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The PAP-NAP one decade later: patient risk factors, indications, and clinically relevant emotional and motivational influences on PAP use

  • Sleep Breathing Physiology and Disorders • Original Article
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Abstract

Study objectives

Positive airway pressure (PAP) noncompliance remains a major barrier in obstructive sleep apnea (OSA) treatment. The PAP-NAP, a daytime PAP “test-drive,” has been associated with increased PAP use, but risk factors and indications for the procedure remain unspecified.

Methods

A retrospective chart review was conducted on 139 patients who (1) were diagnosed with OSA (n = 116) or upper airway resistance syndrome (UARS) (n = 23); (2) adamantly refused to proceed with either a full-night attended titration or in-home trial of PAP; and (3) elected to proceed with a PAP-NAP instead. Risk factors for PAP rejection (identified on intake) and indications for the PAP-NAP (identified post-diagnostic polysomnography) were confirmed through multiple encounters with sleep center personnel. All patients completed the PAP-NAP, which utilizes an elaborate desensitization program to provide a less challenging introduction and facilitate a gentler adaptation to pressurized air as well as to test advanced PAP modes when subjective or objective expiratory pressure intolerance emerges. Both emotional aversion toward and lack of motivation for PAP therapy were assessed pre- and post-PAP-NAP. PAP use was determined several months post-procedure.

Results

At intake, most common risk factors for PAP rejection were depression, insomnia, and claustrophobia; most common indications for PAP-NAP were general reluctance, anxiety, and claustrophobia. Procedure averaged 3+ hours [tech coaching, 83 (± 30) min; napping, 107 (± 57) min]. Ninety-nine percent required advanced PAP. Compared to baseline, emotional aversion (p = 0.0001) and motivation (p = 0.0001) significantly improved for the entire sample of which 86% completed full-night titrations and 78% filled PAP prescriptions. At final follow-up, 71% (n = 98) were users and 29% (n = 41) were non-users. Compared to non-users, users showed significantly greater decreases in emotional aversion (p <  0.001; Z = − 6.11) and greater increases in motivation (p <  0.001; Z = − 8.57).

Conclusion

PAP-NAP was associated with a sizeable proportion of highly reluctant patients proceeding to titrations they initially had rejected, and the majority achieved PAP user status. Improvements in emotional aversion and motivation were associated with increased PAP use. Randomized control trials must assess the experiential component at the core of the PAP-NAP procedure and its efficacy in reversing early PAP rejecters.

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Abbreviations

ABPAP:

Auto-bilevel positive airway pressure

AHI:

Apnea hypopnea index

ASV:

Adaptive servo-ventilation

BPAP:

Bilevel positive airway pressure

CMS:

Centers for Medicare and Medicaid Services

CompSA:

Complex sleep apnea

CPAP:

Continuous positive airway pressure

EMO:

Emotional aversion to PAP therapy

EPI:

Expiratory pressure intolerance

ISI:

Insomnia severity index

MOTIV:

Motivation to proceed with PAP therapy

MSAS:

Maimonides Sleep Arts & Sciences

ODD:

Objective data download

OSA:

Obstructive sleep apnea

PSG:

Polysomnogram

RDI:

Respiratory disturbance index

SDB:

Sleep-disordered breathing

UARS:

Upper airway resistance syndrome

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Authors and Affiliations

  1. Sleep & Human Health Institute, 6739 Academy N.E., Suite 380, Albuquerque, NM, 87109, USA

    Victor A. Ulibarri, Barry Krakow & Natalia D. McIver

  2. Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, NM, USA

    Victor A. Ulibarri, Barry Krakow & Natalia D. McIver

  3. Los Alamos Medical Center, Los Alamos, NM, USA

    Barry Krakow

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  1. Victor A. Ulibarri
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  2. Barry Krakow
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  3. Natalia D. McIver
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Correspondence to Barry Krakow.

Ethics declarations

Conflict of interest

Mr. Ulibarri and Ms. McIver declare that they have no conflict of interest. Dr. Krakow’s conflict of interest statement is as follows:

I have 6 main activities related to my work in sleep medicine:

For websites, I own and operate 6 sites that provide education and offer products and services for sleep disorders patients:

 Also, these websites market a PAP-NAP handbook and a PAP-NAP instructional video.

For intellectual property, I market and sell 3 books for sleep disorders patients:

  • Insomnia Cures

  • Turning Nightmares into Dreams

  • Sound Sleep, Sound Mind

For clinical services, I own and operate one commercial sleep center:

  • Maimonides Sleep Arts & Sciences, Ltd.

For educational and consulting services:

  • I conduct CME/CEU educational programs for medical and mental health providers to learn about sleep disorders. Sometimes these programs involve the attendee paying a fee directly to our center. Other times, I conduct the workshops at other locations, which may be paid for by vendors such as Respironics and RESMED or other institutions such as the AMEDDC&S, VAMC, and regional sleep center conferences. A recent consultation was conducted for ASOCorp, a manufacturer of nasal strips.

  • I am also president of a nonprofit sleep research center, the Sleep & Human Health Institute (www.shhi.org), which occasionally provides consultation services or receives grants for pilot studies, the most recent of which were:

    • ResMed ~$400,000 January 2015 (funding for randomized control trial of treatment in insomnia patients); work completed in 2019

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Ulibarri, V.A., Krakow, B. & McIver, N.D. The PAP-NAP one decade later: patient risk factors, indications, and clinically relevant emotional and motivational influences on PAP use. Sleep Breath 24, 1427–1440 (2020). https://doi.org/10.1007/s11325-019-01988-z

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