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CC BY-NC-ND 4.0 · Sleep Sci 2018; 11(03): 174-182
DOI: 10.5935/1984-0063.20180032
ORIGINAL ARTICLE

Access to CPAP treatment in patients with moderate to severe sleep apnea in a Latin American City

Juan Facundo Nogueira
1   Instituto Argentino de Investigación Neurológica, Sleep Laboratory - Buenos Aires - Ciudad Autonoma de Buenos Aires - Argentina.
2   Hospital de Clínicas, University of Buenos Aires, Sleep Laboratory - Buenos Aires - Ciudad Autonoma de Buenos Aires - Argentina.
3   Grupo Argentino de Investigación en Apneas del Sueño, Cooperative Group of Research - Buenos Aires - Ciudad Autonoma de Buenos Aires - Argentina.
,
Guido Simonelli
3   Grupo Argentino de Investigación en Apneas del Sueño, Cooperative Group of Research - Buenos Aires - Ciudad Autonoma de Buenos Aires - Argentina.
4   Walter Reed Army Institute of Research, Behavioral Biology Branch - Silver Spring - Maryland - United States.
,
Vanina Giovini
2   Hospital de Clínicas, University of Buenos Aires, Sleep Laboratory - Buenos Aires - Ciudad Autonoma de Buenos Aires - Argentina.
3   Grupo Argentino de Investigación en Apneas del Sueño, Cooperative Group of Research - Buenos Aires - Ciudad Autonoma de Buenos Aires - Argentina.
,
María Florencia Angellotti
1   Instituto Argentino de Investigación Neurológica, Sleep Laboratory - Buenos Aires - Ciudad Autonoma de Buenos Aires - Argentina.
2   Hospital de Clínicas, University of Buenos Aires, Sleep Laboratory - Buenos Aires - Ciudad Autonoma de Buenos Aires - Argentina.
3   Grupo Argentino de Investigación en Apneas del Sueño, Cooperative Group of Research - Buenos Aires - Ciudad Autonoma de Buenos Aires - Argentina.
,
Eduardo Borsini
3   Grupo Argentino de Investigación en Apneas del Sueño, Cooperative Group of Research - Buenos Aires - Ciudad Autonoma de Buenos Aires - Argentina.
,
Glenda Ernst
3   Grupo Argentino de Investigación en Apneas del Sueño, Cooperative Group of Research - Buenos Aires - Ciudad Autonoma de Buenos Aires - Argentina.
,
Carlos Nigro
3   Grupo Argentino de Investigación en Apneas del Sueño, Cooperative Group of Research - Buenos Aires - Ciudad Autonoma de Buenos Aires - Argentina.
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Introduction: The most effective treatment for moderate to severe obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP) but adherence may be a limiting factor. Most compliance studies often only include patients under CPAP treatment, neglecting the importance of access to treatment. The aim of this study was to evaluate CPAP access and compliance in OSA patients, after CPAP indication and titration.

Methods: We included moderate to severe OSA patients, diagnosed by in-lab polysomnography (PSG), with CPAP indication and effective pressure titration. Between 12 to 18 months after treatment was indicated a telephone questionnaire was administered including questions about access to CPAP, reasons of no access, reported adherence and symptoms improvement.

Results: A total of 213 patients responded to the survey (171 males, mean age 53.4±13.5 and BMI 34.02±8.8 kg/m2). Almost a third of the patients (28.2%) did not initiate CPAP treatment. Out of 213, 153 patients (71.8%) started treatment with CPAP and 120 (56.3%) reported still being under treatment a year after indication, additionally, 85.8% reported that they were using it =4hs/night. Those who accessed to CPAP were on average, older age, had full coverage of treatment by their medical insurance, required lower effective pressure and experienced more severe sleepiness compared to those individuals who did not accessed to CPAP.

Discussion: A significant proportion of OSA patients with CPAP indication did not initiate and/or eventually abandoned CPAP. Approximately only 50% of the patients were still under treatment, with acceptable self-reported adherence rate and clinical response, one year after the initial treatment indication. Additional measures are necessary to increase access to CPAP and improve long-term compliance.

Sleep Apnea - Obstructive - Continuous Positive Airway Pressure - Compliance - Education

Take home message

We need a more appropriate approach to reach the majority of patients who do not yet have a diagnosis and also those who cannot access treatment, or who leave it after it has been initiated. It should address very diverse factors ranging from coverage to decreasing bureaucratic steps or paperwork for the patients; from the development of new strategies that motivate and well-predispose patients to the treatment as well as targeted interventions for patients at risk of not initiating it.


Ethical approval

This study has been approved by the Ethics committee of the participating Institution and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All individual provided informed consent before participating in the study.




Publication History

Received: 05 March 2018

Accepted: 15 August 2018

Article published online:
13 October 2023

© 2023. Brazilian Sleep Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • REFERENCES

  • 1 Nogueira F, Nigro C, Cambursano H, Borsini E, Silio J, Avila J. [Practical guidelines for the diagnosis and treatment of obstructive sleep apnea syndrome]. Medicina (B Aires). 2013;73(4):349-62. [Article in Spanish].
  • 2 Durán J, Esnaola S, Rubio R, Iztueta A. Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr. Am J Respir Crit Care Med. 2001;163(3 Pt 1):685-9.
  • 3 Grupo Español de Sueño. Consenso Nacional sobre el síndrome de apneas- hipopneas del sueño. Arch Bronconeumol. 2005;41(Suppl 4):3-110.
  • 4 Young T, Peppard P, Palta M, Hla KM, Finn L, Morgan B, et al. Populationbased study of sleep-disordered breathing as a risk factor for hypertension. Arch Intern Med. 1997;157(15):1746-52.
  • 5 Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000;342(19):1378-84.
  • 6 Mehra R, Benjamin EJ, Shahar E, Gottlieb D, Nawabit R, Kirchner H, et al.; Sleep Heart Health Study. Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep Heart Health Study. Am J Respir Crit Care Med. 2006;173(8):910-6.
  • 7 Harbison J, O’Reilly P, McNicholas WT. Cardiac rhythm disturbances in the obstructive sleep apnea syndrome: effects of nasal continuous positive airway pressure therapy. Chest. 2000;118(3):591-5.
  • 8 Wang H, Parker JD, Newton GE, Floras JS, Mak S, Chiu KL, et al. Influence of obstructive sleep apnea on mortality in patients with heart failure. J Am Coll Cardiol. 2007;49(15):1625-31.
  • 9 Peker Y, Kraiczi H, Hedner J, Löth S, Johansson A, Bende M. An independent association between obstructive sleep apnoea and coronary artery disease. Eur Respir J. 1999;14(1):179-84.
  • 10 Artz M, Young T, Finn L, Skatrud JB, Bradley TD. Association of sleepdisordered breathing and the occurrence of stroke. Am J Respir Crit Care Med. 2005;172(11):1447-51.
  • 11 George CF. Sleep apnea, alertness and motor vehicle crashes. Am J Respir Crit Care Med. 2007;176(10):954-6.
  • 12 Coughlin SR, Mawdsley L, Mugarza JA, Calverley PM, Wilding JP. Obstructive sleep apnoea is independently associated with an increased prevalence of metabolic syndrome. Eur Heart J. 2004;25(9):735-41.
  • 13 Kono M, Tatsumi K, Saibara T, Nakamura A, Tanabe N, Takiguchi Y, et al. Obstructive sleep apnea syndrome is associated with some components of metabolic syndrome. Chest. 2007;131(5):1387-92.
  • 14 Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328(17):1230-5.
  • 15 Arnardottir E, Bjornsdottir E, Olafsdottir K, Benediktsdottir B, Gislason T. Obstructive sleep apnoea in the general population: highly prevalent but minimal symptoms. Eur Respir J. 2016;47(1):194-202.
  • 16 Tufik S, Santos-Silva R, Taddei JA, Azeredo Bittencourt L. Obstructive Sleep Apnea Syndrome in the Sao Paulo Epidemiologic Sleep Study. Sleep Med. 2010;11(5):441-6.
  • 17 Heinzer R, Vat S, Marques-Vidal P, Marti-Soler H, Andries D, Tobback N, et al. Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med. 2015;3(4):310-8.
  • 18 Giles TL, Lasserson TJ, Smith BH, White J, Wright J, Cates CJ. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev. 2006;(3):CD001106.
  • 19 Fleetham J, Ayas N, Bradley D, Ferguson K, Fitzpatrick M, George C, et al.; CTS Sleep Disordered Breathing Committee. Canadian Thoracic Society guidelines: diagnosis and treatment of sleep disordered breathing in adults. Can Respir J. 2006;13(7):387-92.
  • 20 White J, Cates C, Wright J. Continuous positive airways pressure for obstructive sleep apnoea. Cochrane Database Syst Rev. 2002;(2):CD001106.
  • 21 Loube DI, Gay PC, Strohl KP, Pack AI, White DP, Collop NA. Indications for positive airway pressure treatment of adult obstructive sleep apnea patients: a consensus statement. Chest. 1999;115(3):863-6.
  • 22 Kribbs NB, Pack AI, Kline LR, Smith PL, Schwartz AR, Schubert NM, et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis. 1993;147(4):887-95.
  • 23 Weaver TE, Kribbs NB, Pack AI, Kline LR, Chugh DK, Maislin G, et al. Night-to-night variability in CPAP use over the first three months of treatment. Sleep. 1997:20(4):278-83.
  • 24 Pépin JL, Krieger J, Rodenstein D, Cornette A, Sforza E, Delguste P, et al. Effective compliance during the first 3 months of continuous positive airway pressure. A European prospective study of 121 patients. Am J Respir Crit Care Med. 1999;160(4):1124-9.
  • 25 Haniffa M, Lasserson TJ, Smith I. Interventions to improve compliance with continuous positive airway pressure for obstructive sleep apnoea. Cochrane Database Syst Rev. 2004;(4):CD003531.
  • 26 Meurice JC, Ingrand P, Portier F, Arnulf I, Rakotonanahari D, Fournier E, et al.; ANTADIR Working Group “PPC”, CMTS ANTADIR. A multicentre trial of education strategies at CPAP induction in the treatment of severe sleep apnoea-hypopnoea syndrome. Sleep Med. 2007;8(1):37-42.
  • 27 Nogueira F, De Luca M, Simonelli G, Vera D, Vera S, Rey R. [What happens with patients after they have been diagnosed sleep apnea?]. Rev Argent Med Respir. 2007;2:41-7. [Article in Spanish].
  • 28 Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep. 1999;22(5):667-89.
  • 29 Berry RB, Brooks R, Gamaldo CE, Harding SM, Marcus CL, Vaughn BV et al, for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, Version 2.0. 2012 [cited 2018 Feb 19]. Available from: www.aasmnet.org
  • 30 Gay P, Weaver T, Loube D, Iber C; Positive Airway Pressure Task Force; Standards of Practice Committee; American Academy of Sleep Medicine. Evaluation of Positive Airway Pressure Treatment for Sleep Related Breathing Disorders in Adults. Sleep. 2006;29(3):381-401.
  • 31 Morgenthaler TI, Aurora RN, Brown T, Zak R, Alessi C, Boehlecke B, et al.; Standards of Practice Committee of the AASM; American Academy of Sleep Medicine. Practice Parameters for the Use of Autotitrating Continuous Positive Airway Pressure Devices for Titrating Pressures and Treating Adult Patients with Obstructive Sleep Apnea Syndrome: An Update for 2007. An American Academy of Sleep Medicine report. Sleep. 2008;31(1):141-7.
  • 32 Wolkove N, Baltzan M, Kamel H, Dabrusin R, Palayew M. Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea. Can Respir J. 2008;15(7):365-9.
  • 33 Santin M J, Jorquera A J, Jordán J, Bajut F, Masalán A P, Mesa L T, et al. [Longterm continuous positive airway pressure (CPAP) use in obstructive sleep apnea]. Rev Med Chile. 2007;135(7):855-61. [Article in Spanish].
  • 34 Wang Y, Gao W, Sun M, Chen B. Adherence to CPAP in patients with obstructive sleep apnea in a Chinese population. Respir Care. 2012;57(2):238-43.
  • 35 Torre Bouscoulet L, López Escárcega E, Castorena Maldonado A, Vázquez García JC, Meza Vargas MS, Pérez-Padilla R. [Continuous positive airway pressure used by adults with obstructive sleep apneas after prescription in a public referral hospital in Mexico city]. Arch Bronconeumol. 2007;43(1):16-21. [Article in Spanish].
  • 36 Pieters T, Collard P, Aubert G, Dury M, Delguste P, Rodenstein DO. Acceptance and long-term compliance with nCPAP in patients with obstructive sleep apnoea syndrome. Eur Respir J. 1996;9(5):939-44.
  • 37 Krieger J, Kurtz D, Petiau C, Sforza E, Trautmann D. Long-term compliance with CPAP therapy in obstructive sleep apnea patients and in snorers. Sleep. 1996;19(9 Suppl):S136-43.
  • 38 McArdle N, Devereux G, Heidarnejad H, Engleman HM, Mackay TW, Douglas NJ. Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med. 1999;159(4 Pt 1):1108-14.
  • 39 Young T, Finn L, Peppard PE, Szklo-Coxe M, Austin D, Nieto FJ, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep. 2008;31(8):1071-8.
  • 40 Budhiraja R, Parthasarathy S, Drake CL, Roth T, Sharief I, Budhiraja P, et al. Early CPAP use identifies subsequent adherence to CPAP therapy. Sleep. 2007;30(3):320-4.
  • 41 Elkhouli O, Wolkove N, Baltzan M. Predictors of continuous positive airway pressure (CPAP) compliance and satisfaction after split-night protocol. Chest. 2005;128(4 Suppl):222S.
  • 42 Simon-Tuval T, Reuveni H, Greenberg-Dotan S, Oksenberg A, Tal A, Tarasiuk A. Low socioeconomic status is a risk factor for CPAP acceptance among adult OSAS patients requiring treatment. Sleep. 2009;32(4):545-52.
  • 43 Sin D, Mayers I, Man G, Pawluk L. Long-term compliance rates to continuous positive airway pressure in obstructive sleep apnea: a populationbased study. Chest. 2002;121(2):430-5.
  • 44 Amfilochiou A, Tsara V, Kolilekas L, Gizopoulou E, Maniou C, Bouros D, et al. Determinants of continuous positive airway pressure compliance in a group of Greek patients with obstructive sleep apnea. Eur J Intern Med. 2009;20(6):645-50.
  • 45 Chai-Coetzer CL, Luo YM, Antic NA, Zhang XL, Chen BY, He QY, et al. Predictors of long-term adherence to continuous positive airway pressure therapy in patients with obstructive sleep apnea and cardiovascular disease in the SAVE study. Sleep 2013;36(12):1929-37.
  • 46 Wild MR, Engleman HM, Douglas NJ, Espie CA. Can psychological factors help us to determine adherence to CPAP? A prospective study. Eur Respir J. 2004;24(3):461-5.
  • 47 Sucena M, Liistro G, Aubert G, Rodenstein D, Pieters T. Continuous positive airway pressure treatment for sleep apnoea: compliance increases with time in continuing users. Eur Respir J. 2006;27(4):761-6.
  • 48 Pelletier-Fleury N, Rakotonanahary D, Fleury B. The age and other factors in the evaluation of compliance with nasal continuous positive airway pressure for obstructive sleep apnea syndrome. A Cox’s proportional hazard analysis. Sleep Med. 2001;2(3):225-32.
  • 49 Waldhorn RE, Herrick TW, Nguyen MC, O’Donnell AE, Sodero J, Potolicchio SJ. Long-term compliance with nasal continuous positive airway pressure therapy of obstructive sleep apnea. Chest. 1990;97(1):33-8.
  • 50 Engleman HM, Asgari-Jirhandeh N, McLeod AL, Ramsay CF, Deary IJ, Douglas NJ. Self-reported use of CPAP and benefits of CPAP therapy: a patient survey. Chest. 1996;109(6):1470-6.
  • 51 Meslier N, Lebrun T, Grillier-Lanoir V, Rolland N, Henderick C, Sailly J, 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 J. 1998;12(1):185-92.
  • 52 Popescu G, Latham M, Allgar V, Elliott MW. Continuous positive airway pressure for sleep apnoea/hypopnoea syndrome: usefulness of a 2 week trial to identify factors associated with long term use. Thorax. 2001;56(9):727-33.
  • 53 Hudgel DW, Fung C. A long-term randomized, cross-over comparison of auto-titrating and standard nasal continuous airway pressure. Sleep. 2000;23(5):645-8.
  • 54 Massie CA, McArdle N, Hart RW, Schmidt-Nowara WW, Lankford A, Hudgel DW, et al. Comparison between automatic and fixed positive airway pressure therapy in the home. Am J Respir Crit Care Med. 2003;167(1):20-3.
  • 55 Pan American Health Organization. El sistema de salud argentino y su trayectoria de largo plazo: logros alcanzados y desafíos futuros. PAHO; 2011 [cited 2018 Feb 19]. Available from: https://www.paho.org/arg/index.php?option;com_content&view;article&id;860:el-sistemasalud-argentino-trayectoria-largo-plazo-logros-alcanzados-desafiosfuturos&Itemid;225