Chest
Volume 155, Issue 6, June 2019, Pages 1272-1287
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Contemporary Reviews in Sleep Medicine
Adherence to CPAP: What Should We Be Aiming For, and How Can We Get There?

https://doi.org/10.1016/j.chest.2019.01.012Get rights and content

The purpose of this review was to summarize what is currently known regarding two important questions facing the field of sleep medicine today: (1) How many hours of CPAP use per night are necessary to improve daytime symptoms and reduce cardiovascular risk associated with OSA?; and (2) What strategies could be implemented to optimize adherence in clinical settings? Despite the widespread adoption of a threshold approach to CPAP management, the literature to date suggests a dose-response relationship between CPAP usage and a range of outcomes, including sleepiness, functional status, and BP; the data also suggest that the optimal adherence level differs depending on the outcome in question. Over the years, psychological measures of behavior change constructs have been increasingly recognized as the most consistent predictors of CPAP adherence, and, as such, the most successful interventions for optimizing adherence have been behavioral in nature. Unfortunately, behavioral therapies have not been translated from highly controlled research settings to comparative-effectiveness studies and finally into routine care, mainly due to feasibility and cost issues. More recently, theory-driven telemedicine adherence interventions have emerged, which take advantage of the framework that already exists in the United States and elsewhere for real-time remote-monitoring of CPAP. Combining theory-driven behavioral approaches with telemedicine technology could hold the answer to increasing real-world CPAP adherence rates, although randomized studies are still required, and socioeconomic barriers to telemedicine will need to be addressed to promote health equity.

Section snippets

Optimal Adherence for Controlling Daytime Symptoms

Despite the widespread adoption of a threshold approach to CPAP management,40 the literature to date suggests that the optimal usage level differs depending on the outcome in question. In an uncontrolled study of 149 patients with severe OSA, the average usage level at which normalization of symptoms occurred differed substantially for self-reported sleepiness (4 h per night), objective sleepiness (6 h per night), and functional status (7.5 h per night).41 A similar study of 174 patients found

Optimal Adherence for Controlling Cardiovascular Symptoms

There is also evidence that greater CPAP use is associated with improvements in surrogate cardiovascular outcomes. A secondary analysis of a 2010 randomized trial in which 359 nonsleepy patients with OSA and hypertension were randomized to receive CPAP or conservative treatment indicated that the reductions in BP were increasingly evident in patients grouped according to adherence (≤ 3.6, 3.61-5.65, and > 5.65 h per night).44 Similarly, a 2013 trial found a positive correlation between CPAP

Exploring the Concept of a “Dose-Response” Relationship Between Adherence and Outcomes

It is widely accepted that a dose-response relationship exists between CPAP usage and a range of outcomes, with “dose” in this context referring to hours of usage per night rather than the pressure setting. In considering a dose-response relationship, however, it is important to account for the sensitivity of each outcome measure, the level of impairment pretreatment, and the habitual sleep duration of each patient. CPAP adherence is usually defined as simply hours per night rather than as a

The Role of CPAP for Patients With Mild OSA

Although there is a positive association between AHI and symptoms such as sleepiness, the correlation is far from perfect, such that there are patients with very high AHIs who report little if any daytime impact of OSA and also patients with low AHIs who report debilitating impairment. In the latter group, it is generally agreed that a trial of CPAP may be warranted.56 Whether to prescribe CPAP to patients in the former group is less clear.57, 58 Regardless, several trials recruiting patients

Alternative Care Providers, Augmented Support, and Educational Interventions to Increase Adherence

Several studies have concluded that the approaches used in primary care or nurse-led management can have a positive effect on adherence and clinical outcomes.64, 65, 66 Results are conflicting as to whether the provision of educational materials67, 68, 69, 70 and/or augmented clinical support such as more frequent appointments, telephone calls, and home visits71, 72, 73 have a major impact on CPAP adherence. Most clinics offer a combination of these interventions. A simpler alternative to

Remote Monitoring and Telemedicine

The ability to monitor CPAP adherence remotely, as well as important therapy parameters such as estimated residual disease, pressure profiles, and mask leak, provides potential to use this technology for the implementation of Web-based adherence interventions (summarized in Table 3).96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106 The scope for telemedicine in CPAP includes automated, personalized feedback for patients, targeted troubleshooting and support based on individual patient data,

Conclusions

Poor acceptance of and adherence to CPAP therapy is one of the major issues facing our field, not only because it is associated with ongoing disease burden despite widespread availability of diagnostic and treatment services but also because suboptimal CPAP usage has prevented a thorough understanding of important trials designed to clarify the impact of OSA on cardiovascular risk and the role of CPAP in mitigating that risk. Many studies have tested the impact of a range of interventions

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST the following: M. S. A. is a full-time employee and stakeholder of Philips. J. P. B. is a full-time employee of Philips, which is a company that focuses on sleep and respiratory care. J. P. B. holds a part-time appointment at Brigham and Women’s Hospital. The interests of J. P. B. were reviewed and are managed by Brigham and Women’s Hospital and Partners HealthCare in accordance with their conflict of interest policies. J.

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