CPAP The Treatment of Choice for Patients with OSA

Transcription

1 CPAP The Treatment of Choice for Patients with OSA Samuel T. Kuna, M.D. Department of Medicine Center for Sleep and Respiratory Neurobiology University of Pennsylvania Pulmonary, Critical Care & Sleep Section Philadelphia VAMC

2 CPAP The Treatment of Choice for Patients with OSA Outline of Presentation CPAP is a highly efficacious treatment for OSA Objective measurement of CPAP adherence Predictors of CPAP adherence CPAP adherence and neighborhood socioeconomic status Optimal nightly use of CPAP treatment Preliminary results from the CATNAP study

3 CPAP An Efficacious Treatment Staging Split Night Polysomnogram Respiratory Oximetr y Body Position CPAP

4 Nasal CPAP - A Pneumatic Splint Pressure AASM practice parameters for use of CPAP. Sleep. 29(3): , 2006.

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6 Patterns of CPAP Adherence

7 Patterns of CPAP Adherence

8 Bimodal Distribution of CPAP Use % Subjects Week Weaver et al. Sleep 20:278-83, 1997

9 Objectively Measured CPAP Adherence CPAP used less frequently than prescribed Patients underestimate their use of CPAP Mask on-time is 90% of power on-time CPAP adherence comparable to that for other medical treatments Kribbs et al. ARRD 147: , 1993

10 Relationship Btwn Nightly Hours of CPAP Use and Normalization of Outcomes ESS FOSQ MSLT Weaver et al. Sleep 30: 711-9, 2007

11 CATNAP Study Double blind, randomized, placebo-controlled, parallel groups study of the functional improvement efficacy of CPAP treatment in patients with mild to moderate OSA (AHI 5 30 events/hr Epworth Sleepiness Scale 11 Patients were randomized to either: 8 weeks of active nasal CPAP or 8 weeks of sham treatment followed by 8 weeks of cross-over, open label active treatment.

12 CATNAP Sites Long Island Jewish New York Univ. Western Ontario Web Portal Penn PSG Reading Lab Emory Univ. National Jewish Center Data Coordinating Center Penn

13 Sham CPAP as a Placebo Intervention

14 Screened (n = 385) Inclusion/Exclusion Criteria not met (n = 61); Not interested in participating (n = 43) Randomized (n = 281) Baseline Assessment (n = 239) Withdrew pre-intervention (n = 42) Active CPAP (n = 121) Sham CPAP (n = 118) Withdrew (n = 8) Withdrew (n = 8) 8 week Follow-up Assessment

15 FOSQ Total Score Mean Changes (SD) from Baseline to Week 8 by Group in the Primary Efficacy Cohort (mitt) Mean change (SD) FOSQ Total Score mean change ES= 0.41 (95% CI 0.14 to 0.67) LSE of dif. in mean change 0.95 (SE=0.34) with p=0.006 mean change Active (N=113) Sham (N=110)

16 What Predicts CPAP Adherence? Initial Clinic Visit Baseline Assessment Education Mode of Testing CPAP Treatment CPAP Adherence Outcomes

17 What Factors Predict CPAP Adherence? Presence of excessive daytime sleepiness Severity of OSA (apnea-hypopnea index) Education/support programs at CPAP initiation In-line humidification Bed partner Self-referral Mask interface No conclusive evidence that adherence is determined by pressure level, Cflex, autocpap, or bilevel pressure support

18 Short Course Eszopiclone on CPAP Adherence Nights Used, hr/night Nights Used, % Week --- Eszopiclone --- Placebo Week Lettieri et al. Ann Intern Med 151: , 2009

19 Race as a Predictor of CPAP Adherence Hours of CPAP Use Caucasians (n = 34) African Americans (n = 28) 0 One Week One Month Sawyer A. (personal communication)

20 Philadelphia: A Tale of Two Cities? CPAP Adherence and Neighborhood Socioeconomic Status Platt et al. Sleep 32(6): , 2009

21 Methods Retrospective cohort study, Philadelphia VAMC (n = 266) New diagnosis OSA, starting on CPAP ( ) Patient address Zip+4 US Census 2000 US Census block group data: Median household income % Adults with high school education % Employment % Racial composition (percent minority) % Married households Outcome: Objective CPAP adherence 4 hrs/day in first week of treatment Platt et al. Sleep 32(6): , 2009

22 Odds Ratio Demographic and Clinical Variables (95% CI) Age (per 10 years) 1.1 ( ).39 Race Black (vs. white) 0.9 ( ).64 Married (vs. not married) 1.7 ( ).002 Employment (vs. other) Occupation Listed 1.4 ( ).18 Retired Unadjusted Results Unattended Diagnostic PSG (vs. in-lab) 1.3 ( ) Charlson Index 2 (versus 1) 0.8 ( ).20 BMI (per SD) and AHI (per SD) 1.0 ( ).56 Epworth total score (per SD) 1.0 ( ) ( ) P value Neighborhood Socioeconomic Index 1.4 ( ) < Platt et al. Sleep 32(6): , 2009

23 Adjusted Results Variable Odds Ratio (95% CI) p-value Neighborhood Socioeconomic Index (per SD change) 1.4 ( ) <.001 Age (per 10 years) 1.1 ( ).21 Race Black (vs. white) 1.2 ( ).66 Married (vs. not married) 1.4 ( ).08 Employment Occupation Listed (vs. other) 1.4 ( ).19 Retired 1.1 ( ) Charlson Index 2 (vs 1) 0.9 ( ).52 Platt et al. Sleep 32(6): , 2009

24 CPAP Adherence and Neighborhood Socioeconomic Status Platt et al. Sleep 32(6): , 2009

25 CPAP The Treatment of Choice for Obstructive Sleep Apnea CPAP is a highly efficacious treatment for OSA Adherence to CPAP should be objectively assessed Long term adherence is determined in the first few days of treatment We lack good predictors of whether patients will adhere to CPAP treatment CPAP adherence is associated with neighborhood socioeconomic status and medication adherence Differential response in measures of daytime sleepiness regarding minimum daily hours of CPAP use needed to effect a maximal response.