Adherence with continuous positive airway pressure (CPAP)
- Terri Weaver, PhD, RN, FAAN
Terri Weaver, PhD, RN, FAAN
- Professor and Dean, College of Nursing
- University of Illinois at Chicago
Obstructive sleep apnea (OSA) is a disorder that is characterized by obstructive apneas and hypopneas due to repetitive collapse of the upper airway during sleep. Continuous positive airway pressure (CPAP) is an effective therapy for OSA, but adherence is suboptimal . The prevalence, consequences, and identification of nonadherence will be reviewed here. Interventions that may improve adherence are also discussed. Initiation of CPAP therapy is described separately. (See "Initiation of positive airway pressure therapy for obstructive sleep apnea in adults".)
Definition — There is no consensus on the definition of nonadherent use to CPAP treatment. We suggest that less than four hours be used as a general metric, since several studies have shown that normalization of daytime sleepiness, quality of life, and neurocognitive function improve with four or more hours of use [1-4]. Improvements in cardiovascular disease conditions and diabetes have also been greater in those using CPAP for greater than four hours [5-7]. Studies have used four hours as the cutoff point differentiating adherence and nonadherence to the treatment, and consequently insurers have also adopted this cutoff. However, outcome expectations should be individually defined to determine the appropriate target for nightly usage.
The expectation of nightly use is dependent upon patient goals. For example, one study showed that in those who have impaired levels on several salient outcomes, the duration of use to achieve a normal value depends on the metric . If the goal is to improve self-reported sleepiness, four hours of use was sufficient to achieve a normal score on the Epworth Sleepiness Scale . In evaluating fitness for duty in a commercial truck driver, six hours would be needed to achieve a normal level of objective alertness in the multiple sleep latency test, and 7.5 hours would be required to improve to normal daytime functioning on the Functional Outcomes of Sleep Questionnaire . Five hours of use improved neurobehavioral performance .
Prevalence — It is estimated that 29 to 83 percent of patients are nonadherent, when nonadherence is defined as a mean of ≤4 hours of use per night [1,8]. The mean duration of use is only three hours per night (on those nights when it is used) among patients who are nonadherent. In contrast, the mean duration of CPAP use is six hours per night among patients who use it every night as directed . Overall, the average duration of CPAP use is approximately five hours per night across numerous studies . Studies indicate that greater than six hours per night results in normal levels of objectively measured and self-reported daytime sleepiness, as well as significantly improved memory and daily functioning [2,3,10].
Patients generally make the decision to adhere to CPAP therapy early during the first week of therapy, usually by the second to fourth day [1,11-13]. Those who adhere generally increase their duration of nightly use gradually. As an example, one study demonstrated that patients who used CPAP for more than two years increased their duration of use approximately eight minutes per night during each year of therapy .
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