Positive Pressure Therapy: A Perspective on Evidence-based Outcomes and Methods of Application

Abstract

The sleep medicine community has increasingly recognized the necessity that clinical care be based on high-quality levels of evidence. Although research supports a favorable influence of positive airway pressure (PAP) therapy on risk for significant adverse outcomes in patients with severe obstructive sleep apnea-hypopnea (OSAH), welldesigned trials are still required to elucidate the effect of PAP on health, quality of life, and economic risks in patients with milder OSAH. Similarly, although there is strong evidence supporting various PAP titration strategies and PAP modalities in patients with severe OSAH without significant medical and psychiatric comorbidities, there is insufficient high-level evidence assessing and comparing the clinical efficacy and health care cost implications of various titration paradigms and various PAP modalities in individuals with milder OSAH and those with comorbid conditions. For ethical and other reasons, it may not be possible to apply a randomized controlled design to address all questions. However, whichever design is employed, it must be rigorously developed with attention to all potential confounders with adequate power to provide compelling, high-quality evidence.Keywords: obstructive sleep apnea; positive airway pressure; therapy of sleep apnea Wright and colleagues generated considerable self-examination within the field of sleep medicine with the publication of their literature review of the health consequences of obstructive sleep apnea-hypopnea (OSAH) and the effectiveness of continuous positive airway pressure (CPAP) therapy for this disorder (1). The authors concluded that perhaps with the exception of reducing sleepiness and motor vehicle crashes, evidence of benefit from treatment with CPAP was, at best, weak. Wright and coworkers supported their contention by citing numerous flaws in the studies that were published to that time. Inadequacies were identified in research design and analyses, including lack of randomized controlled trials, as well as failure to account for carryover effects and potential confounders.It is evident that well-designed and conducted randomized controlled trials (RCTs) yield high-quality evidence, but they carry costs as well as benefits. Several authors (2-4) have asserted that the hierarchy of research design quality, as reflected by the evidence-grading pyramid, is flawed and artificial, with the results of many well-done non-RCTs withstanding the test of time. It has been further argued that RCT design may rigidly restrict the intervention to a single paradigm, whereas in clinical practice, physicians adjust therapies according to the specific clinical features of individual patients (2, 4). Thus, the generalizability of the results of randomized controlled clinical trials to clinical care may be imperfect. Moreover, these authors contended that similar evidence from more than one, well-done observational study usually corroborates the results of an RCT examining the same issue. RCTs are also usually costly (5) and, if comparably re...

Increased incidence of nonfatal cardiovascular events in stroke patients with sleep apnoea: effect of CPAP treatment

“…In keeping with other transverse and longitudinal studies [6,7], very recent new data from the Sleep Heart Health study [8] confirm an increased adjusted incidence of stroke in a wide community-based sample of males with AHI .19 events?h -1 (HR: 2.86) and female with AHI .25 events?h -1 . Furthermore, SAHLIN et al [10] have reported a higher risk of long-term mortality in stroke patients with OSA (AHI .15 events?h -1 ; HR 1.76), with similar results to those of our group (AHI .20 events?h -1 ; HR 2.91) [11].…”

“…Nasal continuous positive airway pressure (CPAP) is the most recognised and most cost-effective treatment for severe or symptomatic OSA [6]. Large-scale studies have established moderate-to-severe untreated OSA as an independent modifiable risk factor for stroke and other cardiovascular events (CVE) [7][8][9].…”

Long-Term Therapy with Continuous Positive Airway Pressure in Obstructive Sleep Apnea: Adherence, Side Effects and Predictors of Withdrawal – A ‘Real-Life’ Study

“…In several studies, normalization of sleep architecture, reduction of daytime sleepiness, improvement in mood and quality of life, reduction of motor vehicle crashes and a decrease in cardiovascular events have been demonstrated [1,2]. In addition, there are sufficient data to conclude that in severe OSAS, PAP therapy is associated with improved survival [3]. These positive treatment effects depend substantially on the adherence of the patient to the therapy.…”

Emerging Therapies for Obstructive Sleep Apnea

“…Continuous positive airway pressure (CPAP) is considered the ''standard of care'' for the treatment of OSA. Therapeutic use of CPAP mitigates many of the acute pathophysiologic responses that result from sleep-disordered breathing [13,14]. Yet, despite these benefits, therapeutic acceptance and adherence remain significant challenges to patients and clinicians.…”