Background
Although effective in the treatment of obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) is not universally accepted by users. Educational, supportive and behavioural interventions may help people with OSA recognise the need for regular and continued use of CPAP.

Objectives
To assess the effectiveness of strategies that are educational, supportive or behavioural in encouraging people who have been prescribed CPAP to use their machines.

Search methods
Searches were conducted on the Cochrane Airways Group Specialised Register of trials. Searches are current to 17 January 2013.

Selection criteria
We included randomised parallel controlled trials that assessed an intervention designed to inform participants about CPAP or OSA, to support them in using CPAP or to modify their behaviour in increasing their use of CPAP machines. Studies of any duration were considered.

Data collection and analysis
Two review authors assessed studies to determine their suitability for inclusion in the review. Data were extracted independently and were entered into Review Manager software for analysis.

Main results
Thirty studies (2047 participants) were included. We categorised studies by intervention type: supportive interventions during follow-up, educational interventions and behavioural therapy. Across all three intervention classes, most studies incorporated elements of more than one intervention. For the purposes of this systematic review, we categorised them by the prevailing type of intervention, which we expected would have the greatest impact on the study outcome.

Baseline Epworth Sleepiness Scale (ESS) scores indicated that most participants experienced daytime sleepiness, and CPAP was indicated on the basis of sleep disturbance indices. A vast majority of recruited participants had not used CPAP previously. Most of the studies were at an unclear risk of bias overall, although because of the nature of the intervention, blinding of both study personnel and participants was not feasible, and this affected a number of key outcomes. Adverse events were not reported in these studies.

Low- to moderate-quality evidence showed that all three types of interventions led to increased machine usage in CPAP-naive participants with moderate to severe OSA syndrome. Compared with usual care, supportive ongoing interventions increased machine usage by about 50 minutes per night (0.82 hours, 95% confidence interval (CI) 0.36 to 1.27, N = 803, 13 studies; low-quality evidence), increased the number of participants who used their machines for longer than four hours per night from 59 to 75 per 100 (odds ratio (OR) 2.06, 95% CI 1.22 to 3.47, N = 268, four studies; low-quality evidence) and reduced the likelihood of study withdrawal (OR 0.65, 95% CI 0.44 to 0.97, N = 903, 12 studies; moderate-quality evidence). With the exception of study withdrawal, considerable variation was evident between the results of individual studies across these outcomes. Evidence of an effect on symptoms and quality of life was statistically imprecise (ESS score -0.60 points, 95% CI -1.81 to 0.62, N = 501, eight studies; very low-quality evidence; Functional Outcomes of Sleep Questionnaire 0.98 units, 95% CI -0.84 to 2.79, N = 70, two studies; low-quality evidence, respectively).

Educational interventions increased machine usage by about 35 minutes per night (0.60 hours, 95% CI 0.27 to 0.93, N = 508, seven studies; moderate-quality evidence), increased the number of participants who used their machines for longer than four hours per night from 57 to 70 per 100 (OR 1.80, 95% CI 1.09 to 2.95, N = 285, three studies; low-quality evidence) and reduced the likelihood of withdrawal from the study (OR 0.67, 95% CI 0.45 to 0.98, N = 683, eight studies; low-quality evidence). Participants experienced a small improvement in symptoms, the size of which may not be clinically significant (ESS score -1.17 points, 95% CI -2.07 to -0.26, N = 336, five studies).

Behavioural therapy led to substantial improvement in average machine usage of 1.44 hours per night (95% CI 0.43 to 2.45, N = 584, six studies; low-quality evidence) and increased the number of participants who used their machines for longer than four hours per night from 28 to 47 per 100 (OR 2.23, 95% CI 1.45 to 3.45, N = 358, three studies; low-quality evidence) but with high levels of statistical heterogeneity. The estimated lower rate of withdrawal with behavioural interventions was imprecise and did not reach statistical significance (OR 0.85, 95% CI 0.57 to 1.25, N = 609, five studies, very low-quality evidence).

Authors' conclusions
In CPAP-naive people with severe sleep apnoea, low-quality evidence indicates that supportive interventions that encourage people to continue to use their CPAP machines increase usage compared with usual care. Moderate-quality evidence shows that a short-term educational intervention results in a modest increase in CPAP usage. Low-quality evidence indicates that behavioural therapy leads to a large increase in CPAP machine usage. The impact of improved CPAP usage on daytime sleepiness, quality of life and long-term cardiovascular risks remains unclear. For outcomes reflecting machine usage, we downgraded for risk of bias and inconsistency. An additional limitation for daytime sleepiness and quality of life measures was imprecision. Trials in people who have struggled to persist with treatment are needed, as currently little evidence is available for this population. Optimal timing and duration and long-term effectiveness of interventions remain uncertain. The relationship between improved machine usage and effect on symptoms and quality of life requires further assessment. Studies addressing the choice of interventions that best match individual patient needs and therefore result in the most successful and cost-effective therapy are needed.

Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea

Purpose Research during the past 10–20 years shows that positional therapy (PT) has a significant influence on the apnea–hypopnea index. These studies are predominantly performed as case series on a comparably small number of patients. Still, results have not found their way into the daily diagnostic and treatment routine. An average of 56% of patients with obstructive sleep apnea (OSA) have positiondependent OSA (POSA), commonly defined as a difference of 50% or more in apnea index between supine and nonsupine positions. A great deal could be gained in treating patients with POSA with PT. The aim of this paper was to perform a thorough review of the literature on positional sleep apnea and its therapy. Methods A broad search strategy was run electronically in the MEDLINE and EMBASE databases using synonyms for position and sleep apnea. Results Sixteen studies were found which examined the effect of PT on OSA. In this literature review, we discuss the various techniques, results, and compliance rates. Conclusion Long-term compliance for PT remains an issue, and although remarkable results have been shown using innovative treatment concepts for PT, there is room for both technical improvement of the devices and for further research.

/pdf/the-undervalued-potential-of-positional-therapy-in-position-5q4thpaokk.pdf

The undervalued potential of positional therapy in position-dependent snoring and obstructive sleep apnea—a review of the literature

BACKGROUND: Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnea (OSA). However, compliance is a significant problem and has been incompletely assessed in long-term studies.

/pdf/long-term-compliance-with-continuous-positive-airway-57892kbytn.pdf

Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea.

Some patients experience weight regain (WR) or insufficient weight loss (IWL) after bariatric surgery (BS) We undertook a scoping review of WR and IWL after BS We searched electronic databases for studies addressing the definitions, prevalence, mechanisms, clinical significance, preoperative predictors, and preventive and treatment approaches including behavioral, pharmacological, and surgical management strategies of WR and IWL Many definitions exist for WR, less so for IWL, resulting in inconsistencies in the reported prevalence of these two conditions Mechanisms and preoperative predictors contributing to WR are complex and multifactorial A range of the current knowledge gaps are identified and questions that need to be addressed are outlined Therefore, there is an urgent need to address these knowledge gaps for a better evidence base that would guide patient counseling, selection, and lead to improved outcomes

/pdf/weight-regain-and-insufficient-weight-loss-after-bariatric-2b1as77ar8.pdf

Weight Regain and Insufficient Weight Loss After Bariatric Surgery : Definitions, Prevalence, Mechanisms, Predictors, Prevention and Management Strategies, and Knowledge Gaps—a Scoping Review

Positional obstructive sleep apnoea (POSA), defined as a supine apnoea–hypopnoea index (AHI) twice or more as compared to the AHI in the other positions, occurs in 56 % of obstructive sleep apnoea patients. Positional therapy (PT) is one of several available treatment options for these patients. So far, PT has been hampered by compliance problems, mainly because of the usage of bulky masses placed in the back. In this article, we present a novel device for treating POSA patients. Patients older than 18 years with mild to moderate POSA slept with the Sleep Position Trainer (SPT), strapped to the chest, for a period of 29 ± 2 nights. SPT measures the body position and vibrates when the patient lies in supine position. Thirty-six patients were included; 31 patients (mean age, 48.1 ± 11.0 years; mean body mass index, 27.0 ± 3.7 kg/m2) completed the study protocol. The median percentage of supine sleeping time decreased from 49.9 % [20.4–77.3 %] to 0.0 % [range, 0.0–48.7 %] (p < 0.001). The median AHI decreased from 16.4 [6.6–29.9] to 5.2 [0.5–46.5] (p < 0.001). Fifteen patients developed an overall AHI below five. Sleep efficiency did not change significantly. Epworth Sleepiness Scale decreased significantly. Functional Outcomes of Sleep Questionnaire increased significantly. Compliance was found to be 92.7 % [62.0–100.0 %]. The Sleep Position Trainer applied for 1 month is a highly successful and well-tolerated treatment for POSA patients, which diminishes subjective sleepiness and improves sleep-related quality of life without negatively affecting sleep efficiency. Further research, especially on long-term effectiveness, is ongoing.

http://www.sidesleeping.co.uk/uploads/2/3/1/6/23169594/van_maanen_2012.pdf

The sleep position trainer: a new treatment for positional obstructive sleep apnoea

In a retrospective cohort study, we evaluated whether improvements in nasal continuous positive airway pressure (nCPAP) technology, particularly the introduction of automatic adjustment of the nCPAP pressure (auto-CPAP), have led to better acceptance and (long-term) compliance in patients with obstructive sleep apnea syndrome (OSAS) as compared to earlier reported data. Questionnaires were sent to 256 patients, who were referred to our clinic for an overnight polysomnography from January 1997 to July 2005 and received nCPAP therapy for OSAS. Of the 256 patients, 24 patients were unavailable for follow-up. Of the remaining 232 patients, 58 patients (25%) had discontinued therapy, while 174 patients (75%) were still using nCPAP after 2 months to 8 years of follow-up. One Hundred and thirty eight (79%) of these 174 patients used nCPAP for at least 4 h/night during ≥ 5 nights/week, 82,1% of the conventional nCPAP (fixed pressure CPAP) group (n = 78) and 77,1% of the auto-CPAP group (n = 96). Therefore, including the 58 failures, only 59.5% of patients can be seen as compliant. There were no statistical differences between the fixed pressure CPAP and auto-CPAP users, and between the compliant and non-compliant users according to age, BMI, AHI and Epworth sleepiness scale (ESS). Auto-CPAP patients used significantly more cm H2O. The long-term compliance of nCPAP therapy has have increased only slightly since the introduction of the fixed pressure CPAP 25 years ago, in spite of many efforts to improve it. It seems that a plateau has been reached and that it is unrealistic to aim at a substantially higher compliance rate.

/pdf/acceptance-and-long-term-compliance-of-ncpap-in-obstructive-3xs1vevgf3.pdf

Acceptance and long-term compliance of nCPAP in obstructive sleep apnea.

Important endpoints of bariatric surgery are weight loss and improvement of comorbidities, of which obstructive sleep apnea (OSA) is the highest accompanying comorbidity (70 %). This study aimed to evaluate the influence of OSA on weight loss after bariatric surgery and to provide predictive factors for insufficient weight loss (defined as ≤50 % excess weight loss (EWL)) at 1 year follow-up. All consecutive patients, who underwent primary laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between 2006 and 2014 were retrospectively reviewed. Patients with data on preoperative apnea-hypopnea index (AHI) and pre- and postoperative body mass index (BMI) were included. After surgery, the percentage excess weight loss (%EWL) and BMI changes were compared between preoperatively diagnosed OSA-, subdivided in mild, moderate, and severe OSA, and non-OSA patients. Multivariable logistic regression analysis evaluated predictive factors for ≤50 % EWL. A total of 816 patients, 522 (64 %) with and 294 (36 %) without OSA, were included. After 1 year, OSA patients achieved less %EWL than non-OSA patients (65.5 SD 20.7 versus 70.3 SD 21.0; p < 0.01). The lowest %EWL was seen in severe OSA patients (61.7 SD 20.2). However, when adjusted for waist circumference, BMI, and age, no effect of OSA was seen on %EWL or changes in BMI. Although AHI, gender, age, BMI, type of surgery, and type II diabetes were predictive factors for ≤50 % EWL (area under the curve 0.778), the AHI as variable was of little importance. The presence of OSA does not individually impair weight loss after bariatric surgery.

Bob T. J. van den Berg

Papers

Acceptance and long-term compliance of nCPAP in obstructive sleep apnea.

Predictive Factors for Insufficient Weight Loss After Bariatric Surgery: Does Obstructive Sleep Apnea Influence Weight Loss?