Auto-titrating versus fixed continuous positive airway pressure for the treatment of obstructive sleep apnea: a systematic review with meta-analyses

Abstract

BackgroundObstructive sleep apnea is a relatively common disorder that can lead to lost productivity and cardiovascular disease. The form of positive airway treatment that should be offered is unclear.MethodsMEDLINE and the Cochrane Central Trials registry were searched for English language randomized controlled trials comparing auto-titrating positive airway pressure (APAP) with continuous positive airway pressure (CPAP) in adults with obstructive sleep apnea (inception through 9/2010). Six researchers extracted information on study design, potential bias, patient characteristics, interventions and outcomes. Data for each study were extracted by one reviewer and confirmed by another. Random effects model meta-analyses were performed for selected outcomes.ResultsTwenty-four randomized controlled trials met the inclusion criteria. In individual studies, APAP and fixed CPAP resulted in similar changes from baseline in the apnea-hypopnea index, most other sleep study measures and quality of life. By meta-analysis, APAP improved compliance by 11 minutes per night (95% CI, 3 to 19 minutes) and reduced sleepiness as measured by the Epworth Sleepiness Scale by 0.5 points (95% CI, 0.8 to 0.2 point reduction) compared with fixed CPAP. Fixed CPAP improved minimum oxygen saturation by 1.3% more than APAP (95% CI, 0.4 to 2.2%). Studies had relatively short follow-up and generally excluded patients with significant comorbidities. No study reported on objective clinical outcomes.ConclusionsStatistically significant differences were found but clinical importance is unclear. Because the treatment effects are similar between APAP and CPAP, the therapy of choice may depend on other factors such as patient preference, specific reasons for non-compliance and cost.

Impact of Treatment with Continuous Positive Airway Pressure (CPAP) on Weight in Obstructive Sleep Apnea

“…However, the levels of adherence in this study are similar to those in other long-term randomized controlled trials. 13,14,32 Furthermore, given our current findings, greater adherence would likely have made the differences in weight between CPAP and Sham even more striking. Second, in comparison to the CPAP group, more participants in the Sham group failed to complete the study.…”

Effect of Heated Humidification on CPAP Therapy Adherence in Subjects With Obstructive Sleep Apnea With Nasopharyngeal Symptoms

“…All of our subjects resided in Bangkok or a neighboring province with reported outdoor relative humidity over the year of approximately 80% (according to World Weather & Climate Information, www.weather-andclimate.com. Accessed January 22,2016). This substantially lower average relative humidity was mostly explained by the effect of air conditioners.…”

“…However, this improvement may be substantial when compared with autotitrating CPAP, which provides only an additional 11 min compared with conventional fixed-pressure CPAP. 22 Autotitrating CPAP also generally yields a more expensive cost compared with adding heated humidification; in particular, some newer CPAP devices have built-in heated humidification with a cost comparable with that of conventional CPAP. Because our study lasted for only 4 weeks, a study with a longer duration is needed to confirm the clinical benefit and cost-effectiveness of adding heated humidification to CPAP in OSA treatment.…”

Advanced Positive Airway Pressure Modalities

“…A more recent randomized 6-week trial in almost 200 unselected patients showed a more modest difference in adherence of 0.2 h per night (12 min) and a small difference in sleepiness between APAP and CPAP [20]. Meta-analyses of randomized trials in mostly CPAP naïve patients have consistently shown small but usually statistically significant differences in adherence of 11-14 min per night favoring APAP [21][22][23][24]. A Cochrane review found no difference in residual AHI; however, there was a very small but significant difference in the Epworth Sleepiness Scale of 0.5 points favoring APAP [22].…”