Predictive Factors of Long-term Compliance With Nasal Continuous Positive Airway Pressure Treatment in Sleep Apnea Syndrome

doi:10.1378/chest.105.2.429

Chest

Volume 105, Issue 2, February 1994, Pages 429-433

https://doi.org/10.1378/chest.105.2.429 Get rights and content

The long-term acceptability of treatment with nasal continuous positive airway pressure (CPAP) was studied prospectively in 44 patients with obstructive sleep apnea syndrome. At 14 months on the average after starting treatment with CPAP, 30 patients (68 percent) were found to be compliant (characterized by use of the apparatus every night throughout the night, for more than 5 h per night). The daily use of nasal CPAP was significantly correlated to the initial apnea/hypopnea index (p = 0.013; r = 0.37), as well as to the percentage of light sleep (p = 0.045; r = 0.30) and slow-wave sleep (p = 0.037; r = — 0.31) during the initial polygraphic recording. We found a strong correlation between the daily use of nasal CPAP and the difference in the apnea/hypopnea index (p = 0.025; r = — 0.34), the difference in mean oxygen saturation during sleep (p = 0.013; r = 0.38), and the difference in hypersomnia scores (p = 0.006; r = — 0.40) obtained before and after treatment by nasal CPAP. Thus, patients used CPAP much more if they had an initial significant clinical handicap and if they were aware of the beneficial effects of CPAP. Under these conditions, patients tended to use the apparatus for the optimal length of time, regardless of the side effects linked to the treatment. This ensured efficacy and the maintenance of good compliance. This study confirms the importance of supervision of the time counter, as well as regular encouragement of patients to use the treatment as long as possible each night, in order to extract a maximum benefit from treatment by nasal CPAP.

Section snippets

Materials and Methods

Between March 1989 and August 1991, 54 patients suffering from SAS (defined as an apnea/hypopnea index [AHI] greater than 15 per hour of sleep) were included in a prospective study of the long-term acceptance of nocturnal nasal CPAP. Only 44 among the 54 patients were retained because of a consistent use greater than 6 months. The reasons for exclusion were (1) refusal to be treated by CPAP, either immediately (3 patients) or after being treated for a few days (2 patients); (2) failure of CPAP

Results

Forty-four patients were studied for a mean of 14 months (range, 8 to 39 months) after beginning the treatment. Data on the use of CPAP are detailed in Table 1. At the end of the study, 41 patients still used their apparatus every night, and the apparatus was used all night by 36 patients. At this time the quantitative study of the mean length of time that the apparatus was used, determined with a time counter, gave an average of 6.02 ± 2.48 h per night, compared to 7 ± 1.65 h based on the

Discussion

In order to study the compliance of patients with CPAP, we defined compliance as a function of subjective and objective criteria. To be defined as compliant, patients had to use the apparatus throughout the night every night, for an average duration equal to or greater than 5 h per night (time counter). By applying these criteria, compliance was 68 percent (30 of 44).

The choice of such strict criteria is based on the necessity of preventing oxygen desaturation during sleep, which leads to

ACKNOWLEDGMENTS

We thank Dr. C. Baraton for assistance in data collection.

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Positive airway pressure treatment (CPAP) is the gold standard for obstructive sleep apnea syndrome (OSAS). CPAP is highly effective, but its issue lays in poor adherence rates mainly caused by its invasive nature and related stigma. In accordance with a biopsychosocial model of CPAP adherence, psychosocial interventions have been implemented to alleviate low rates of adherence with promising results. The increase in the number of psychosocial interventions has highlighted the need to systematically evaluate their effectiveness. This review aims to identify psychosocial interventions used to increase CPAP adherence, to compile available data on their effectiveness, and the reasons why they are effective. Moreover, the review evaluates the impact of the interventions on sleep quality. Experimental and quasi-experimental studies testing psychosocial interventions (excluding educational only interventions) that aimed to increase CPAP adherence in adults with obstructive sleep apnea vs. no intervention or control group were included. A literature search in PsycINFO, MEDLINE, COCHRANE, EMBASE, CINAHL, and Web of Science was performed for studies published in English and French between 1980 and January 2020. Risk of bias and methodological quality were assessed using the Joanna Briggs Institute Critical Appraisal Tools. Fourteen studies were included involving 1923 participants, six trials tested a motivational intervention, three trials tested a cognitive behavioral intervention and five others tested one of the following: relaxation, exposition therapy, phone coaching, audiotape or stage-matched intervention. Thirteen studies reported a positive effect of the intervention on CPAP adherence, while one reported no effect. Psychosocial interventions for CPAP adherence appear effective at increasing sleep quality, but more studies are needed to test this hypothesis. Reasons for the effectiveness of the interventions were pooled into five categories: time related, the intervention's adaptability, the patient's characteristics, the intervention's nature and characteristics and the intervention's specifics and target. The current review raises a significant gap between the biomedical and psychosocial domains. In fact, even in a psychosocial intervention study, the interpretation of the results revolves around biomedical models and very little consideration is given to biopsychosocial models. Our findings demonstrate the importance of examining the relationship between psychosocial variables and CPAP adherence to better tailor interventions to increase CPAP adherence.
A Validation Study of Four Different Cluster Analyses of OSA and the Incidence of Cardiovascular Mortality in a Hispanic Population
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Previous studies reported a strong association between sleepiness-related symptoms and comorbidities with poor cardiovascular outcomes among patients with moderate to severe OSA (msOSA). However, the validation of these associations in the Hispanic population from South America and the ability to predict incident cardiovascular disease remain unclear.
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Using the SantOSA cohort, we reproduced four cluster analyses (Sleep Heart Health Study [SHHS], Icelandic Sleep Apnea Cohort [ISAC], Sleep Apnea Cardiovascular Endpoints [SAVE], and The Institute de Recherche en Sante Respiratoire des Pays de la Loire [IRSR] cohorts) following a cluster analysis similar to each training dataset. The incidence of cardiovascular mortality was constructed using a Kaplan-Meier (log-rank) model, and Cox proportional hazards models were adjusted by confounders.
Among 780 patients with msOSA in our cohort, two previous cluster analyses (SHHS and ISAC) were reproducible. The SAVE and IRSR cluster analyses were not reproducible in our sample. We identified the following subtypes for SHHS: “minimally symptomatic,” “disturbed sleep,” “moderate sleepiness,” and “severe sleepiness.” For ISAC, three different subtypes (“minimally symptomatic,” “disturbed sleep,” and “excessive sleepiness”) were similar to the original dataset. Compared with “minimally symptomatic,” we found a significant association between “excessive sleepiness” and cardiovascular mortality after 5 years of follow-up in SantOSA, hazard ratio (HR), 5.47; 95% CI, 1.74-8.29; P < .01; and HR, 3.23; 95% CI, 1.21-8.63; P = .02, using the SHHS and ISAC cluster analyses, respectively.
Among patients with msOSA, a symptom-based approach can validate different OSA patient subtypes, and those with excessive sleepiness have an increased risk of incident cardiovascular mortality in the Hispanic population from South America.
Oral Appliances for Snoring and Obstructive Sleep Apnea
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Of 315 enrolled patients, 237 remained on MRD treatment at two years, and 197 had follow-up data. The treatment success rate at two years was 67%; AHI <5/h, <10/h and <15/h was achieved in 30%, 56% and 72% of patients, respectively. On multivariate analysis, ≥50% decrease in AHI at 3–6 months and absence of nocturia at 3–6 months were significant predictors of MRD treatment continuation. Adverse events were generally mild, and the majority occurred in the first year of treatment.
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Citation Excerpt :
Similar findings were reported in a retrospective chart review of 369 patients with moderate or severe OSAS who were recommended to receive CPAP: at one year, older male patients with higher AHI values were more adherent to CPAP [21]. In addition, a highly significant correlation of compliance with the initial AHI was found in a small study of OSAS patients at 14 months on the average after starting treatment with CPAP [22]. Moreover, an association between compliance to treatment and severity of OSAS was also reported in a retrospective study evaluating 156 patients with OSAS: patients with a higher AHI were those who better adhered to long-term treatment with CPAP [23].
Continuous positive airway pressure (CPAP) therapy is a highly effective treatment for obstructive sleep apnea syndrome (OSAS). However, poor adherence is a limiting factor, and a significant proportion of patients are unable to tolerate CPAP. The aim of this study was to determine predictors of long-term non-compliance with CPAP.
CPAP treatment was prescribed to all consecutive patients with moderate or severe OSAS (AHI ≥15 events/h) (n = 295) who underwent a full-night CPAP titration study at home between February 1, 2002 and December 1, 2016. Adherence was defined as CPAP use for at least 4 h per night and five days per week. Subjects had periodical follow-up visits including clinical and biochemical evaluation and assessment of adherence to CPAP.
Median follow-up observation was 74.8 (24.2/110.9) months. The percentage of OSAS patients adhering to CPAP was 41.4% (42.3% in males and 37.0% in females), and prevalence was significantly higher in severe OSAS than in moderate (51.8% vs. 22.1%; p < 0.001; respectively). At multivariate analysis, lower severity of OSAS (HR = 0.66; CI 95 0.46–0.94) p < 0.023), cigarette smoking (HR = 1.72; CI 95 1.13–2.61); p = 0.011), and previous cardiovascular events (HR = 1.95; CI 95 1.03–3.70; p = 0.04) were the only independent predictors of long-term non-adherence to CPAP after controlling for age, gender, and metabolic syndrome.
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: revision accepted May 27.

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Chest

Clinical InvestigationsSleep, Breathing and Nasal VentilationPredictive Factors of Long-term Compliance With Nasal Continuous Positive Airway Pressure Treatment in Sleep Apnea Syndrome

Section snippets

Materials and Methods

Results

Discussion

ACKNOWLEDGMENTS

Chest

Lancet

Chest

Chest

Chest

Chest

Chest

Traitement instrumental du syndrome des apnées du sommeil

Rev Mal Respir

Le traitement chirurgical du syndrome d'apnées du sommeil

Rev Mal Respir

Nocturnal asthma: role of snoring and obstructive sleep apnea

Am Rev Respir Dis

Clinical Investigations
Sleep, Breathing and Nasal Ventilation
Predictive Factors of Long-term Compliance With Nasal Continuous Positive Airway Pressure Treatment in Sleep Apnea Syndrome