June 14, 2007 (Minneapolis) — Although treatment with continuous positive airway pressure (CPAP) has been shown to effectively treat obstructive sleep apnea (OSA) when used correctly, getting patients to comply with treatment is an ongoing challenge. Clinicians looking to improve compliance might want to follow the lead of a protocol established by an American Academy of Sleep Medicine (AASM)-accredited sleep center, which found that rigorous education, strict and ongoing follow-up, and an organized approach to the use of CPAP raised compliance rates far above the national average.
"We believe that a coordinated program with intense follow-up and great emphasis on education that lets patients know about their disease helps with CPAP compliance," senior author of the study, Siva Ramachandran, MD, from the Sleep Wellness Center of Pottstown, in Pennsylvania, told Medscape at the 21st Annual Meeting of the Associated Professional Sleep Societies.
In this study of more than 300 patients with OSA treated at an AASM-accredited sleep clinic, all participants were educated about OSA through a program that included written materials and follow-up by a technologist before they entered the sleep study. Each participant was then sent to a specialized CPAP clinic to view a video on OSA, be fitted for a mask, and receive a CPAP machine with a downloadable compliance card. Patients were seen after 1 month, at which time compliance data were obtained. During this time, patients had open access to the clinic.
According to Maureen Weiss, CRT, who is the CPAP coordinator and organizer of this program, it takes a lot of work to get this type of program to happen, and the main difficulty for the patients is the mask. "They won't use the CPAP machine if the mask is uncomfortable," she said, "so we go through a lengthy fitting program with them. We also give them 30 days to change their mind."
Compliance was determined by duration of use. Participants were considered to be compliant with treatment if they used CPAP more than 4 hours and not compliant if they used it for less than 4 hours.
Overall, the authors found that 82% of the patients used CPAP for more than 4 hours a night, with a mean duration of 6.19 hours. For the 18% of participants who used CPAP for less than 4 hours a night, the mean duration of usage was 2.41 hours. Only body-mass index (BMI) and apnea/hypopnea index (AHI) significantly differed between the groups, with the compliant group having significantly higher BMI (36.05 kg/m2 vs 33.31; P = .02) and AHI (35.55 vs 25.44; P = .01) than the noncompliant group.
"When you compare the 2 groups," said Dr. Ramachandran, "we found that, to some extent, the severity of the disease does [have an] impact on CPAP usage."
For Michael J. Twery, PhD, director of the National Center on Sleep Disorders Research, compliance will continue to be an important consideration for the usage of CPAP. "The degree to which an individual follows a recommended CPAP treatment has many influences, which have not been well studied, such as the nature of the airway obstruction in a particular patient, the capabilities of a particular CPAP device, sleep environment, lifestyle issues affecting sleep duration, family status, demographics, and quality of healthcare delivery."
Talking about his own experience, Dr. Twery told Medscape that "compliance is maximized through frequent contact with patients, asking how it is going, monitoring the usage data recorded by the CPAP machine frequently, providing appropriate feedback, and providing study subjects with assistance in fitting and adjusting the CPAP masks."
"Even with intense follow-up," he said, "typical usage in large populations may average 4 to 5 hours a night."
According to Dr. Twery, a study will soon be published in the journal Sleep that shows that as little as 4 to 5 hours of CPAP is needed to minimize sleepiness, but that "more than 7 hours per night with CPAP is needed to obtain peak improvement in quality of life."
For Dr. Ramachandran, the important thing is not the numbers. "What we really think about in terms of CPAP usage is not so much the numbers but the matter of consistency of usage," he said. "What can we do to make that impact?" That, he said, is what the study is about.
SLEEP 2007: the 21st Annual Meeting of the Associated Professional Sleep Societies: Abstract 1046. Presented June 12, 2007.
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