Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment

Abstract

Introduction:The purpose of this systematic review is to provide supporting evidence for the clinical practice guideline for the treatment of obstructive sleep apnea (OSA) in adults using positive airway pressure (PAP). Methods: The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of PAP with no treatment as well as studies that compared different PAP modalities. Meta-analyses were performed to determine the clinical significance of using PAP in several modalities (ie, continuous PAP, auto-adjusting PAP, and bilevel PAP), to treat OSA in adults. In addition, meta-analyses were performed to determine the clinical significance of using an in-laboratory versus ambulatory strategy for the initiation of PAP, educational and behavioral interventions, telemonitoring, humidification, different mask interfaces, and flexible or modified pressure profile PAP in conjunction with PAP to treat OSA in adults. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations. Results: The literature search resulted in 336 studies that met inclusion criteria; 184 studies provided data suitable for meta-analyses. The data demonstrated that PAP compared to no treatment results in a clinically significant reduction in disease severity, sleepiness, blood pressure, and motor vehicle accidents, and improvement in sleep-related quality of life in adults with OSA. In addition, the initiation of PAP in the home demonstrated equivalent effects on patient outcomes when compared to an in-laboratory titration approach. The data also demonstrated that the use of auto-adjusting or bilevel PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP. Furthermore, data demonstrated a clinically significant improvement in PAP adherence with the use of educational, behavioral, troubleshooting, and telemonitoring interventions. Systematic reviews for specific PAP delivery method were also performed and suggested that nasal interfaces compared to oronasal interfaces have improved adherence and slightly greater reductions in OSA severity, heated humidification compared to no humidification reduces some continuous PAP-related side effects, and pressure profile PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP.

BPAP is an effective second‐line therapy for obese patients with OSA failing regular CPAP: A prospective observational cohort study

“…included participants who had previously shown non‐adherence to CPAP (<4 h/night) and reported an increase in adherence of 0.8 h/night when patients used flexible BPAP (BiFlex). These results suggest a potentially beneficial use of BPAP as a second‐line therapy for patients who are non‐adherent to CPAP . Recently, a study by Benjafield et al .…”

“…Previous studies have shown that BPAP and CPAP therapies can achieve similar efficacy in controlling OSA, but these studies did not focus on patients requiring high pressures to achieve control of OSA. A meta‐analysis by Patil et al . found no clinically significant difference between CPAP and BPAP.…”

“…The study was registered as a service review (local clinical governance approval board reference number: GSTT/2017/6977) and patients provided informed verbal consent. The terminology used in this paper is in keeping with the recommendations of the American Academy of Sleep Medicine …”

BPAP for CPAP failures: For the many or the few

“…Positive airway pressure (PAP) therapy is the primary treatment modality for obstructive sleep apnoea (OSA) . While continuous PAP (CPAP) was the first treatment modality described in 1981, bi‐level PAP (BPAP) has subsequently been found to be effective in the treatment of OSA.…”

“…Traditionally, BPAP was primarily used for OSA with co‐morbid respiratory disorders, but it is also used in uncomplicated OSA for a variety of reasons, including CPAP failure due to higher pressure requirements or CPAP intolerance due to pressure discomfort. Despite its use for CPAP failures, there is a paucity of evidence that BPAP is effective in these patients …”