Aerophagia During CPAP for OSA: The Case for Auto-CPAP and Nasal Mask (original) (raw)

CPAP Therapy via Oronasal Mask for Obstructive Sleep Apnea

Chest, 1994

To determine the effectiveness of oronasal masks for positive pressure therapy in alleviating obstructive sleep apnea (OSA). Methods and procedures: Polysomnographic records of all 245 patients with OSA who underwent therapeutic trials of either continuous positive airway pressure (CPAP) or bilevel positive airway pressure between January 1991 and December 1992 were reviewed. Thirty patients who had been prescribed positive pressure therapy employing an oronasal mask were identified. Two patients known to be successfully treated with CPAP via oronasal mask underwent repeat polysomnography. The initial portion of the study was a diagnostic evaluation during which the patients were untreated. During the second portion of the study, both patients used CPAP via an oronasal mask while wearing a mouthpiece designed to maintain oral patency. Results: The 30 patients with OSA who were identified in this study had significant amelioration of OSA while receiving positive pressure therapy via oronasal mask compared with the baseline, diagnostic polysomnogram (apnea index: 55.3 ± 36.9-1.6 ± 3.7, p<0.001; hypopnea index: 21.2 ± 20-+2.7 ± 4.9, p<0.001; nadir of Sa0 2 : Jn the last decade, nasal continuous positive airway pressure (CPAP) therapy has been shown repeatedly to maintain upper airway patency effectively during sleep in patients with obstructive sleep apnea (OSA)J-ll The most compelling obstacle to successful therapy with this modality is suboptimal patient compliance. Despite improvements in CPAP machine design over the years, long-term patient compliance with therapy varies between 50 and 85 percent.l.l0-16 Included among the complaints expressed by patients about CP AP therapy is the nasal interface , which is variably associated with air leaks, conjunctivitis, skin abrasion, claustrophobia, rhinitis, rhinorrhea, nasal congestion, oral dryness, and inability to maintain a closed mouth during sleep with

A novel, simplified approach to starting nasal CPAP therapy in OSA

Respiratory Medicine, 2004

Background: Due to ever increasing referral rates, we have had to move the nasal CPAP induction program for patients with obstructive sleep apnoea (OSA) out of the sleep laboratories and into an outpatient setting. We report the effects this has had on patient outcomes.

Efficacy versus Effectiveness in the Treatment of Obstructive Sleep Apnea: CPAP and Oral Appliances

Obstructive sleep apnea (OSA) is a chronic disorder and effective long-term treatment is necessary to prevent associated health risks. Standard treatment remains continuous positive airway pressure which is highly efficacious but has well-recognized limitations, with suboptimal patient acceptance and adherence rates, which in turn obviates the desired health benefits. The leading alternative device treatment is oral appliances. Patients often report preferring oral appliances to CPAP treatment, with better usage rates. However, unlike CPAP, inter-individual variability in the efficacy of oral appliance therapy means that patients are often left with some residual OSA. Despite discrepancies in efficacy (apnea-hypopnea index [AHI] reduction) between CPAP and oral appliances, randomized trials show similar improvements in health outcomes between treatments, including sleepiness, quality of life, driving performance, and blood pressure. Similar results in terms of health outcomes suggests that although the two treatments have different efficacy and treatment usage profiles, these result in similar overall effectiveness. In this narrative review, we discuss efficacy versus effectiveness in relation to CPAP and oral appliance treatment of OSA. Citation: Sutherland K, Phillips CL, Cistulli PA. Efficacy versus effectiveness in the treatment of obstructive sleep apnea: CPAP and oral appliances. Journal of Dental Sleep Medicine 2015;2(4):175–181. E fficacy and effectiveness are important concepts to distinguish when evaluating treatment performance. Treatment efficacy refers to how well an intervention works under ideal circumstances whereas, effectiveness is how well an intervention performs in the real world where conditions are not controlled. Therefore treatment effectiveness is particularly important in management of chronic disease. Obstructive sleep apnea (OSA) is a common sleep disorder characterized by repetitive upper airway obstruction leading to intermittent hypoxia and sleep fragmentation. There has been a dramatic increase in OSA prevalence over the last two decades, attributable to the obesity epidemic, with at least moderate OSA now evident in 17% of middle-aged men and 9% of middle-aged women. 1 OSA is associated with excessive daytime sleepiness and lower quality of life as well as increased risk of workplace and motor vehicle accidents, hypertension and cardiovascular disease, type 2 diabetes, and all-cause mortality. 2–9 Therefore effective management of this chronic disorder is imperative to not only improve symptoms but to prevent long-term health risks. Standard care is the highly efficacious treatment, continuous positive airway pressure (CPAP). This therapy involves delivery of pressurized air to the upper airway during sleep via a nasal mask interface and tube connected to a pump. The pressurized air acts to splint open the upper airway preventing it from collapsing during sleep. The effectiveness of this therapy is therefore dependent upon its ability to overcome airway collapse (efficacy) as well as the time course over which a patient applies it during sleep (compliance). While the efficacy of CPAP is generally high, in the real world long-term health effects of CPAP are likely to be compromised by low compliance and suboptimal hours of treatment use. Treatment usage as a proportion of the total sleep period when a patient is vulnerable to OSA is often overlooked as a confounder of efficacy. However, treatment usage compared to sleep time is an important aspect of real-world effectiveness. Importantly, treatment effectiveness warrants consideration when comparing effects of other OSA treatment options which may not have the same level of efficacy as CPAP but may have a better usage profile. In this review we discuss efficacy and effectiveness between first line OSA treatment CPAP and the leading alternative device treatment, oral appliances. EFFICACY VERSUS EFFECTIVENESS IN OSA Efficacy, in the context of OSA, reflects the ability of treatment to prevent the occurrence of obstructive breathing events during periods when the treatment is being physically applied. This is assessed by the number of obstructive breathing events per hour of sleep or apnea-hypopnea index (AHI). An AHI < 5 events/h indicates absence of disease or a completely effica-cious treatment. In a fully compliant patient (using treatment for 100% of sleep time) efficacy measured as AHI on treatment (AHI Treatment) will give an accurate reflection of OSA treatment effectiveness. However sleep time off treatment becomes an important consideration when compliance is suboptimal. The potential impact of suboptimal CPAP compliance on AHI has been considered using formulas that adjust AHI Treatment for sleep time off treatment when AHI can presumably revert to untreated levels (AHI Untreated). 10,11 When the untreated portion of the night with OSA reoccurrence is taken into consideration, CPAP effectiveness can dramatically decrease depending on OSA severity and total sleep time. Good CPAP adherence is generally set at a benchmark of 4 h/night; however, the rationale for this benchmark is not overly evidence based. Moreover when taking into consideration sleep time off treatment, 4 h of CPAP use during an 8-h sleep period may only reduce

Adherence to CPAP therapy improves quality of life and reduces symptoms among obstructive sleep apnea syndrome patients

Sleep and Breathing, 2012

The aim of the study was to asses quality of life and symptoms of obstructive sleep apnea syndrome (OSAS) patients after adhering to 6 months of continuous positive airway pressure (CPAP) treatment. Methods A group of 50 patients (41 men and 9 women) were diagnosed by polysomnography and treated with CPAP therapy for 6 months. Their symptoms and healthrelated quality of life were assessed by administering a validated and translated version of the sleep apnea quality of life index (SAQLI). Sleepiness was measured using the Epworth Sleepiness Scale (ESS) and through electronic monitoring of CPAP usage per night of sleep. Results Mean CPAP usage was 4.5±0.5 h per night. Comparisons between quality of life indexes before and after CPAP treatment showed an improvement in the total SAQLI score (3.8±0.9 vs. 5.8±0.8 after CPAP, p<0.01), in daily functioning (4.2±1.4 vs. 6.0±0.9, p<0.01), social interactions (4.8±1.3 vs.6.3±0.7, p<0.01), emotional functioning (4.4±1.4 vs. 5.7±1.0, p<0.01), symptoms (1.6±0.8 vs. 5.8±1.2, p<0.01), and in the ESS (13.7±6.5 vs. 3.9± 3.8, p<0.01). Regarding the patients' symptoms, improvement was noticed for "sleepiness while watching a spectacle" (96%), "reading" (95%), "carrying on a conversation" (95%), "driving" (92.9%), "restless sleep" (87.8%), and "urinating more than once per night" (84.8%). Smaller improvements were observed for the reported "dry mouththroat upon awakening" (36.1%),"excessive fatigue" (54.5%), and "decreased energy" (55.3%). Conclusion We conclude that OSAS patients who adhere to nighttime CPAP therapy show significant improvement of their quality of life, daytime sleepiness, and other symptoms after 6 months of treatment with CPAP.

Compliance with nasal CPAP in obstructive sleep apnea patients

Sleep Medicine Reviews, 1997

Continuous positive airway pressure (CPAP) is currently the treatment of choice fey the majority of patients with obstructive sleep apnea (OSA). After a CPAP trial, the 'initial acceptance rate is 70-80%. Patients who derive no subjective benefit from suck a trial are poor candidates for home treatment with CPAP because they are likely to exkibit lower adherence and compliance rates. About 90% of OSA patients provided with CPAP apparatus will adhere to long-term CPAP treatment. Patients abandoning CPAP do so during the first few months of home therapy, a period during which close monitoring and support is warranted. Because of the strong correlation between the machine run time and effective pressure delivered at the nasal mask (90-95%), the time-counter of the CPAP device is sufficient to monitor compliance in clinical practice, allowing for early intervention in cases of suboptimal use. Longterm acceptors of CPAP display a satisfactory compliance (5-6.5 k of average daily use) which compares favourably with compliance with treatment in other chronic diseases. Lower acceptance and compliance rates have been reported in North America as compared to Europe. This could be related to cultural differences or different routines of prescription and follow-up.

Effect of CPAP Therapy in Improving Daytime Sleepiness in Indian Patients with Moderate and Severe OSA

Journal of clinical and diagnostic research : JCDR, 2016

Obstructive Sleep Apnoea (OSA) is a highly prevalent disease and a major public health issue in India. Excessive daytime sleepiness is an almost ubiquitous symptom of OSA. Epworth Sleepiness Scale (ESS) score is a validated objective score to measure the degree of daytime sleepiness. Continuous Positive Airway Pressure (CPAP) therapy has been established as the gold standard treatment modality for OSA patients. A few Indian studies have reported the effectiveness of CPAP therapy in improving ESS scores after 1(st) month of CPAP use. To observe both, short-term (one month) and long-term (three month) effects of CPAP therapy on ESS scores in moderate to severe OSA patients. The patients complaining of excessive day-time sleepiness, snoring and choking episodes during sleep, consecutively presenting to medicine OPD over a period of 2 years, were subjected to Polysomnography (PSG). Seventy-three patients with apnoea-hypopnea index (AHI) ≥15 were categorised as having moderate to severe ...

Nasal function and CPAP compliance

Auris Nasus Larynx, 2018

Continuous positive airway pressure (CPAP) is the mainstay therapy for patients with obstructive sleep apnea (OSA) however compliance with CPAP is variable. Nasal ailments, such as nasal congestion are frequently mentioned as a cause for CPAP non-compliance, and potentially could be addressed prior to CPAP initiation, however, no specific criteria or recommendations for the evaluation and management of these patients exist. The aim of this retrospective study is to evaluate the effects of nasal anatomic features and disease on adherence to CPAP therapy for patients with OSA and determine the indications for pre-CPAP nasal treatment by using data obtained at clinical examination. Methods: In total, 711 adult patients with initial diagnosis of OSA and an apnea-hypopnea index of 20 who were amenable to CPAP were included. We analyzed nasal parameters, past history of nasal disease, subjective symptoms, and disease severity in addition to whether CPAP therapy had been initiated, rate of CPAP therapy use (initial and 1 year), treatment continuation rate at 2 months and 1 year, and nasal treatments for all patients. Results: CPAP therapy was initiated in 543 of 711 patients. Nasal resistance was significantly higher in patients who discontinued therapy soon after CPAP initiation. Nasal disease and nasal parameters were not found to be predictors of treatment adherence at 1 year. Allergic rhinitis, moderate to severe nasal congestion at bedtime, slight or extensive sinus opacification, and a high nasal septum deviation score were found to be independent predictors of nasal treatment, while strong awareness of nasal congestion, a past history of sinusitis, and a total nasal resistance (supine position) of 0.35 Pa/cm 3 /s were independent predictors of surgical treatment. Conclusion: Long-term CPAP therapy adherence in patients with OSA can be predicted from initial CPAP adherence. Nasal disease and nasal parameters are important factors for early CPAP therapy discontinuation and should be adequately treated before therapy initiation to ensure long-term adherence. Indications for pre-CPAP nasal treatment and nasal surgery for patients with OSA can be predicted from the data obtained at the first examination, and these patients should be treated differently from those without OSA.

Auto bi-level pressure relief–PAP is as effective as CPAP in OSA patients—a pilot study

Sleep and Breathing, 2012

Purpose Continuous positive airway pressure (CPAP) is the therapy of choice for the treatment of obstructive sleep apnea (OSA). Not all patients can use CPAP therapy with adequate compliance. There is a need to develop more comfortable modes. Auto bi-level Pressure Relief-Positive Airway Pressure (ABPR-PAP) can be an alternative. We conducted a prospective double-blind, randomised trial to evaluate the efficacy and compliance of ABPR-PAP compared with CPAP in OSA patients. Methods We included 35 CPAP naive patients (age 53.3± 10.3 years, BMI 31.0±5.0 kg/m 2 , ESS 10.0±4.2) diagnosed with moderate to severe OSA who underwent a successful CPAP titration. Patients were randomised into the CPAP or the ABPR-PAP treatment group. We used the same device (BIPAP® Auto, Philips Respironics) for CPAP or ABPR-PAP. Apnea-hypopnea index (AHI) was determined using polysomnography before (AHI 40.6±18.3 per hour) and after treatment. Results Eighteen patients received CPAP and the remaining 17 received APBR-PAP. Groups were similar in terms of demographics and OSA severity. There were no serious adverse events during the trial. CPAP was fixed by a sleep expert and ABPR-PAP varied (range 5-15 cmH 2 O). AHI decreased in the CPAP group to 6.4±5.7 per hour and in the ABPR-PAP group to 4.8±3.6 per hour in the first night (N=35). After 3 months, the AHI decreased in the CPAP group to 4.4±5.3 per hour and in the ABPR-PAP group to 2.6±3.8 per hour (N=32). Differences between the groups were not statistically significant. There were no differences in compliance. Conclusions ABPR-PAP is a promising new ventilation mode that enables effective treatment of OSA patients. Assessed for eligibility (n=82) Excluded (n=47) ♦ Not meeting inclusion criteria (n=28) ♦ Declined to participate (n=19) ♦ Other reasons (n=0) Analysed (n=17) ♦ Excluded from analysis (n=1) Deviation from protocol time schedule Lost to follow-up (n=1) Allocated to CPAP (n=18) ♦ Received allocated intervention (n=18) ♦ Did not receive allocated intervention (n=0) Lost to follow-up (n=2) Allocated to ABPR-PAP (n=17) ♦ Received allocated intervention (n=17) ♦ Did not receive allocated intervention (n=0) Analysed (n=15) ♦ Excluded from (n=2) Deviation from protocol time schedule Randomized (n=35)

Therapeutic alternatives with CPAP in obstructive sleep apnea

Journal of Mind and Medical Sciences

Obstructive Sleep Apnea (OSA), characterized by airflow cessation (apnea) or reduction (hypopnea) due to repeated pharyngeal obstructions during sleep, causes frequent disruption of sleep and hypoxic events. The condition is linked to many adverse health related consequences, such as neurocognitive and cardiovascular disorders, and metabolic syndrome. OSA is a chronic condition requiring long-term treatment, so treatment using continuous positive airway pressure (CPAP) has become the gold standard in cases of moderate or severe OSA. However, its effectiveness is influenced by patients' adherence. Surgery for OSA or treatment with oral appliances can be successful in selected patients, but for the majority, lifestyle changes such as exercise and dietary control may prove useful. However, exercise training remains under-utilized by many clinicians as an alternative treatment for OSA. Other interventions such as oral appliance (OA), upper way stimulation, and oropharyngeal exercises are used in OSA. Because the benefit of all these techniques is heterogeneous, the major challenge is to associate specific OSA therapies with the maximum efficacy and the best patient compliance.