Continuous positive airway pressure (CPAP) is considered the gold standard for effective
treatment of obstructive sleep apnea (OSA). However, many patients refuse to initiate
or adhere to this form of therapy. Thus, a variety of interventions have been explored
to improve CPAP compliance, ranging from sleep hypnotics1 to nasal steroids,2
but variations in the methodology of delivering positive airway pressure (PAP) are
commonly advocated to improve adherence.
In this issue of the Journal, there are 2 superficially unrelated papers
pertaining to delivery of PAP to patients with obstructive sleep apnea (OSA). In
the first paper, Marcus and colleagues describe a randomized clinical trial in children
with OSA of standard CPAP or a proprietary mode of PAP during which pressure decrements
during both late inspiration and expiration were permitted.3 There was no difference in adherence between the 2 modes after
3 months. With both modes, adherence was suboptimal, with substantial variability
in hours of usage within the experimental groups. In the second paper by Powell
and colleagues,4 a group of adults with
OSA who had a suboptimal laboratory CPAP titration were randomized to either standard
CPAP or a proprietary auto-adjusting bilevel device with inspiratory and expiratory
pressure relief options. Similar to the study by Marcus et al., there was no difference
in adherence after 3 months. However, the absence of statistical significance between
the 2 groups despite 73% of bilevel users being compliant to PAP therapy vs. 59%
in the CPAP group could reflect that the study may have been underpowered to detect
a smaller, but clinically meaningful, difference (Type II error). Nonetheless, 2
studies are presented, 1 in children and 1 in adults. Both tested an alternative
new method of delivering PAP, with results in both failing to show any clear advantages
with the new technology.
What are the lessons to be learned from these 2 studies? First, it does not seem
that for the average patient, either child or adult, there is any clear advantage
to using these newer modes of delivering PAP. Admittedly, there is less data concerning
PAP adherence in children, and it is possible that future studies may provide greater
clarity for this group. However, given the heterogeneity in results from a number
of studies, routine use of auto-bilevel or flexible inspiratory or expiratory relief
cannot be recommended. Nevertheless, for an individual patient, these alternatives
may address an impediment to using PAP and increase adherence. Second, new PAP modes
do not appear to be the “magic bullet” to improve suboptimal adherence
to PAP. A recent meta-analysis of auto-CPAP studies found no adherence benefits.5 Similarly, a prior Cochrane systematic
review had suggested that the effect of auto-CPAP in increasing hours of use was
still unclear. The study of Powell and colleagues would be responsive to the need
to fill that particular knowledge gap by providing additional information to suggest
that the auto-bilevel modality confers no improvement in adherence.6 Although unproven, some patients, such as those who require
high treatment pressures, may have better adherence with auto-CPAP. Unfortunately,
such a subpopulation of patients was not the target for the current study by Powell
et al. in this issue of the Journal. Fourth, a recent study has suggested
that high air leak levels are associated with poor adherence to auto-PAP therapy.7 Newer device technologies that abrogate
air leak may facilitate adherence, and such newer device technologies need to be
conceived and tested. Finally, such negative device trials suggest that any improvement
in PAP adherence rates will more likely occur by addressing social and psychological
obstacles to usage rather than newer technical innovations in PAP delivery or interface
These 2 studies remind us that new therapeutic approaches to the treatment of OSA
are needed. Despite newer PAP modes/interfaces, multiple types of oral appliances,
and a variety of surgical approaches, a large number of patients are left without
a viable treatment alternative. There is a substantial body of research that has
provided information regarding the pathophysiology of OSA, and certainly more needs
to be learned. However, translation of this knowledge into useful treatment options
for patients remains an elusive goal.
Dr. Quan is Editor-in-Chief of Journal of Clinical Sleep Medicine. The other
authors have indicated no financial conflicts of interest.
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