Treatment of Obstructive Sleep Apnea: Achieving Adherence to Positive Airway Pressure Treatment and Dealing with Complications

Key points

Quantifying adherence with positive airway pressure treatment

Currently accepted insurance criteria in the United States contend that “adherent” equates to the use of PAP greater than 4 hours per night for at least 70% of nights.15, 18 Therefore, an individual only has to use PAP 86 hours per month, or 35% of the total recommended sleep time, to be considered adherent. Although many argue that this definition of adherence is grossly insufficient and most likely contributes to the limited ability of PAP to resolve both symptoms and consequences associated

What factors affect adherence to positive airway pressure treatment?

A number of factors have been identified that influence both acceptance of and adherence to PAP therapy. More easily measured factors relate to demographic, physiologic, and disease-specific variables. Perhaps more important, the influence of a patient’s understanding of the underlying disorder and therapeutic strategy, their perceived benefit of treatment, their initial experiences with an intervention, and their overall health behaviors are becoming increasingly recognized as impactful

Common barriers to adherence to positive airway pressure treatment and how to overcome them

Initial experience with PAP predicts long-term use, so potential barriers to adherence should be addressed early and readdressed on an ongoing basis.19, 27, 40 A proactive clinical approach is particularly important, because many new PAP users report side effects during the acclimatization phase of therapy.⁴⁷ Common complaints impacting adherence are sinus congestion, mask discomfort, insomnia, and claustrophobia. Early assessment and intervention may improve adherence and long-term patient

Pharmacologic interventions to improve adherence to positive airway pressure treatment

Sedative hypnotics, in particular nonbenzodiazepine receptor agonists (NBRAs), offer an attractive option for improving adherence, particularly when used during the initial experiences with PAP. NBRAs do not adversely impact the AHI, oxygen saturation (SpO₂), sleep architecture, or response to PAP therapy.111, 112, 113 The use of a sedative hypnotic during initial polysomnography has been shown to improve adherence, likely by facilitating a more accurate pressure determination and by improving

Complications of positive airway pressure therapy and how to prevent or overcome them

Although safe and typically well-tolerated, there are several potential complications of PAP therapy, in addition to vasomotor rhinitis already discussed, that may have a negative impact on adherence. Proper patient education may mitigate the development of many of these complications. In addition, patients should be queried regarding their occurrence during each follow-up visit to promptly recognize and treat them to minimize their effect on PAP tolerance.

Aerophagia may result from positive

Summary

PAP remains the most efficacious treatment for OSA and is the first choice of treatment for most patients. However, challenges with adherence remain problematic. Numerous trials show improved subjective and objective outcomes from successfully treating OSA. In contrast, several studies have failed to observe that PAP significantly improves symptoms or end-organ dysfunction. However, these studies are largely limited by insufficient use of therapy. The fact remains that PAP only works if it is