A French survey of 3,225 patients treated with CPAP for obstructive sleep apnoea: benefits, tolerance, compliance and quality of life

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1 Eur Respir J 1998; 12: DOI:.1183/ Prited i UK - all rights reserved Copyright ERS Jourals Ltd 1998 Europea Respiratory Joural ISSN A Frech survey of 3,225 patiets treated with CPAP for obstructive sleep apoea: beefits, tolerace, compliace ad quality of life N. Meslier, T. Lebru +, V. Grillier-Laoir, N. Rollad +, C. Hederick +, J-C. Sailly +, J-L. Racieux aa A Frech survey of 3,225 patiets treated with CPAP for obstructive sleep apoea: beefits, tolerace, compliace ad quality of life. N. Meslier, T. Lebru, V. Grillier-Laoir, N. Rollad, C. Hederick, J-C. Sailly, J-L. Racieux. ERS Jourals Ltd ABSTRACT: The aim of this study was to ivestigate i a large populatio of patiets with obstructive sleep apoea ad o log-term treatmet with cotiuous positive airway pressure (CPAP) the patiets' perceptio of symptomatic improvemet, side-effects ad quality of life. Questioaires were mailed via local respiratory homecare associatios to 5,339 Frech patiets who had bee treated at home for at least 6 moths with CPAP machies ad who cotiued their treatmet. I total, 3,225 questioaires were aalysable. More tha 8% of the respodig patiets reported that CPAP treatmet had greatly improved their symptoms. Despite discomfort related to asal problems ad excess oise from the blower, the mea rate of use for the whole populatio was 6 h 36 mi±2 h 15 mi. The perceived health evaluated by the Nottigham Health Profile was good (mea score <5) for at least 75% of the patiets i each dimesio explored. The perceived health was sigificatly related to the improvemet i symptoms, the overall satisfactio ad the objective compliace. This retrospective study idicates that patiets who cotiued cotiuous positive airway pressure treatmet for more tha 6 moths felt a great improvemet i their symptoms, were satisfied with the treatmet ad had a relatively good perceptio of their health. Eur Respir J 1998; 12: Service de Peumologie, Cetre Hospitalier Uiversitaire Agers, Frace. + CRES- GE (Cetre de Recherches Ecoomiques Sociologiques et de Gestio), Uiversité Catholique de Lille, Frace. ANTADIR (Associatio Natioale pour le Traitemet à Domicile des Isuffisats Respiratoires), Paris, Frace. Correspodece: N. Meslier, Laboratoire d'efr et de Sommeil, Service de Peumologie, CHU, 4 rue Larrey, 4933 Agers Cedex 1, Frace Fax: Keywords: Compliace, log-term treatmet, asal cotiuous positive airway pressure, quality of life, tolerace Received: August Accepted after revisio April This study was performed by ANTADIR with support from the Miistry of Research ad Techology i the domai of "Ecoomic evaluatio of prevetio ad treatmet strategies". Fiacial support was also provided by the Natioal Social Security Office (CNAM) ad CFPO, Pierre Medical ad SEFAM compaies. Sice its first descriptio i 1981 [1], asal cotiuous positive airway pressure (CPAP) has become the treatmet of choice for patiets with obstructive sleep apoea sydrome (OSAS). Its therapeutic efficacy has bee clearly demostrated. Nasal CPAP elimiates apoea, hypopoea ad sorig, ad improves sleep quality ad the symptoms of OSAS, above all the excessive daytime sleepiess [2 5]. Log-term compliace with asal CPAP has bee reported to rage 65 9% [3, 6 14] ad 8 28% of the patiets refuse the treatmet after a oe-ight trial of asal CPAP [ 12]. The use of asal CPAP is ofte associated with complaits of asal problems, oise from the blower ad the icoveiece of the treatmet related to the CPAP machie ad the asal mask [9, 15, 16]. These side-effects ad costraits may affect the compliace [7, 16]. However, oe importat factor ifluecig the compliace is the perceptio of beefits by the patiet [9] ad particularly the improvemet i daytime sleepiess [7,, 16]. Patiets with OSAS have also bee reported to have a deterioratio of geeral health status [17], ad a improvemet i their perceived health status ad quality of life might also ifluece the compliace with asal CPAP. Nasal CPAP was itroduced i Frace i Sice that time, the umber of patiets treated with asal CPAP at home has icreased dramatically. For a large umber of patiets, oce the CPAP treatmet has bee prescribed by a physicia, the CPAP device is provided to the patiet by a local associatio for home care of patiets with respiratory disorders. The local associatios are grouped ito a atioal associatio, Associatio Natioale pour le Traitemet à Domicile des Isuffisats Respiratoires (ANTA- DIR). I each local associatio, techicias visit the patiets three or four times a year ad at each visit they read the built-i time couter of the CPAP device to calculate the mea rate of use per day ad report it to the physicia who iitially prescribed the treatmet. A atiowide survey of patiets treated with CPAP for at least 6 moths was iitiated by ANTADIR i 1993 ad coducted via the local associatios. The aims of this study were to specify the sociodemographic characteristics of the patiets receivig log-term treatmet with CPAP, to aalyse their perceived beefits, tolerace, compliace, overall satisfactio ad quality of life. Methods The survey was coducted betwee Jue ad September Questioaires were mailed via the local associatios

2 186 N. MESLIER ET AL. to all patiets registered with the participatig associatios who were started o asal CPAP at home before Jauary 1, 1993 ad who were still o CPAP at the time of the survey. The questioaires comprised three sectios: 1) a sociodemographic questioaire (age, sex, marital status, educatioal level, socioprofessioal activities); 2) a questioaire o the perceived beefits, tolerace, compliace ad overall satisfactio; ad 3) a validated questioaire o the quality of life (Nottigham Health Profile (NHP), part 1). To evaluate the modificatio of the symptoms observed with asal CPAP, patiets were asked questios o sorig, fragmeted sleep, restless sleep, daytime sleepiess, fatigue, irritability ad morig headache. The possible aswers were: "greatly decreased", "decreased", "uchaged", "icreased" ad "greatly icreased", or "ot cocered" or "do't kow" for each parameter. Patiets were also asked to idicate the three mai improvemets that they had perceived from the treatmet, from 12 proposed aswers. To evaluate the tolerace of asal CPAP, patiets were asked questios o possible side-effects of asal CPAP, tolerace to the asal mask ad the disturbace related to the oise of the device for themselves ad their bedparter. The subjective compliace was evaluated by the followig two questios: 1) Do you use your asal CPAP every ight? If ot, how may ights a week do you use it? 2) Do you use your asal CPAP all ight log? If ot, how may hours a ight do you use it? The overall satisfactio with the treatmet ad with the CPAP device was also ivestigated. Quality of life was assessed usig the NHP [18], traslated ad validated i Frech [19]. The first part of the NHP was used, which icludes 38 items explorig six dimesios of perceived health: eergy, pai, sleep, physical mobility, emotioal reactios ad social isolatio. For each item the aswer is yes (=1) or o (=). Each item is weighted ad a fial score is calculated for each dimesio by addig the weighted aswer of each item. For each dimesio, the score rages from (excellet perceptio of health) to (very poor perceptio of health). The results of the NHP i a age-matched cotrol populatio of 611 (298 males, 313 females) healthy subjects aged 64 yrs, were provided by A. Leplège (Iserm, U292, Le Kremli-Bicêtre, Frace). The patiets retured their questioaires to the local associatio ad the techicias added to the questioaire a record providig details of the machie used by the patiets, the level of pressure ad the readigs of the time couter to eable calculatio of the rate of use. The rate of use was calculated from the last two records of the time couter durig the 6 moths precedig the questioaire. Compliace was calculated as the differece betwee two readigs of the time couter, divided by the umber of days separatig the two readigs. Statistical aalysis All questioaire resposes were tabulated. The statistical aalysis was performed by a statisticia from the CRESGE (Cetre de Recherches Ecoomiques Sociologiques et de Gestio (CRESGE). The frequecy of idividual resposes was couted. Compariso of the distributio of patiets betwee groups was performed usig the test of equality of proportios ad the Ma-Whitey test. Mea values were compared usig the Studet's t-test or the Kolmogorov-Smirov test for the NHP scores. Two-tailed p-values <.5 were cosidered sigificat. Results Descriptio of the populatio Twety-eight of the 32 local associatios participated i the study. At the time of the survey, 5,339 patiets had bee usig CPAP treatmet for at least 6 moths withi these associatios. Of these, 3,593 patiets (67%) aswered the questioaire but 368 questioaires were rejected because of missig data, maily the lack of time couter readigs. Thus, 3,225 questioaires were aalysed. The mea umber of patiets icluded i each associatio was 115 (rage 6 2). The populatio icluded 2,796 males (87%) ad 429 females (13%). Their mea age was 59±11 yrs (media 6 yrs) ad 52% were aged >59 yrs. Eighty per cet of the patiets were married or cohabitig. This percetage is sigificatly higher tha i the geeral Frech populatio over yrs, where the percetage was 7% (p<.5) []. The educatioal level of the patiets differed from that of the Frech populatio by the small umber of subjects without ay diploma (4.5% i the study populatio ad 34% i the Frech populatio; p<.1). Twety-two per cet of the patiets had graduated from high school. The proportio of patiets livig i a rural area was 38%. Twety-ie per cet of the patiets lived i a urba area of more tha 5, ihabitats. The socioprofessioal activities of the populatio did ot differ from the geeral populatio, except for the proportio of white-collar employees, which was lower i the sample tha i the geeral Frech populatio (14 versus 26.5%; p<.5) [21]. Thirty-two per cet of the patiets still had a professioal activity at the time of the survey. Treatmet had bee used for loger tha 1 yr by 78% of the patiets ad for >4 yrs by 9%. The mea CPAP level was 9.9±2.4 cmh 2 O. Pressure raged 8 12 cmh 2 O i 72% of the patiets. It was <8 cmh 2 O i 14.6% ad >12 for 13.4% of patiets (fig. 1). Twelve CPAP devices from six differet compaies were used. A humidifier was used by 18% of the patiets. The CPAP device had bee chaged i 37% of the patiets. The mai reasos were CPAP dysfuctio, the oise of the blower ad the prescriptio of devices icludig a humidifier. Most patiets used a stadard asal mask, 5% used a airway delivery ad maagemet (ADAM) circuit ad 11% of the patiets used idividually moulded asal masks. Efficacy Assessmet of chages i symptoms with CPAP showed that iitially the patiets were highly symptomatic. The frequecy of the mai symptoms before CPAP was 9% for sorig, fatigue ad daytime sleepiess, 89% for fragmeted sleep ad 8% for restless sleep. Irritability or depressio had bee preset i 57% of the populatio ad morig headache had bee less frequet (49%).

3 CPAP TREATMENT FOR OBSTRUCTIVE SLEEP APNOEA 187 Patiets % 3 4 Sixty-ie per cet of the patiets complaied simultaeously of sorig, fatigue, daytime sleepiess, restless sleep ad fragmeted sleep prior to CPAP. Four of these five symptoms were preset i 87% of the patiets. The percetage of patiets who cosidered that their symptoms had decreased or greatly decreased owig to CPAP was 92% for sorig, 86% for daytime sleepiess, 83% for fatigue ad restless sleep ad 78% for fragmeted sleep. A improvemet i irritability or depressio was reported by 65% of the patiets. Morig headache was decreased i 66% of the patiets (fig. 2). Three per cet of the patiets reported o improvemet i ay symptom. The replies o the three mai improvemets perceived followig treatmet (table 1) showed that the most frequet aswers were better quality of sleep, a reductio i sorig ad a reductio i daytime sleepiess. Nearly 7% of the 1,28 patiets at work cosidered that their work was easier sice the treatmet. Tolerace >15 Pressure level cmh 2 O Fig. 1. Distributio of patiets accordig to the cotiuous positive airway pressure level (cmh 2 O) used at the time of the survey. Tolerace to the asal mask was good i 42% of the patiets ad very good i 15%. It was poor or very poor i Patiets % SN Frag Rest Day Fat Irr, Dep Head Symptom Fig. 2. Chages i symptoms perceived by patiets ad attributed to cotiuous positive airway pressure treatmet. : greatly decreased; : decreased; : uchaged; : icreased; : greatly icreased. SN: sorig; Frag: fragmeted sleep; Rest: restless sleep; Day: daytime sleepiess; Fat: fatigue; Irr, Dep: irritability or depressio; Head: morig headache. Table 1. Mai improvemets perceived by the patiets treated with cotiuous positive airway pressure (CPAP) for at least 6 moths Proposed aswers Percetage of patiets metioig this aswer I have a better quality of sleep I feel more refreshed whe I wake up I feel less tired durig the day I feel less sleepy durig the day I feel i better coditio durig the day I am less irritable, I am i a better mood I have a better memory I breathe more easily My sleep is less fragmeted I feel more secure while drivig My sorig has decreased My sexual activity has improved 9%. The two most frequet complaits were dry mouth ad throat (52.2%) ad, for patiets who did ot live aloe, the oise of the blower disturbig their bedparter (47%). May patiets complaied of side-effects related to the ose: cogestio (26%), soreess (27%) ad drippy ose (24%). Red eyes or cojuctivitis were reported by 28% of the populatio. The blower was too oisy for 15% of the patiets themselves. There was o differece i the frequecy of most of the complaits betwee patiets treated for <1 yr ad patiets treated for a loger time. However, a drippy ose was more frequet i patiets treated for >1 yr tha i patiets treated for <1 yr (p<.5). The pressure level had some ifluece o two complaits: a dry mouth ad a drippy ose were more frequet i patiets with a pressure level >12 cmh 2 O tha i patiets with a pressure <8 cmh 2 O. Compliace ad overall satisfactio Patiets were asked to metio the three mai improvemets they had perceived from their CPAP treatmet. Resposes to the questioaire evaluatig compliace showed that 89% of the patiets reported that they used their CPAP every ight. The others said that they used it o average for 4 ights a week. Usage of the CPAP all ight log was reported by 76% of the patiets. Those who did ot, said they used it for 5 h a ight. Good compliace, i.e. every ight ad all ight log, was reported by 73% of the respodets ad poor compliace, i.e. either every ight or all ight log, by 8% of them. Readigs of the built-i time couter showed a mea rate of use for the whole respodig populatio of 6 h 36 mi±2 h 15 mi. The rate of use was loger tha 4 h ight -1 for 86% of the patiets (fig. 3). There was a good agreemet betwee the patiets' reported compliace ad the use calculated from the time couter. Patiets with good self-reported compliace had a mea rate of use of 7 h 17 mi. The rate of use was 5 h mi for patiets who reported itermediate compliace, i.e. either every ight but ot all ight log or ot every ight but all ight log, ad 3 h 3 mi for patiets with poor compliace (table 2). There was a sigificat relatioship betwee the objective compliace calculated from the time couter ad the improvemet i symptoms ad the tolerace of the treatmet (table 3). Patiets who reported a great improvemet i sorig ad

4 188 N. MESLIER ET AL. Patiets % > Time h Fig. 3. Compliace (mea daily rate of use) calculated from the time couter. Table 2. Compariso betwee the self-reported use ad the daily use rate calculated from the time couter All ight log Not all ight log Every ight Not every ight =236 (73%) 7 h 17 mi (1 h 47 mi) =4 (3%) 5 h mi (2 h 33 mi) =512 (16%) 5 h mi (1 h 51 mi) =248 (8%) 3 h 3 mi (2 h 13 mi) For each aswer, the first umber represets the umber of patiets (% of the populatio) ad the secod umber idicates the mea daily use rate calculated from the time couter (SD). Table 3. Relatioship betwee the objective compliace ad the improvemet i symptoms, tolerace ad overall satisfactio Rate of use per ight <4 h 4 7 h Š7 h + % % % Sorig Greatly decreased Daytime sleepiess Greatly decreased Fatigue Greatly decreased Mask tolerace Very good or good Satisfactio with the device Very satisfied Satisfactio with the therapy Very satisfied : The rate of use was calculated from the time couter. + : umber of patiets givig the correspodig aswer. For each item the sum of the two umbers is ot equal to 3,225 patiets as some patiets did ot aswer the item. : for each compliace category, the umber of patiets is expressed as a percetage of the total umber of patiets who gave the same respose to the questioaire. daytime sleepiess had a better compliace tha patiets whose sorig or daytime sleepiess was less reduced or uchaged or icreased (p<.1). Good or very good tolerace to the asal mask was also associated with better compliace (p<.1). There was o ifluece of the pressure level o the compliace. The overall satisfactio with the CPAP device was good for 59% ad very good for 31% of the patiets. Eight per cet of the patiets could ot say whether they were satisfied or ot. The overall satisfactio with the results of the treatmet was eve greater, as 93% of the patiets were satisfied or very satisfied. Six per cet were either satisfied or usatisfied. The overall satisfactio was sigificatly correlated with the compliace (p<.1) (table 3). Nottigham Health Profile Amog the 38 items of the NHP, the most frequet aswers were: "I soo ru out of eergy" (55% of patiets), "I fid it hard to stad for log" (46%), "I have trouble gettig up ad dowstairs" (46%) ad "I fid it hard to bed" (%). The lowest score (9.9) was observed for the dimesio of social isolatio. The worst perceived dimesio was eergy, with a mea score of The scores were 21.4 for physical mobility, 19.2 for sleep, 17.7 for pai ad 13.8 for emotioal reactios. Fiftee per cet of the patiets had a very bad perceptio of the dimesio eergy, with a score of, whereas the percetage of patiets with a score of i the other dimesios was <2.5% (fig. 4). The percetage of patiets with a rather good perceptio of their status (score <5) was 77% for physical mobility ad 92% for emotioal reactios. The percetage of patiets with a very good perceptio, i.e. a score of, was oly 25% for physical mobility. It raged 5% for eergy, sleep, pai ad emotioal reactios ad reached 74% for social isolatio. O average, OSAS patiets treated with CPAP had a good perceptio of their health, with a score of i at least four of six dimesios i % of the patiets. Patiets older tha 6 yrs had a poorer perceptio of their health tha patiets <6 yrs old. The score was sigificatly higher for eergy, physical mobility, sleep, pai Patiets % 8 6 EN Phys Sleep Soc Category Pai Emot Fig. 4. Distributio of patiets i each dimesio of the Nottigham Health Profile accordig to score categories. : ; : 25; : 25 5; : 5 75; : 75 ; :. EN: eergy; Phys: physical mobility; Soc: social isolatio; Emot: emotioal reactios. There was o patiet i the score categories 25 ad 75 for EN.

5 CPAP TREATMENT FOR OBSTRUCTIVE SLEEP APNOEA 189 ad social isolatio (p<.1). They had a better perceptio of emotioal reactios (p<.1). Females with OSAS treated with CPAP had a poorer perceptio of their health tha males. The mea score for eergy was 31.8±35.4 for males ad.2±38.3 for females (p<.1). The differece betwee males ad females was sigificat for each dimesio, eve o the best perceived dimesio, social isolatio (mea score 8.9± 19.4 for males ad 16.3±24.4 for females; p<.1). The percetage of patiets who did ot feel isolated at all was 76% i males ad oly 61% i females (p<.1). A compariso of healthy subjects aged 64 yrs with patiets of the preset populatio withi the same age rage showed that females ad males treated with CPAP had a poorer perceptio of their health tha ormal cotrols. The differece i the mea score was sigificat for each dimesio for females (p<.1) (fig. 5a) ad for eergy, physical mobility, sleep ad social isolatio (p<.1) for males (fig. 5b). The greatest differeces betwee our patiets ad healthy subjects were observed for eergy ad physical mobility. For the other dimesios, the differece was sigificat but small. For each dimesio, the perceptio of health was better for patiets who were very satisfied with the treatmet tha for the others (p<.1) ad for patiets who reported that their symptoms (sorig, daytime sleepiess, fatigue, restless sleep or fragmeted sleep) were greatly reduced (p<.1). Aalysis of the quality of life with regard to the objective compliace (table 4) showed that patiets with a itermediate compliace (use per ight 4 7 h) had a a) 5 Score b) Score EN Phys Sleep Soc Pai Emot Category Fig. 5. Compariso of the Nottigham Health Profile scores betwee healthy subjects aged 64 yrs ( ) ad patiets of the study populatio i the same age rage ( ) for a) females ad b) males. EN: eergy; Phys: physical mobility; Soc: social isolatio; Emot: emotioal reactios. : p<.5. NS NS Table 4. Relatioship betwee the objective compliace ad the perceptio of quality of life evaluated by the six dimesios explored by the Nottigham Health Profile Rate of use per ight <4 h 4 7 h Š7 h Eergy mea score Physical mobility mea score Sleep mea score Social isolatio mea score Pai mea score Emotioal reactios mea score ± ± ± ± ± ±22.8 better perceptio of their health tha poorly compliat patiets (use per ight <4 h). They had also a better perceptio of their health tha very compliat patiets (use per ight >7 h) i all dimesios except sleep. Very compliat patiets differed from poorly compliat patiets by a lower score, i.e. a better perceptio i emotioal reactios (p<.5) ad sleep (p<.1). Discussio ± ± ± ± ± ± ± ± ±24.3 ## ± ± ±21.2 # : The rate of use was calculated from the time couter. Compariso betwee patiets with poor ad itermediate compliace: : p<.5; : p<.1; betwee patiets with itermediate ad good compliace: : p<.1; betwee patiets with poor ad good compliace: # : p<.5, ## : p<.1. This study of a populatio of more tha 3, patiets from differet areas of Frace showed that more tha 7% of OSAS patiets treated with CPAP for at least 6 moths ad who respoded to the questioaire had a good compliace with the treatmet ad that the compliace was related to the perceived beefits, tolerace ad overall satisfactio with the treatmet. Their geeral health status or quality of life, although good, remaied lower tha that of healthy subjects. This retrospective study aimed to describe a atiowide populatio of patiets who were treated with CPAP i Frace. This survey was coducted via the local associatios deliverig the CPAP devices. The CPAP treatmet was prescribed by physicias whose criteria for decidig to treat with CPAP were ot kow from the associatios. However, i Frace, at the time of the survey, there was o apoea/hypopoea idex (AHI) criterio for reimbursemet of CPAP by the social security system. No iformatio could be obtaied o the percetage of patiets who refused home treatmet with CPAP. To have a idea of the percetage of patiets who abadoed their treatmet, data from the ANTADIR Observatory, which regroups 25 local associatios, were aalysed. Betwee 1985 ad December 1992 asal CPAP was istalled at home i 5,283 patiets.

6 19 N. MESLIER ET AL. Durig this period, 75 (14%) discotiued their treatmet. As 23 of these associatios participated i the preset survey, this percetage ca be assumed to be represetative of the Frech patiets treated via the local associatios. This retrospective study may be affected by bias iheret i this kid of study. The patiets who retured questioaires (67%) might be the most compliat ad satisfied patiets, as suggested by HOFFSTEIN et al. [9]. To evaluate this bias, the results from 12 associatios (1,541 patiets) where the respose rate was at least 75% (mea respose rate 84%) were compared with the results from 16 associatios (1,684 patiets) where the respose rate was lower tha 75% (mea respose rate 51%). A low respose rate was ot associated with a greater improvemet i symptoms or a higher compliace or a better quality of life. Eve though this bias caot be completely excluded, the differece i the respose rate betwee the 28 associatios does ot appear to be related to patiet compliace ad satisfactio. The daily rate of use by each patiet was assessed from the time couter ad calculated from the last two records before the survey. Thus, the time for which the CPAP uit power was o was calculated. It has already bee show that the effective use (time for which the effective pressure was applied) represets 89 97% of the ruig time [13, 14, 16, 22]. It was foud that 2,783 (86%) patiets who respoded had a CPAP rate of use >4 h. I 95 patiets treated for at least 1 yr, PIETERS et al. [23] foud that 74% of patiets used their CPAP device for >4 h ight -1. Cosiderig the worst hypothesis, i.e. that all patiets who did ot respod had a poor compliace, the percetage of the whole populatio (5,339 patiets) usig their CPAP device for at least 4 h ight -1 will be 52%. This hypothesis was cosidered to be ulikely as the mea daily use rate observed i this populatio (6 h 36 mi) was similar to the compliace observed i other studies [8, 23 26] ad especially i studies [15, 22] o patiets who did ot reject the treatmet early o ad were treated chroically (6.5 h ad 7.1 h, respectively). The preset study does ot provide iformatio o the compliace with CPAP of OSAS patiets i geeral, but o patiets chroically treated ad who did ot reject the treatmet. The patiets were treated for at least 6 moths ad 78% for >1 yr. Thus, either patiets with very poor compliace who usually discotiued CPAP durig the iitial period of treatmet, i.e. after 4 moths or less of treatmet [7, 9, 27], or patiets who rejected their treatmet later o were icluded i this study. This may explai the low percetage of patiets who perceived o beefits at all from the treatmet (3%). The percetage of patiets cotiuig treatmet whilst they perceived o beefits is similar to percetages observed i other studies o chroically treated patiets, which were 6.4% [9] ad 1% [15]. A relatioship was foud betwee the rate of use measured by the time couter ad the improvemet i symptoms ad, particularly, i daytime sleepiess ad sorig. This lik betwee compliace ad perceived beefits has bee observed i previous studies [7, 9,, 24, 26]. Most of the complaits were related to asal problems, but also to the oise of the blower, which disturbed the bedparter. More tha 5% of the patiets had experieced at least oe asal problem sice they started CPAP treatmet. These side-effects do ot appear to chage over time as the percetage of patiets complaiig of sideeffects was similar i patiets treated for less ad for >1 yr, with oe exceptio: the frequecy of drippy ose was greater i patiets treated for >1 yr. Such a high percetage of side-effects has bee reported previously [9, 15, 24] ad it is ot surprisig that they affect the compliace. There was a higher rate of use i patiets who reported good or very good tolerace to the asal mask. Ideed, mask itolerace has bee show, together with the lack of perceived beefits, as oe of the mai reasos for discotiuig CPAP [7]. Despite the high percetage of side-effects ad the discomfort due to the mask, most patiets who respoded to the questioaire were satisfied or very satisfied with either the CPAP device or the results of the therapy. I this populatio treated with asal CPAP for at least 6 moths ad up to 8 yrs, satisfactio with the treatmet reached 93%. Log-term compliace with CPAP was also related to the degree of satisfactio. KRIBBS et al. [16] also foud a better satisfactio score i regular users of CPAP tha i irregular users. No ifluece of the pressure level was foud, either o the perceived beefits, the tolerace, the compliace or the overall satisfactio with the treatmet. These results are cosistet with a previous report [15]. Thus, the cliical usefuless of "itelliget" CPAP desiged to deliver the lowest possible pressure to prevet respiratory disorders [28, 29] remais to be evaluated. Very few studies have assessed the quality of life of patiets with OSAS before treatmet [17] or the ifluece of CPAP treatmet o quality of life [14, 3]. KRIBBS et al. [3] used the sickess impact profile to measure health ratig ad foud a improvemet from pretreatmet to post-treatmet after a mea treatmet duratio of 2 3 moths. ENGLEMAN et al. [14] used part 2 of the NHP to evaluate the ifluece of 4 weeks' treatmet with asal CPAP. They foud a improvemet i the social life, sex life ad ability to carry out domestic chores. I the preset study, the quality of life of patiets treated with CPAP was evaluated usig part 1 of the NHP. This geeral health-status questioaire ivestigates multiple dimesios of health that may be affected by OSAS, e.g. sleep ad eergy. It is simple ad most patiets are able to complete the questioaire i a few miutes. It has bee traslated ad validated i Frech ad data from healthy Frech subjects are available. This questioaire has also bee used by FORNAS et al. [17] i utreated OSAS patiets. They showed that OSAS patiets had a poorer perceptio of their health tha cotrol subjects i all NHP dimesios except for emotioal reactios. The worst perceived dimesios were eergy, sleep ad emotioal reactios. I treated patiets eergy was also foud to be the worst perceived dimesio. However, the results idicate that OSAS patiets treated with CPAP have a rather good perceptio of their health, as the mea score was lower tha 25 for all dimesios except for eergy ad % of the patiets had a score of i at least four of six dimesios. Compariso of the preset populatio with the utreated populatio studied by FORNAS et al. [17] is difficult as they did ot calculate weighted scores. Furthermore, their cotrol group was composed of osorig healthy subjects who were ot radomly selected ad ot represetative of the geeral populatio.

7 CPAP TREATMENT FOR OBSTRUCTIVE SLEEP APNOEA 191 The two studies evaluatig pretreatmet ad post-treatmet quality of life i OSAS usig differet questioaires [14, 3] showed a improvemet with CPAP treatmet but did ot compare the study populatio to healthy subjects. Compariso betwee healthy subjects ad our patiets withi the same age rage shows that patiets with OSAS treated with CPAP have a differet perceptio of their health. The mai differeces are observed for eergy ad physical mobility, ad social isolatio for females. I the preset study populatio, females had a more egative perceptio of their health tha males. However, this differece betwee females ad males is also observed i healthy subjects. The differece i the quality of life betwee OSAS patiets ad healthy subjects might be related to coditios usually associated with OSAS, such as obesity, hypertesio, cardiovascular diseases ad diabetes. A relatioship was also foud betwee the quality of life ad the perceived beefits ad overall satisfactio with the treatmet. Patiets whose symptoms were greatly improved ad who were very satisfied with the treatmet had a better perceptio of their health tha the other patiets. The relatioship betwee quality of life ad compliace is less clear, as quality of life was better i patiets with itermediate compliace tha i patiets with good compliace ad quality of life of very compliat patiets was differet from poorly compliat patiets for oly sleep ad emotioal reactios. It ca be speculated that very compliat patiets, who are ofte patiets with more severe OSAS [6, 9, 13, 3] ad are usually more obese [6, 9], more frequetly have associated diseases ad that i these subjects sleep apoea is ot the oly coditio that may affect perceived health. 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