Interventions to improve use of continuous positive airway pressure for obstructive sleep apnoea
Abstract
Background
Continuous Positive Airways Pressure (CPAP) is currently considered to be the cornerstone of therapy for sleep apnoea (OSA). However compliance with this treatment is frequently poor, which may lead to ongoing symptoms of sleep disruption, daytime sleepiness and poor waking cognitive function. Mechanical and psychological/educational interventions have been proposed to try to increase the hours of use of CPAP therapy.
Objectives
To determine the efficacy of interventions designed to increase compliance with CPAP.
Search methods
We searched the Cochrane Airways Group Sleep Apnoea Specialised Register (January 2004).
Selection criteria
Randomised controlled trials (RCTs) assessing interventions to improve compliance with CPAP usage were considered for inclusion in the review.
Data collection and analysis
Two reviewers assessed articles for inclusion in the review and extracted data. Attempts were made to obtain additional unpublished data from the trialists.
Main results
24 studies met the inclusion criteria with 1007 participants. Each of the mechanical interventions was compared with fixed CPAP alone. Auto‐CPAP (13 studies): A small, significant difference was observed in hours of use, but this effect disappeared when we took account of the variation between the studies. There may be a subgroup of patients who respond better than others. Most participants preferred auto‐CPAP to fixed CPAP where this was measured. Bi‐level PAP (3 studies): No significant differences were observed in machine use. One small study found no difference in preference. Patient titrated CPAP (1 study): No significant difference was observed in compliance. Humidification (1 study): This small study found no significant difference in machine usage. Educational/psychological interventions (6 studies): One small study demonstrated superior machine usage in patients treated with cognitive behavioural therapy + CPAP versus CPAP alone but only after 12 weeks. In one, larger study intensive support including home visits increased hours of use. No other study demonstrated significant effects in favour of active treatment.
Authors' conclusions
The effect of Auto‐CPAP in increasing hours of use in unselected patients starting this treatment remains unclear. Different pooled analyses gave conflicting results and it may be that carefully selected participants may respond more favourably than others. The evidence in support of Bi‐PAP, self‐titration and humidification is lacking and studies are required in these areas. There is some evidence that psychological/educational interventions improve CPAP usage. This requires confirmation in larger studies of longer duration, with rigorous follow‐up. The cost‐benefit ratio of such interventions requires assessment. Future studies need to consider the effects of treatment in participants who are poorly compliant. The studies assembled were characterised by high machine usage in the control groups, and low withdrawal rates making it less likely that any benefit could be demonstrated.
PICOs
Plain language summary
Interventions to improve use of continuous positive airway pressure for obstructive sleep apnoea
Obstructive sleep apnoea (OSA) occurs when the airway obstructs and breathing stops temporarily during sleep. Although effective, continuous positive airways pressure (CPAP) requires regular use, and many people cannot tolerate it, or do not use it every night. The main interventions used to improve compliance are: mechanical, that is modifying the way in which CPAP is delivered (such as auto‐CPAP, Bi‐level PAP, additional humidification) and educational/psychological interventions aimed at improving understanding of the necessity of treatment and encouraging people to use it regularly. We examined the evidence for these different approaches. None of the mechanical interventions led to a clinically important increase in hours of use. Most participants expressed a preference for the auto‐CPAP machine rather than fixed pressure. When Bi‐level PAP and fixed CPAP were compared, initial patient acceptance was greater for Bi‐level PAP in one study, but long term usage in those accepting treatment was similar for both devices. The evidence for educational/psychological interventions is sparse but suggest that they may be helpful. Further trials are needed in order to demonstrate whether such interventions are effective in the long term, and an efficient use of resources.
