Positive Airway Pressure Therapy In Patients Research Articles

Effects of Positive Airway Pressure on Cardiorespiratory Fitness in Patients with Concomitant Obstructive Sleep Apnea and Cardiovascular Disease.

Background and Objectives: Obstructive sleep apnea (OSA) is common in cardiovascular disease (CVD), although positive airway pressure (PAP) treatment has not been demonstrated to improve the cardiovascular outcome. The objective of this study is to investigate the impact of adherence to PAP therapy on cardiopulmonary exercise testing (CPET) performance in patients with concomitant OSA and CVD. Materials and Methods: This preliminary study involved symptomatic OSA patients requiring PAP treatment who had CVD. All subjects underwent polysomnography, echocardiography, and CPET at baseline. After 6 to 12 months of PAP treatment, CPET performance was re-assessed. The changes in CPET parameters before and after PAP treatment were compared between patients who were adherent to PAP and patients who were not adherent to PAP. Results: A total of 16 OSA patients with an apnea-hypopnea index of 32.0 ± 23.4 were enrolled. Patients were classified into the adherent (n = 9) and non-adherent (n = 7) groups with regard to PAP adherence. After 6 to 12 months of PAP treatment, the PAP-adherent group showed a greater increase in peak VO2 than the PAP-non-adherent group, but the difference between the two groups was not significant (p = 0.581). The decrease in ventilatory equivalent for the carbon dioxide slope (VE/VCO2) was significantly greater in the PAP-adherent group compared to the PAP-non-adherent group (p = 0.030). Conclusions: Adherence to PAP therapy for OSA is associated with an improvement in the VE/VCO2 slope, as an index of the ventilatory response to exercise, in patients with CVD. Screening for sleep apnea in CVD patients may be warranted, and strategies to optimize adherence to PAP in these patients are beneficial. Further evidence is needed to elucidate whether CPET could be routinely used to monitor treatment responses of OSA to PAP therapy in patients with CVD.

Association Between Sleep Apnea Treatment and Health Care Resource Use in Patients With Atrial Fibrillation.

Obstructive sleep apnea (OSA) contributes to the generation, recurrence, and perpetuation of atrial fibrillation, and it is associated with worse outcomes. Little is known about the economic impact of OSA therapy in atrial fibrillation. This retrospective cohort study assessed the impact of positive airway pressure (PAP) therapy adherence on health care resource use and costs in patients with OSA and atrial fibrillation. Insurance claims data for ≥1 year before sleep testing and 2 years after device setup were linked with objective PAP therapy use data. PAP adherence was defined from an extension of the US Medicare 90-day definition. Inverse probability of treatment weighting was used to create covariate-balanced PAP adherence groups to mitigate confounding. Of 5867 patients (32% women; mean age, 62.7 years), 41% were adherent, 38% were intermediate, and 21% were nonadherent. Mean±SD number of all-cause emergency department visits (0.61±1.21 versus 0.77±1.55 [P=0.023] versus 0.95±1.90 [P<0.001]), all-cause hospitalizations (0.19±0.69 versus 0.24±0.72 [P=0.002] versus 0.34±1.16 [P<0.001]), and cardiac-related hospitalizations (0.06±0.26 versus 0.09±0.41 [P=0.023] versus 0.10±0.44 [P=0.004]) were significantly lower in adherent versus intermediate and nonadherent patients, as were all-cause inpatient costs ($2200±$8054 versus $3274±$12 065 [P=0.002] versus $4483±$16 499 [P<0.001]). All-cause emergency department costs were significantly lower in adherent and intermediate versus nonadherent patients ($499±$1229 and $563±$1292 versus $691±$1652 [P<0.001 and P=0.002], respectively). These data suggest clinical and economic benefits of PAP therapy in patients with concomitant OSA and atrial fibrillation. This supports the value of diagnosing and managing OSA and highlights the need for strategies to enhance PAP adherence in this population.

Positive Airway Pressure Therapy Adherence and Health Care Resource Use in Patients With Obstructive Sleep Apnea and Heart Failure With Preserved Ejection Fraction.

Background Obstructive sleep apnea (OSA) is common in heart failure with preserved ejection fraction (HFpEF). However, current evidence is equivocal regarding the potential benefits of treating OSA with positive airway pressure (PAP) therapy in HFpEF. This study assessed the association between adherence to PAP therapy and health care resource use in patients with OSA and HFpEF. Methods and Results Administrative insurance claims data linked with objective PAP therapy usage data from patients with OSA and HFpEF were used to determine associations between PAP adherence and a composite outcome including hospitalizations and emergency room visits. One-year PAP adherence was based on an adapted US Medicare definition. Propensity score methods were used to create groups with similar characteristics across PAP adherence levels. The study cohort included 4237 patients (54.0% female, mean age 64.1 years); 40% were considered adherent to PAP therapy (30% intermediate adherent, 30% nonadherent). In the matched cohort, PAP-adherent patients had fewer health care resource use visits than nonadherent patients, a 57% decrease in hospitalizations, and a 36% decrease in emergency room visits versus the year before PAP initiation. Total health care costs were lower in adherent patients than nonadherent patients ($12 732 versus $15 610, P<0.001). Outcomes for intermediately adherent patients were most similar to those for nonadherent patients. Conclusions Treating OSA with PAP therapy in patients with HFpEF was associated with a reduction in health care resource use. These data highlight the importance of managing concomitant OSA in patients with HFpEF, and the need for strategies to enhance PAP adherence in this population.

Impact of the COVID-19 pandemic on adherence to positive airway pressure treatment in patients with obstructive sleep apnea: systematic review and meta-analysis.

The adverse effects of the COVID-19 pandemic on sleep have been well studied. However, whether the COVID-19 pandemic impacted positive airway pressure (PAP) adherence in patients with obstructive sleep apnea (OSA) remains unclear. To evaluate the impact of the COVID-19 pandemic on adherence to PAP therapy in patients with OSA. A retrospective cohort study, systematic review, and meta-analysis. The retrospective study included adults with OSA who received PAP prescriptions within the year before and the year after the start date of COVID-19 social distancing (22 March 2020) in South Korea. The threshold of clinical significance for PAP adherence was defined as 0.5 h/day. We also searched for relevant studies published up to 15 January 2023 using the MEDLINE and Embase databases. We performed a random-effects meta-analysis of our findings with the identified studies regarding the standardized mean change (SMC) with a 95% CI of PAP adherence. Our study included a total of 306 patients (mean age, 59.7 years; men, 73.5%). The average daily PAP usage was 5.10 ± 1.63 h before the COVID-19 pandemic and 4.79 ± 1.96 h during the pandemic (mean difference, -0.31 h/day; 95% CI, -0.46 to -0.15 h/day; p < 0.001 using paired t-test). After identifying 10 observational before-and-after studies through a systematic review, we conducted a meta-analysis that included our original data and showed that adherence to PAP treatment was not different before and during the COVID-19 pandemic (SMC, 0.01; 95% CI, -0.18 to 0.19; p = 0.952). Although the COVID-19 pandemic had a statistically negative impact on adherence to PAP treatment in South Korea, the effect was not clinically relevant in patients with OSA. According to our meta-analysis, adherence to PAP treatment was not different before and during the COVID-19 pandemic in patients with OSA. PROSPERO database; No.: CRD42023414268; URL: https://www.crd.york.ac.uk/PROSPERO.

Abstract 13554: Effect of Positive Airway Pressure Therapy for Obstructive Sleep Apnea in Heart Failure Patients With Reduced Ejection Fraction - Implications for Healthcare Resource Utilization

Introduction: Obstructive sleep apnea (OSA) is common in heart failure, although the impact of OSA treatment remains unclear. We assessed the association between adherence to positive airway pressure (PAP) therapy and healthcare resource utilization in patients with OSA and heart failure with reduced ejection fraction (HFrEF). Methods: Administrative insurance claims data linked with objective PAP therapy usage data from patients with OSA and HFrEF were used to measure the association of PAP adherence and a composite clinical outcome of hospitalization and emergency room (ER) visits. US Medicare defines PAP compliance as usage of the device for at least 4 hours/night for 70% of nights in a consecutive 30-day period over 90 days. PAP adherent patients met these criteria for all 4 90-day periods, while PAP non-adherent patients did not meet these criteria for any 90-day period over one year. Propensity score methods were used to create well matched groups with differing PAP adherence levels. Results: The study cohort consisted of 3,182 eligible patients (69.9% male, mean age 59.7 years) of whom 39% were considered adherent to PAP therapy (29% intermediate-adherent, 31% non-adherent). In the year after PAP prescription, after propensity score matching, PAP adherent patients had fewer hospital visits than non-adherent patients, driven by a 24% reduction in ER visits for adherent patients (Table 1a). These results remained consistent with inverse probability weighting and furthermore showed there were no statistically significant differences between intermediate-adherent and non-adherent patients for any outcome (Table 1b). Conclusions: Treating OSA with PAP therapy in patients with HFrEF is associated with a reduction in the composite outcome of hospitalization and ER visits, driven primarily by a reduction in ER visits. Consistent adherence to PAP therapy is required to realize these benefits.

Abstract 11028: Positive Airway Pressure Therapy for Obstructive Sleep Apnea in Heart Failure Patients With Preserved Ejection Fraction - Implications for Healthcare Resource Utilization

Introduction: Heart failure patients with preserved ejection fraction (HFpEF) frequently have co-morbid obstructive sleep apnea (OSA), although the impact of OSA treatment remains unclear in this patient population. We assessed the association between adherence to positive airway pressure (PAP) therapy and healthcare resource utilization in patients with OSA and HFpEF. Methods: Administrative insurance claims data linked with objective PAP therapy usage data from patients with OSA and HFpEF were used to measure the association of PAP adherence and healthcare resource utilization, defined by hospitalizations and emergency room (ER) visits. US Medicare defines PAP compliance as use for at least 4 hours/night for 70% of nights in a consecutive 30-day period over 90 days. PAP adherent patients met this criteria for all 4 90-day periods, while PAP non-adherent patients did not meet this criteria for any 90-day period over one year. Propensity score methods were used to create well matched groups with differing PAP adherence levels. Results: The study cohort consisted of 4,237 eligible patients (54.0% female, mean age 64.1 years), of whom 40% were considered adherent to PAP therapy (30% intermediate-adherent, 30% non-adherent). After propensity score matching on prior year covariates, during the year after PAP prescription, PAP adherent patients had fewer hospital visits than non-adherent patients, with a 57% reduction in hospitalizations and a 36% reduction in ER visits for PAP adherent patients (Table 1a). These results remained consistent with inverse probability weighting, and furthermore showed a significant difference in hospitalizations between intermediate-adherent and non-adherent patients, but no significant difference in ER visits (Table 1b). Conclusions: Treating OSA with PAP therapy in patients with HFpEF is associated with a reduction in hospitalizations and ER visits. Adherence to PAP therapy is required to realize these clinical benefits.

Adherence to Positive Airway Pressure Therapy in Patients With Obstructive Sleep Apnea.

Adherence to either continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) therapy in patients with obstructive sleep apnea syndrome (OSAS) represents a real challenge to sleep medicine physicians. Many risk factors/predictors for nonadherence exist, and usually, it is multifactorial. Long-term nonadherence with CPAP therapy has been associated with the use of CPAP for <4 hours/night during early treatment, moderate to severe obstructive sleep apnea (OSA), poor self-efficacy, and unsupportive bed partner. The American Academy of Sleep Medicine (AASM) recommends follow-up of patients with OSA within the first two weeks of CPAP use to optimize adherence. Measures to improve adherence to positive airway pressure (PAP) therapy go through an integrated approach that involves behavioral therapy and prompt management of side effects. Pharmacologic therapy in the form of a sedative-hypnotic sleep aid has a minor role in managing nonadherence to CPAP based on the greater risk of side effects. This article will briefly discuss the risk factors and management of nonadherence to PAP therapy in patients with OSAS.

Impact of Positive Airway Pressure Therapy Adherence on Outcomes in Patients with Obstructive Sleep Apnea and Chronic Obstructive Pulmonary Disease.

Rationale: The co-occurrence of obstructive sleep apnea and chronic obstructive pulmonary disease, termed overlap syndrome, has a poor prognosis. However, data on positive airway pressure (PAP) treatments and their impact on outcomes and costs are lacking. Objectives: This retrospective observational study investigated the effects of PAP on health outcomes, resource usage, and costs in patients with overlap syndrome. Methods: Deidentified adjudicated claims data for patients with overlap syndrome in the United States were linked to objectively measured PAP user data. Patients were considered adherent to PAP therapy if they met Centers for Medicare and Medicaid Services criteria for eight 90-day timeframes from device setup through 2-year follow-up. Propensity score matching was used to create comparable groups of adherent and nonadherent patients. Healthcare resource usage was based on the number of doctor visits, all-cause emergency room visits, all-cause hospitalizations, and PAP equipment and supplies, and proxy costs were obtained. Measurements and Main Results: A total of 6,810 patients were included (mean age, 60.8 yr; 56% female); 2,328 were nonadherent. Compared with the year before therapy, there were significant reductions in the number of emergency room visits, hospitalizations, and severe acute exacerbations during 2 years of PAP therapy in patients who were versus were not adherent (all P < 0.001). This improvement in health status was paralleled by a significant reduction in the associated healthcare costs. Conclusions: PAP usage by patients with overlap syndrome was associated with reduced all-cause hospitalizations and emergency room visits, severe acute exacerbations, and healthcare costs.

The effect of positive airway pressure therapy on intraocular pressure and retina in severe obstructive apnea syndrome.

To identify and compare changes in intraocular pressure (IOP), macular, and peripapillary retinal nerve fiber layer (RNFL) thickness using optical coherence tomography (OCT) measurements before and after 3 months of positive airway pressure (PAP) therapy in patients with severe obstructive sleep apnea syndrome (OSAS). Twenty-five patients diagnosed with severe OSAS in the neurology sleep outpatient clinic were included in the study. Ophthalmologic examinations were performed at the time of diagnosis and after 3months of PAP therapy. Statistical analysis of comparisons of pre-treatment and post-treatment measurements of IOP and OCT was performed. Before the PAP therapy, the correlations between central corneal thickness (CCT), body mass index (BMI), OCT, IOP, and sleep parameters were statistically analyzed. Compared to the pre-treatment measurements at the time of diagnosis, post-treatment measurements showed insignificant decrease in IOP, significant increase in mean macular thickness and significant thinning in superior nasal RNFL. There was no correlation found between pre-treatment measurements including IOP, OCT, CCT, BMI, and sleep parameters. The effect of intermittent hypoxia and hypercapnia on the IOP and macula may be reversible in severe OSAS patients receiving 3months of PAP therapy, but the reversibility of the neurodegenerative effects of OSAS on RNFL with this treatment seems controversial. OCT can be considered to be a promising technique for monitoring disease progression under PAP therapy in patients with severe OSAS.

Sex differences regarding the impact of a standardized adaptation session in Colombian patients with obstructive sleep apnea and poor adherence to positive airway pressure devices

Introduction: Positive airway pressure (PAP) is the most effective treatment for obstructive sleep apnea (OSA) but adherence is poor. The Sleep-disordered breathing clinic of Fundación Neumológica Colombiana (FNC) has a standardized adaptation session (SAS) aimed at patients with difficulties in using PAP devices. Objective: To evaluate the impact of a SAS in short-term adherence to PAP therapy in patients with OSA and to determine sex differences. Materials and methods: Before-after single cohort study conducted in 40 people aged ≥ 18 years with an AHI ≥ 15/hour and treated at the FNC, Bogotá D.C. (Colombia) between 2015 and 2017, and who attended a SAS due to poor adherence to PAP therapy (defined as &lt;4 hours use in 70% of nights). Data on the hours of use of the PAP device and the % of days in which it was used &gt;4 hours were recorded before and after the intervention to evaluate changes in patients’ adherence. Descriptive statistics were used for data analysis. The paired samples t-test was used for the comparison of variables before and after the intervention. Results: A significant increase was observed in the PAP device use (1.8 hours, 95%CI: 1.3-2.3; p&lt;0.001) and in the % of days its use was &gt;4 hours (35.6%, 95%CI: 26.0-45.3; p&lt;0.001); in men the increase was greater in both cases (2.3 hours, 95%CI: 1.7-2.9; p=0.029 and 47.8%, 95%CI: 32.9-62.8; p=0.029). Conclusion: The SAS offered by the FNC, which includes education strategies and the identification and solving of barriers hindering the use of PAP devices, significantly increased the hours of use of the device and the % of days in which it was used more than 4 hours in the study population, in particular in men.

Positive airway pressure therapy for chronic pain in patients with obstructive sleep apnea-a systematic review.

Obstructive sleep apnea (OSA) is prevalent in patients with chronic non-cancer pain. OSA may lead to low sleep quality and an increase in pain sensitivity. Patients reporting greater sleep impairment tend to experience higher pain intensity and vice versa. Positive airway pressure (PAP) is the current gold standard treatment for OSA. This review aims to evaluate the efficacy of PAP therapy in patients with comorbid chronic pain and OSA in influencing pain outcomes like pain intensity, tolerance, threshold, and sensitivity. We performed a systematic literature search for studies published after 1990, utilizing the following databases: Medline, Medline In-Process/ePubs, Embase, Cochrane CENTRAL, and the Cochrane Database of Systematic Reviews. Search terms included "chronic pain," "sleep disorders," and "positive airway pressure." Of 1982 initial studies, ten studies met the study inclusion criteria. Seven of these studies examined the effect of PAP therapy on chronic pain, of which five demonstrated improved pain outcomes, specifically, headache pain. The effect of PAP therapy on chronic non-headache pain was found to be inconclusive. When examining the three studies that did not involve chronic pain patients, PAP therapy effectively increased pain threshold and tolerance in two studies (p = 0.03 and p = 0.01). An association exists between PAP therapy and decreased chronic headache outcomes in patients with OSA. Additionally, research shows that PAP therapy may increase pain tolerance and threshold. Future high-quality evidence is required to further investigate the association between PAP and non-headache chronic pain.

The Impact of National Health Insurance Coverage on Compliance With Positive Airway Pressure Therapy in Patients With Obstructive Sleep Apnea.

Objectives. Compliance with positive airway pressure (PAP) in patients with obstructive sleep apnea (OSA) directly affects its treatment efficacy. Since July 2018, polysomnography and PAP therapy have been covered by the National Health Insurance (NHI), which has reduced the price barrier and promoted PAP therapy in Korea. This study aimed to compare changes in PAP compliance before and after NHI implementation.Methods. This study is a retrospective analysis in a tertiary hospital setting in Korea. From 2011 to 2019, patients with OSA (apnea-hypopnea index ≥5) treated using a PAP device for ≥1 month were included. They were classified as belonging to the pre-insurance (PI) group (having started PAP before July 2018) or the NHI group (having received a PAP reimbursement by the NHI service). We collected and analyzed medical records and PAP use information for between-group comparisons of compliance. We defined compliance as the percentage of usage days, the percentage of days with usage for ≥4 night hours, and average daily usage hours.Results. We included 146 and 100 patients in the PI and NHI groups, respectively. Automatic PAP mode and NHI were independent predictors of compliance B at the 3- and 9-month follow-up points. The NHI group showed significantly higher compliance A at 3, but not 9 months. For compliance B, the NHI group showed significantly higher compliance than the PI group at 1 month and 3 months, but not at 9 months. Compared with the PI group, the NHI group showed significantly higher compliance C only at 3 months.Conclusion. The NHI has positively affected PAP therapy in patients with OSA. Insurance policy may affect compliance within the first 3 months of PAP therapy.

Factors determining the long-term compliance with PAP therapy in patients with sleep-related epilepsy

IntroductionIn adult patients with epilepsy, treatment of comorbid obstructive sleep apnea syndrome (OSAS) by positive airway pressure (PAP) therapy results in improvements in the control of seizures. This is the first study investigating the long-term compliance with PAP therapy in patients with sleep-related epilepsy and OSAS. MethodsIn this longitudinal study, patients with sleep-related epilepsy and OSAS were followed-up for five years. The compliance with PAP therapy was defined as the use of PAP therapy for at least four hours per night for more than 70 % of nights. ResultsA total of 58 patients with sleep-related epilepsy and OSAS completed study protocol. Eleven patients (19.0 %) refused PAP treatment for OSAS, and 13 patients (22.3 %) showed irregular use. Remaining 34 patients (58.7 %) were compliant with PAP therapy. Females were found to be more compliant than males (p = 0.027), while the age was not found to correlate with the compliance (p = 0.721). Epilepsy-related factors including the types of seizures, whether pure sleep-related or mixed (p = 0.403), localization (p = 0.920) or lateralization (p = 0.697) of discharges, showed no effect on the compliance with PAP therapy. On the other hand, patients with a lower number of seizures (p = 0.042) or with a lower seizure frequency (p = 0.048) showed better compliance with PAP therapy. Polysomnographic parameters including severity of OSAS failed to show a significant correlation. ConclusionOur findings showed that about two thirds of the study population was compliant with PAP therapy after a mean follow-up duration of almost three years. Newly-diagnosed patients, mostly females, with a lower number of total seizures and lower seizure frequency seem to be more compliant with PAP therapy, which implies the significance of investigation and treatment of OSAS as early as possible in the patients with sleep-related seizures.

Abstract 13815: Prognostic Impact of Sleep Disordered Breathing in Hospitalized Patients Following Acute Heart Failure

Introduction: Identifying hospitalized patients at a high risk for worse long-term clinical outcomes following acute heart failure (AHF) is important. However, limited data regarding influence of sleep-disordered breathing (SDB) and its treatment by positive airway pressure (PAP) on post-discharge clinical outcomes in hospitalized patients following AHF are available. Hypothesis: Presence of SDB may be associated with worse long-term clinical outcomes, which may be reversible by PAP therapy in patients with AHF. The aim of this study is to investigate relationship between SDB, its treatment by PAP and long-term clinical outcomes. Methods: After the initial improvement of AHF, overnight polysomnography was performed on consecutive hospitalized patients whose left ventricular (LV) ejection fraction ≤45% between May 2012 and April 2018. In the present study, SDB was defined as an apnea-hypopnea index ≥15. Patients with SDB were subdivided as those with or without PAP treatment. The incidence of deaths and re-hospitalizations due to exacerbation of heart failure until April 2019 were assessed by stepwise multivariable Cox proportional model. Results: Overall, 241 patients were enrolled. Among them, 73% had SDB and 29% were initiated into PAP. At a median follow-up of 1.7 years, 89 patients had clinical events (36.9%). In the stepwise multivariable analysis, SDB was associated with increased risk of clinical events (hazard ratio [HR], 2.20; P=0.007). Among SDB patients, stepwise multivariable analysis showed that PAP treatment was associated with reduced risk of clinical events (HR 0.45; P=0.022). Conclusions: In hospitalized patients following AHF, presence of SDB was associated with worse long-term clinical outcomes, which may be reversible by PAP therapy. Thus, following AHF, hospitalized patients with LV systolic dysfunction should be evaluated whether they have SDB and considered for SDB treatment before discharge.

0737 Diagnostic Value And Financial Effects Of Recertification Polysomnography In Medicare Patients With Obstructive Sleep Apnea

Abstract Introduction The annual cost of diagnosis and treatment of obstructive sleep apnea (OSA) exceeds 12.4 billion dollars in the United States. The Centers for Medicare and Medicaid Services (CMS) require that after initiation of positive airway pressure (PAP) therapy patients have physician follow up and comply with specific requirements. Otherwise, continued PAP benefits are terminated and patients must undergo repeat sleep testing to reinstate therapy. Repeat testing can become an economic burden. We hypothesize that restudying patients prior to reinstating PAP therapy does not change the diagnosis and may only result in increased health care costs. Methods A chart review of polysomnographic studies (PSG) was performed on Medicare referrals made for the purposes of recertification to the Memorial Hermann Sleep center between October 2018 and 2019. Demographic and diagnostic data (including AHI) were collected. The percentage of patients with a change of diagnosis between the initial study and the recertification study was documented. Results 429 Medicare patients were referred for polysomnography. 34 patients were referred for PAP recertification. The average age in the recertification group was 65 years, 47% were male with an average BMI of 33.4 kg/m2. The average AHI on the recertification study was 33.5 events/hour (range 7-114). None of the patients sent for PAP recertification by polysomnography had a negative study for OSA. Conclusion Repeat PSG did not change the need for PAP therapy in patients originally diagnosed with OSA (all the patients continued to qualify). The mandatory referral of all patients who do not meet the CMS requirements for continued benefits for PAP, represents an extra cost to the health care system without a change in the clinical therapy. This money may better be utilized in providing patient education known to improve adherence to PAP. Support N/A

The Role of Positive Airway Pressure Therapy in Adults with Obesity Hypoventilation Syndrome. A Systematic Review and Meta-Analysis.

Rationale: Obesity hypoventilation syndrome (OHS) is an undesirable complication of severe obesity. Although weight loss is an accepted component of management, it is difficult to achieve and sustain the degree of weight loss necessary to reverse OHS. As such, positive airway pressure (PAP) during sleep has become the cornerstone therapy for most patients with OHS. However, the value of PAP therapy remains uncertain.Objective: To perform a systematic review to determine whether adults with OHS should be treated with PAP therapy or not.Methods: This systematic review informed an international, multidisciplinary panel of experts who had converged to develop a clinical practice guideline on OHS for the American Thoracic Society. MEDLINE, the Cochrane Library, and Embase were searched from January 1946 to March 2019 for studies that compared PAP therapy (i.e., continuous PAP or noninvasive ventilation) to no PAP therapy in patients with OHS. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to appraise the quality of evidence.Results: The search identified 2,994 unique articles. The full text of 56 articles was reviewed, and 25 studies were selected, including 3 randomized trials, 12 nonrandomized comparative studies, and 10 randomized and nonrandomized studies without a comparator group. Sample size ranged from 21 to 1,527 patients. PAP was associated with increased resolution of OHS and improvements in mortality, gas exchange, daytime sleepiness, sleep quality, quality of life, and emergency department visits. Nearly half of patients experienced trivial adverse effects related to PAP therapy. Certainty in the estimated effects was low or very low for most outcomes.Conclusions: The panel made a conditional (i.e., weak) recommendation that PAP therapy during sleep be offered to patients with OHS to improve outcomes. This recommendation was based on very low-quality evidence.

The Association Between Adherence to Positive Airway Pressure Therapy and Long-Term Outcomes in Patients With Obesity Hypoventilation Syndrome: A Prospective Observational Study.

To assess the role of different levels of adherence and long-term effects of positive airway pressure (PAP) therapy on gas exchange, sleepiness, quality of life, depressive symptoms, and all-cause mortality in patients with obesity hypoventilation syndrome (OHS). A total of 252 patients with newly diagnosed OHS were followed up for a minimum of 2 years after PAP initiation. PAP adherence (h/night) was monitored. Arterial blood gas samples were taken with patients being alert for more than 4 hours after morning awakening. Subjective daytime sleepiness (Epworth Sleepiness Scale [ESS]), quality of life (Short Form 36 [SF-36]) and patient's depressive symptoms (Beck Depression Inventory [BDI]) were assessed before and at the end of the follow-up period, along with all-cause mortality. At the end of the follow-up period (median duration [25th-75th percentile], 30 [24-52] months), PaO2 increased from baseline (72.7 ± 10.3 versus 63.2 ± 10.6, P < .001) and both PaCO2 and HCO3- decreased (43.0 [39.2-45.0] versus 50.0 [46.7-55.4] and 27.5 ± 3.2 versus 31.4 ± 4.2, respectively, P < .001). In addition, PAP therapy significantly improved ESS (7 [4-9] versus 14 [11-16], P < .001), BDI (8.8 ± 4.9 versus 15.5 ± 7.3, P < .001) and SF-36 (82 [78-87] versus 74 [67-79], P < .001) scores. Over the follow-up period 11 patients died. Patients who used PAP for > 6 h/night had significant improvements (P < .05) in blood gases and SF-36 scores than less adherent patients. Increased hours of use and long-term therapy with PAP are effective in the treatment of patients with OHS. Clinicians should encourage adherence to PAP therapy in order to provide a significant improvement in clinical status and gas exchange in these patients. A commenary on this article appears in this issue on page 1455. Title: PAP Therapy in Patients With Obesity Hypoventilation Syndrome, Registry: ClinicalTrials.gov, Identifier: NCT03449641, URL: https://clinicaltrials.gov/ct2/show/NCT03449641.

0518 TREATMENT OF SLEEP DISORDERED BREATHING IN HYPERMOBILE PATIENTS

Patients with hypermobility syndromes often have difficulty using Positive Airway Pressure (PAP) Therapy for treatment of their Sleep Disordered Breathing. To investigate this, the CPAP titrations of patients with hypermobility were studied in detail. The attended PAP titrations of 19 consecutive patients with a Beighton hypermobility score of 5 or greater at a neurology institute were retrospectively reviewed. Of 19 patients, 6 had Sleep Apnea - Unspecified (Upper Airway Resistance Syndrome) (G47.30) and 13 had Obstructive Sleep Apnea (G47.33). All ± values reflect the standard error of the mean. During titrations, after an initial nadir for scorable hypopneas was achieved, 11 of 19 patients experienced an average increase of 10.24 ± 2.5 in their hypopnea index as pressure was increased. At their hypopnea nadir, 15 of 19 patients’ AHI was 0 and an average Respiratory Effort Related Arousal Index of 38.4 ± 6.7 remained. Example titrations and images of typical airways in hypermobile patients will be presented. 1. In typical CPAP titrations hypopneas and RERAs should generally decrease and eventually plateau as PAP is increased. However, the pattern observed in the titration of these patients with hypermobility is somewhat atypical. 2. In hypermobile patients, the high RERA index at the hypopnea nadir, with subsequent increases in both with increasing pressure, could be explained by the following mechanism: In hypermobile patients, the epiglottis is more flexible than usual, and even though the upper portion of the lower airway can be expanded by PAP, increasing pressure in hypermobile patients could lead to epiglottal closure. 3. Auto-titrating CPAPs currently do not measure RERA’s well, because of their inability to assess EEG arousals, despite having formidable algorithms which can measure changes in airway resistance. Thus, the use of auto-titrating PAP devices may not be effective in the relief of sleep complaints in patients with hypermobility and SDB. 4. This lack of effectiveness could lead to poor compliance with PAP therapy in patients with hypermobility. 5. Thus, patients with hypermobility probably need an attended PAP titration to achieve optional airway patency, and resolution of their complaints related to SDB.