change is the only constant in health care; and with change comes uncertainty, anticipation and trepidations. The adoption of the Patient Protection and Affordable Care Act, commonly known as the Affordable Care Act (ACA), is undoubtedly the most sweeping health care law passed by Congress since the creation of Medicare in 1965. The ACA is ushering in fundamental transformation that is likely to change the landscape of healthcare delivery in the U.S. It is very likely that the implementation of the ACA provisions will have signifi cant unintended and unforeseen consequences for medical professionals, patients, insurers and businesses. 1 Despite this uncertainty, it is clear that the ACA will shift the emphasis toward improving the outcome of care and reducing costs, perhaps by focusing on integration of care among providers and across care settings. Within this broad context of change, the fiof sleep medicine is undergoing its own radical transformation. Sleep medicine is no longer a specialty about a single disease, a single test, or a single device; instead, sleep medicine professionals provide care transcending organ based specialties, caring for one third of human life, a critical third that has direct impact on every aspect of health. The challenge before us is to develop care models that meet three aims: optimal patient experience, including quality and satisfaction; improving the health of population; and decreasing the cost of care. What are the key themes that are likely to infl uence the practice of sleep medicine in the new era of health care reform? I will highlight several areas that require our attention in the coming year.

Correlates of a Prescription for Bilevel Positive Airway Pressure for Treatment of Obstructive Sleep Apnea among Veterans

The acceptance of portable home-based polysomnography together with auto-titrating CPAP has bypassed the need for a laboratory polysomnography. Since bilevel airway pressure (BPAP) is titrated in the sleep lab, patients diagnosed using portable home-based polysomnography may not have the opportunity to receive BPAP. It is unknown whether the patients who would have ordinarily received a BPAP would benefit from it. We determine correlates of receiving BPAP and of being switched from BPAP to CPAP. We examine whether patients with these correlates have better adherence to BPAP versus CPAP. Retrospective Cohort Study (Correlates at baseline) of 2,513 VA patients with a sleep study between January 2003 and October 2006 and receiving continuous or bilevel positive airway pressure (CPAP [N = 2,251]) or BPAP [N = 262]) by the end of 2007. PAP adherence up to 30 months was assessed. Significant correlates of BPAP were older age (p < 0.001), higher BMI and CHF (p < 0.01), COPD (p < 0.001), higher blood CO₂ (p < 0.05), higher AHI and OSA severity (p < 0.001), lower nadir SpO₂ (p < 0.001), and greater sleepiness (ESS) (p < 0.01). Patients on BPAP were more adherent to PAP therapy (p < 0.01), but the association largely disappeared following adjustment for BPAP correlates. There was preliminary evidence that these correlates predict long-term adherence to PAP therapy regardless of mode. We identified baseline factors that can help clinicians decide whether to prescribe an auto-BPAP as first-line therapy and that predict good long-term PAP adherence.

Driving On “Auto”: Hands-On is More Effective Than Hands-Free

Driving On “Auto”: Hands-On is More Effective Than Hands-Free

The Future of Behavioral Sleep Medicine: A Report on the Presentations Given at the Ponte Vedra Behavioral Sleep Medicine Consensus Conference, March 27–29, 2009

A major goal of the Behavioral Sleep Medicine Consensus Conference held in Ponte Vedra, Florida on March 27 through 29, 2009 was to have 15 key opinion leaders provide the latest information on their areas of expertise. Those leaders represented the breadth of the behavioral sleep medicine field (pediatrics, adults, insomnia, PAP adherence, and circadian rhythm disorders) and included clinicians and researchers from a variety of settings (academia, private practice, the military, and primary care). The presentations highlighted the milestones already achieved by the field (critical mass, solid empirical base, 30+ training programs, certification, dedicated journal, and dedicated textbook), as well as important future directions (more clinical research, public relations campaigns, training, and reimbursement).

Cervical Cancer Beliefs and Pap Test Screening Practices Among Chinese American Immigrants

To examine beliefs and Pap test utilization among Chinese American women, the largest Asian female population in the United States. Cross-sectional descriptive, correlational study. Metropolitan areas of Portland, OR. 100 foreign-born Chinese women aged 40 years and older. Three questionnaires were modified, translated, combined, and pretested. Participants completed the self-administered questionnaire in a group setting. Utilization of Pap test screening, health beliefs, and cultural and sociodemographic variables. Sixty-eight percent reported having a Pap test within the prior three years (adherence), and 84% reported ever having a Pap test. The odds of Pap test use and adherence decreased with increasing age. Women with insurance or a regular healthcare provider had better odds of Pap test use and adherence. Older age, older age when a participant moved to the United States, and increased modesty were negatively associated with ever having had a Pap test. Age and cultural beliefs influence Pap test use and adherence. The strength of provider recommendation and healthcare access as predictors suggest areas for interventions designed to increase screening for cervical cancer. Nurses play a vital role in preventive health care, especially with the growing number of advanced practice nurses delivering primary care. Primary healthcare providers should be reminded of their influential role in increasing adherence to cancer screening. Further health policy action is necessary to extend screening coverage to those who do not have adequate health insurance.

Association of genes encoding P fimbriae, CS31A antigen and EAST 1 toxin among CNF1-producing Escherichia coli strains from cattle with septicemia and diarrhea

Fifty-six CNF1-producing Escherichia coli strains isolated from cattle with diarrhea or septicemia were screened by PCR for the detection of pap, sfa, afa, clpG, or f17 adherence factor and EAST 1 toxin genes. All the isolates were pap-positive, in accordance with the close association of pap, CNF1 and α-hemolysin genes observed on human and porcine E. coli. Only the gene encoding the P adhesin of class III (PrsG) was detected. Genes encoding CS31A antigen (71%) and S fimbriae (34%) (but not Afa or F17) were detected among the bovine isolates. E. coli producing both CNF1 and plasmid-encoded CS31A is a new example of association between bacterial clones and plasmid-mediated virulence factors. The EAST 1 toxin-encoding gene was detected on 66% of the CNF1-producing isolates but was linked to CS31A rather than to CNF1. These results suggest a close association between EAST 1 toxin and the adherence factor CS31A among pathogenic bovine E. coli.

Association of genes encoding P fimbriae, CS31A antigen and EAST 1 toxin among CNF1-producing Escherichia coli strains from cattle with septicemia and diarrhea.

Fifty-six CNF1-producing Escherichia coli strains isolated from cattle with diarrhea or septicemia were screened by PCR for the detection of pap, sfa, afa, clpG, or f17 adherence factor and EAST 1 toxin genes. All the isolates were pap-positive, in accordance with the close association of pap, CNF1 and alpha-hemolysin genes observed on human and porcine E. coli. Only the gene encoding the P adhesin of class III (PrsG) was detected. Genes encoding CS31A antigen (71%) and S fimbriae (34%) (but not Afa or F17) were detected among the bovine isolates. E. coli producing both CNF1 and plasmid-encoded CS31A is a new example of association between bacterial clones and plasmid-mediated virulence factors. The EAST 1 toxin-encoding gene was detected on 66% of the CNF1-producing isolates but was linked to CS31A rather than to CNF1. These results suggest a close association between EAST 1 toxin and the adherence factor CS31A among pathogenic bovine E. coli.

Purified P fimbriae from two cloned gene clusters of a single pyelonephritogenic strain adhere to unique structures in the human kidney

We have completed immunofluorescence binding studies of purified fimbriae from two clones which express Pap or Pap-2 fimbriae. Although the two fimbrial types exhibited common binding to the uroepithelia of the bladder and renal pelvis and to occasional cells located within the glomeruli which we have termed glomerular elements, only Pap-2 fimbriae adhered to Bowman's capsule. Previous studies have demonstrated that the Gal alpha 1----4Gal disaccharide moiety is capable of inhibiting Pap hemagglutination and adherence to uroepithelial cells. Results of our experiments demonstrate that this disaccharide is not sufficient for blocking binding of Pap-2 fimbriae to Bowman's capsule but that GalNAc beta 1----3Gal completely blocks Pap-2 adherence to Bowman's capsule. These results indicate that the different hemagglutination capacities of the two clones reflect different receptor specificities and differential tissue tropisms in the urinary tract. These unique receptor specificities may provide uropathogenic strains of Escherichia coli carrying multiple chromosomal copies of pap-like gene clusters with the advantage of increased numbers of binding sites within the urinary tract. This, in turn, might improve the chances of colonization and the establishment of infection.

Detection by molecular hybridization of pap, afa, and sea adherence systems in Escherichia coli strains associated with urinary and enteral infections

The genetic determinants resposible for the adherence of Escherichia coli to uroepithelial cells have been identified in recent years by genetic and molecular methods. Specific DNA probes for each of the three operons which have been cloned so far ( pap, afa, sfa/foc operons) have been used in colony hybridization experiments to detect the presence of each of these operons in the chromosomal DNA of 443 strains of E. coli; 186 strains were frompatients with urinary tract infections (pyelonephritis, 106 strains; cystitis, 59; asymptomatic bacteriuria, 21) and 257 were strains from the stools of healthy subjects (61) or from patients with various enteral infections (196). E.coli strains harbouring the pap operon were found more frequently in the urine of patients with pyelonephritis (ifp < 0.001) and cystitis (p < 0.01) than in control stools. The presence of two operons ( pap+ afa) or ( pap+ sfa/foc) was only observed in uropathogenic strains. (p < 0.02). Pap and sfa/foc operons were never found in strains causing enteral infection; however, the afa operon was found in 7.6% of the enteropathogenic E. coli.