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Background. Continuous positive airway pressure (CPAP) is an effective therapy for obstructive sleep apnoea (OSA). Despite proven benefits of CPAP in OSA, adherence has been sub-optimal. The present study was designed to evaluate the compliance of CPAP therapy and factors affecting it in patients with moderate to severe OSA.
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Original Article
Mixed Method Model to Assess CPAP Adherence Among Patients with
Moderate to Severe OSA
Priya Ramachandran1, Uma Devaraj1, Sandeepa HS2, Kavitha V1, Uma Maheswari K1 and George D’Souza1
Department of Pulmonary Medicine1, St. John’s Medical College Hospital, Bangalore and BGS Global Hospital2,
Bangalore, India
Background. Continuous positive airway pressure (CPAP) is an eective therapy for obstructive sleep apnoea (OSA). Despite
proven benets of CPAP in OSA, adherence has been sub-optimal. The present study was designed to evaluate the compliance
of CPAP therapy and factors aecting it in patients with moderate to severe OSA.
Methods. Patients diagnosed to have moderate/severe OSA (apnoea-hypopnoea index [AHI] >15) during the period April to
December 2015 were evaluated using a pre-dened questionnaire on the number of hours of usage, number of nights per week
usage and challenges faced in using CPAP; Epworth Sleepiness Score was recorded. CPAP usage was documented from the
downloaded data from their CPAP machines.
Results. Forty patients (mean age 50.6±11.4 years; 29 men) were studied. Their average body mass index (BMI) was 33.2 Kg/m2.
Of these, 31 had severe OSA (mean AHI 47.8 per hour). The objective usage of CPAP among patients with OSA was less by 89
minutes when compared with perceived duration (p=0.001). Twenty patients had used the device for less than four hours per
night. Patients reported social factors, dryness of mouth, not reapplying machine aer nocturia, power shut down and reduced
motivation as reasons for non-adherence to use CPAP.
Conclusions. Despite the recognised benets of CPAP, the acceptance and adherence with therapy remains a considerable
barrier. Objective assessment of CPAP compliance should be a part of routine follow-up in patients with OSA.
[Indian J Chest Dis Allied Sci 2019;61:119-122]
Key words: Obstructive sleep apnoea, CPAP, Compliance, Adherence.
Obstructive sleep apnoea (OSA) is a disorder that is
portrayed by abnormal collapse of the pharyngeal airway
during sleep leading to apnoeic episodes and repetitive
arousals from sleep.1 Apnoea-hypopnoea index (AHI) is
the measure of total number of apnoea and hypopnoea
events per hour of sleep.2 An AHI of ve or greater
in combination with self-reported hyper-somnolence
is indicative of clinically symptomatic sleep apnoea
syndrome. Sleep apnoea syndrome is associated with
cardiovascular diseases, such as hypertension, angina,
arrhythmias, coronary heart disease and congestive heart
failure.3 In community-based studies even mild occult sleep
apnoea is associated with hypertension, excessive day-time
somnolence, morning headaches, mental and cognitive
impairments, erectile dysfunction, bromyalgia and higher
rates of automobile and work related accidents.4
Continuous positive airway pressure (CPAP) is an
eective therapy for OSA.5 CPAP use reduces day-time
sleepiness, enhances daily function, elevates mood, reduces
automobile accidents and decreases blood pressure and
other cardiovascular events.6 Despite proven benets of
CPAP in OSA syndrome, and an initial acceptance rate
of 70% to 80%7, the adherence has been shown to be sub-
optimal.8 It is estimated that 29% to 83% of patients are
non-adherent to CPAP therapy (CPAP use ≤4 hours of
use per night).9 In a recent study,10 CPAP adherence was
evaluated to be 30.3% and inability to buy the CPAP device
was quoted as the main barrier to adherence. Sparse data is
available on the causative factors leading to non-adherence
to CPAP. Hence, we designed this study to evaluate the
compliance to CPAP therapy and factors aecting CPAP
Material and Methods
Adult patients above the age of 18 years, diagnosed to
have moderate/ severe OSA (AHI >15) from April 2015 to
December 2015 were contacted through telephone. The
study was initiated aer Institutional Ethics Commiee
approval. Patients who gave history of CPAP use for a
duration of a month or more were invited to participate
in the study. The subjects were recently diagnosed and
were using the CPAP for a duration of 3-10 months. The
[Received: May 14, 2018; accepted aer revision: August 14, 2018]
Correspondence and reprint requests: Dr Uma Devaraj, 3rd Floor, PFT Lab, Oncology Block, St. John’s Medical College, Sarjapur
Road, Bangalore-560 034 (Karnataka), India; E-mail:
subjects were enquired about the compliance of CPAP
therapy, and were invited to visit the sleep clinic. A wrien
informed consent was taken and subjects’ identity was
coded, ensuring condentiality and anonymisation of data.
During this visit the subjects received a brief explanation
of OSA and the use of CPAP regularly, by the sleep
physician. Demographic details, like age, gender, body-
mass index (BMI) and presence of comorbid conditions
were noted. A pre-dened questionnaire which included
questions on number of hours of use of CPAP, CPAP used
for number of nights per week, the challenges in using
CPAP (each parameter was rated on a 5 point Likert scale)
and Epoworth Sleepiness Score (ESS) was administered.
The use of CPAP machine was noted from the downloaded
data from their CPAP machines.
Statistical Analysis
Categorical variables were described by frequencies and
proportions; continuous variables were compared by
“student t” test or Wilcoxon rank sum where appropriate,
and for comparing proportions Chi-square or Fisher’s
exact test was used. Multivariable logistic regression, with
dependent variable as number of minutes of CPAP use per
night and the independent variables being age, gender,
BMI, AHI and co-morbidities, was done to observe the eect
of variable factors on CPAP compliance. Analysis was done
using statistical soware Statistical Package for the Social
Sciences (SPSS) (Version 17, Chicago, IL). A two-tailed p
value of <0.05 was considered statistically signicant.
A total of 121 patients were contacted through telephone.
Forty patients had consented to participate in the study.
Their mean age was 50.6±11.4 years; there were 29 men
(Table 1). Ischaemic heart disease and hypothyroidism
were present in three patients each. The mean duration of
usage as reported by the patients was 322.5 minutes. On
analysing the download data of the CPAP machine, the
mean duration of usage was 233 minutes. There was a
dierence of 89 minutes between the perceived duration
and the actual usage of CPAP machine among patients
studied for OSA (p=0.001, 95% condence intervals [CI],
-96.71 to -37.73). Of the 40 patients studied, 20 had used the
device for less than four hours per night and three patients
reported using CPAP for four or less number of days per
week. Thus, only 17 of the 40 (42.5%) patients studied were
compliant with CPAP therapy. Thirteen patients did not
reconnect CPAP in the night if there was awakening (for
Median use of CPAP was 230 minutes in women
as compared to 270 minutes in men. Women were 2.16
(95% CI, 0.7-6.62) times more likely to be non-adherent
than men. None of the factors, such as age, BMI, AHI
and co-morbidities show any signicant eect on CPAP
compliance in the subjects.
There was no dierence in compliance when
considering the mask interface (nasal [n=23] versus full-face
mask [n=17]); rental device (n=5) versus own CPAP device
(n=35). Manual (n=23) versus auto CPAP (n=17) also did not
determine the adherence to CPAP in these patients.
The challenges in using CPAP (each parameter was
rated on a 5 point Likert scale) are given in table 2.
Table 2. Factors for non-compliance
Factor Yes No
Ill-ing mask 14 26
Leak 14 26
Nasal stuness 18 22
Headache 7 33
Noise 7 34
Dryness of mouth 29 11
Gastric distension 8 32
anxiety 3 27
Interruption of power 3 27
Social inhibition 20 20
Skin Changes 139
Obstructive sleep apnoea is a non-communicable disease
with considerable prevalence rate of 13.4%.11 It is well
known that CPAP therapy is eective only when the
device is applied and there are no long lasting eects.
Hence, adherence to CPAP is vital for the treatment to be
eective. Adherence to CPAP therapy has been appalling
at 50%8 to 70%,12 also considering a 25% drop-out rate
in the long term.13 A vast dierence between subjective
adherence (85.1%) and objective adherence (64.5%) has
been reported.14 They have also noted a poor follow-up rate
of 38.3%, which might have contributed to the observed
adherence levels.
Adherence to CPAP Therapy in Patients with OSA Priya Ramachandran et al
Table 1. Patient’s characteristics
Characteristics Result (N=40)
Age (years) 50.6±11.4
Male: Female 29:11
Mean BMI (Kg/m2)33.2
Severe OSA 31
Mean AHI (per hour) 47.8
Smokers 14
Alcohol use 10
Diabetes 23
Hypertension 32
Denition of abbreviations: BMI=Body mass index; OSA=Obstructive
sleep apnoea; AHI=Apnoea-hypopnoea index
2019; Vol. 61 121The Indian Journal of Chest Diseases & Allied Sciences
Though India has a huge burden of OSA, and patients
diagnosed as OSA are initiated on treatment, there is sparse
data on how many patients actually use the CPAP therapy
as recommended. To the best of our knowledge, this is the rst
study to explore the subjective and objective assessment of
CPAP compliance in India.
In the present study, 42.5% of the patients studied
showed adherence to CPAP therapy. Some distinctive
factors emerged as obstacles to CPAP adherence. Dryness
of mouth, nasal stuness, ill-ing mask and leak from
the mask end were cited as common reasons for the non-
compliance. Twenty-nine and 18 subjects aributed their
non-compliance to dryness of mouth and nasal stuness,
respectively. Subjects reported CPAP non-compliance when
relatives or friends came to visit them, or when they were
travelling. Surprisingly, embarrassment to use the CPAP
due to social inhibition reported by 50% of the subjects. So
far there are no previous reports which have looked into
the social aspects of CPAP therapy.
Previous systematic review by Andrade et al15 have
concluded lower adherence and higher CPAP abandonment
with oro-nasal masks than the nasal masks. On the contrary,
our patients did not show a dierence in adherence when
comparing those using nasal mask versus oro-nasal mask.
This is probably due to the small number of subjects in the
present study.
Headache, excessive noise and gastric distension are the
other frequently cited reasons for non-compliance; these
have been quoted as causes for non-compliance to a similar
extent in previous studies.1,2 CPAP usage has been linked
to reduction of headaches in 30% of patients.16 However,
seven reported reduced compliance due to headache.
Many patients had related headache to the pressure on the
face due to the mask interface.
Three subjects each related power shut down and
reduced motivation as the main reason for non-adherence.
Thus far, power shut down as a reason for non-compliance
has not been reported, signifying the unique situation
where a sophisticated machine is available as therapy
but the power supply to operate the same is sometimes
Regular CPAP use is known to reduce the mean number
of nocturia incidents by 2.3.17 Not only the frequency of
urination but volume of urination is also reduced with
CPAP use. In our subjects, though many commenced sleep
with CPAP machine, some reported of not reapplying the
machine aer geing up for urination. In elderly men,
concomitant benign prostatic hypertrophy (BPH) should
be appropriately considered, investigated and treated as a
cause of nocturnal polyuria.
None of our subjects reported claustrophobia as a
reason for CPAP non-compliance which was unforeseen,
whereas Edmond et al18 have noted claustrophobia in 63%
of their subjects. Claustrophobic subjects were twice likely
to be non-adherent to CPAP as compared to those without
claustrophobia. Targeted interventions aer identication
of subjects with claustrophobia tendencies may improve
CPAP adherence.18,19
A standardised assessment for insomnia, which is a
known factor that impacts adherence, was not performed.
The number of subjects in this study was small, hence
excludes any risk factor stratication between compliant
and non-compliant subjects. Along with this, medications
of interest, especially non-benzodiazepine receptor agonist,
which can improve adherence were not reported, which
are the limitations of this study.
Salient features evident from this study are that minor factors,
such as nasal stuness, dryness of mouth, travelling/social
factors are major hurdles for adherence to CPAP therapy. With
advancement in device designs, modes of CPAP delivery and
beer and comfortable mask interface, CPAP compliance
can be improved. Regular counselling about the disease,
impact of consistent CPAP use will improve the motivation
for CPAP adherence. There is a signicant dierence in the
perceived duration of usage and the actual usage of CPAP
among patients with OSA. Objective assessment of CPAP
compliance should be a part of routine follow-up in patient
with OSA. A roadmap comprising solutions to the commonly
faced challenges, such as nasal stuness, mask leak should
be devised to improve the compliance. Hitherto unexplored
factors, such as social inhibition and power disruptions have
emerged as a cause of non-compliance. Further studies are
required to assess the factors aecting CPAP compliance
among patients with OSA.
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Adherence to CPAP Therapy in Patients with OSA Priya Ramachandran et al
Approximately one billion adults worldwide ages 30–69 years have obstructive sleep apnea (OSA), while the number of individuals with moderate-to-severe OSA is estimated to be nearly 425 million (Benjafield et al., Lancet Respir Med. 7(8):687–698, 2019). These numbers continue to increase in parallel with global estimates of chronic disease, perpetuating a vicious cycle: chronic disease is often brought upon by poor health, and OSA is a known contributor to poor health outcomes in the absence of proper and timely treatment (Benjafield et al., Lancet Respir Med. 7(8):687–698, 2019). Given its multifactorial socioeconomic and health consequences, OSA poses a high societal burden. At present, the care and treatment of patients with OSA varies greatly by country and even provinces or states. Nasal continuous positive airway pressure (CPAP) is internationally recognized as the “gold” standard for OSA treatment (Rotenberg et al., J Otolaryngol Head Neck Surg. 45:23, 2016). Despite its usage, worldwide estimates of CPAP efficacy are low due to problematic patient adherence and absent government-funded benefits. This chapter aims to explore CPAP adherence rates from an international perspective. Included in this chapter is a list of excerpts from professionals around the world in the field of sleep medicine sharing their perspective and their country’s statistics regarding CPAP adherence.
Full-text available
The objective of this study was to determine the prevalence and pattern of excessive daytime sleepiness (EDTS) in Indian college students. This was a cross-sectional study that was conducted among 1215 undergraduate students, using the Epworth Sleep Scale (ESS) and a sociodemographic survey. A high proportion (45%) of EDTS was observed, and the problem was significantly greater in professional courses. A probability of association of EDTS with coffee/tea consumption, alcohol consumption and smoking was also observed in the study.
Full-text available
Objective: To review the efficacy of current treatment options for adults with obstructive sleep apnea (OSA). Methods: Review of the literature. Results: OSA, characterized by repetitive ≥ 10-second interruptions (apnea) or reductions (hypopnea) in airflow, is initiated by partial or complete collapse in the upper airway despite respiratory effort. When left untreated, OSA is associated with comorbid conditions, such as cardiovascular and metabolic diseases. The current "gold standard" treatment for OSA is continuous positive air pressure (CPAP), which pneumatically stabilizes the upper airways. CPAP has proven efficacy and potential cost savings via decreases in health comorbidities and/or motor-vehicle crashes. However, CPAP treatment is not well-tolerated due to various side effects, and adherence among OSA subjects can be as low as 50% in certain populations. Other treatment options for OSA include improving CPAP tolerability, increasing CPAP adherence through patient interventions, weight loss/exercise, positional therapy, nasal expiratory positive airway pressure, oral pressure therapy, oral appliances, surgery, hypoglossal nerve stimulation, drug treatment, and combining 2 or more of the aforementioned treatments. Despite the many options available to treat OSA, none of them are as efficacious as CPAP. However, many of these treatments are tolerable, and adherence rates are higher than those of the CPAP, making them a more viable treatment option for long-term use. Conclusion: Patients need to weigh the benefits and risks of available treatments for OSA. More large randomized controlled studies on treatments or combination of treatments for OSA are needed that measure parameters such as treatment adherence, apnea-hypopnea index, oxygen desaturation, subjective sleepiness, quality of life, and adverse events.
Full-text available
Purpose: To assess the efficacy of the continuous positive airway pressure (CPAP) on nocturia in patients with obstructive sleep apnea (OSA). Methods: A literature review was performed to identify all published clinical trials of CPAP for the treatment of nocturia. The search included the following databases: MEDLINE, Embase, and the Cochrane Controlled Trials Register. The reference lists of the retrieved studies were also investigated. Results: Five publications involving a total of 307 patients were used in the analysis, which compared the number of incidents of nocturia before and after CPAP treatment. We found that patients with OSA and nocturia who were treated with CPAP had a significant decrease in the frequency of nocturia and the volume of urine associated with it. The mean number of nocturia incidents (standardized mean difference [SMD], -2.28; 95% confidence interval [CI], -2.42 to -2.15; P<0.00001) and the associated urine volume (SMD, -183.12; 95% CI, -248.27 to -117.98; P<0.00001) indicated that CPAP was effective. Besides, the Epworth Sleepiness Scale (SMD, -5.88; 95% CI, -6.56 to -5.21; P<0.00001) and the CPAP apnea-hypopnea index (SMD, -31.57; 95% CI, -33.87 to -29.28; P<0.00001) indicated that CPAP significantly improved the quality of sleep. Conclusions: This meta-analysis indicates that CPAP maybe an effective treatment for reducing nocturia associated with OSA and improving the quality of life of such patients.
Full-text available
Continuous positive airway pressure (CPAP) is the gold standard for the treatment of obstructive sleep apnea (OSA). Although CPAP was originally applied with a nasal mask, various interfaces are currently available. This study reviews theoretical concepts and questions the premise that all types of interfaces produce similar results. We revised the evidence in the literature about the impact that the type of CPAP interface has on the effectiveness of and adherence to OSA treatment. We searched the PubMed database using the search terms "CPAP", "mask", and "obstructive sleep apnea". Although we identified 91 studies, only 12 described the impact of the type of CPAP interface on treatment effectiveness (n = 6) or adherence (n = 6). Despite conflicting results, we found no consistent evidence that nasal pillows and oral masks alter OSA treatment effectiveness or adherence. In contrast, most studies showed that oronasal masks are less effective and are more often associated with lower adherence and higher CPAP abandonment than are nasal masks. We concluded that oronasal masks can compromise CPAP OSA treatment adherence and effectiveness. Further studies are needed in order to understand the exact mechanisms involved in this effect.
Full-text available
Although continuous positive airway pressure (CPAP) is effective in treating obstructive sleep apnoea (OSA), inadequate adherence remains a major cause of treatment failure. This study aimed to determine long term adherence to auto adjusting-CPAP (APAP) and its influencing factors including the role of initial compliance. Eighty-eight male patients with newly diagnosed moderate/severe OSA were included. After initiation of APAP treatment, patients had periodic follow-up appointments at 2 weeks, 6 months and then annually for at least 5 years. Patient's compliance to therapy was assessed in each appointment and predictors to treatment abandonment and poor compliance were evaluated. The studied population had a mean age of 53.8 years and mean apnoea-hypopnoea index of 52.71/h. The mean time of follow-up was 5.2 (±1.6) years, during that time 22 (25%) patients abandoned APAP, those who maintained treatment had good compliance to it since 94% of them used it more than 4 h/day for at least 70% of days. A significant negative association was found between age, % of days and mean time of APAP use on 12th day and 6th month and the risk of abandoning. APAP use lower than 33% and 57% of days at 12th day and 6th month, respectively had high specificity (∼100%) to detect treatment abandonment. the majority of patients adheres to long term APAP treatment and has good compliance after 5-years of follow-up. Age and initial compliance (% days of use and mean hour/day) have the ability to predict future adherence, as soon as 12 days and 6 months after initiation.
Full-text available
There are very few data on objectively assessed long-term compliance with continuous positive airway pressure (CPAP). No single factor has been consistently identified as predictive of continued CPAP use. Adherence to and associations with objective CPAP use were examined in 639 of 3900 patients in whom CPAP treatment was started between 1994 and 2005. Kaplan-Meier survival analyses were used to estimate the proportion of patients still on CPAP. Cox regression models were used to explore the effects of covariates on continued use of CPAP. The median (IQR) follow-up time after initiating CPAP therapy was 3.9 (1.5-6.9) years and the average use of CPAP was 6.2 (4.5-7.3) h/night. The percentage of patients adherent to CPAP after 5 and 10 years was 81% and 70%, respectively. Multivariate analysis, including gender, age, neck circumference, Epworth Sleepiness Score, oxygen desaturation index (ODI) and research study participation, indicated that ODI was the only clinical variable independently associated with long-term adherence to CPAP (HR per 1 event=0.97, p<0.001, 95% CI 0.96 to 0.98). ODI categories were significantly associated with the risk for stopping CPAP in multivariate analysis (using ODI group 0-15/h as reference, HR for ODI group >15-30/h=0.68, p=0.100, 95% CI 0.43 to 1.08; for ODI group >30-60/h=0.37, p<0.001, 95% CI 0.22 to 0.60; and for ODI group >60/h=0.17, p=0.001, 95% CI 0.06 to 0.48). The majority of patients with sleep-disordered breathing are using CPAP in the long term and the severity of sleep-disordered breathing rather than sleepiness determines long-term adherence to CPAP therapy.
Conference Paper
Introduction It is general perception that Indian patients don't buy CPAP due to its high cost but no study is available to support this. Aims To understand the reasons and barriers for uptake of CPAP by Indian OSA patients Methodology We compared socioeconomic status, disease severity, CPAP buying behavior of “buyers” v/s “non buyers” group and CPAP compliance behavior of “compliant” v/s “noncompliant” group. Result: Out of 187 OSA pt who were prescribed PAP therapy, 79 followed up for study. Only 29 patients (36.7%) bought CPAP and out of these only 24 pt (30.3%) were compliant. Out of non buyers patients {30/50 i.e.50.5%} patients said cost of CPAP as the major barrier in buying CPAP. In patients who are able to buy CPAP, a good adherence pattern (24/29 i.e. 82.7%) was seen. Patients with higher monthly income {above 36,997 INR (USDollar 550)} were more compliant to use CPAP than lower income group (p=0.029) but there was borderline difference found in CPAP buying behaviour in these two groups (p=0.058). When we compared the income of people who said that money was one of the primary reasons for not being able to buy CPAP with those who said they bought CPAP despite of financial constraints, there was no difference in income. This shows that attitude of patients towards their disease is also an important factor. Patients with more severe disease(lower nadir O2, higher AHI or OHS) were more eager to buy CPAP and were more compliant to therapy. Conclusion Main reason for not using CPAP in India is inability to buy CPAP followed by pt's behavior and attitude. Awareness regarding benefits of CPAP needs to be increased among patients. More severe OSA patients are more likely to buy and adhere to CPAP.
This authoritative guide to sleep medicine is also available as an e-dition, book (ISBN: 1416003207) plus updated online reference! The new edition of this definitive resource has been completely revised and updated to provide all of the latest scientific and clinical advances. Drs. Kryger, Roth, and Dementand over 170 international expertsdiscuss the most recent data, management guidelines, and treatments for a full range of sleep problems. Representing a wide variety of specialties, including pulmonary, neurology, psychiatry, cardiology, internal medicine, otolaryngology, and primary care, this whos who of experts delivers the most compelling, readable, and scientifically accurate source of sleep medicine available today. Includes user-friendly synopses of important background information before all basic science chapters. Provides expert coverage of narcolepsy * movement disorders * breathing disorders * gastrointestinal problems * neurological conditions * psychiatric disturbances * substance abuse * and more. Discusses hot topics such as the genetic mechanisms of circadian rhythms * the relationship between obesity, hormones, and sleep apnea * sleep apnea and arterial hypertension * and more. Includes a new section on Cardiovascular Disorders that examines the links between sleep breathing disorders and cardiovascular abnormalities, as well as the use of sleep related therapies for congestive heart failure. Provides a new section on Womens Health and Sleep Disorders that includes information on the effects of hormonal changes during pregnancy and menopause on sleep. Features the fresh perspectives of 4 new section editors. Employs a more consistent chapter organization for better readability and easier navigation.
(1) Determine claustrophobia frequency in adults with obstructive sleep apnea (OSA) after first CPAP night; (2) determine if claustrophobia influences CPAP non-adherence. Claustrophobia is common among CPAP-treated OSA adults yet few studies have examined the problem. Secondary analysis of prospective, longitudinal study of OSA adults (n = 97). CPAP-Adapted Fear and Avoidance Scale (CPAP-FAAS) collected immediately after CPAP titration polysomnogram. objective CPAP use at 1week and 1month. Sixty-three percent had claustrophobic tendencies. Females had higher CPAP-FAAS scores than males. FAAS ≥25, positive score for claustrophobic tendencies, was influential on CPAP non-adherence at 1week (aOR = 5.53, 95% CI 1.04, 29.24, p = 0.04) and less CPAP use at 1month (aOR = 5.06, 95% CI 1.48, 17.37, p = 0.01) when adjusted for body mass index and CPAP mask style. Claustrophobia is prevalent among CPAP-treated OSA adults and influences short-term and longer-term CPAP non-adherence. Interventions are needed to address this treatment-related barrier. Copyright © 2015 Elsevier Inc. All rights reserved.
To determine the clinical variables that best predict long- term continuous positive airway pressure (CPAP) adherence among patients with cardiovascular disease who have obstructive sleep apnea (OSA). 12-mo prospective within-trial observational study. Centers in China, Australia, and New Zealand participating in the Sleep Apnea cardioVascular Endpoints (SAVE) study. There were 275 patients age 45-70 y with cardiovascular disease (i.e., previously documented transient ischemic attack, stroke, or coronary artery disease) and OSA (4% oxygen desaturation index (ODI) > 12) who were randomized into the CPAP arm of the SAVE trial prior to July 1, 2010. Age, sex, country of residence, type of cardiovascular disease, baseline ODI, severity of sleepiness, and Hospital Anxiety and Depression Scale (HADS) scores plus CPAP side effects and adherence at 1 mo were entered in univariate analyses in an attempt to identify factors predictive of CPAP adherence at 12 mo. Variables with P < 0.2 were then included in a multivariate analysis using a linear mixed model with sites as a random effect and 12-mo CPAP use as the dependent outcome variable. CPAP adherence at 1, 6, and 12 mo was (mean ± standard deviation) 4.4 ± 2.0, 3.8 ± 2.3, and 3.3 ± 2.4 h/night, respectively. CPAP use at 1 mo (effect estimate ± standard error, 0.65 ± 0.07 per h increase, P < 0.001) and side effects at 1 mo (-0.24 ± 0.092 per additional side effect, P = 0.009) were the only independent predictors of 12- mo CPAP adherence. Continuous positive airway pressure use in patients with coexisting cardiovascular disease and moderate to severe obstructive sleep apnea decreases significantly over 12 months. This decline can be predicted by early patient experiences with continuous positive airway pressure (i.e., adherence and side effects at 1 month), raising the possibility that intensive early interventions could improve long-term continuous positive airway pressure compliance in this patient population. Clinical Trials,, NCT00738179. Chai-Coetzer CL; Luo YM; Antic NA; Zhang XL; Chen BY; He QY; Heeley E; Huang SG; Anderson C; Zhong NS; McEvoy RD. Predictors of long-term adherence to continuous positive airway pressure therapy in patients with obstructive sleep apnea and cardiovascular disease in the SAVE study. SLEEP 2013;36(12):1929-1937.