Long-term Compliance with Nasal Continuous Positive Airway Pressure Therapy: DISCUSSION part 2

Compliant and noncompliant patients were not distinguished by age, sex, or weight at the time of presentation. Each group had equally severe OSA as measured by AHI and the degree of nocturnal oxygen desaturation. Noncompliant patients responded as well as compliant patients to nasal CPAP with dramatic reductions in apneas and less severe oxygen desatur­ation. No significant differences were noted in the prescribed level of nasal CPAP or in weight change.

Differences were noted between the compliant and noncompliant patients in the severity of daytime sleepiness and history of previous palatal surgery. Severe daytime sleepiness was significantly more frequent in the compliant group (p = 0.0004). Issa et al acknowledged the importance of this symptom and observed that the reemergence of daytime hyper- somnolence was the single most important motive for resumption of therapy in their noncompliant patients. levitra professional

A history of UPPP was more common in the noncompliant group (p = 0.004, Fishers exact test). UPPP conceivably might result in anatomic changes in the posterior pharynx that affect patient comfort while using nasal CPAP. For example, incomplete closure of the oral airway by the soft palate might lead to an increased air leak through the mouth. However, analysis of the adverse reactions of patients with previous UPPP does not support this hypothesis. There was no significant difference in the frequency or variety of adverse reactions reported by the UPPP group. Patients with UPPP did not refuse home therapy more often nor did they discontinue therapy earlier than other noncompliant patients. There was also no significant difference in the frequency or variety of adverse reactions reported by noncompliant patients with previous UPPP and the other noncom­pliant patients. Further analysis of the subgroup with previous palatal surgery revealed a lower overall percentage with severe daytime sleepiness (75 per­cent) compared with all patients receiving home nasal

CPAP (80 percent). All patients in the compliant UPPP group complained of severe daytime sleepiness (ten of ten) whereas only five of ten who were noncompliant after UPPP reported this symptom (p<0.05, Fishers exact test). Therefore, a lower prevalence of daytime hypersomnolence may be partially responsible for the significant number of noncompliant patients in the UPPP group. Were patients with previous UPPP more likely to be noncompliant because of a self-selection bias against nasal CPAP? This seems unlikely since 20 of the 22 patients with UPPP were referred from ear, nose, and throat physicians after failure of surgery and 15 of 22 patients had their surgery prior to the time nasal CPAP was available at our center.

Our data suggest that severe subjective daytime sleepiness that resolves with therapy is correlated with long-term compliance with home nasal CPAP therapy of OSA. Patients without the subjective complaint of daytime sleepiness may be less inclined to tolerate the inconvenience and adverse reactions associated with nasal CPAP. Multiple sleep latency testing was not available for all our patients but might corroborate subjective hypersomnolence. The elimination of day­time sleepiness with nasal CPAP suggests that other causes of daytime sleepiness besides sleep apnea (such as narcolepsy or periodic leg movements) were not clinically important. Age, sex, severity of OSA, or a complete response to therapy did not seem to influ­ence long-term compliance significantly.
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This review also serves to emphasize the importance of continued follow-up in patients with OSA. Ninety percent of the noncompliant patients discontinued therapy in the first year. Eleven of 23 patients sought no alternative treatment for their OSA yet presumably continued to suffer from severe sleep disruption and nocturnal oxygen desaturation. Few of our patients were able to achieve sufficient weight reduction, even while receiving nasal CPAP, to obviate the need for further therapy. In a recent retrospective analysis He and associates reported an increased mortality for patients with OSA with an apnea index greater than 20 and for patients with UPPP with persistent OSA after surgery. Periodic surveillance of patient compli­ance and response to therapy would certainly seem warranted in these groups. For patients with persistent OSA who cannot comply with nasal CPAP therapy, alternative treatments, medical or surgical, should be considered.

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Tags: Airway Pressure, Long-term Compliance, Nasal Continuous

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