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Annual Congress of Malaysian Thoracic Society
Symposium 4A
Sleep Disorders
Initiating continuous positive airway pressure (CPAP)
in obstructive sleep apnea
Amanda Piper
Australia
Continuous positive airway pressure is well established therapy for the management of obstructive sleep
apnea (OSA), and is associated with substantial improvement in daytime functioning and quality of life.
However, the effectiveness of CPAP is frequently hindered by poor or nonadherence to therapy. A multitude of
factors can influence whether an individual accepts and then uses CPAP consistently. While previous studies
have evaluated physiological and patient characteristics as predictors of adherence (1), more recent studies
have focused on the role of psychological factors and cognitive perceptions in influencing the decision about
CPAP use (2). Several studies have found early experiences with CPAP impact on the individual’s decision
to use CPAP (2,3), and this early pattern of use predicts long term adherence (4). Consequently, promoting
a positive initial experience with CPAP is seen as crucial in encouraging patients to continue therapy long
term. Three key aspects of initiating CPAP therapy will be discussed: a) the impact on adherence of how an
effective pressure level is titrated, b) improvements in device technology to lessen side-effects commonly
associated with CPAP use and c) education and support of the individual commencing CPAP. Evidence to date
suggests that simplified approaches to the determination of effective pressures have not impacted negatively
on CPAP adherence, at least in appropriately selected individuals (5). Considerable effort has been put into
modification of CPAP devices to lessen side effects, and while these have been effective in reducing symptoms
associated with therapy use, there is currently little evidence that these have had a clinically significant impact
on adherence, at least in CPAP naïve individuals (6). More recent work has shown that educational support
combined with behavioural strategies employed early in the CPAP experience is most likely to influence CPAP
use (7). In general, studies evaluating device modifications and educational strategies on CPAP adherence
have assessed CPAP naïve patients with moderate to severe apnea. More work is needed to determine the
impact of these interventions in subjects with much milder disease, and those who are likely to be, or are
already established, as poorly adherent to therapy.
References
1. Weaver & Grunstein, Proc Am Thorac Soc 2008; 5:173-178
2. Sawyer et al, Qual Health Res 2010;20:873-892
3. Lewis et al, Sleep 2004;27:134-138
4. Drake et al, Sleep 2003;26:308-311
5. Collen et al, Sleep 2009;14:93-99
6. Smith & Lasserson, Cochrane Database Syst Rev 2009
7. Richards et al, Sleep 2007;30:635-40
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