Reversal of PAP Failure With the REPAP Protocol.

BACKGROUND: Re-titrations, an atypical approach to reverse PAP failure, was investigated retrospectively. METHODS: Application of our re-titration of PAP (REPAP) protocol in subjects with previous PAP failure assessed original technology (masks, modes, and pressures) in 273 subjects, of which 70% reported co-occurring psychiatric conditions. The REPAP protocol emphasized changes in pressure modes and settings to address expiratory pressure intolerance and residual breathing events; mask changes were facilitated. Objective sleep and breathing metrics and subjective post-titration ratings were analyzed in subsequent PAP users and non-users. RESULTS: Following REPAP protocol (average follow-up = 2 y), 196 of 273 subjects with previous PAP failure were PAP users, and 77 were non-users. Previous PAP failure was attributed to technology factors, including pressure intolerance, mask discomfort, adaptation difficulties, and no benefits. At second opinion re-titration, mask changes resolved discomfort, mouth breathing, or leak (91.2% of sample); pressure mode changes resolved expiratory pressure intolerance (83.5%); and pressure setting changes decreased residual breathing events and improved air flow (96.7%), all of which were associated with renewed PAP use. PAP users showed objective sleep improvements on re-titrations and reported better sleep quality than non-users. Multiple logistic regressions showed 2 subjective, re-initiation predictors: (1) post-re-titration ratings of better sleep quality and (2) less anticipated difficulty in using PAP after initial or multiple re-titrations. User rates were significantly higher for subjects completing multiple (n = 158) versus one (n = 115) re-titration (80% vs 61%, P = .001). In multiple re-titration subjects, PAP users showed significance or a trend for lower apnea-hypopnea index (P = .02, g = 0.48) and respiratory disturbance index (P = .07, g = 0.36) compared with non-users. Available user downloads averaged >5 h/night. CONCLUSIONS: Technology-related problems due to mask discomfort/leak, pressure intolerance, and residual breathing events were associated with PAP failure in subjects seeking second opinions. Technological solutions (changes in masks, modes, and pressures) were addressed during REPAP protocol, after which 72% of subjects re-initiated PAP use. These technological interventions were associated with improved objective and subjective sleep variables and reversal of PAP failure.

Adherence and Subthreshold Adherence in Sleep Apnea Subjects Receiving Positive Airway Pressure Therapy: A Retrospective Study Evaluating Differences in Adherence Versus Use.

BACKGROUND: Research on subthreshold compliance with positive airway pressure (PAP) therapy in sleep apnea patients may inform clinical sleep medicine practice. We retrospectively assessed compliant and subthreshold compliant sleep apnea subjects to test whether regular but fewer hours of PAP use would demonstrate clinically meaningful improvements and correlate with outcomes. METHODS: A chart review was conducted of 113 consecutive sleep apnea subjects, naive to treatment, who completed a titration study and filled a PAP therapy prescription. Objective data categorized subjects into 3 groups: compliant, subthreshold compliant, and minimal use. Outcome measures assessed changes in insomnia, sleepiness, and nocturia on average 7 months from PAP initiation. Correlation coefficients analyzed dose-response relationships between hours of use and changes in outcomes. RESULTS: Among 113 PAP attempters, 104 (92%) were current users. Among 93 users with objective data, regular (consistent) PAP users included 59 compliant and 21 subthreshold compliant, and 13 subjects were minimal users. Compliant users averaging 6.6 ± 1.3 h/night and 42.0 ± 12.1 h/week showed the largest outcome improvements (all P < .05) with moderate to large effects for insomnia (d = 0.94), sleepiness (d = 0.58), and nocturia (d = 0.56). Subthreshold users averaging 4.1 ± 0.7 h/night but only 18.0 ± 5.6 h/week showed a large effect for insomnia (d = 0.76, P = .03) and nonsignificant, small effects for sleepiness (d = 0.38) and nocturia (d = 0.22). Correlation coefficients showed a trend for decrease in insomnia (P = .08; r = .20) and a significant decrease in nocturia (P = .034; r = 0.25), each in association with hours of PAP use. CONCLUSIONS: In a clinical sample, 86% of sleep apnea subjects regularly used PAP, but adherence was 63%. Regular users showed clinical treatment effects and potential dose-response relationships, suggesting that the term use offers advantages over the term adherence. Currently, subthreshold compliance may not merit insurance coverage in many countries, an issue affecting many sleep apnea patients.