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Clinical Investigations: SLEEP AND BREATHING |

Clinical Outcomes Related to Interface Type in Patients With Obstructive Sleep Apnea/Hypopnea Syndrome Who Are Using Continuous Positive Airway Pressure* FREE TO VIEW

Clifford A. Massie; Robert W. Hart
Author and Funding Information

*From the Center for Sleep Health of Suburban Lung Associates, Elk Grove Village, IL.

Correspondence to: Clifford A. Massie, PhD, Suburban Lung Associates, 810 Biesterfield Rd, Suite 404, Elk Grove Village, IL 60007; e-mail: clifford.massie@sublung.com



Chest. 2003;123(4):1112-1118. doi:10.1378/chest.123.4.1112
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Published online

Study objectives: To evaluate the effect of interface on objective compliance, patient satisfaction, adverse effects, quality of life, and residual sleep-disordered breathing in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS) using continuous positive airway pressure (CPAP).

Design: Randomized, cross-over.

Setting: Two suburban community-based hospital sleep laboratories.

Patients: Data were collected on 39 patients with OSAHS (mean age, 48.7 years), in whom CPAP was a novel treatment.

Interventions: Interventions were nasal pillows (Breeze; Mallinckrodt Corporation; Minneapolis, MN) and nasal mask (Contour; Respironics; Murrysville, PA).

Measurements and results: Outcomes assessed at the completion of each 3-week treatment period were objective compliance, adverse effects, and satisfaction with CPAP (CPAP questionnaire), daytime sleepiness (Epworth sleepiness scale [ESS]), quality of life (Functional Outcomes of Sleep Questionnaire [FOSQ]), sleep diary, and residual sleep-disordered breathing (apnea-hypopnea index [AHI]). Patients were randomly assigned to use the nasal pillows or the nasal mask following laboratory titration and initiated on CPAP (pressure range, 5 to 14 cm H2O). The percentage of days utilized favored the nasal pillows (94.1% vs 85.7%; p = 0.02), but minutes of use per night did not differ (nasal pillows, 223 min; nasal mask, 288 min). ESS scores were lower and the FOSQ total scores were higher following CPAP treatment (p < 0.001), but no differential treatment effects were noted. Fewer adverse effects, less trouble getting to sleep and staying asleep, and less air leak were reported with nasal pillows (p < 0.04). The mean ± SD pretreatment AHI (47.1 ± 35.1/h) was significantly lower following treatment with CPAP for both types of interface (nasal pillows, 10.2 ± 9.8/h; nasal mask, 7.0 ± 7.7/h; p < 0.001).

Conclusions: Nasal pillows are a well-tolerated and effective interface for OSAHS patients receiving CPAP at ≤ 14 cm H2O. Use of nasal pillows was associated with fewer adverse effects and better sleep quality during the first 3 weeks of CPAP therapy. Further investigation is needed to determine whether interface type affects long-term CPAP use.

Continuous positive airway pressure (CPAP) is typically delivered via nasal mask to patients with obstructive sleep apnea/hypopnea syndrome (OSAHS), acting as a pressure splint to maintain upper airway patency. CPAP may also be delivered via nasal pillows or oronasal mask. Interface can have a significant impact on acceptance and adherence to CPAP therapy. Adverse effects such as claustrophobia and mask discomfort, air leak, pressure sores, and mask dislodgement compromise CPAP use.16 Nasal pillows offer potential advantages over the nasal mask. First, there is less contact with the face, which may attenuate the feeling of claustrophobia and help prevent pressure sores and minimize discomfort. Second, patients may perceive less air leak, as leak would occur away from the eyes. Third, the design of the headgear may enhance patient comfort and simplify use.

Proper mask fit is paramount. Patients usually receive their first exposure to interface in the laboratory setting, although acclimation and desensitization may occur before the titration study in the context of the physician’s office. Laboratory titrations are often performed only with a nasal mask without patients being shown nasal pillows or given a choice. Nasal pillows may be reserved for patients who complain of claustrophobia, or who cannot otherwise tolerate the nasal mask, and are not used as first-line interface. Initial choice of interface may be particularly important since early experience with CPAP plays a role in long-term adherence to therapy.68

Mask discomfort has been included as an adverse effect on questionnaires assessing CPAP compliance, but interface type has rarely been the subject of systematic investigation. In a randomized cross-over trial comparing nasal mask with oronasal mask, CPAP use with the nasal mask was 1 h more per night compared to the oronasal mask.9 Patients reported fewer adverse effects while using the nasal mask and preferred this type of interface. The oronasal mask may be too uncomfortable for long-term use, even with the addition of heated humidification to decrease airway dryness and reduce mouth leak.10 The present study compared the nasal pillows and nasal mask on objective compliance, adverse effects, satisfaction with therapy, quality of life, and residual sleep-disordered breathing in OSAHS patients receiving CPAP.

Subjects

Eligible patients were between 18 years and 70 years of age, had an OSAHS diagnosis (apnea-hypopnea index [AHI] ≥ 15/h or AHI ≥ 5 plus daytime sleepiness),11 and had not received CPAP treatment previously. Exclusion criteria included wake resting arterial oxygen saturation < 90%, evidence of upper airway tract infection or flu-like symptoms at the time of titration, elective surgery scheduled before conclusion of the study, or prior surgical intervention for OSAHS. Patients were not eligible if they required bilevel positive airway pressure or supplemental oxygen.

At the time of initial polysomnography, patients gave consent. Participants agreed to use CPAP for the duration of the 6-week study and to provide feedback on the interface and satisfaction with CPAP therapy. Patients were not informed that the study was designed to assess compliance, but they were debriefed at the conclusion of the study regarding compliance monitoring. Institutional review board approval was obtained from the two hospital-based sleep laboratories; the consent forms were identical.

Questionniares

Patients completed the Functional Outcomes of Sleep Questionnaire (FOSQ) prior to initiating CPAP therapy and at the end of each treatment period. The FOSQ is a quality-of-life instrument designed to assess the impact of excessive daytime sleepiness (EDS) on activities of daily living.12 The FOSQ provides a global score and five scales: general productivity, social outcome, activity level, vigilance, and intimate relationships and sexual activity. Patients also completed the Epworth sleepiness scale (ESS).13

At each assessment interval, patients completed the FOSQ, ESS, and a questionnaire designed to assess adverse effects and satisfaction with CPAP therapy (Table 1 ). Patients maintained a sleep diary for the first week of each treatment, and rated adverse effects and sleep quality using a visual analog scale (VAS). Diary questions included the following: How well did your mask fit? (very badly—very well); How much trouble did you have putting on the mask? (severe trouble—no trouble); Did you have air leaking from the mask? (much air leaking—no air leaking); Did you have trouble keeping the mask in place? (severe trouble—no trouble); How restful was your sleep? (very restless—very restful); How refreshed did you feel this morning? (exhausted—very refreshed); How much discomfort did you get from the pressure? (severe discomfort—no discomfort); and Did you have a dry or congested nose or throat? (much dryness—no dryness). For all VAS questions, higher numbers indicated a more positive response.

Study Design

A randomized cross-over design was employed. Patients were assigned to nasal pillows (Breeze; Mallinckrodt Corporation; Minneapolis, MN) or nasal mask (Contour; Respironics; Murrysville, PA). CPAP titration was performed in the laboratory with the appropriate interface and heated humidity (HC100 humidifier; Fisher & Paykel; Auckland, New Zealand). Each patient underwent either all-night CPAP titration or a split-night study according to American Academy of Sleep Medicine standards.14 Titration protocols were identical at both sites. Effective pressure was attained when evidence of apneas, hypopneas, snoring, and hypoxemia were ameliorated. CPAP was prescribed after the polysomnogram was reviewed by a board-certified sleep specialist.

Interface fitting was performed according to the written instructions of the manufacturers. A registered polysomnographic technologist and board-certified sleep specialist reviewed written instructions with each technician. Hands-on fitting was performed, and each technician was given feedback and checked for accuracy. The nasal pillows were fitted using the side straps. The cradle was fit just below the curve at the back of the head. Adjustments were made to the height of the cradle, length of the hose guide across the top of the head, and height of the plenum shell. The final adjustment was the angle of the plenum shell. Medium-size nasal pillows were used first; nasal pillow size was reassessed after placement and changed if needed based on patient comfort and adequate seal. The nasal mask was fitted using the sizing gauge. Each nasal mask was equipped with the SimpleStrap, Whisper-Swivel II exhalation port, and appropriate size spacer (Respironics). Mask, headgear, and spacer adjustments were made with the interface in place. For both types of interface, patients were queried regarding comfort, and adjustments were made until the patient felt comfortable and a proper fit was obtained. Additional adjustments were made as needed during the laboratory titration to minimize leak and maximize comfort. Patients were given the interface following the laboratory titration. They were instructed not to make any changes and to bring the interface with them to the first office visit, at which time fit was reassessed.

For the first 3 weeks, patients used the same interface as in the titration study. Patients then switched to the alternate interface for the final 3 weeks. Patients utilized the Mallinckrodt 418A (Mallinckrodt Corporation) CPAP machine and the HC100 heated humidifier. At the first office visit, patients were initiated on CPAP and given detailed information about the use and care of the CPAP machine, humidifier, interface, and related accessories. At each office visit, the FOSQ, ESS, and CPAP questionnaire were completed. Patients were given the sleep diary to maintain for the first week of each treatment period. At the final visit, patients kept both types of interface and they were informed of the compliance monitoring.

At each visit, patients were told that a pressure check was required as part of the study protocol. While patients completed the questionnaires, compliance data were downloaded from the Mallinckrodt 418A using SilverLining software, version 2.0 (Mallinckrodt Corporation). A pressure transducer recorded use only when the patient was breathing with the mask in place. The Mallinckrodt 418A recorded sleep-disordered breathing during therapy, and reported an apnea index and a hypopnea index.

Statistical Analyses

Values are given as mean ± SD. Comparisons between baseline and treatment conditions were conducted using one-way analysis of variance. Interface comparisons were conducted using paired t tests or, in the case of nonnormally distributed data, Wilcoxon signed-rank tests. Unless otherwise indicated, statistical significance required p ≤ 0.05, two-tailed.

Patient Characteristics

Forty-two patients were enrolled in the study. Three patients were unable to complete the protocol. One patient traveled to Europe and was unable to use the equipment. An unrelated medical condition developed in one patient; he was dropped from the study but maintained on CPAP treatment. One patient was unavailable for follow-up.

Thirty-nine patients completed the 6-week protocol. Twenty-four patients underwent full-night CPAP titrations, and 15 patients underwent split-night studies. Twenty patients were randomized to the nasal pillows, and the remaining 19 patients were randomized to the nasal mask. There were no differences between randomized groups in age, gender, study type, body mass index, AHI, or CPAP pressure (all p values ≥ 0.18; Table 2 ). Differences were noted only for age, gender, and study type between the two sleep laboratories (p values ≤ 0.05).

Compliance

Three compliance indexes were calculated: percentage of days used (PER), mean daily use for all days (TOT), and mean daily use for days with use > 0 min (UTL). A significant difference was observed between the nasal pillows (94.1 ± 8.3%) and the nasal mask (85.7 ± 23.5%) on PER (p = 0.02). No differences were noted between nasal pillows and nasal mask on TOT or UTL (p values ≥ 0.10; Table 3 ). CPAP use ranged from 184 to 456 min per night with nasal pillows and from 22 to 463 min per night with the nasal mask.

Residual Sleep-Disordered Breathing

Mean AHI was calculated for each of the treatment periods, where daily use was > 0 min. A significant main effect for AHI was observed (F2,37 = 38.8; p < 0.001). Residual sleep-disordered breathing did not differ between the two types of interface (p = 0.83). These data are presented in Table 3 .

Daytime Sleepiness

A significant main effect for daytime sleepiness was observed (F2,37 = 30.6; p < 1). ESS scores were lower following 3 weeks of CPAP treatment, but no difference in ESS scores were observed between the two types of interface (p = 0.84).

Sleep Diary

Patients maintained a sleep diary daily for the first week of each treatment. Mean values were calculated for each of the eight items. Patients reported less air leak with the nasal pillows (p = 0.008). No other differences were observed.

Quality of Life

A significant main effect for total FOSQ score was observed (F2,37 = 20.9; p < 0.001). Significant main effects were noted for the following individual scales: vigilance (F2,37 = 15.5; p < 0.001), activity level (F2,37 = 11.7; p < 0.001), social outcome (F2,37 = 6.2; p = 0.003), and general productivity (F2,37 = 13.5; p < 0.001). The interpersonal and sexual relationships scale did not differ between baseline and treatment. No differences were noted between the nasal pillows and nasal mask on FOSQ total score or any of the individual scales (all p values ≥ 0.83).

CPAP Questionnaire

At the conclusion of each treatment period, adverse effects and satisfaction with CPAP were assessed and a global score calculated by summing questions 1 to 12. Nasal pillows was associated with fewer overall adverse effects (t = 3.8; p < 0.001). Individual-item analysis revealed significant differences for all questions pertaining to the interface (questions 1 to 6). Patients reported a greater degree of overall satisfaction with nasal pillows (p = 0.001) and less trouble getting to sleep and staying asleep (p values ≤ 0.04). Comparisons for questions 13 to 18 of the CPAP questionnaire are presented in Table 4 .

This is the first report of CPAP use, adverse effects, and residual sleep-disordered breathing with nasal pillows, when compared to nasal mask. Fewer overall adverse effects, including less air leak and better self-reported sleep quality, were reported when CPAP was used with nasal pillows. Attempted CPAP use during the first 3 weeks of therapy favored nasal pillows, but use per night did not differ between the two types of interface. The greater attempt at CPAP use with nasal pillows was likely due to self-report of better sleep quality, fewer adverse effects, and greater satisfaction with this type of interface.

Adverse effects related to interface are common and may compromise CPAP use. Pressure sores, mask dislodgement, feeling claustrophobic, air leak, and sore eyes occur in 20 to 50% of OSAHS patients receiving CPAP.26,15 Self-report of air leak3 and sore eyes4 correlate negatively with CPAP use. Conversely, increased CPAP use is related to good or very good tolerance to the nasal mask. Nearly 50% of patients who reported CPAP use ≥ 4 h per night had good or very good tolerance to the nasal mask, whereas only 9% of patients with use < 4 h per night reported good tolerance.16 Patients whose objective CPAP use was less regular (< 4 h per night) complained of claustrophobia from the mask, which was the only adverse effect related to CPAP use that differentiated regular from irregular users.6

CPAP compliance studies have included interface problems on questionnaires assessing adverse effects with CPAP, but interface type has seldom been the subject of systematic investigation. In one randomized, cross-over trial, the nasal mask was compared to an oronasal mask, with compliance gains of 1.0 h per night reported with the nasal mask.9 Increased CPAP use was likely due to patients rating the nasal mask as more comfortable and less claustrophobic. However, patients also reported greater air leak with the nasal mask. In another study that compared nasal mask with an oronasal mask, only 2 of 17 patients offered the oronasal mask accepted it for long-term use.10 The oronasal mask may be used in patients with persistent mouth leak not corrected by aggressive treatment of nasal pathology and the addition of heated humidification. In the present study, nasal pillows use was associated with less air leak. Eye soreness and discomfort caused by air leak is not only bothersome to the patient but, as noted above, can compromise CPAP use. Nasal pillows are typically not first-line interface, and may be reserved only for patients that complain of claustrophobia or who cannot otherwise tolerate the nasal mask. Adverse effects may be lessened if this interface is considered at CPAP initiation.

The goal of laboratory titration is to eliminate sleep-disordered breathing. Residual sleep-disordered breathing was acceptably low for both types of interface, and comparable to previous CPAP efficacy studies.1720 ESS and FOSQ scores were improved from pretreatment values for both types of interface, indicating that the reduction in AHI was sufficient to attenuate the daytime consequences of OSAHS. Several studies have demonstrated reductions in EDS and improvements in quality of life following CPAP treatment.2124

The equivalent reduction in AHI observed with both types of interface is a noteworthy finding. Nasal pillows may not be considered for patients who require higher CPAP pressure levels because of concerns regarding the nature of the mask seal and the possibility of inadequate pressure delivery. Objective leak was not monitored by the CPAP machine used in this study. Consequently, the patient’s report of less air leak could not be compared to quantitative data. Prior research indicates that mask leak has minimal effect on AHI.25 During 2 months of fixed-pressure CPAP use, no correlation between mask leak and AHI was reported. Leak values varied from patient to patient and from night to night, but even periods of high leak had a negligible impact on AHI. In this study, CPAP pressure range was 5 to 14 cm H2O. All patients randomized to nasal pillows were successfully titrated in the laboratory. Prior investigations report effective CPAP pressure levels in the range of 8 to 13 cm H2O, with SDs of approximately 2 to 3 cm H2O.,2,6,1617 A broad range of OSAHS severity was represented in these studies, including patients with moderate-to-severe disease. Nasal pillows should be considered for initial laboratory titration, rather than being reserved for patients who cannot tolerate nasal masks.

Compliance with CPAP is well recognized to be less than optimal. Interventions that increase CPAP compliance include the addition of heated humidity, intensive support/education, and autotitrating CPAP.2628 Heated humidity was supplied to all patients in this study. Patients were told not to make any changes to the humidifier setting if they felt comfortable. If water droplets appeared in the mask, patients were told to decrease the setting by 0.5 U until condensation no longer appeared. Many patients needed to lower the setting on the humidifier when using the nasal pillows because of condensation in the tubing and mask. It is not clear why this occurred, but suggests that adverse effects associated with nasal airway resistance may be attenuated with lower humidity settings. Patients were monitored closely during this study and provided with extensive education regarding OSAHS and CPAP use. Demand characteristics do not appear to have influenced compliance; CPAP use during this study was in the range of 5 h per night, similar to other studies that covertly monitored compliance early in therapy.7,2930

A challenge to performing this type of study was choosing a “standard” nasal mask. The nasal mask chosen for this study is widely available and used frequently in laboratory and clinical settings. However, interface has changed considerably over the years; newer types of interface are designed to be more comfortable and to attenuate discomfort caused by improper fit, including skin abrasion and air leak. It is possible that fewer differences in adverse effects and attempt at use would have occurred with a newer generation nasal mask. Another limitation is the relatively short assessment interval. While the goal was to determine whether differences in CPAP use as a function of interface occurred early in treatment, no long-term follow-up of these patients was conducted. At the conclusion of the 3-week study, patients kept both types of interface. Many patients chose to use the nasal pillows as the primary interface, but also expressed an intention to alternate interface use. It is important that interface be matched to individual patient needs and that patients be followed up closely to assess their clinical response to therapy. Minimizing adverse effects related to interface early in therapy may result in greater acceptance of long-term CPAP use.

In summary, this study confirms our clinical impression that patients feel less claustrophobic and report less discomfort with use of nasal pillows. Fewer adverse effects and improved self-reported sleep quality with nasal pillows use were observed. This may have accounted for the greater attempt at CPAP use during the first 3 weeks of therapy. Improvements in quality of life and reductions in AHI and EDS were noted for both types of interface. Nasal pillows are an effective and well-tolerated interface for patients with OSAHS receiving CPAP at ≤14 cm H2O.

Abbreviations: AHI = apnea-hypopnea index; CPAP = continuous positive airway pressure; EDS = excessive daytime sleepiness; ESS = Epworth sleepiness scale; FOSQ = Functional Outcomes of Sleep Questionnaire; OSAHS = obstructive sleep apnea/hypopnea syndrome; PER = percentage of days used; TOT = daily use for all days; UTL = daily use for days with use > 0 min; VAS = visual analog scale

This study was supported by a grant from Mallinckrodt Corporation. No other payments, excluding the cost of conducting the study, were made to the authors. The authors have no proprietary, financial, or equity interest in either the sponsor or the product. The authors had full access to all of the data in this study and take complete responsibility for the integrity of the data and the accuracy of the data analysis. Mallinckrodt Corporation assisted in the design of the study, but had no involvement in the collection, analysis, and interpretation of the data; in the writing of the report; and in the decision to submit for publication.

Table Graphic Jump Location
Table 1. CPAP Questionnaire
* 

Questions 13–18 rated on a 100-mm VAS. Measures range from 0 (poorest) to 100 (highest possible rating).

Table Graphic Jump Location
Table 2. Demographic and Polysomnography Variables for 39 Patients Randomized to Nasal Pillows or Nasal Mask on Titration and Initial Treatment*
* 

Data are expressed as No. or mean ± SD.

 

χ2 analysis.

Table Graphic Jump Location
Table 3. Differences in Outcome Measures Between Nasal Pillows and Nasal Mask*
* 

Data are presented as mean ± SD.

 

p < 0.05.

 

Results are significantly different from baseline (p < 0.001).

Table Graphic Jump Location
Table 4. CPAP Questionnaire Data*
* 

Data are expressed as mean ± SD. Measures range from 0 (poorest) to 100 (highest possible rating).

 

p = 0.001.

 

p ≤ 0.004.

Sanders, MH, Gruendl, CA, Rogers, RM (1986) Patient compliance with nasal CPAP therapy for sleep apnea.Chest90,330-333. [PubMed] [CrossRef]
 
Pepin, JL, Leger, P, Veale, D, et al Side effects of nasal continuous positive airway pressure in sleep apnea syndrome.Chest1995;107,375-381. [PubMed]
 
Kalan, A, Kenyon, GS, Seemungal, TAR, et al Adverse effects of nasal continuous positive airway pressure therapy in sleep apnoea syndrome.J Laryngol Otol1999;113,888-892. [PubMed]
 
Engleman, HM, Asgari-Jirhandeh, N, McLeod, AL, et al Self-reported use of CPAP, and benefits of CPAP therapy.Chest1996;109,1470-1476. [PubMed]
 
Janson, C, Noges, E, Svedberg-Brandt, S, et al What characterizes patients who are unable to tolerate continuous positive airway pressure (CPAP) treatment?Respir Med2000;94,145-149. [PubMed]
 
Kribbs, NB, Pack, AI, Kline, LR, et al Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea.Am Rev Respir Dis1993;147,887-895. [PubMed]
 
Weaver, TE, Kribbs, NB, Pack, AI, et al Night-to-night variability in CPAP use over the first three months of treatment.Sleep1997;20,278-283. [PubMed]
 
McArdle, N, Devereux, G, Heidarnejad, H, et al Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome.Am J Respir Crit Care Med1999;159,1108-1114. [PubMed]
 
Mortimore, IL, Whittle, AT, Douglas, NJ Comparison of nose and face mask CPAP therapy for sleep apnea.Thorax1998;53,290-292. [PubMed]
 
Martins De Araujo, MT, Vieira, SB, Vasquez, EC, et al Heated humidification or face mask to prevent upper airway dryness during continuous positive airway pressure therapy.Chest2000;117,142-147. [PubMed]
 
American Academy of Sleep Medicine Task Force. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research.Sleep1999;22,667-689. [PubMed]
 
Weaver, TE, Laizner, AM, Evans, LK, et al An instrument to measure functional status outcomes for disorders of excessive sleepiness.Sleep1997;20,835-843. [PubMed]
 
Johns, MW A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale.Sleep1991;14,540-545. [PubMed]
 
American Sleep Disorders Association Report. Practice parameters for the indications for polysomnography and related procedures.Sleep1997;20,406-422. [PubMed]
 
Rauscher, H, Formanek, D, Popp, W, et al Self-reported vs measured compliance with nasal CPAP for obstructive sleep apnea.Chest1993;103,1675-1680. [PubMed]
 
Meslier, N, Lebrun, T, Grillier-Lanoir, V, et al A French survey of 3,225 patients treated with CPAP for obstructive sleep apnoea: benefits, tolerance, compliance and quality of life.Eur Respir J1998;12,185-192. [PubMed]
 
Series, F, Marc, I, Cormier, Y, et al Required levels of nasal continuous positive airway pressure during treatment of obstructive sleep apnoea.Eur Respir J1994;7,1776-1781. [PubMed]
 
Teschler, H, Berthon-Jones, M, Thompson, AB, et al Automated continuous positive airway pressure titration for obstructive sleep apnea syndrome.Am Respir Crit Care Med1996;154,734-740
 
Loredo, JS, Ancoli-Israel, S, Dimsdale, JE Effect of continuous positive airway pressure vs placebo continuous positive airway pressure on sleep quality in obstructive sleep apnea.Chest1999;116,1545-1549. [PubMed]
 
Jokic, R, Klimaszewski, A, Sridhar, G, et al Continuous positive airway pressure requirement during the first month of treatment in patients with severe obstructive sleep apnea.Chest1998;114,1061-1069. [PubMed]
 
D’Ambrosio, C, Bowman, T, Mohsenin, V Quality of life in patients with obstructive sleep apnea: effect of nasal continuous positive airway pressure; a prospective study.Chest1999;115,123-129. [PubMed]
 
Engleman, HM, Martin, SE, Deary, IJ, et al Effect of continuous positive airway pressure treatment on daytime function in sleep apnoea/hypopnoea syndrome.Lancet1994;343,572-575. [PubMed]
 
Jenkinson, C, Davies, RJO, Mullins, R, et al Comparison of therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomized prospective parallel trial.Lancet1999;353,2100-2105. [PubMed]
 
Engleman, HM, Martin, SE, Deary, IJ, et al Effect of continuous positive airway pressure treatment on daytime function in sleep apnoea/hypopnoea syndrome.Lancet1994;343,572-575. [PubMed]
 
Teschler, H, Wessendorf, TE, Farhat, AA, et al Two months auto-adjusting vs conventional nCPAP for obstructive sleep apnoea syndrome.Eur Respir J2000;15,990-995. [PubMed]
 
Massie, CA, Hart, RW, Peralez, K, et al Effects of humidification on nasal symptoms and compliance in sleep apnea patients using continuous positive airway pressure.Chest1999;116,403-408. [PubMed]
 
Hoy, CJ, Vennelle, M, Kingshott, RN, et al Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome?Am J Respir Crit Care Med1999;159,1096-1100. [PubMed]
 
Hudgel, DW, Fung, C A long-term randomized, cross-over comparison of auto-titrating and standard nasal continuous airway pressure.Sleep2000;23,645-648. [PubMed]
 
Pepin, JL, Krieger, J, Rodenstein, D, et al Effective compliance during the first 3 months of continuous positive airway pressure.Am J Respir Crit Care Med1999;160,1124-1129. [PubMed]
 
Popescu, G, Latham, M, Allgar, V, et al Continuous positive airway pressure for sleep apnea/hypopnea syndrome: usefulness of a 2 week trial to identify factors associated with long term use.Thorax2001;56,727-733. [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1. CPAP Questionnaire
* 

Questions 13–18 rated on a 100-mm VAS. Measures range from 0 (poorest) to 100 (highest possible rating).

Table Graphic Jump Location
Table 2. Demographic and Polysomnography Variables for 39 Patients Randomized to Nasal Pillows or Nasal Mask on Titration and Initial Treatment*
* 

Data are expressed as No. or mean ± SD.

 

χ2 analysis.

Table Graphic Jump Location
Table 3. Differences in Outcome Measures Between Nasal Pillows and Nasal Mask*
* 

Data are presented as mean ± SD.

 

p < 0.05.

 

Results are significantly different from baseline (p < 0.001).

Table Graphic Jump Location
Table 4. CPAP Questionnaire Data*
* 

Data are expressed as mean ± SD. Measures range from 0 (poorest) to 100 (highest possible rating).

 

p = 0.001.

 

p ≤ 0.004.

References

Sanders, MH, Gruendl, CA, Rogers, RM (1986) Patient compliance with nasal CPAP therapy for sleep apnea.Chest90,330-333. [PubMed] [CrossRef]
 
Pepin, JL, Leger, P, Veale, D, et al Side effects of nasal continuous positive airway pressure in sleep apnea syndrome.Chest1995;107,375-381. [PubMed]
 
Kalan, A, Kenyon, GS, Seemungal, TAR, et al Adverse effects of nasal continuous positive airway pressure therapy in sleep apnoea syndrome.J Laryngol Otol1999;113,888-892. [PubMed]
 
Engleman, HM, Asgari-Jirhandeh, N, McLeod, AL, et al Self-reported use of CPAP, and benefits of CPAP therapy.Chest1996;109,1470-1476. [PubMed]
 
Janson, C, Noges, E, Svedberg-Brandt, S, et al What characterizes patients who are unable to tolerate continuous positive airway pressure (CPAP) treatment?Respir Med2000;94,145-149. [PubMed]
 
Kribbs, NB, Pack, AI, Kline, LR, et al Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea.Am Rev Respir Dis1993;147,887-895. [PubMed]
 
Weaver, TE, Kribbs, NB, Pack, AI, et al Night-to-night variability in CPAP use over the first three months of treatment.Sleep1997;20,278-283. [PubMed]
 
McArdle, N, Devereux, G, Heidarnejad, H, et al Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome.Am J Respir Crit Care Med1999;159,1108-1114. [PubMed]
 
Mortimore, IL, Whittle, AT, Douglas, NJ Comparison of nose and face mask CPAP therapy for sleep apnea.Thorax1998;53,290-292. [PubMed]
 
Martins De Araujo, MT, Vieira, SB, Vasquez, EC, et al Heated humidification or face mask to prevent upper airway dryness during continuous positive airway pressure therapy.Chest2000;117,142-147. [PubMed]
 
American Academy of Sleep Medicine Task Force. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research.Sleep1999;22,667-689. [PubMed]
 
Weaver, TE, Laizner, AM, Evans, LK, et al An instrument to measure functional status outcomes for disorders of excessive sleepiness.Sleep1997;20,835-843. [PubMed]
 
Johns, MW A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale.Sleep1991;14,540-545. [PubMed]
 
American Sleep Disorders Association Report. Practice parameters for the indications for polysomnography and related procedures.Sleep1997;20,406-422. [PubMed]
 
Rauscher, H, Formanek, D, Popp, W, et al Self-reported vs measured compliance with nasal CPAP for obstructive sleep apnea.Chest1993;103,1675-1680. [PubMed]
 
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