Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea

Ian Smith; Toby J Lasserson

doi:10.1002/14651858.CD003531.pub3

Scolaris Content Display Scolaris Content Display

Topics

Figure 1

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

Navigate to figure in ReviewOpen in new tab

Figure 2

Forest plot of comparison: 1 Auto‐CPAP versus fixed CPAP, outcome: 1.1 Machine usage (hours/night) ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Figure 3

Forest plot of comparison: 1 Auto‐CPAP versus fixed CPAP, outcome: 1.2 Machine usage ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Figure 4

Funnel plot of comparison: 1 Auto‐CPAP versus fixed CPAP, outcome: 1.2 Machine usage ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Figure 5

Forest plot of comparison: 1 Auto‐CPAP versus fixed CPAP, outcome: 1.3 Machine usage (on nights when CPAP used 'effectively').

Navigate to figure in ReviewOpen in new tab

Figure 6

Funnel plot of comparison: 1 Auto‐CPAP versus fixed CPAP, outcome: 1.11 Epworth Sleepiness Score ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Figure 7

Forest plot of comparison: 2 Bi‐level PAP versus fixed CPAP, outcome: 2.1 Machine usage (hours/night) ‐ 1st arm/parallel studies [hrs/nt].

Navigate to figure in ReviewOpen in new tab

Figure 8

Forest plot of comparison: 4 CPAP with expiratory pressure relief versus fixed CPAP, outcome: 4.1 Machine usage (hours/night) ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Figure 9

Forest plot of comparison: 3 CPAP with expiratory pressure relief versus fixed CPAP, outcome: 3.2 Machine usage (hours/nt) ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Figure 10

Forest plot of comparison: 4 Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone, outcome: 4.1 Machine usage (hours/night) ‐ 1st arm parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.1

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 1 Machine usage (hours/night) ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.2

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 2 Machine usage ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.3

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 3 Machine usage (on nights when CPAP used 'effectively').

Navigate to figure in ReviewOpen in new tab

Analysis 1.4

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 4 Machine usage (frequency of usage as % of days) ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.5

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 5 Machine usage (% of nights of > 4 hours of use) ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.6

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 6 Machine usage (frequency of usage as % of days) ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.7

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 7 Number of participants who applied CPAP therapy > 4 hrs day/5 days/week ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.8

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 8 Patient preference (auto‐CPAP/not auto‐CPAP).

Navigate to figure in ReviewOpen in new tab

Analysis 1.9

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 9 Withdrawals (parallel group trials/first arm cross‐over trials).

Navigate to figure in ReviewOpen in new tab

Analysis 1.10

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 10 Epworth Sleepiness Scale ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.11

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 11 Epworth Sleepiness Scale ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.12

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 12 Arousals(events/hr) ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.13

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 13 Arousals (events/hr) ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.14

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 14 Apnoea Hypopnoea Index (events/hr) ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.15

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 15 Apnoea Hypopnoea Index (events/hr) ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.16

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 16 Systolic blood pressure (parallel group studies).

Navigate to figure in ReviewOpen in new tab

Analysis 1.17

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 17 Diastolic blood pressure (parallel group studies).

Navigate to figure in ReviewOpen in new tab

Analysis 1.18

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 18 Pressure of CPAP treatment (parallel studies).

Navigate to figure in ReviewOpen in new tab

Analysis 1.19

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 19 Pressure of CPAP treatment (cross‐over studies).

Navigate to figure in ReviewOpen in new tab

Analysis 1.20

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 20 Number of subjects where AHI reduced to < 10 events/hour.

Navigate to figure in ReviewOpen in new tab

Analysis 1.21

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 21 SF‐36 parallel group studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.22

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 22 SF‐36 ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.23

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 23 Quality of life: functional outcome of sleep questionnaire (FOSQ) ‐ parallel group/1st arm cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.24

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 24 Sleep Association Quality of Life Index (SAQLI) ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 1.25

Comparison 1 Auto‐CPAP versus fixed CPAP, Outcome 25 Side effects.

Navigate to figure in ReviewOpen in new tab

Analysis 2.1

Comparison 2 Bi‐level PAP versus fixed CPAP, Outcome 1 Machine usage (hours/night) ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 2.2

Comparison 2 Bi‐level PAP versus fixed CPAP, Outcome 2 Machine usage (hours/night) ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Analysis 2.3

Comparison 2 Bi‐level PAP versus fixed CPAP, Outcome 3 Mean days CPAP used.

Navigate to figure in ReviewOpen in new tab

Analysis 2.4

Comparison 2 Bi‐level PAP versus fixed CPAP, Outcome 4 Withdrawals ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 2.5

Comparison 2 Bi‐level PAP versus fixed CPAP, Outcome 5 Patient preference ‐ BiPAP/no preference or CPAP.

Navigate to figure in ReviewOpen in new tab

Analysis 2.6

Comparison 2 Bi‐level PAP versus fixed CPAP, Outcome 6 Epworth Sleepiness Score ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 2.7

Comparison 2 Bi‐level PAP versus fixed CPAP, Outcome 7 Change in quality of life score (FOSQ).

Navigate to figure in ReviewOpen in new tab

Analysis 2.8

Comparison 2 Bi‐level PAP versus fixed CPAP, Outcome 8 End of treatment functional outcome of sleep questionnaire (FOSQ).

Navigate to figure in ReviewOpen in new tab

Analysis 3.1

Comparison 3 CPAP with expiratory pressure relief versus fixed CPAP, Outcome 1 Machine usage (hours/night) ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 3.2

Comparison 3 CPAP with expiratory pressure relief versus fixed CPAP, Outcome 2 Machine usage (hours/night) ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Analysis 3.3

Comparison 3 CPAP with expiratory pressure relief versus fixed CPAP, Outcome 3 End of treatment Epworth sleepiness scores ‐ parallel groups/first arm crossovers.

Navigate to figure in ReviewOpen in new tab

Analysis 3.4

Comparison 3 CPAP with expiratory pressure relief versus fixed CPAP, Outcome 4 End of treatment Epworth score (cross‐over studies).

Navigate to figure in ReviewOpen in new tab

Analysis 3.5

Comparison 3 CPAP with expiratory pressure relief versus fixed CPAP, Outcome 5 Change in Epworth Sleepiness Score ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 3.6

Comparison 3 CPAP with expiratory pressure relief versus fixed CPAP, Outcome 6 End of treatment AHI (parallel groups/first arm cross‐overs).

Navigate to figure in ReviewOpen in new tab

Analysis 3.7

Comparison 3 CPAP with expiratory pressure relief versus fixed CPAP, Outcome 7 End of treatment AHI (cross‐over studies).

Navigate to figure in ReviewOpen in new tab

Analysis 3.8

Comparison 3 CPAP with expiratory pressure relief versus fixed CPAP, Outcome 8 Treatment satisfaction score ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 3.9

Comparison 3 CPAP with expiratory pressure relief versus fixed CPAP, Outcome 9 Treatment comfort score ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 3.10

Comparison 3 CPAP with expiratory pressure relief versus fixed CPAP, Outcome 10 Treatment interface score ‐ 1st arm/parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 4.1

Comparison 4 Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone, Outcome 1 Machine usage (hours/night) ‐ 1st arm parallel studies.

Navigate to figure in ReviewOpen in new tab

Analysis 4.2

Comparison 4 Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone, Outcome 2 Machine usage (hours/night) ‐ crossover studies.

Navigate to figure in ReviewOpen in new tab

Analysis 4.3

Comparison 4 Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone, Outcome 3 AHI.

Navigate to figure in ReviewOpen in new tab

Analysis 4.4

Comparison 4 Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone, Outcome 4 Epworth Sleepiness Score ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Analysis 4.5

Comparison 4 Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone, Outcome 5 Preference.

Navigate to figure in ReviewOpen in new tab

Analysis 4.6

Comparison 4 Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone, Outcome 6 Nasal symptoms.

Navigate to figure in ReviewOpen in new tab

Analysis 4.7

Comparison 4 Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone, Outcome 7 Nasal symptoms ‐ cross‐over studies.

Navigate to figure in ReviewOpen in new tab

Table 1. Table of devices

Device	Mechanism	UK prices (2007)	US prices (2007)
Fixed CPAP	A single pressure is set. The device attempts to maintain this during inspiration and expiration and throughout the period of use.	£260 to £465	$399 to $575
Auto‐titrating continuous positive airway pressure	High and low pressure limits are set. The device adjusts its pressure within these limits to try to maintain a patent airway. The pressure does not vary between inspiration and expiration but will vary across the period of use.	£410 to £825	$739 to $997
C‐FlexTM (expiratory pressure relief)	A basic pressure is set for the period of use. The device tracks patient effort and drops from the basic pressure by a preset amount at the start of expiration, increasing back to the basic pressure at the end of expiration. The pressure drops by 1 of 3 amounts selected according to patient comfort.	Included in Respironics CPAP devices, no extra charge	—
Bi‐level positive airway pressure	Two pressure levels are set. The device aims to co‐ordinate with patient breaths to deliver the higher pressure throughout inspiration and the lower pressure throughout expiration. If the patient has no respiratory effort some machines will produce timed or back up breaths.	£1500 to £3950	$1585 to $2459
Heated humidification	—	£175 to £250	$184 to $260
		The prices quoted are indicative only. They do not include discounts available for bulk purchase.

Table 1. Table of devices

Navigate to table in Review

Table 2. Search history

Version	Detail
Issue 4, 2004	Following electronic searches conducted on the Cochrane Airways Group sleep apnoea trials register 1180 studies were identified. From searches run on Psycinfo on 16 April 2003, 243 references were identified. Seventy studies were retrieved for full paper assessment. Four studies were ongoing (Douglas 2000; Hukins 2001; Morton 2001; Zozula 2001). A total of 46 studies were excluded ‐ please see 'Characteristics of excluded studies'. Twenty‐four studies met the inclusion criteria for the review. One study (Sériès 1997) was identified from the bibliography of d'Ortho 2000. One non‐English language paper is awaiting assessment from the most recent electronic search (Huang 2001, January 2004). The most common reason for exclusion from the review was lack of randomisation (N = 16). Nine studies were excluded as they were laboratory‐based and not designed to detect effects on long‐term compliance. Four papers were review articles. Planès 2003 compared home‐titrated auto‐CPAP with laboratory‐titrated fixed CPAP and was excluded on the basis that the study comparison was two‐fold, and subject to confounding. Four studies were excluded due to the comparison of active interventions, rather than active and control treatments (Khanna 2003; Massie 1999; Wiest 1999; Wiest 2002).
April 2003 to January 2005	Following an update search conducted in January 2005, a total of 65 references were identified. Following the identification of duplicates, a total of 16 studies were identified as being potentially relevant. Two studies are ongoing (Allen 2004; CRISP). A supplementary search of PubMed in March 2005 identified one additional reference (Hukins 2004). Seven new studies met the inclusion criteria of the review (DeMolles 2004; Hussain 2004; Hukins 2004; Marrone 2004; Marshall 2003; Noseda 2004; Taylor 2003).
January 2006	References identified: 83 References selected for potential relevance: 45 Obtained as full text for further scrutiny: 18 Studies meeting revised entry criteria: 12

Table 2. Search history

Navigate to table in Review

Table 3. Numbers entering and completing studies

Study	Screened	Entered	Completed	% Screened	% Entered	Mean hours used (control group)
Ballard 2007	204	104	104	51	100	2.9
Blau 2007	Not reported	35	32	NA	91	5.6
Castronovo 2006	Not available	50	40	NA	80	Not available
d'Ortho 2000	Not available	25	25	N/A	100	4.7
Dolan 2008	Not available	184	142	N/A	76%	5.28
Ficker 2002	Not available	100	95	N/A	95	4.8
Galetke 2008	Not available	20	20	NA	100	6.38
Gay 2003	Not available	40	27	N/A	67.5	5.6
Gfüllner 2007	Not available	Not available	18	Not available	Not available	5.32
Gonzalez‐Moro 2005	Not available	20	Unclear	N/A	N/A	Not reported
Hudgel 2000	Not available	53	39	N/A	73.58	5.5
Hukins 2004	58	55	46	79	84	4.86
Hussain 2004	Not reported	10 (assumed)	10	N/A	100	3.7
Jarvis 2006	Not available	Not available	20	Not available	Not available	6.79
Kendrick 2002	Not reported	41	27	N/A	65.85	Not available
Konermann 1998	Not reported	50	48	N/A	96	5.6
Loube 2004	Not reported	Not reported	Not reported	N/A	N/A	Not reported
Marrone 2004	Not reported	22 (assumed)	22	N/A	100	4.4
Marshall 2008	Not reported	NA	19	NA	NA	3
Massie 2003	Not reported	46	44	N/A	95.6	4.51
Meurice 1996	Not reported	16	16	N/A	100	5.7
Meurice 2007	Not reported	83	65	NA	78	6.5
Modrak 2007	Not available	Not available	26	Not available	Not available	5.1
Muir 1998	Not available	Not available	16	Not available	Not available	4.9
Neill 2003	Not available	42	37	Not available	88	5.3
Nilius 2006	Not available	52	51	Not available	98	5.2
Nolan 2007	Not available	34	29	Not available	85	4.9
Noseda 2004	93	27	24	26%	89	5.3 ‐ Data given for average usage on 'effective nights'
Nussbaumer 2006	Not available	34	30	Not available	88	4.8
Patruno 2007	Not available	40	31	Not available	78	6.1
Randerath 2001	Not available	52	47	Not available	90	5.25
Reeves‐Hoché 1995	Not available	83	62	Not available	75	5
Resta 2004	Not available	20	20	Not available	100	5.3
Rochford 2006	Not available	Not available	13	Not available	Not available	4.6
Rostig 2003	Not available	30	30 (assumed)	Not available	100 (assumed)	3.8
Salgado 2006	Not available	39	39 (assumed)	Not available	100 (assumed)	5.5
Senn 2003	Not available	31	29	Not available	93.55	7.10
Sériès 1997	39	36	36	92.3	100	Not available
Sériès 2001	Not available	48	48 (assumed)	Not available	100 (assumed)	4.22
Teschler 2000	Not reported	10	10	N/A	100	6.10
To 2008	Not reported	43	41	NA	95	3.8
Torvaldsson 2003	Not reported	11 (assumed)	11	N/A	100 (assumed)	Not available
Wenzel 2007	Not available	20 (assumed)	20	NA	100 (assumed)	5.8
West 2006	633 (reported as patients being offered CPAP at the time of the study from the clinic)	98	86	16	88	5.6
Worsnop 2003	Not reported	54	54 (assumed)	N/A	100 (assumed)	4.5

Table 3. Numbers entering and completing studies

Navigate to table in Review

Comparison 1. Auto‐CPAP versus fixed CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Machine usage (hours/night) ‐ 1st arm/parallel studies Show forest plot	10	444	Mean Difference (IV, Fixed, 95% CI)	0.22 [‐0.05, 0.49]

2 Machine usage ‐ cross‐over studies Show forest plot	18	900	Mean hrs/night (Fixed, 95% CI)	0.21 [0.08, 0.35]

3 Machine usage (on nights when CPAP used 'effectively') Show forest plot	3		Mean hrs/nights used (Fixed, 95% CI)	0.42 [0.05, 0.78]

4 Machine usage (frequency of usage as % of days) ‐ cross‐over studies Show forest plot	7		% (Fixed, 95% CI)	3.34 [‐0.09, 6.77]

5 Machine usage (% of nights of > 4 hours of use) ‐ cross‐over studies Show forest plot	2		% (Fixed, 95% CI)	6.25 [‐0.05, 12.54]

6 Machine usage (frequency of usage as % of days) ‐ 1st arm/parallel studies Show forest plot	2	93	Mean Difference (IV, Fixed, 95% CI)	‐0.79 [‐6.57, 4.98]

7 Number of participants who applied CPAP therapy > 4 hrs day/5 days/week ‐ 1st arm/parallel studies Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8 Patient preference (auto‐CPAP/not auto‐CPAP) Show forest plot	12		Odds Ratio (M‐H, Random, 95% CI)	Totals not selected

9 Withdrawals (parallel group trials/first arm cross‐over trials) Show forest plot	8	350	Odds Ratio (M‐H, Fixed, 95% CI)	1.47 [0.63, 3.43]

10 Epworth Sleepiness Scale ‐ 1st arm/parallel studies Show forest plot	8	353	Mean Difference (IV, Fixed, 95% CI)	‐0.09 [‐0.94, 0.75]

11 Epworth Sleepiness Scale ‐ cross‐over studies Show forest plot	13	696	ESS (Fixed, 95% CI)	‐0.67 [‐1.18, ‐0.16]

12 Arousals(events/hr) ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

13 Arousals (events/hr) ‐ cross‐over studies Show forest plot	2		Events/hr (Fixed, 95% CI)	‐1.00 [‐3.36, 1.36]

14 Apnoea Hypopnoea Index (events/hr) ‐ 1st arm/parallel studies Show forest plot	10	412	Mean Difference (IV, Random, 95% CI)	0.27 [‐1.02, 1.56]

15 Apnoea Hypopnoea Index (events/hr) ‐ cross‐over studies Show forest plot	12		Events/hr (Fixed, 95% CI)	0.13 [‐0.50, 0.76]

16 Systolic blood pressure (parallel group studies) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

17 Diastolic blood pressure (parallel group studies) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

18 Pressure of CPAP treatment (parallel studies) Show forest plot	8	351	Mean Difference (IV, Random, 95% CI)	‐1.60 [‐3.00, ‐0.20]

19 Pressure of CPAP treatment (cross‐over studies) Show forest plot	15		Mean Difference (Random, 95% CI)	‐2.08 [‐3.06, ‐1.10]

20 Number of subjects where AHI reduced to < 10 events/hour Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

20.1 Parallel studies	0		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.2 Cross‐over studies	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21 SF‐36 parallel group studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

21.1 Emotional	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.2 Physical	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
22 SF‐36 ‐ cross‐over studies Show forest plot	5		SF‐36 units (Fixed, 95% CI)	Subtotals only

22.1 Physical functioning	1		SF‐36 units (Fixed, 95% CI)	‐1.0 [‐12.07, 10.07]
22.2 Role physical score	1		SF‐36 units (Fixed, 95% CI)	‐6.0 [‐17.07, 5.07]
22.3 Bodily pain score	1		SF‐36 units (Fixed, 95% CI)	‐1.0 [‐13.55, 11.55]
22.4 General health score	1		SF‐36 units (Fixed, 95% CI)	6.0 [‐3.80, 15.80]
22.5 Vitality	5		SF‐36 units (Fixed, 95% CI)	2.99 [‐0.01, 5.98]
22.6 Social functioning score	1		SF‐36 units (Fixed, 95% CI)	2.0 [‐7.80, 11.80]
22.7 Role emotional score	1		SF‐36 units (Fixed, 95% CI)	8.0 [‐3.43, 19.43]
22.8 Mental health score	1		SF‐36 units (Fixed, 95% CI)	3.0 [‐5.31, 11.31]
23 Quality of life: functional outcome of sleep questionnaire (FOSQ) ‐ parallel group/1st arm cross‐over studies Show forest plot	1		Mean Difference (Fixed, 95% CI)	Totals not selected

24 Sleep Association Quality of Life Index (SAQLI) ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

25 Side effects Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

25.1 Mask leak	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.2 Mouth leak	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.3 Nasal irritation/obstruction	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.4 Pressure intolerance	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.5 Partner dislike	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. Auto‐CPAP versus fixed CPAP

Navigate to table in Review

Comparison 2. Bi‐level PAP versus fixed CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Machine usage (hours/night) ‐ 1st arm/parallel studies Show forest plot	4	225	Mean Difference (IV, Fixed, 95% CI)	0.06 [‐0.31, 0.43]

2 Machine usage (hours/night) ‐ cross‐over studies Show forest plot	2		hours/night (Fixed, 95% CI)	Totals not selected

3 Mean days CPAP used Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4 Withdrawals ‐ 1st arm/parallel studies Show forest plot	4	249	Odds Ratio (M‐H, Fixed, 95% CI)	0.58 [0.22, 1.54]

5 Patient preference ‐ BiPAP/no preference or CPAP Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6 Epworth Sleepiness Score ‐ 1st arm/parallel studies Show forest plot	3	79	Mean Difference (IV, Fixed, 95% CI)	0.22 [‐1.27, 1.72]

7 Change in quality of life score (FOSQ) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

8 End of treatment functional outcome of sleep questionnaire (FOSQ) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 2. Bi‐level PAP versus fixed CPAP

Navigate to table in Review

Comparison 3. CPAP with expiratory pressure relief versus fixed CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Machine usage (hours/night) ‐ 1st arm/parallel studies Show forest plot	2	203	Mean Difference (IV, Fixed, 95% CI)	0.20 [‐0.09, 0.49]

2 Machine usage (hours/night) ‐ cross‐over studies Show forest plot	3	128	Mean Difference (Fixed, 95% CI)	0.17 [‐0.26, 0.60]

3 End of treatment Epworth sleepiness scores ‐ parallel groups/first arm crossovers Show forest plot	3	252	Mean Difference (IV, Random, 95% CI)	0.74 [‐1.69, 3.18]

4 End of treatment Epworth score (cross‐over studies) Show forest plot	1		Mean Difference (Fixed, 95% CI)	Totals not selected

5 Change in Epworth Sleepiness Score ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6 End of treatment AHI (parallel groups/first arm cross‐overs) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

7 End of treatment AHI (cross‐over studies) Show forest plot	1		Mean Difference (Fixed, 95% CI)	Totals not selected

8 Treatment satisfaction score ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

9 Treatment comfort score ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

10 Treatment interface score ‐ 1st arm/parallel studies Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 3. CPAP with expiratory pressure relief versus fixed CPAP

Navigate to table in Review

Comparison 4. Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Machine usage (hours/night) ‐ 1st arm parallel studies Show forest plot	2	93	Mean Difference (IV, Fixed, 95% CI)	0.16 [‐0.79, 1.11]

2 Machine usage (hours/night) ‐ crossover studies Show forest plot	1		hours/nt (Fixed, 95% CI)	Totals not selected

3 AHI Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4 Epworth Sleepiness Score ‐ cross‐over studies Show forest plot	1		ESS units (Fixed, 95% CI)	Totals not selected

5 Preference Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6 Nasal symptoms Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

7 Nasal symptoms ‐ cross‐over studies Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7.1 Dry nose	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 Discharging or runny nose	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.3 Congested or blocked nose	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.4 Bleeding nose	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.5 Reduced sense of smell	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.6 Sinus infection	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.7 Sinus pain or headache	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 4. Heated humidification + fixed pressure CPAP versus fixed pressure CPAP alone

Navigate to table in Review

The Cochrane Library

Scolaris Language Selector Scolaris Language Selector

Cochrane Review language

Website language

Scolaris Content Language Banner Portlet Scolaris Content Language Banner Portlet

Scolaris Content Display Scolaris Content Display

Topics

Scolaris Language Selector Scolaris Language Selector

Scolaris Content Display Scolaris Content Display

Previously accessed institutions

Scolaris Content Display Scolaris Content Display

Institutional users

Previously accessed institutions

Other access options

Cochrane Review language

Website language

Related content

Related reviews and protocols

Topics

Copy or download citation

Cochrane Review language

Website language

Previously accessed institutions

Institutional users

Previously accessed institutions

Other access options