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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4566_Библиотеки_им_академика_М_И_Перельмана
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Adherence to CPAP treatment
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Follow-up can be augmented and improved with new techniques: cloud-based
platforms, smartphone applications and internet-based patient-engagement tools.
These tools have two main benefits: they can be used to telemonitor patients for early
recognition of sub-optimal treatment, allowing intervention; and they can enhance
the patient’s treatment experience, through active patient engagement (APE), leading
to improved use.
Behavioural interventions yield a clinically significant increase in hourly device usage
when compared with usual care and oer the most considerable improvements in
average nightly CPAP usage when compared with the other intervention classes. These
cognitive behavioural or motivational strategies usually include multiple modalities.
They can result in an increase in CPAP use by improving self-ecacy, implementing
social support and generating a positive attitude towards CPAP treatment.
Summary
Poor CPAP adherence is widely acknowledged as a critical limiting factor in OSA
treatment as it lowers total therapy ecacy, putting many OSA patients at risk of
comorbid diseases and reduced quality of life. Adopting technological advances
in care management will allow clinicians to treat patients who have sleep apnoea
more eectively and eciently. Although excellent adherence has been reported in
some clinical trials, more variable results have been observed in clinical practice.
Therefore, rigorous randomised controlled trials are required before solid clinical
recommendations are made regarding the improvement of adherence.
Further reading
• Askland K, et al. (2020). Educational, supportive and behavioural interventions to improve
usage of continuous positive airway pressure machines in adults with obstructive sleep
apnoea. Cochrane Database Syst Rev; 4: CD007736.
• Bakker JP, et al. (2019). Adherence to CPAP: what should we be aiming for, and how can we
get there? Chest; 155: 1272–1287.
• Buyse B, et al. (2022). High adherence to continuous positive airway pressure (CPAP) in
patients with obstructive sleep apnea (OSA) in Belgium: a narrative review. Acta Clin Belg; 77:
710–720.
• Kennedy B, et al. (2019). Pressure modification or humidification for improving usage of
continuous positive airway pressure machines in adults with obstructive sleep apnoea.
Cochrane Database Syst Rev; 12: CD003531.
• May AM, et al. (2018). CPAP adherence predictors in a randomized trial of moderate-to-severe
OSA enriched with women and minorities. Chest; 154: 567–578.
• Neill AM, et al. (2003). Humidified nasal continuous positive airway pressure in obstructive
sleep apnoea. Eur Respir J; 22: 258–262.
• Patel SR, et al. (2021). Age and sex disparities in adherence to CPAP. Chest; 159: 382–389.
• Pépin JL, et al. (2021). CPAP therapy termination rates by OSA phenotype: a French nationwide
database analysis. J Clin Med; 10: 936.
• Rapelli G, et al. (2021). Improving CPAP adherence in adults with obstructive sleep apnea
syndrome: a scoping review of motivational interventions. Front Psychol; 12: 705364.
• Sabaté E (2003). Adherence to long-term therapies: evidence for action. Switzerland, World
Health Organization.
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Adherence to CPAP treatment
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• Sunwoo BY, et al. (2020). Strategies to augment adherence in the management of sleep-
disordered breathing. Respirology; 25: 363–371.
• Weaver TE, et al. (2007). Relationship between hours of CPAP use and achieving normal levels
of sleepiness and daily functioning. Sleep; 30: 711–719.
185ERS Handbook: Respiratory Sleep Medicine
Monitoring positive airway
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pressure therapy
Bertien Buyse, Alexandros Kalkanis and Dries Testelmans
The eectiveness of PAP is limited by suboptimal adherence and it is dicult to predict
which patients will remain compliant. The use of remote monitoring and telemedicine
has become increasingly important in this area – these tools are covered elsewhere in
this Handbook. Here, we focus on clinical follow-up of PAP therapy.
Frequency and duration of PAP monitoring
PAP use in the early month(s) of adoption is a major determinant of PAP use in longer
periods. Close follow-up is therefore important during the initial weeks of PAP use.
The frequency of monitoring is a matter of debate, and is dependent on context and
the local health economy. However, it is advised that monitoring should start as early
as possible – it is better to start within 7 days than aer 3 months. OSA outcome
assessment should be performed at each follow-up (figure 1).
If PAP use is considered inadequate, prompt and intensive eorts should be made
to improve its usage. Beyond troubleshooting interventions, specific behavioural
interventions (cognitive behavioural therapy or motivational enhancement) might be
appropriate. The initiation of PAP therapy should be regarded as a trial of treatment:
under close monitoring with troubleshooting by an experienced PAP therapist for a
Key points
• Close monitoring is important during the early stages of PAP use, because
initial PAP adherence is a major determinant of PAP use over the longer term.
• The need for repeat monitoring tests (PSG or (home) respiratory PG) is limited.
• PAP tracking system data on residual respiratory events and leaks must be
interpreted with caution, with consideration of the patient’s clinical situation.
• Monitoring should be performed by healthcare professionals who are
experienced in sleep medicine, and patients should be promptly referred
back to the sleep physician if problems arise (failure to improve sleepiness,
comorbid insomnia, etc.).
• Wherever appropriate, PAP-intolerant patients should meet the sleep
physician who will refer them for non-PAP OSA therapy or care for other
(sleep) health disorders.
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Monitoring positive airway pressure therapy
Patient PAP tracking system: objective data on
metabolic complications
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Check:
• Resolution of sleepiness and/or changes related
to other OSA symptoms or quality-of-life
measures, patient and spousal satisfaction
• PAP side-eects
Educate on:
• Proper sleep hygiene, obtaining an adequate
amount of sleep
• Avoidance of factors that worsen OSA (e.g
alcohol, smoking), and weight loss in the case
of overweight/obese patients
Screen for comorbidities:
• Measure arterial BP
• Check for potential cardiac, vascular and
Adherence
Residual
respiratory
events
and
Pressure
Leaks
Figure 1. OSA outcomes assessment tool.
month, success (or failure) is usually seen; if treatment is not successful, non-PAP
therapies for OSA or treatment options for other (sleep) health disorders should be
considered.
Aer initial and successful PAP setup, long-term follow-up is important, with experts
recommending annual review. OSA outcome assessment should be performed at every
follow-up. OSA is a chronic disease, and clinicians should be aware of the possible
development of medical OSA-related complications. Even those with resolution of
OSA due to weight loss or (bariatric) surgery should continue to be monitored for the
return of symptoms.
Repeat sleep monitoring tests
Re-evaluation with sleep monitoring is only appropriate in a limited set of circumstances,
as follows.
Recurrent or persistent symptoms
PSG or (home) respiratory polygraphy (PG) is appropriate if symptoms return despite
good adherence to CPAP.
If there is an unexplained change in adherence or clinical suspicion of a separate sleep
disorder, repeat PSG may be considered.
Where there is suspicion of another sleep disorder such as narcolepsy, then PSG
should precede other tests, such as a MSLT.
Clinically significant weight gain or loss (a change in body weight of 10–20%)
If clinically significant weight gain results in the re-emergence of symptoms
such as daytime sleepiness, interrupted sleep or snoring, it may be appropriate
to perform PSG with CPAP titration, or PG to determine whether OSA is ongoing.
Some practitioners may elect to forego testing in this setting, and instead increase
pressure either empirically or according to the downloaded P90 or P95 data from
an auto-adjusting device, then reassess. (For more on auto-CPAP, see chapter 8.3
of this Handbook.)
187ERS Handbook: Respiratory Sleep Medicine
Monitoring positive airway pressure therapy
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Repeat PSG or PG can be considered aer a reduction in weight. If the subject has
undergone bariatric surgery, repeat testing should only be considered aer ⩾3 months
of recovery. The decision to repeat PSG or PG may lead to changes in management,
such as the discontinuation of OSA treatment, and empiric adjustments in therapy
(such as pressure reductions) can occur in the absence of testing.
Where repeat testing is performed, it is important that PAP is discontinued for several
days to correctly evaluate the full abolishment or (partial) return of the disease.
Development of or a change in CVD
Although there is no direct evidence to guide testing, it can be considered in certain
clinical situations: development or worsening of BP, development of HF, newly
discovered arrhythmias, such as atrial fibrillation (AF), and a new stroke event.
Persistent elevation of the AHI
Repeat monitoring tests can be performed where there is persistent elevation of the
AHI on the CPAP tracking system, and particularly where sleep symptoms are noted.
Other considerations
The threshold for repeat testing is contextual, e.g. a mildly elevated residual AHI (up to
10 or even 15 events·h−1) in a patient with re-emergence of OSA symptoms warrants
either empiric adjustment of pressure (which can obviate the need for testing)
or repeat testing. However, a similar elevated residual AHI in the absence of OSA
symptoms is of unknown significance, and may not represent an obvious indication
for testing. Evidence for treatment-emergent CSA (TECSA), demonstrated by a high
central apnoea index on the tracking system report, could represent an indication for
repeat testing. As TECSA dissipates over time in a substantial proportion of patients, a
minimum of 3 months of CPAP therapy prior to repeat testing is recommended.
CPAP tracking systems
Tracking systems provide summary statistics on pressure, adherence, leak and
residual events. They also present detailed graphs (for individual nights, for example),
providing the user with a better understanding of the relationship between pressure,
leak and residual events.
Pressure and CPAP adherence can be reliably determined using CPAP tracking systems.
Tracking systems also visualise data on leaks. Evaluation of the presence or absence
of large leaks is a prerequisite of the correct interpretation of the statistics the device
presents on residual events, e.g. the functioning of dierent algorithms for the
detection of residual obstructive events depends on the absence of a relevant leakage.
CPAP manufacturers have an ‘unintentional leak’ limit in the range of 30 L·min−1
and the tracking systems demonstrate and visualise data on these (‘too large’) leaks.
There is no threshold for clinically significant leaks (expressed in L·min−1) that relate to
patient adherence. Therefore, addressing leakage (in the absence of residual events) is
only indicated if there is a complaint from the patient or from the bed partner.
Data on residual respiratory events are not always easy to interpret. The devicederived AHI diers from that scored by PSG, for several reasons:
1) The respiratory event indices are based on hours of device use, whereas the indices
on PSG are based on hours of sleep.
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2) Respiratory events detected by the devices are based solely on measurement of
airflow. In contrast, multiple signals are used to score respiratory events on PSG,
particularly hypopnoeas and respiratory eort-related arousals (RERAs). In addition to
airflow, oxygen saturation, EEG/EMG arousals and chest/abdominal wall movement
signals (to dierentiate between obstructive and central events) are used.
3) The measurements by the device are automated, using dierent specific proprietary
algorithms depending on the brand.
Most devices overestimate the AHI at lower levels (≤10 events·h−1) and underestimate
the AHI at higher levels. The devices appear to be particularly accurate in detecting
apnoeas, but the skew in the AHI relationship is due to the device’s detection of
hypopnoeas. Manual scoring of hypopnoea not only demands a reduction in amplitude
but also an accompanying desaturation and/or arousal, whereas on the CPAP device,
only amplitude is used. Analysis has shown that automatic CPAP detection of an
AHI of ≥10 events·h−1 has a high specificity, but only modest sensitivity for an AHI
of ≥10 events·h−1 on PSG. Consequently, if the AHI on the CPAP tracking system is
<10 events·h−1, clinicians can be confident that the patient is on ecacious treatment.
Patients with an AHI of ≥10 events·h−1 may or may not be adequately treated and,
depending on clinical correlation, may require further evaluation.
Dierentiating (residual) central and obstructive apnoeas, based on the PAP tracking
system report, is not straightforward. PAP devices are not able to measure respiratory
eort; they use a surrogate signal and when detecting an apnoea, the devices try to
test airway patency. Dierent methods are used: a cardiogenic pulse artefact in the
flow is only present if the airway is open; other devices provide a single pressure pulse
or small oscillation in the flow, which is only reflected to the flow sensors if the airway
is closed. Recently, it was demonstrated that approximately a third of the devicedetected apnoeas scored as a closed airway were central apnoeas on PSG (be aware
that the airway may close during a central event, without respiratory eort). The
reverse was also true, although less frequent: 13% of the device-detected apnoeas
scored as an open airway were obstructive events on PSG.
However, a preponderance of events with an open airway on the CPAP tracking system
strongly suggests the presence of central apnoeas.
Other devices oer the RERA index (RERA-I). The value of this index has been evaluated
in a few studies, and the intraclass correlation coecient between the RERA-I detected
by the device and the RERA-I on PSG was found to be low. This is not surprising, because
PSG criteria require an arousal on event termination, but the device only uses airflow.
To the best of our knowledge, there are no studies on the performance of CPAP devices
relating to snore detection.
The performance of monitoring
Guidelines only mention that initial and long-term follow-up should be performed
by healthcare professionals – beyond sleep physicians, this can include technologists
and nurses with experience in sleep medicine. It remains unclear how much training
and experience a nonmedical healthcare provider would need before they can provide
unsupervised care for a patient who has begun CPAP therapy. There are several
arguments to suggest that follow-up, even long-term follow-up, should be performed
in close collaboration with a sleep physician.
189ERS Handbook: Respiratory Sleep Medicine
Monitoring positive airway pressure therapy
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Interpretation of the residual AHI on the PAP tracking system can be confusing, and
meticulous clinical evaluation should be performed by a sleep specialist (as described
earlier).
Sleepiness does not improve in some patients aer PAP, and may re-appear in others,
with multiple factors involved. To evaluate the cause and impact of sleepiness, a full
sleep and medical history must be taken by a sleep specialist before wake-promoting
drugs can be prescribed. In addition to poor adherence, PAP-related problems should
also be ruled out. Suboptimal therapeutic pressure, leaks or poor mask fitting are
causes of persistent respiratory events, sleep fragmentation and sleepiness. PAP
treatment may also be associated with TECSA. Other causes of persistent daytime
somnolence should be assessed. Screening should be performed for comorbid sleep
disorders such as chronic sleep deprivation or, more rarely, narcolepsy, idiopathic
hypersomnia or neurological diseases associated with somnolence or the use of
sedative/hypnotic drugs. Depression and medical conditions such as metabolic
disorders (obesity, diabetes, hypothyroidism) should also be considered.
Comorbid insomnia and sleep apnoea (COMISA) is a frequent reason to rely on a
sleep specialist. COMISA requires a complex personalised diagnostic and treatment
approach, oen in a multidisciplinary setting, with the option of more specific
insomnia-related therapeutic options, such as cognitive behavioural therapy for
insomnia.
PAP-intolerant patients oen explore non-PAP treatments, and communication on
this topic between healthcare providers and patients can generate confusion because
of the variety of non-PAP treatment options available. These patients should meet
the sleep specialist to discuss the sleep study again and review the patient’s barriers
to PAP. Patients can then be referred within an integrated coordinated care model
for non-PAP therapies for OSA or other care for (sleep) health disorders, if these
are felt appropriate (not all patients with an elevated AHI are suering from a sleep
apnoea syndrome).
Conclusion
Managing PAP therapy does not involve a ‘set and forget’ approach. Regular followup by healthcare professionals experienced in sleep medicine and working in close
collaboration with the sleep specialist is of utmost importance, especially at the start
of therapy. The use of an OSA outcomes assessment tool can be helpful.
Further reading
• Badr MS, et al. (1995). Pharyngeal narrowing/occlusion during central sleep apnea. J Appl
Physiol; 78: 1806–1815.
• Bakker JP, et al. (2019). Adherence to CPAP: what should we be aiming for, and how can we
get there? Chest; 155: 1272–1287.
• Berry RB, et al. (2012). Respiratory event detection by a positive airway pressure device. Sleep;
35: 361–367.
• Caples SM, et al. (2021). Use of polysomnography and home sleep apnea tests for the
longitudinal management of obstructive sleep apnea in adults: an American Academy of Sleep
Medicine clinical guidance statement. J Clin Sleep Med; 17: 1287–1293.
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Monitoring positive airway pressure therapy
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• Craig S, et al. (2022). Investigation and management of residual sleepiness in CPAP-treated
patients with obstructive sleep apnoea: the European view. Eur Respir Rev; 31: 210230.
• Epstein LJ, et al. (2009). Clinical guideline for the evaluation, management and long-term care
of obstructive sleep apnea in adults. J Clin Sleep Med; 5: 263–276.
• Gagnadoux F, et al. (2017). Validation of the System One RemStar Auto A-Flex for obstructive
sleep apnea treatment and detection of residual apnea-hypopnea index: a European
randomized trial. J Clin Sleep Med; 13: 283–290.
• Johnson KG, et al. (2015). Treatment of sleep-disordered breathing with positive airway
pressure devices: technology update. Med Devices; 8: 425–437.
• Lebret M, et al. (2017). Factors contributing to unintentional leak during CPAP treatment:
a systematic review. Chest; 151: 707–719.
• Li QY, et al. (2015). Detection of upper airway status and respiratory events by a current
generation positive airway pressure device. Sleep; 38: 597–605.
• Patil SP, et al. (2019). Treatment of adult obstructive sleep apnea with positive airway pressure:
an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE
assessment. J Clin Sleep Med; 15: 301–334.
• Patil SP, et al. (2019). Treatment of adult obstructive sleep apnea with positive airway
pressure: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med;
15: 335–343.
• Schwab RJ, et al. (2013). An ocial American Thoracic Society statement: continuous positive
airway pressure adherence tracking systems. The optimal monitoring strategies and outcome
measures in adults. Am J Respir Crit Care Med; 188: 613–620.
• Shelgikar AV, et al. (2017). Multidisciplinary alternatives to CPAP program for CPAP-intolerant
patients. J Clin Sleep Med; 13: 505–510.
• Sweetman A, et al. (2021). Bi-directional relationships between co-morbid insomnia and sleep
apnea (COMISA). Sleep Med Rev; 60: 101519.
191ERS Handbook: Respiratory Sleep Medicine
Evaluation of positive
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airway pressure ecacy
Gisèle Maury and Dries Testelmans
The management of OSA patients does not end aer starting PAP therapy for OSA. An
essential component of OSA management is the assessment of the ecacy and (side-)
eects of PAP therapy and the need for further therapy modifications.
What is a ‘good response’ to PAP therapy? A combination of PAP ecacy in terms
of objective and clinical parameters with well-used PAP treatment, and absent, or
at most, mild PAP-related side-eects, allowing for good tolerance and comfort is
probably the most favourable scenario. The optimal measure of PAP treatment ecacy
should demonstrate control of symptoms, control of AHI and good therapy adherence.
For clinicians, this is a challenge. Clinic visits, questionnaires assessing symptoms,
repeated sleep studies to evaluate respiratory events and oxygen saturation or data
available from downloads of PAP devices are used to evaluate treatment ecacy.
In this chapter, we discuss the evaluation of PAP therapy ecacy with a focus on
evaluation of symptoms and dierent physiological parameters.
Monitoring of PAP therapy using clinic visits, data downloads and telemonitoring are
covered in separate chapters of this Handbook.
Key points
• Good PAP ecacy in terms of objective and clinical parameters, with well-used
PAP treatment on the one hand and absent or, at most, mild PAP-related
side-eects allowing for good tolerance and comfort on the other hand, is
probably the most favourable scenario.
• Evolution of symptoms can be evaluated with a full sleep history;
questionnaires can be a useful adjunct, but several lack reliability or validation
in OSA patients.
• In patients with persistent symptoms or PAP-related problems, PSG or
portable monitoring during PAP treatment is recommended. An awareness
of possible portable monitoring limitations regarding AHI/RDI assessment
is important.
• Optimal PAP titration: reduces RDI to <5 events·h−1 for ≥15-min duration;
includes supine REM sleep at the selected pressure that is not continually
interrupted by spontaneous arousals or awakenings.
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Evaluation of PAP ecacy
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Evaluation of symptoms
In general, an optimal control of symptoms is aimed for with OSA treatment. Possible
symptoms include snoring, witnessed apnoeas, excessive sleepiness, nocturia,
insomnia, headache, sleep fragmentation and cognitive dysfunction. However,
treatment ecacy cannot be evaluated on improvement of symptoms alone, as it is
an imprecise indicator of treatment success, and some patients may be symptomfree at the outset.
Sleepiness
Daytime sleepiness can be assessed subjectively using the ESS, which evaluates the
probability of dozing o in eight dierent situations. It is estimated that the minimum
clinically important improvement in the ESS lies between −2 and −3. However, the
reliability and repeatability of the ESS have been challenged recently. Objective and
less-performed tests in patients with OSA include the MSLT and the Maintenance
of wakefulness test (MWT), which measure the propensity to fall asleep and the
ability to stay awake, respectively. Assessment of sleepiness and vigilance could be of
importance regarding decisions on driving ability.
In general, PAP is able to improve daytime sleepiness. A recent meta-analysis by the
American Academy of Sleep Medicine (AASM) demonstrated a significant reduction in
subjective sleepiness (ESS score) aer CPAP, whereas among objective tests, changes
were significant for the MWT, but not for the MSLT.
However, improvement of sleepiness aer PAP is not seen in all patients. In patients
with residual sleepiness, a full sleep history should be taken by a sleep specialist
followed by evaluation of possible PAP-related problems; in patients with persisting
elevated AHI, a PSG during PAP treatment is recommended. Additionally, other
causes of EDS should be evaluated, including adequate sleep hygiene and the impact
of comorbidities (e.g. depression) and current medical treatment (e.g. hypnotics).
Quality of life
Assessment of quality of life is an important outcome measure in the care of
chronic diseases and evaluation of treatment alternatives. Dierent questionnaires
are proposed, including OSA-related quality-of-life questionnaires (e.g. Functional
Outcomes of Sleep Questionnaire (FOSQ), Sleep Apnea Quality of Life Index (SAQLI))
and generic quality-of-life questionnaires (e.g. EuroQol (EQ-5D), 36-item Short-Form
Health Survey (SF-36)). A meta-analysis, which included studies using the SF-36,
showed that CPAP is an eective treatment for improvement in health-related quality
of life in OSA. However, a systematic review on patient-reported outcome measures
(PROMs) in patients with OSA showed that none of the PROMs were fully validated for
patients with OSA, and there were few high-quality validation studies.
Evaluation of physiological parameters
The AHI is still considered the most important marker of severity of sleep apnoea. Other
objective parameters are S
aO
Many methods are used to evaluate these parameters. Using PSG, the sleep–wake
assessment provides indices (AHI or oxygen desaturation index (ODI)) with total sleep
time as the denominator, while the EEG analysis allows for detection of arousals, which
play a role in scoring hypopnoeas, and sleep architecture. Portable monitoring devices
use a dierent denominator in the calculation of the indices, giving a respiratory
disturbance index (RDI) rather than AHI.
, sleep architecture/sleep quality, BP and cardiac rhythm.
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