Positive Airway Pressure Usage Research Articles

Adhesion molecule increases in sleep apnea: beneficial effect of positive airway pressure and moderation by obesity.

BackgroundElevated levels of intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) may contribute to cardiovascular disease and are associated with obstructive sleep apnea (OSA) and obesity. The relationship between OSA and obesity in determining ICAM-1 and VCAM-1 levels, and the effect of treatment, is unclear.ObjectiveOur aim was to study whether positive airway pressure (PAP) usage resulted in changes in ICAM-1 and VCAM-1 after 2 years within 309 OSA patients from the Icelandic Sleep Apnea Cohort, and determine how obesity affected such changes.Subjects/MethodsThe mean body mass index (BMI) was 32.4±5.1 kg/m2; subjects had moderate-to-severe OSA (apnea-hypopnea index = 45.0±20.2) and 79% were male. There were 177 full PAP users (≥4 hours/night and ≥20 of last 28 nights), 44 partial (<4 hours/night or <20 nights), and 88 non-users.ResultsICAM-1 (p<0.001) and VCAM-1 (p=0.012) change was significantly different among the PAP groups. The largest ICAM-1 differences were among the most obese subjects (p<0.001). At follow-up, non-users had increased ICAM-1 compared to decreased levels in full users. All groups had increased VCAM-1, but non-users had a significantly larger increase than full users.ConclusionWithin moderate-to-severe OSA patients, PAP usage prevents increases in adhesion molecules observed in non-users after two years. For ICAM-1, the largest effect is in the most obese subjects. As OSA and obesity commonly coexist, the usage of PAP to limit increases in adhesion molecules may decrease the rate of progression of OSA-related cardiovascular disease.

The Role of Severity of Obstructive Sleep Apnea Measured by Apnea–Hypopnea Index in Predicting Compliance With Pressure Therapy, a Meta-analysis

Obstructive sleep apnea (OSA) is associated with diabetes, hypertension, stroke, coronary artery disease, and premature death. Positive airway pressure (PAP) is the mainstay of therapy. Despite its effective treatment with PAP therapy, noncompliance remains high. Many factors determine compliance. The role of severity of OSA measured by the apnea-hypopnea index (AHI) remains controversial. Meta-analysis of studies examining this role of AHI was performed. A systematic review of the medical literature was conducted using PubMed and Cochrane library by utilizing different combinations of key words: sleep apnea, AHI, compliance, and nonadherence. Inclusion criteria were English articles; Studies with adult population; with 2 groups of patients (compliant and noncompliant); Studies utilizing objective definition of compliance (PAP usage of >4 hours per night for 70% of days or usage >5 d/wk and for >4 hours per night). Studies were analyzed by standard methods of meta-analysis. The studies were heterogeneous for AHI; therefore, the random effect model was used. Six hundred forty-one manuscripts were found. Of these, 230 were found to be appropriate for full text evaluation. Thirty-one met inclusion criteria. Twelve of these studies used objective criteria for PAP compliance and were hence included in meta-analysis. All the subjects had OSA determined by polysomnography, for whom PAP was employed. Compliance to PAP therapy was evaluated after a period of time ranging from 4 weeks to 8 years. There were 1438 subjects included in the meta-analysis; 886 subjects were PAP compliant, whereas 552 subjects were noncompliant. A greater AHI was found in PAP compliant patients. The mean difference between compliant and noncompliant groups was 5.9 (95% confidence interval: 0.19-11.67, P < 0.05). Patients with mild OSA are less likely to be compliant with PAP therapy. These patients should receive aggressive management particularly at the start of therapy with close follow-up to increase compliance.

Maximizing Positive Airway Pressure Adherence in Adults

Positive airway pressure (PAP) therapy is considered the most efficacious treatment of obstructive sleep apnea (OSA), especially moderate to severe OSA, and remains the most commonly prescribed. Yet suboptimal adherence presents a challenge to sleep-medicine clinicians. The purpose of the current review is to highlight the efficacy of published interventions to improve PAP adherence and to suggest a patient-centered clinical approach to enhancing PAP usage.

Residual sleepiness in sleep apnea patients treated by continuous positive airway pressure

Hypoxic brain damage might explain persistent sleepiness in some continuous positive airway pressure-compliant obstructive sleep apnea called residual excessive sleepiness. Although continuous positive airway pressure may not be fully efficient in treating this symptom, wake-promoting drug prescription in residual excessive sleepiness is no longer allowed by the European Medicines Agency. The aim of this study is to describe residual excessive sleepiness phenotypes in a large prospective sample of patients with obstructive sleep apnea. Residual excessive sleepiness was defined by an Epworth Sleepiness Scale score ≥ 11. Eligible patients from the French National Sleep Registry attending follow-up continuous positive airway pressure visits numbered 1047. Patients using continuous positive airway pressure < 3 h (n = 275), with residual apnea-hypopnea index > 15 h⁻¹ (n = 31) or with major depression were excluded (n = 150). Residual excessive sleepiness prevalence in continuous positive airway pressure-treated obstructive sleep apnea was 13% (18% for those with an initial Epworth Sleepiness Scale score > 11), and significantly decreased with continuous positive airway pressure use (9% in ≥ 6 h night⁻¹ continuous positive airway pressure users, P < 0.005). At the time of diagnosis, patients with residual excessive sleepiness had worse subjective appreciation of their disease (general health scale, Epworth Sleepiness Scale and fatigue score), and complained more frequently of continuous positive airway pressure side-effects. Residual excessive sleepiness prevalence was lower in severe obstructive sleep apnea than in moderate obstructive sleep apnea (11% when AHI > 30 h⁻¹ versus 18% when AHI 15-30, P < 0.005). There was no relationship between residual excessive sleepiness and body mass index, cardiovascular co-morbidities or diabetes. Continuous positive airway pressure improved symptoms in the whole population, but to a lower extent in patients with residual excessive sleepiness (fatigue scale: -5.2 versus -2.7 in residual excessive sleepiness- and residual excessive sleepiness+ patients, respectively, P < 0.001). Residual excessive sleepiness prevalence decreased with continuous positive airway pressure compliance. Hypoxic insult is unlikely to explain residual excessive sleepiness as obstructive sleep apnea severity does not seem to be critical. Residual symptoms are not limited to sleepiness, suggesting a true 'continuous positive airway pressure-resistant syndrome', which may justify treatment by wake-promoting drugs.

Behaviorally based adherence program for pediatric patients treated with positive airway pressure

Positive Airway Pressure (PAP) devices are being increasingly used in pediatric populations for problems including Obstructive Sleep Apnea. There is limited literature regarding pediatric adherence with PAP treatment or successful interventions that improve adherence. This paper describes a clinical program for pediatric PAP users which was designed to improve adherence of patients prescribed PAP therapy and involves intensive assessment and behavioral intervention. The design and implementation of the program is described, including the purpose, goals, programmatic structure, clinical content, type and training of personnel, strengths and limitations and financial concerns as well as the challenges with the development and application of the program's protocol. Preliminary outcome data show short-term improvements in consistent usage for many of the patients. The program shows some promise and provides a framework for future program development and research.

The Quest to Improve CPAP Adherence—PAP Potpourri is Still Not the Answer, but More Research is Needed

Al-though we both agree that addressing psychosocial barriers to positive airway pressure (PAP) adherence is important, we are unmoved by the arguments presented to support their contention that newer PAP modalities can improve PAP usage for all patients. To date, studies attempting to demonstrate improved compliance with new PAP modalities have been, at best inconsistent in their fi ndings (reviewed in Antonescu-Turcu).

The effect of continuous positive airway pressure usage on sleepiness in obstructive sleep apnoea: real effects or expectation of benefit?

RationalePlacebo responses are complex psychobiological phenomena and often involve patient expectation of benefit. With continuous positive airway pressure (CPAP) treatment of obstructive sleep apnoea, greater hours of CPAP use are...

Abstract: Identifying Longitudinal Patterns of Adherence to Treatment for Obstructive Sleep Apnea

Increasing adherence to medical recommendations is crucial for improving health outcomes and reducing costs of health care. To improve adherence, we have to better understand behavior change over time. The focus of this study was adherence to treatment for obstructive sleep apnea (OSA). Adherence to positive airway pressure (PAP), the most common treatment for OSA, is poor. This study involved an international sample of 161 participants, each with approximately 180 nights of data, and had three phases. First, a separate time series analysis was performed for each individual. Time series parameters included the mean (average hours of use per night), level (the intercept), slope (the rate of change over time), variance (variability in use), and autocorrelation (a measure of dependency). Second, a dynamic cluster analysis was performed to find homogenous subgroups of individuals with similar adherence patterns. A four-cluster solution was found, and the subgroups were labeled (see Figure 1): Great Users (17.2%; high mean and level, no slope), Good Users (32.8%; moderate mean and level, no slope), Poor Users (22.7%; low mean and level, negative slope), and Slow Decliners (moderate mean and level, negative slope, high variance). Third, participants in the identified subgroups were compared on a number of variables that were not involved in the clustering to establish external validity. Some notable findings at later time points include the following: Great Users reported the most self-efficacy (confidence to use PAP), Poor Users reported the most sleepiness, and Great Users reported the highest quality of sleep. Combining time series analysis and dynamic cluster analysis is a useful way to evaluate adherence patterns at both the individual level and subgroup level. Psychological variables relevant to adherence patterns, such as self-efficacy, could be the focus of interventions to increase PAP usage.

Does Home Sleep Testing Impair Continuous Positive Airway Pressure Adherence in Patients With Obstructive Sleep Apnea?

The increasing recognition of obstructive sleep apnea (OSA) and demand for polysomnography has created a need for home sleep testing (HST) using unattended diagnostic and titration studies. Although these studies increase access to care and reduce cost, the limited interaction with sleep laboratories may negatively affect positive airway pressure (PAP) adherence. We sought to determine the difference in PAP use between HST and traditional in-laboratory studies. This observational cohort study included 210 patients with OSA classified into three equal groups. Following preestablished guidelines, group 1 underwent unattended, type III home diagnostic and unattended home auto-adjustable PAP (APAP) titrations; group 2 underwent in-laboratory, type I diagnostic and continuous PAP titration studies; group 3 underwent type I diagnostic and APAP titration studies. Group 1 was primarily managed and educated in a primary care clinic, whereas groups 2 and 3 received extensive education in an academic sleep medicine center. Objective measures of PAP use during the first 4 to 6 weeks of therapy were compared between groups. Type of study and location of care did not affect PAP adherence. PAP was used for 70%, 73%, and 72% of nights in groups 1, 2, and 3, respectively (P = .94). Mean hours of nightly use (4.4 ± 2.0 h, 4.7 ± 1.5 h, and 4.6 ± 1.5 h; P = .98) was also similar. Regular use was observed in 54%, 51%, and 50% of subjects (P = .84). Discontinuation rates were similar between groups. PAP usage did not differ between those undergoing HST vs in-laboratory studies. HST offers a more accessible and cost-effective alternative without compromising therapeutic adherence.

Adolescents with Obstructive Sleep Apnea Adhere Poorly to Positive Airway Pressure (PAP), but PAP Users Show Improved Attention and School Performance

BackgroundObstructive Sleep Apnea (OSA) is associated with medical and neurobehavioral morbidity across the lifespan. Positive airway pressure (PAP) treatment has demonstrated efficacy in treating OSA and has been shown to improve daytime functioning in adults, but treatment adherence can be problematic. There are nearly no published studies examining functional outcomes such as academic functioning in adolescents treated with PAP. This study was conducted as an initial step towards determining whether PAP treatment improves daytime functioning among adolescents with OSA.MethodsSelf-reported academic grades, self- and parent-reported academic quality of life, and objectively-measured attention were assessed before and after PAP was clinically initiated in a sample of 13 obese adolescents with OSA, as well as 15 untreated obese Controls without OSA. Based on adherence data, the treated group was divided into PAP Users (n = 6) and Non-Adherent participants (n = 7).ResultsThough demographically similar, the three groups significantly differed in how their academic performance and attention scores changed from baseline to follow-up. Non-Adherent participants showed worsening functioning over time, while PAP Users showed stable or improved functioning, similar to controls.ConclusionAlthough many adolescents prescribed PAP for OSA are non-adherent to the treatment, those who adhere to treatment can display improved attention and academic functioning.

Long-Term Therapy with Continuous Positive Airway Pressure in Obstructive Sleep Apnea: Adherence, Side Effects and Predictors of Withdrawal – A ‘Real-Life’ Study

Background: Long-term adherence to positive airway pressure (PAP) treatment is essential in patients with obstructive sleep apnea syndrome (OSAS). Objectives: The aim of the present study was to analyze treatment adherence under real-life conditions and factors associated with discontinuation of PAP therapy. Methods: Patients newly diagnosed with OSAS and started on PAP therapy were contacted by telephone after a minimum of 1 year. Side effects, quality of life, subjective treatment adherence and Epworth Sleepiness Scale (ESS) scores were assessed. Objective treatment adherence was calculated by reading the built-in run time counter of the PAP device. Anthropometric parameters, level of education, apnea-hypopnea index (AHI), ESS score and the type of PAP therapy prescribed at the time of the first stay in the sleep lab were collected retrospectively. Results: Median follow-up was 13 months (range 7–18 months). Of 303 patients (69 female, 234 male) available for this study, 191 patients (63%) still used the PAP device regularly (‘users’), while 83 (27.4%) had definitively discontinued PAP treatment (‘nonusers’). In the nonusers group, 29 patients (34.9%) discontinued PAP treatment within the first 3 months. In the users group, subjective PAP usage was 6.6 ± 1.5 h/night and objective adherence was 4.7 ± 2.3 h/night. Objective nightly use of PAP treatment correlated significantly with baseline AHI (r = 0.13, p = 0.041) but not with sex, age, body mass index, ESS score or education level. Patients with a low AHI and ESS score and patients without a coexisting medical condition or with more than two comorbidities tended to discontinue PAP therapy more frequently. Conclusions: PAP treatment adherence has to be optimized in OSAS patients. When initiating PAP therapy, clinicians have to focus on those patients at risk for discontinuing treatment. Education sessions and closer follow-up are possible strategies to improve treatment adherence and to avoid treatment discontinuation.

Paradoxical reaction of blood pressure on sleep apnoea patients treated with Positive Airway Pressure

IntroductionObstructive Sleep Apnoea Syndrome (OSAS) patients may develop hypertension and Positive Airway Pressure (PAP) is an effective treatment in blood pressure (BP) control. ObjectivesAnalyse a hypertensive OSAS population with unexpected BP rise after PAP usage and verify correlations between BP rise, either with OSAS severity index or nocturnal ventilatory support compliance. MethodsDescriptive, retrospective analysis of 30 patients with PAP treated OSA, for one year, on average, and with previous controlled hypertension, who developed a rise in BP, defined as augmentation of > 5mmHg in systolic (SBP) and/or diastolic BP (DBP), after PAP usage. Co-relational analysis of BP increase, with OSAS severity indexes and therapy compliance, using Pearson coefficient. ResultsOf 508 consecutive patients followed in our Department, treated with nocturnal ventilatory support, 30 evolved with BP rise after initiating treatment (age 58±10.8 years; Apnoea-Hypopnoea Index [AHI], 46.1±18.68). After PAP usage, mean blood pressure (MBP), Systolic BP (SBP) and Diastolic BP (DBP) variation was 16±15mmHg, 20± 25mmHg and 6± 19.4mmHg, respectively. No patient showed significant BMI increase. Epworth Sleepiness Scale (ESS) value decreased 8.9 ± 5.48 points. MBP, SBP and DBP variations were not correlated with P90/P95, residual AHI, leaks or PAP compliance. ConclusionsNo specific characteristics were identified in the group who developed a rise in BP with PAP usage. No correlations were found between rises in BP and OSAS severity indexes or PAP compliance. Neither BMI nor variation in wakefulness status explained the rise in BP. Studies relate polymorphisms of b1-adrenoreceptors with different BP responses to ventilatory support. More studies are needed to clarify the cause of this paradoxical response.

Reacção paradoxal da pressão arterial ao tratamento com pressão positiva na via aérea em doentes com apneia do sono

Introduction Obstructive Sleep Apnoea Syndrome (OSAS) patients may develop hypertension and Positive Airway Pressure (PAP) is an effective treatment in blood pressure (BP) control. Objectives Analyse a hypertensive OSAS population with unexpected BP rise after PAP usage and verify correlations between BP rise, either with OSAS severity index or nocturnal ventilatory support compliance. Methods Descriptive, retrospective analysis of 30 patients with PAP treated OSA, for one year, on average, and with previous controlled hypertension, who developed a rise in BP, defined as augmentation of > 5 mmHg in systolic (SBP) and/or diastolic BP (DBP), after PAP usage. Co-relational analysis of BP increase, with OSAS severity indexes and therapy compliance, using Pearson coefficient. Results Of 508 consecutive patients followed in our Department, treated with nocturnal ventilatory support, 30 evolved with BP rise after initiating treatment (age 58 ± 10.8 years; Apnoea-Hypopnoea Index [AHI], 46.1 ± 18.68). After PAP usage, mean blood pressure (MBP), Systolic BP (SBP) and Diastolic BP (DBP) variation was 16 ± 15 mmHg, 20 ± 25 mmHg and 6 ± 19.4 mmHg, respectively. No patient showed significant BMI increase. Epworth Sleepiness Scale (ESS) value decreased 8.9 ± 5.48 points. MBP, SBP and DBP variations were not correlated with P90/P95, residual AHI, leaks or PAP compliance. Conclusions No specific characteristics were identified in the group who developed a rise in BP with PAP usage. No correlations were found between rises in BP and OSAS severity indexes or PAP compliance. Neither BMI nor variation in wakefulness status explained the rise in BP. Studies relate polymorphisms of β1-adrenoreceptors with different BP responses to ventilatory support. More studies are needed to clarify the cause of this paradoxical response.

Treatment compliance in patients lost to follow-up after polysomnography

Studies on positive airway pressure (PAP) compliance typically focus only on patients who returned for follow-up. In this study, we examined patients who failed to follow-up after their initial polysomnogram (PSG) and PAP titration to determine their treatment status in terms of PAP usage. On retrospective chart review, we identified 57 patients who, based on PSG findings and symptoms, required the use of PAP but failed to follow-up after titration. Twenty-five of these patients were successfully contacted and agreed to an interview. Only 7 (28%) patients were using PAP on a regular basis. The remaining 18 (72%) patients were noncompliant. A significant proportion (24%) of OSA patients who required treatment with PAP were lost to follow-up after polysomnography. This group of patients has previously been ignored in the literature. We showed in this study that majority (72%) of these patients were not being treated adequately for OSA.

Improving pediatric compliance with positive airway pressure therapy: the impact of behavioral intervention.

The purposes of this study were (1) to describe behavior interventions provided to improve compliance with positive airway pressure (PAP) therapies in children with obstructive sleep apnea, (2) to survey physician and caregiver satisfaction with these interventions, and (3) to present preliminary outcome data on the effects of these interventions. Retrospective, descriptive analysis. Pediatric psychology consultation service at a university-affiliated rehabilitation hospital. 20 children (aged 1-17 years) with obstructive sleep apnea, referred by physicians for noncompliance with PAP. Patients self-selected into 1 of 3 groups: (1) a group receiving a 1.5-hour consultation and recommendation session (CR+), (2) a group receiving consultation and recommendations plus a course of behavior therapy (BT), and (3) a group for whom behavior therapy was recommended after the consultation and recommendations, but the family did not follow-up (CR-). Prior to behavior intervention, none of the children were consistently wearing the PAP equipment. After intervention, 75% of children who received behavior intervention (CR+ and BT groups) successfully tolerated PAP with increased hours of documented usage. This was in contrast to children whose families declined recommended behavior therapy (CR- group), of whom 0% increased their usage of PAP. High satisfaction ratings were obtained from referring physicians and patient caregivers for children in the CR+ and BT groups. The results are encouraging and support the importance of behavior analysis and therapy for increasing compliance and making the benefits of PAP available to a greater number of children.

The Effect of Positive Reinforcement on Hourly Compliance in Nasal Continuous Positive Airway Pressure Users with Obstructive Sleep Apnea

Previous reports have described compliance with nasal continuous positive airway pressure (nCPAP) for the treatment of obstructive sleep apnea (OSA) only in terms of the number of patients able to use it beyond their initial trial night or those continuing after some home use. Because of a possible difference between the level of compliance (mean number of hours of use per 24 h) needed for symptomatic relief of OSA versus cardiovascular improvement, the level of hourly compliance in chronic nCPAP users may be important. The first part of this study prospectively examines compliance in a stable population of OSA patients already using nCPAP for 6 months to 2 yr. The second part is a prospective randomized, crossover study examining the effect of weekly (three times) then monthly (twice) positive reinforcement on hourly compliance of new nCPAP users for 3 months versus no reinforcement for 3 months. Positive reinforcement consisted of telephone discussions with the patients about the severity or complications of OSA, benefits of nCPAP, and suggestions about minimizing side effects. Using self-assessment scales, each patient reported the perceived level of improvement from the untreated to the treated condition and the prevalence and severity of side effects from the nCPAP therapy. The level of compliance in stable, chronic nCPAP users with OSA was 6.1 +/- 2.2 h/24 h (n = 9). For the new nCPAP users during the nonreinforced period, the mean compliance was 6.0 +/- 2.8 h/24 h; that during the reinforcement period was 6.0 +/- 2.7 h/24 h (NS). There was no significant correlation between perceived improvement in OSA symptoms or between the perceived side effects of nCPAP versus hourly compliance.(ABSTRACT TRUNCATED AT 250 WORDS)