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Original Research: SLEEP MEDICINE |

Clinical and Polysomnographic Predictors of Short-Term Continuous Positive Airway Pressure Compliance FREE TO VIEW

Jacob Collen, MD; Christopher Lettieri, MD, FCCP; William Kelly, MD, FCCP; Stuart Roop, MD, FCCP
Author and Funding Information

*From the Department of Internal Medicine (Dr. Collen), Walter Reed Army Medical Center, Washington, DC; and Uniformed Services University of the Health Sciences (Drs. Lettieri, Kelly, and Roop), Bethesda, MD.

Correspondence to: Jacob Collen, MD, 1375 Kenyon Street NW, Apt 220, Washington, DC 20010; e-mail: jacob.collen@us.army.mil


The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the US Government.

Dr. Collen has no conflicts of interest to disclose. Dr. Lettieri has conducted research using unrestricted grants provided by Sepracor Inc to the Henry M. Jackson Foundation for the Advancement of Military Medicine. Dr. Kelly has no conflicts of interest to disclose. Dr. Roop has no conflicts of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2009;135(3):704-709. doi:10.1378/chest.08-2182
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Background:  Poor compliance and initial intolerance limit the effectiveness of continuous positive airway pressure (CPAP) in obstructive sleep apnea. Short-term compliance has been shown to predict long-term use. Unfortunately, few identified variables reliably predict initial CPAP tolerance and use. We sought to identify potential pretreatment variables that would predict short-term use of CPAP.

Methods:  We performed a retrospective review assessing short-term CPAP compliance after 4 to 6 weeks of treatment. Consecutive patients initiating CPAP therapy were included. Demographic and polysomnographic variables were correlated with objective measures of CPAP use. The average hours per night and percentage of nights of CPAP use were correlated with each variable. Variables were also associated with good vs poor compliance, which we defined as > 4 h per night > 70% of nights.

Results:  We included 400 consecutive patients (78% male; mean age, 47 ± 8 years). Of the measured variables, only age (48 ± 8 years vs 46 ± 7 years, p = 0.02) and use of a sedative/hypnotic during CPAP titration (77% vs 57.6%, p < 0.0005) were associated with better compliance. Those receiving a sedative/hypnotic had longer sleep times (345 ± 42 min vs 314 ± 51 min, p < 0.0005) and greater sleep efficiency (84 ± 9% vs 78 ± 11%, p < 0.0005) during polysomnography. CPAP titrations were improved in those receiving sedative/hypnotics, achieving lower respiratory disturbance index on the final CPAP pressure (6 ± 7 vs 10 ± 11, p = 0.04).

Conclusions:  Of the measured variables, only age and a one-time use of sedative/hypnotics during polysomnography correlated with greater short-term CPAP compliance. Hypnotics facilitated better quality CPAP titrations. Reliable predictors of short-term CPAP use could help identify measures to improve long-term compliance.

Obstructive sleep apnea (OSA) is a common disorder that is largely underdiagnosed and undertreated.13 Historically, OSA has been associated with multiple adverse consequences such as increased daytime sleepiness,4 rate of motor vehicle accidents,5 hypertension,68 cerebrovascular disease,8 atherosclerotic disease8,9 and atrial fibrillation.10 Continuous positive airway pressure (CPAP) is recommended as first-line therapy for most patients with OSA11,12 and has been shown to improve sleep quality, reduce daytime sleepiness, and enhance quality of life.13 CPAP may also decrease the risk of cardiovascular disease.1416 Unfortunately, compliance, with regards to hours per night worn and consistency of use, is frequently poor. Of patients who initiate CPAP therapy, approximately 50% stop using it within the first year.17 Discomfort and intolerance of CPAP often impairs early use and may lead to abandonment of therapy during the initial treatment period. Of those patients that successfully transition to CPAP use, nighttime usage ranges from 3.5 to 5.3 h per night.1720

Determinants of compliance typically include psychological and clinical predictors,19,2127 and studies have yielded inconsistent results. Psychological factors include greater perceived severity of disease,28 high health value,24,28 and higher internal locus of control (patients who believe they have significant control over their own circumstances and environment, “readiness,” “self-efficacy”).24,2729 Clinical predictors that have been demonstrated in various studies include degree of sleepiness before treatment,30,31 severity of disease (apnea-hypopnea index [AHI]),30 age,3033 gender,30,31 CPAP pressure prescribed,30 and type of study (traditional or split night).34 Several studies have evaluated various interventions aimed at improving compliance. These include aggressive follow-up and advice by phone,35 dissemination of literature on OSA and CPAP,35 intensive patient education programs and support protocols,24,36,37 and motivational enhancement programs.38 These strategies have been found to have only a modest impact on improving compliance, especially when evaluated in the context of the amount of time and resources required to implement them. Technological advances such as improved mask fit and humidified air have also had little impact on compliance.39

Long-term patterns of CPAP compliance are often influenced by the patient's early experience with CPAP. Prior studies18,30 have found that average nightly CPAP usage during the first 3 months of therapy predicts long-term use. Similarly, long-term compliance may be predicted after only the first few days of CPAP use,32,40 and better sleep efficiency during the initial CPAP titration may predict compliance at 48 days.41 Given this, it appears that compliance with CPAP may be predicted during the initial treatment period. Unfortunately, few variables have been shown to reliably predict who will successfully transition to CPAP or become complaint with therapy. We attempted to determine if any pretreatment clinical or polysomnographic variable would be predictive of initial CPAP tolerance and short-term compliance.

We conducted a retrospective review of consecutive adult patients newly diagnosed with OSA between March 1, 2007, and December 20, 2007. All patients ≥ 18 years old who were not previously receiving CPAP were included. No records were excluded from the final analysis. This study was approved by the Institutional Review Board within our hospital Department of Clinical Investigations.

Data were obtained from review of all clinical records from the initial sleep consultation, follow-up evaluations, and polysomnographic studies. Clinical variables included age, gender, and body mass index (BMI). Degree of somnolence both before and after treatment were assessed using the Epworth sleepiness scale (ESS)42 and visual analog fatigue scale. Polysomnographic data included total sleep time (TST), sleep latency, sleep efficiency, and AHI. We also recorded the percentage of TST spent in slow-wave sleep and rapid eye movement (REM) sleep during CPAP titration. The prescribed CPAP pressure and the AHI at this pressure were also recorded. Patients underwent either traditional sleep studies (diagnostic polysomnography followed by a separate CPAP titration study) or split-night studies (diagnostic polysomnography and CPAP titration during the same night). In patients undergoing split-night studies, the AHI was determined during the diagnostic portion of the test. Similarly, the percentage of time in slow-wave and REM sleep were calculated during the CPAP titration portion of the study. Polysomnographic data were collected (SensorMedics Alpha SomnoStar system; SensorMedics; Yorba Linda, CA) in our sleep disorders clinic, and all polysomnograms were interpreted and scored by the investigators in accordance guidelines published by the American Academy of Sleep Medicine.2,43

All patients received C-Flex CPAP (Respironics; Murrysville, PA) devices with heated humidifiers. There were no titrations with autoadjustable positive airway pressure devices in our cohort, and all individuals underwent attended, in-laboratory polysomnography and CPAP titrations to establish the diagnosis of OSA and initiate CPAP therapy. All patients received extensive counseling and education regarding OSA, CPAP use, and the importance of compliance prior to initiating therapy. CPAP masks were fitted by a respiratory therapist trained in sleep medicine. All patients received a telephone follow-up after 2 weeks to ensure proper mask fit, and all were encouraged to follow-up with our clinic 4 to 6 weeks after initiating therapy.

Per the protocol of our sleep center, unless contraindicated patients are routinely provided with a nonbenzodiazepine sedative/hypnotic to take at the beginning of the study or shortly after lights out in the event of an inability to fall asleep. No hypnotics are given after initial sleep onset. The technician annotates whether or not the patient received a nonbenzodiazepine sedative/hypnotic (zolpidem or eszopiclone). No other agents were used for premedication. Patients chronically using sedating medications are not prescribed additional agents for polysomnography pretreatment in our facility. Data regarding sedative/hypnotic were analyzed using only the individuals who we were able to confirm received premedication with these agents.

CPAP compliance was assessed during a physician follow-up in our sleep clinic 4 to 6 weeks after initiation of therapy. Objective measures of CPAP use were obtained from a downloadable “smart card” compliance monitoring device. The percent of days used, the average time used per night for all nights, the average time used on nights CPAP worn, and the percentage of nights with > 4 h of use were recorded. Similar to prior studies, we defined “good compliance” as the use of CPAP for > 4 h per night on > 70% of nights.18

We analyzed our entire cohort for variables that impacted our definition of good compliance, and then performed subgroup analyses on those variables found to have a statistically significant relationship with good compliance. The primary end points were defined as patient-specific and polysomnographic variables that correlated with good compliance at 4 to 6 weeks after initiation of CPAP therapy. Secondary end points looked at the same variables by quartiles of CPAP compliance (percentage of days CPAP worn, number of hours per night total, number of hours per night on nights used, and use of > 4 h per night on > 70% days prescribed).

Differences between groups were examined using the two-sample t test for continuous variables and the χ2 test for categorical data. Data were presented as mean ± 1 SD; p values < 0.05 were assumed to represent statistical significance. Odds ratios (ORs) are presented together with 95% confidence intervals (CIs). Logistic regression was used to analyze predictors of compliance. Data were analyzed using statistical software (Statistical Package for Social Sciences 13.0; SPSS; Chicago, IL).

We included 400 consecutive patients who presented for initial follow-up following 4 to 6 weeks of CPAP therapy. The majority of subjects (78.0%) were men with a mean age of 47 ± 7.7 years. Mean BMI was 30.3 ± 3.7 kg/m2. Of the performed polysomnographies, 133 were conducted as traditional sleep studies (diagnostic study followed by full-night CPAP titration) and 267 were split-night studies.

Among our cohort, CPAP was used for 78.1% of nights with an average of 3.13 h per night for all nights and 3.26 h per night during nights used. Using our stated definition,18 good compliance was observed in 56.5% (n = 226) of individuals. Of all measured variables, only age (48.2 ± 8.0 years vs 45.8 ± 7.3 years; p = 0.02) and use of a sedative/hypnotic during polysomnography (77.0% vs 57.6%, p < 0.0005) were associated with good compliance when we evaluated the entire cohort. No other variables predicted good compliance with CPAP (Table 1).

Table Graphic Jump Location
Table 1 Characteristics of Study Population Based on Compliance*

*Data are presented as mean ± SD unless otherwise indicated. Compliance = use > 4 h/night, > 70% of days.

Subjects with good compliance tended to be slightly older (48.2 ± 8.0 years vs 45.8 ± 7.3 years, p = 0.02). Those > 50 years old were twice as likely to meet our definition of good compliance, compared to those < 50 years old (p = 0.003; OR, 1.94; 95% CI, 1.26 to 2.98; Table 2). We performed a multivariate analysis to adjust for age (> 50 years vs < 50 years) and found that the impact of hypnotic use on compliance was significant (p = 0.003) when adjusted for age in those patients < 50 years old, and trended toward significance in those > 50 years old (p = 0.08). Among the cohort, 135 subjects (33.8%) were > 50 years old.

Table Graphic Jump Location
Table 2 ORs Between Clinical and Polysomnographic Variables and Good Compliance

Hypnotic usage could be verified in 316 subjects (79.0%). Of these, 214 subjects (67.7%) did and 102 subjects (32.3%) did not receive a one-time dose of a sedative/hypnotic prior to CPAP titration. Twenty-three individuals (5.8%) were chronically using sedating medications, and the use of nonbenzodiazepines during polysomnography could not be determined in 61 subjects (15.3%). These individuals were excluded from this analysis. Patients who used a hypnotic during their CPAP titration had longer TST (344.7 ± 41.9 min vs 313.7 ± 51.2 min, p < 0.0005), greater sleep efficiency (84.3 ± 9% vs 77.5 ± 11%, p < 0.0005), and shorter sleep latency (20.8 ± 17.7 min vs 35.9 ± 27.4 min, p < 0.0005) compared to those who did not. These individuals also had a greater rebound of slow-wave sleep during CPAP titration (10.9 ± 8.3% vs 6.5 ± 6.3%, p = 0.0005). Sedative/hypnotics also facilitated better CPAP titrations and resulted in a lower AHI at the highest CPAP pressure (6.1 ± 7/h vs 9.8 ± 10.7/h, p = 0.04). Short-term CPAP compliance was greater in patients who received a hypnotic prior to polysomnography compared to those that did not. Specifically, CPAP use > 4 h per night for > 70% of nights was greater among those who received a nonbenzodiazepine sedative hypnotic during their CPAP titration than those who did not (59.3% v 37.3%; p < 0.0005; OR, 2.46, 95% CI, 1.51 to 3.99; Table 2). When we assessed which variables were associated with good compliance for the entire cohort, more individuals receiving a sedative/hypnotic during CPAP titration met criteria for good compliance (77.0% vs 57.6%, p < 0.0005). In addition, these individuals used CPAP on more days (79.7% vs 71.3%, p = 0.002) and for longer periods (4.0 ± 1.7 h per night vs 3.2 ± 1.7 h per night, p = 0.0007) compared to those who did not receive a sedative/hypnotic prior to CPAP titration. Among the cohort, 35 individuals received eszopiclone and 179 received zolpidem. Although eszopiclone tended to improve sleep during polysomnography, there were no differences noted in subsequent CPAP compliance between these two agents.

To minimize the impact of a somewhat arbitrary definition of “good compliance,” we reassessed the data by absolute use of CPAP and the measured variables were compared between each quartile of use. Compared to those with the least use of CPAP, those with the highest use were older (49.7 ± 7.9 years vs 44.8 ± 7.8 years, p = 0.001) and were more likely to have received a sedative hypnotic at the time of their CPAP titration (77.1% vs 53.7%, p = 0.002). No other variable was associated with a greater use of CPAP.

Among our cohort, only older age and one-time dose of sedative/hypnotic prior to CPAP titration predicted CPAP compliance in the initial 4 to 6 weeks of therapy. No other variables (gender, BMI, degree of sleepiness, disease severity, rebound of REM or slow-wave sleep, or prescribed CPAP pressure) predicted compliance.

Previous studies have found that gender,30,31 degree of sleepiness,30,31 and severity of disease28,30 influenced compliance with CPAP. Lower prescribed CPAP pressures would be expected to cause less discomfort and better tolerance with subsequent improved compliance. In addition, rebound of slow-wave and REM sleep, or a greater ablation of respiratory events during CPAP titration, have been presumed to predict greater subjective improvements and better compliance with therapy. While we did not observe these relationships, we did find that those receiving a sedative/hypnotic had better CPAP titrations and more slow-wave sleep during polysomnography. It is important to note that our population had a high proportion of patients premedicated with a sedative/hypnotic prior to CPAP titration, a practice that may not occur in other sleep laboratories. Our sleep laboratory has adopted this practice based on two studies44,45 at our institution that show improved CPAP titrations after premedication with a sedative/hypnotic.

There are a number of potential reasons that a sedative/hypnotic administered during the initial CPAP titration may impact subsequent compliance. Nonbenzodiazepine sedative hypnotics are effective in inducing sleep onset and improving sleep continuity. These agents increase TST and less wake after sleep onset, which may facilitate improved CPAP titrations with more time to determine the optimal pressure needed to ablate respiratory events. They may also improve the patient's overall experience in the sleep laboratory setting and initial comfort with CPAP, which has been previously shown to impact short-term compliance.41 Furthermore, they have been shown to be safe in patients with OSA and do not result in an increase in respiratory events or significant reduction in the oxygen saturation nadir.4650

A retrospective review44 found that pretreatment with zolpidem during formal, in-laboratory CPAP titrations significantly improved polysomnographic quality. This study was subsequently validated by a randomized clinical trial45 that found that the quality of polysomnography and CPAP titrations were significantly improved with eszopiclone compared to placebo. In both studies, nonbenzodiazepine hypnotics resulted in a greater ablation of respiratory events during CPAP titration and fewer studies needed to be repeated due to insufficient sleep time, incomplete CPAP titrations, or complete CPAP intolerance.44,45 Drake and colleagues41 found that a patient's initial experience with CPAP, particularly how well they slept during titration (sleep efficiency), was predictive of subsequent compliance. Essentially, patient compliance may be influenced by the initial experience with CPAP (at the time of initial titration), and factors that can improve sleep parameters during the initial titration may be more predictive of short-term compliance than psychological factors, disease severity, and others.

Bradshaw et al48 assessed the impact of zolpidem as a means to improve initial CPAP compliance. In this trial, a 14-day course of sedative/hypnotics during the initial transition to CPAP therapy failed to improve compliance. However, this study was limited by a small sample size and narrowed patient population.51 In addition, the short duration of effect of zolpidem may be insufficient to improve the use of CPAP in the later stages of sleep. Berry and Patel47 assessed the impact of zolpidem on the efficacy of CPAP among patients with severe OSA. They found that zolpidem did not increase the AHI, alter the sleep architecture, or significantly reduce the arterial oxygen nadir. This study showed that zolpidem did not worsen OSA or the efficacy of CPAP. While compliance with CPAP was not specifically assessed, they did observe that zolpidem produced a modest reduction in the mean arousal index that would improve sleep continuity and potentially increase the use of CPAP.47 However, while these studies did not show that sedative/hypnotics improved CPAP compliance, neither study assessed the impact of sedative-hypnotics during CPAP titration. As stated, compliance with therapy may very well be determined after the initial experience with CPAP, which may explain the differences noted between these studies and our observations.32,40

Our study has several limitations. We only included those individuals who returned for follow-up. This creates a potential selection bias. However, within our cohort there was a wide range of compliance, from almost no use of CPAP to those using it for > 4 h on 100% of the nights assessed. While the compliance in those not returning for follow-up care is unknown, it likely represents abandonment of CPAP therapy. This may account for the higher proportion of patients in our cohort who received a hypnotic prior to CPAP titration as this was found to be the greatest predictor of CPAP use. Second, we did not differentiate what nonbenzodiazepine sedative/hypnotic was used when analyzing our results. Patients received either zolpidem or eszopiclone, and it is unclear if our results would differ if we were able to evaluate these populations separately (with larger numbers of patients for each medication). It is possible that a longer-acting hypnotic would perform better as it would promote better sleep continuity during the later part of the study when CPAP titrations are crucial. In addition, we could not verify the use of premedication in one sixth of our cohort, and it is unknown if these individuals would have impacted our results. Our definition of good compliance, while generally accepted, is somewhat arbitrary. However, our observation that only age and use of premedication for CPAP titrations predicted compliance did not differ with regards to our definition of good compliance or absolute use of CPAP. Finally, this was a retrospective study and any conclusions drawn from it should be validated in a prospective fashion.

Our findings suggest that a one-time dose of a nonbenzodiazepine sedative/hypnotic during polysomnography may facilitate better CPAP titrations and improve short-term compliance. Short-term compliance may correlate with long-term compliance and interventions aimed at the initial treatment period would potentially offer the greatest benefit in adaptation to CPAP with subsequent improvements in future use. As such, it is important to better define how the use of sedative/hypnotics during polysomnography can improve short-term compliance in a randomized clinical trial.

AHI

apnea-hypopnea index

BMI

body mass index

CI

confidence interval

CPAP

continuous positive airways pressure

ESS

Epworth sleepiness score

OR

odds ratio

OSA

obstructive sleep apnea

REM

rapid eye movement

TST

total sleep time

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Figures

Tables

Table Graphic Jump Location
Table 1 Characteristics of Study Population Based on Compliance*

*Data are presented as mean ± SD unless otherwise indicated. Compliance = use > 4 h/night, > 70% of days.

Table Graphic Jump Location
Table 2 ORs Between Clinical and Polysomnographic Variables and Good Compliance

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