Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial. Simple interventions improve re-attendance when treating the sleep apnoea syndrome. Improving compliance with nasal CPAP and vigilance in older adults with OAHS. Pilot randomized trial of the effect of wireless telemonitoring on compliance and treatment efficacy in obstructive sleep apnea. A long-term randomized, cross-over comparison of auto-titrating and standard nasal continuous airway pressure. Compliance with nasal CPAP can be improved by simple interventions. Effects of fixed compared to automatic CPAP on sleep in Obstructive Sleep Apnoea Syndrome. Comparison between automatic and fixed positive airway pressure therapy in the home. A pilot trial of a telecommunications system in sleep apnea management. Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome?
To improve adherence to continuous positive airway pressure (CPAP) treatment in participants with obstructive sleep apnea (OSA) using a cognitive behavioral therapy (CBT) intervention.
                A randomized controlled trial.
                A major teaching hospital in Sydney (2005).
                One hundred individuals (96 men), ranging in age from 32 to 81 years, diagnosed with OSA.
                Two 1-hour CBT interventions (including a video of real CPAP users) plus treatment as usual (mask fitting and information) or treatment as usual only.
                Hours of CPAP usage was assessed at 7 nights and 28 nights. Adherence was defined as usage at least 4 hours per night. Questionnaires measuring self-efficacy, social support, and expectancy (mediators of adherence) were given after intervention or after usual treatment. A higher adherence to CPAP therapy was found in the CBT group (2.9 hours difference) relative to treatment as usual (P < 0.001) at 28 days. Only 4 participants in the CBT group did not initiate treatments after their titration study, compared with 15 in the treatment as usual group (P < 0.02). The CBT group had significantly higher scores for self-efficacy (P < 0.001) and social support P < 0.008) but not for expectancy.
                The CBT intervention resulted in both increased adherence and "uptake" of CPAP and therefore would be expected to reduce the social, economic, and health-related consequences of untreated OSA. Interventions to improve treatment outcomes in sleep apnoea-hypopnoea syndrome (SAHS) have had mixed success. Most have concentrated on following the use of a continuous positive airway pressure (CPAP) machines; poorer users may not return for machine readings, so any compliance study must take into account rates of attendance rates. We hypothesised that a series of additional, early support measures would improve re-attendance over a sustained period.
                Prospective, single-blinded interventional study. Seventy-two consecutive patients starting CPAP for SAHS were randomised to receive standard follow-up or extra early support. Attendance rates, CPAP use, Epworth scores, side-effects scores and number of changes to equipment were compared, by intent to treat, in both groups at 1 and 12 months.
                Re-attendance rates were higher in the intervention group at 1 month (P=0.04), 6 months (P=0.07) and 12 months (P=0.12). Those who defaulted tended previously to be poor users of the CPAP machine. For those who re-attended there was no difference in machine use or other outcomes.
                Simple interventions while commencing CPAP improve re-attendance with maximal benefit early on. This could provide more opportunities for solving problems early or considering alternative treatments. By confirming that poorer CPAP users eventually have higher default rates we recommend that future studies on CPAP compliance should first account for re-attendance rates. The present study examined the efficacy of a cognitive-behavioral intervention at improving compliance with CPAP and vigilance in older adults with obstructive sleep apnea/hypopnea syndrome (OSAHS). Participants included 12 subjects who were randomized into one of two groups controlling for age, education, disease severity, and vigilance. The experimental group received two 45-min sessions designed to educate subjects on the consequences of OSAHS and the efficacy of CPAP. The control group received the same extent of therapist contact but did not receive information on OSAHS or CPAP. All subjects were administered a test of vigilance both before and after the study. Compliance data were collected using CPAP devices with internal microprocessors at were read at 1, 4, and 12 weeks after treatment initiation. The results showed that the experimental condition did not enhance compliance after 1 week of treatment but did so by the 12-week follow-up. Subjects in the experimental condition had a run time of 3.2-h per night longer than did those in the control group. Those using CPAP more regularly at 12 weeks also showed greater improvement on vigilance at follow-up. Performance on vigilance testing before the introduction of CPAP was predictive of CPAP use at 12 weeks. In conclusion, a modest cognitive-behavioral intervention may substantially increase CPAP use and vigilance in older adults. Obstructive sleep apnea (OSA) is a prevalent and serious medical condition characterized by repeated complete or partial obstructions of the upper airway during sleep and is prevalent in 2% to 4% of working middle-aged adults. Nasal continuous positive airway pressure (CPAP) is the gold-standard treatment for OSA. Because compliance rates with CPAP therapy are disappointingly low, effective interventions are needed to improve CPAP compliance among patients diagnosed with OSA.
                The aim was to determine whether wireless telemonitoring of CPAP compliance and efficacy data, compared to usual clinical care, results in higher CPAP compliance and improved OSA outcomes.
                45 patients newly diagnosed with OSA were randomized to either telemonitored clinical care or usual clinical care and were followed for their first 2 months of treatment with CPAP therapy. CPAP therapists were not blinded to the participants' treatment group.
                20 participants in each group received the designated intervention. Patients randomized to telemonitored clinical care used CPAP an average of 4.1 +/- 1.8 hours per night, while the usual clinical care patients averaged 2.8 +/- 2.2 hours per night (P = .07). Telemonitored patients used CPAP on 78% +/- 22% of the possible nights, while usual care patients used CPAP on 60% +/- 32% of the nights (P = .07). No statistically significant differences between the groups were found on measures of CPAP efficacy, including measures of mask leak and the Apnea-Hypopnea Index. Patients in the telemonitored group rated their likelihood to continue using CPAP significantly higher than the patients in the usual care group. Patients in both groups were highly satisfied with the care they received and rated themselves as "not concerned" that their CPAP data were being wirelessly monitored.
                Telemonitoring of CPAP compliance and efficacy data and rapid use of those data by the clinical sleep team to guide the collaborative (ie, patient and provider) management of CPAP treatment is as effective as usual care in improving compliance rates and outcomes in new CPAP users. This study was designed as a pilot-larger, well-powered studies are necessary to fully evaluate the clinical and economic efficacy of telemonitoring for this population. This study is a 12-week randomized, cross-over, single-blind comparison of the tolerance, compliance, and symptomatic improvement obtained with standard nasal continuous positive airway pressure (CPAP) vs. an auto-titrating, self-adjusting device (APAP). Sixty newly diagnosed patients, 53 with obstructive sleep apnea (OSA) and seven with upper airway resistance syndrome were studied. Thirty-nine patients (65%) completed the 24-week protocol. Data were complete in 33. In these 33 patients CPAP and APAP reduced the Epworth Sleepiness score from 15+/-1 (+/-SEM) to 8+/-1 and 9+/-1 respectively (both <0.0001 from baseline but NS between modes). The APAP average pressure was lower than the CPAP pressure, 6.4+/-0.4 and 10.6+/-0.4 cm H20, respectively. The average daily machine use was greater with APAP, 6.0+/-0.3 hrs. versus 5.5+/-0.3 hrs. with CPAP (P < 0.04). The number of days of machine use, and the pattern of use were not different between CPAP and APAP. A higher proportion of patients who did not complete the study was randomized to CPAP for their initial treatment period. This study showed that: 1) CPAP and APAP produced an equivalent improvement in daytime sleepiness, 2) APAP pressure was lower than CPAP pressure, 3) patients wore the APAP device longer during nights they used the pressure support system, and 4) patients who began the study with APAP were more prone to continue treatment. We conclude that APAP was better tolerated and used a greater number of hours than CPAP, but the extent of improvement in excessive daytime sleepiness was similar between the two modes of therapy. Effectiveness of continuous positive airway pressure (CPAP) as a treatment of obstructive sleep apnea can be limited by poor compliance, but little is known about how to improve compliance. We performed a randomized, controlled clinical trial among 33 subjects of two interventions to improve compliance. One group of subjects received weekly phone calls to uncover any problems and encourage use, another received written information about sleep apnea and the importance of regular CPAP use, and a third served as control subjects. We found that intervention improved CPAP compliance (p = 0.059) and that the effect was particularly strong when intervention occurred during the first month of CPAP treatment (p = 0.004). Although the sample size did not allow definitive investigation of other explanatory variables, subjects with lower levels of education or those with relatives who used CPAP may have benefited from intervention more than other subjects. We conclude that simple, inexpensive efforts to improve compliance with CPAP can be effective, especially when applied at the start of CPAP treatment, but optimal intervention may vary with certain patient characteristics. Automatic CPAP has been developed to improve CPAP efficiency and compliance. Continually matching the effective pressure may be associated to more frequent arousals that could disturb sleep. The aim of the present study was to compare sleep architecture after one month's home therapy with CPAP or with an AutoCPAP device.
                Twenty OSAS patients (18 M / 2 F) after polysomnographic study with CPAP titration received either an automatic (AutoSet T, ResMed, Sydney, Australia) or a fixed level CPAP machine in a random, single blind fashion for one month. At the end of the home treatment period polysomnography was repeated while CPAP was administered by the same machine used at home.
                There was no significant difference between groups in terms of age (50.0 vs 45.5, NS), sex, BMI (38.3 vs 35.1, NS), RDI (45.4 vs 48.0, NS), and CPAP effective level (9.8 vs 10.8, NS). After one month of therapy the correction of sleep respiratory disturbances and of sleep structure was satisfactory in both groups. No difference in any polysomnographic variable or in subjective sleepiness was found at re-evaluation.
                The results of this study demonstrate that on average CPAP administered by a fixed CPAP machine and by the AutoSet T autoCPAP device has similar effects in improving respiratory function during sleep, nocturnal sleep architecture, and subjective daytime sleepiness after a one-month therapy. As autoCPAP devices are more expensive than fixed CPAP machines, their prescription should be considered only after a clear demonstration of an increase in compliance to treatment by these devices. We tested the hypothesis that continuous positive airway pressure (CPAP) use and outcomes can be improved by an autotitrating CPAP device in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) who require higher CPAP (10 cm H2O or more). In this multisite randomized single-blind cross-over study, 44 patients (mean age, 49 +/- 10 years) were randomized to 6 weeks at laboratory-determined fixed pressure and 6 weeks on autotitrating CPAP. Average nightly use was greater in automatic mode (306 versus 271 minutes, p = 0.005); median and 95th centile pressures in automatic mode were lower (p < 0.002). Automatic CPAP resulted in better SF-36 Vitality scores (65 +/- 20 versus 58 +/- 23, p < 0.05) and mental health scores (80 +/- 14 versus 75 +/- 18, p < 0.05), but no significant difference in Epworth score (p = 0.065). During automatic therapy, patients reported more restful sleep, better quality sleep, less discomfort from pressure, and less trouble getting to sleep for both the first week of therapy and for the averaged scores for Weeks 2-6 (all p values < 0.006). Patients who require higher fixed CPAP use autotitrating CPAP more and report greater benefit from this therapy. Continuous positive airway pressure (CPAP) is an effective therapy for obstructive sleep apnea syndrome (OSAS), although many patients have difficulty adhering to this therapy. The purpose of this study was to investigate the effectiveness of totally automated telephone technology in improving adherence to prescribed CPAP therapy.
                This pilot study was a randomized clinical trial in 30 patients being started on CPAP therapy for OSAS. Patients were randomly assigned to use of a computer telephone system designed to improve CPAP adherence (telephone-linked communications for CPAP [TLC-CPAP]) in addition to usual care (n = 15) or to usual care alone (n = 15) for a period of 2 months. TLC-CPAP is a computer-based system that monitors patients' self-reported behavior and provides education and reinforcement through a structured dialogue.
                A sleep symptoms checklist and the Functional Outcomes of Sleep Questionnaire were administered at study entry and at 2-month follow up. Hours of CPAP use at effective mask pressure were measured by the CPAP device, stored in its memory, and retrieved at the 2-month visit.
                At 2 months, patients randomized to TLC-CPAP had fewer reported sleep-related symptoms (9.4 vs. 13.4, P = 0.047) than those receiving usual care. The average nightly CPAP use in the TLC-CPAP group was 4.4 hours compared with 2.9 hours (P = 0.076) in the usual-care group.
                This pilot study suggests that patients with OSAS started on CPAP and a concurrently administered automated education and counseling system had better CPAP adherence and better control of OSAS symptoms. Continuous positive airway pressure (CPAP) therapy is widely prescribed for patients with the sleep apnea/hypopnea syndrome (SAHS), but the use of CPAP for such patients is disappointingly low. We postulated that providing intensive educational programs and nursing support to SAHS patients might improve CPAP use and outcomes. We also examined the hypothesis that CPAP use would be greater among patients who had initiated their own referral than among those asked to seek help by a partner. We randomized 80 consecutive, new patients with SAHS to receive either usual support or additional nursing input including CPAP education at home and involving their partners, a 3-night trial of CPAP in our institution's sleep center, and additional home visits once they had begun CPAP. The primary outcome variable was objective CPAP use; symptoms, mood, and cognitive function were also assessed after 6 mo. CPAP use over 6 mo was greater (p = 0.003) among patients receiving intensive than among those receiving standard support (5.4 +/- 0.3 versus 3.9 +/- 0. 4 h/night [mean +/- SEM]), with greater improvements (p < 0.05) in SAHS symptoms, mood, and reaction time in the intensively supported group. CPAP use was greater (p = 0.002) among patients who initiated their own referrals. CPAP use and outcomes of therapy can be improved by provision of a nurse-led intensive CPAP education and support program. CPAP use is lower among patients whose partners ask them to seek treatment.
There is some evidence that a supportive intervention which encourages people to continue to use their CPAP machines leads to greater levels of CPAP machine usage than control, although the variation across the studies introduces some uncertainty over how consistent this effect is. We could not find evidence that a short-term educational intervention led to improvements in usage. Cognitive behavioural therapy led to the largest increases in average machine usage, partly because more participants were prepared to try out the treatment. Studies generally recruited CPAP naive patients whose sleep apnoea was severe. Trials in patients who have struggled to persist with treatment are required, as there is currently little evidence in this population. This could make a valuable contribution to our understanding of the complex relationship between initial motivation, ongoing perception of benefit and long-term health benefits.