Rationale In obstructive sleep apnea patients (OSA), continuous positive airway pressure (CPAP) adherence is crucial to improve symptoms and cardiometabolic outcomes. The choice of mask may influence CPAP adherence but this issue has never been addressed properly. Objective To evaluate the impact of nasal pillows, nasal and oronasal masks on CPAP adherence in a cohort of OSA. Methods Newly CPAP treated OSA participating in “Observatoire Sommeil de la Fédération de Pneumologie”, a French national prospective cohort, were included between March 2009 and December 2011. Anthropometric data, medical history, OSA severity, sleepiness, depressive status, treatment modalities (auto-CPAP versus fixed pressure, pressure level, interface type, use of humidifiers) and CPAP-related side effects were included in multivariate analysis to determine independent variables associated with CPAP adherence. Results 2311 OSA (age = 57(12) years, apnea+hypopnea index = 41(21)/h, 29% female) were included. Nasal masks, oronasal masks and nasal pillows were used by 62.4, 26.2 and 11.4% of the patients, respectively. In univariate analysis, oronasal masks and nasal pillows were associated with higher risk of CPAP non-adherence. CPAP non-adherence was also associated with younger age, female gender, mild OSA, gastroesophageal reflux, depression status, low effective pressure and CPAP-related side effects. In multivariate analysis, CPAP non-adherence was associated with the use of oronasal masks (OR = 2.0; 95%CI = 1.6; 2.5), depression, low effective pressure, and side effects. Conclusion As oronasal masks negatively impact on CPAP adherence, a nasal mask should be preferred as the first option. Patients on oronasal masks should be carefully followed.
References
[1]
Sullivan CE, Issa FG, Berthon-Jones M, Eves L (1981) Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet 1: 862–865.
[2]
Marin JM, Agusti A, Villar I, Forner M, Nieto D, et al. (2012) Association between treated and untreated obstructive sleep apnea and risk of hypertension. Jama 307: 2169–2176.
[3]
Marin JM, Carrizo SJ, Vicente E, Agusti AG (2005) Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 365: 1046–1053.
[4]
Pepin JL, Tamisier R, Barone-Rochette G, Launois SH, Levy P, et al. (2010) Comparison of continuous positive airway pressure and valsartan in hypertensive patients with sleep apnea. Am J Respir Crit Care Med 182: 954–960.
[5]
Pepperell JC, Ramdassingh-Dow S, Crosthwaite N, Mullins R, Jenkinson C, et al. (2002) Ambulatory blood pressure after therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomised parallel trial. Lancet 359: 204–210.
[6]
Sharma SK, Agrawal S, Damodaran D, Sreenivas V, Kadhiravan T, et al. (2011) CPAP for the metabolic syndrome in patients with obstructive sleep apnea. N Engl J Med 365: 2277–2286.
[7]
Giles TL, Lasserson TJ, Smith BH, White J, Wright J, et al.. (2006) Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev: CD001106.
[8]
Gagnadoux F, Le Vaillant M, Goupil F, Pigeanne T, Chollet S, et al. (2011) Influence of marital status and employment status on long-term adherence with continuous positive airway pressure in sleep apnea patients. PLoS One 6: e22503.
[9]
Veale D, Chailleux E, Hoorelbeke-Ramon A, Reybet-Degas O, Humeau-Chapuis MP, et al. (2000) Mortality of sleep apnoea patients treated by nasal continuous positive airway pressure registered in the ANTADIR observatory. Association Nationale pour le Traitement A Domicile de l’Insuffisance Respiratoire chronique. Eur Respir J 15: 326–331.
[10]
Weaver TE, Maislin G, Dinges DF, Bloxham T, George CF, et al. (2007) Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep 30: 711–719.
[11]
Barbe F, Duran-Cantolla J, Capote F, de la Pena M, Chiner E, et al. (2010) Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea. Am J Respir Crit Care Med 181: 718–726.
[12]
Rossi VA, Stoewhas AC, Camen G, Steffel J, Bloch KE, et al. (2012) The effects of continuous positive airway pressure therapy withdrawal on cardiac repolarization: data from a randomized controlled trial. Eur Heart J 33: 2206–2212.
[13]
Antic NA, Catcheside P, Buchan C, Hensley M, Naughton MT, et al. (2011) The effect of CPAP in normalizing daytime sleepiness, quality of life, and neurocognitive function in patients with moderate to severe OSA. Sleep 34: 111–119.
[14]
Haentjens P, Van Meerhaeghe A, Moscariello A, De Weerdt S, Poppe K, et al. (2007) The impact of continuous positive airway pressure on blood pressure in patients with obstructive sleep apnea syndrome: evidence from a meta-analysis of placebo-controlled randomized trials. Arch Intern Med 167: 757–764.
[15]
Poulet C, Veale D, Arnol N, Levy P, Pepin JL, et al. (2009) Psychological variables as predictors of adherence to treatment by continuous positive airway pressure. Sleep Med 10: 993–999.
[16]
Wild MR, Engleman HM, Douglas NJ, Espie CA (2004) Can psychological factors help us to determine adherence to CPAP? A prospective study. Eur Respir J 24: 461–465.
[17]
Kohler M, Smith D, Tippett V, Stradling JR (2010) Predictors of long-term compliance with continuous positive airway pressure. Thorax 65: 829–832.
[18]
Lindberg E, Berne C, Elmasry A, Hedner J, Janson C (2006) CPAP treatment of a population-based sample–what are the benefits and the treatment compliance? Sleep Med 7: 553–560.
[19]
Pepin JL, Muir JF, Gentina T, Dauvilliers Y, Tamisier R, et al. (2009) Pressure reduction during exhalation in sleep apnea patients treated by continuous positive airway pressure. Chest 136: 490–497.
[20]
Smith I, Lasserson TJ (2009) Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev: CD003531.
[21]
Beecroft J, Zanon S, Lukic D, Hanly P (2003) Oral continuous positive airway pressure for sleep apnea: effectiveness, patient preference, and adherence. Chest 124: 2200–2208.
[22]
Chai CL, Pathinathan A, Smith B (2006) Continuous positive airway pressure delivery interfaces for obstructive sleep apnoea. Cochrane Database Syst Rev: CD005308.
[23]
Bachour A, Maasilta P (2004) Mouth breathing compromises adherence to nasal continuous positive airway pressure therapy. Chest 126: 1248–1254.
[24]
Baltzan MA, Elkholi O, Wolkove N (2009) Evidence of interrelated side effects with reduced compliance in patients treated with nasal continuous positive airway pressure. Sleep Med 10: 198–205.
[25]
Massie CA, Hart RW (2003) Clinical outcomes related to interface type in patients with obstructive sleep apnea/hypopnea syndrome who are using continuous positive airway pressure. Chest 123: 1112–1118.
[26]
Belge C, Delguste P, Mouchart F, Rodenstein D, Mwenge B (2012) Obstructive apneas during continuous positive airway pressure: unexpected finding with nasal pillow interface. Am J Respir Crit Care Med 185: 112–114.
[27]
Schorr F, Genta PR, Gregório MG, Danzi-Soares NJ, Lorenzi-Filho G (2012) Continuous positive airway pressure delivered by oronasal mask may not be effective for obstructive sleep apnoea Eur Respir J. 40: 503–505.
[28]
Mortimore IL, Whittle AT, Douglas NJ (1998) Comparison of nose and face mask CPAP therapy for sleep apnoea. Thorax 53: 290–292.
[29]
OSFP website. Available: http://www.osfp.fr/portail/. (Date of consultation: 2012/07/20).
[30]
Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 14: 540–545.
[31]
Guelfi JD (1988) Standardized clinical evaluation of depressive and anxious symptomatology. Clin Neuropharmacol 11 Suppl 2S59–68.
[32]
Barbe F, Duran-Cantolla J, Sanchez-de-la-Torre M, Martinez-Alonso M, Carmona C, et al. (2012) Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial. Jama 307: 2161–2168.
[33]
Wang H (2003) Imputation in Clinical Research. Encyclopedia of Biopharmaceutical Statistics. DOI: 10.1081/E-EBS 120007637.
[34]
Laaban JP, Mounier L, Roque d’Orbcastel O, Veale D, Blacher J, et al. (2010) Cardiovascular risk factors in men and women with obstructive sleep apnoea syndrome. Respir Med 104: 1063–1068.
[35]
Anderson FE, Kingshott RN, Taylor DR, Jones DR, Kline LR, et al. (2003) A randomized crossover efficacy trial of oral CPAP (Oracle) compared with nasal CPAP in the management of obstructive sleep apnea. Sleep 26: 721–726.
[36]
Khanna R, Kline LR (2003) A prospective 8 week trial of nasal interfaces vs. a novel oral interface (Oracle) for treatment of obstructive sleep apnea hypopnea syndrome. Sleep Med 4: 333–338.
[37]
Teo M, Amis T, Lee S, Falland K, Lambert S, et al. (2011) Equivalence of nasal and oronasal masks during initial CPAP titration for obstructive sleep apnea syndrome. Sleep 34: 951–955.
[38]
Bakker JP, Neill AM, Campbell AJ (2012) Nasal versus oronasal continuous positive airway pressure masks for obstructive sleep apnea: a pilot investigation of pressure requirement, residual disease, and leak. Sleep Breath 16: 709–716.
[39]
Ebben MR, Oyegbile T, Pollak CP (2012) The efficacy of three different mask styles on a PAP titration night. Sleep Med 13: 645–649.
[40]
Valentin A, Subramanian S, Quan SF, Berry RB, Parthasarathy S (2011) Air leak is associated with poor adherence to autoPAP therapy. Sleep 34: 801–806.
[41]
Borel JC, Gakwaya S, Masse JF, Melo-Silva CA, Series F (2012) Impact of CPAP interface and mandibular advancement device on upper airway mechanical properties assessed with phrenic nerve stimulation in sleep apnea patients. Respir Physiol Neurobiol 183: 170–176.
[42]
Hedner J, Grote L, Bonsignore M, McNicholas W, Lavie P, et al. (2011) The European Sleep Apnoea Database (ESADA): report from 22 European sleep laboratories. Eur Respir J 38: 635–642.
[43]
El-Solh AA, Moitheennazima B, Akinnusi ME, Churder PM, Lafornara AM (2011) Combined oral appliance and positive airway pressure therapy for obstructive sleep apnea: a pilot study. Sleep Breath 15: 203–208.
