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Postgraduate Education Corner
CONTEMPORARY REVIEWS IN SLEEP MEDICINE
CHEST
680
Postgraduate Education Corner
P
ositive airway pressure (PAP) therapy is the most
commonly prescribed treatment for obstructive
sleep apnea (OSA) and is considered the most effi ca-
cious. However, poor adherence presents a signifi cant
challenge for clinicians and limits the effectiveness of
therapy. PAP usage must be maximized to optimize
treatment effect and improve outcomes. A number
of studies have identifi ed physiologic, psychologic,
and equipment-related factors related to PAP use.
Researchers continue to improve efforts to identify
patients at risk for poor adherence to PAP therapy,
and interventions to improve PAP use appear prom-
ising and continue to be refi ned. Forward-thinking
sleep-medicine professionals have begun to establish
active PAP-therapy adherence programs based on the
best available evidence.
The purpose of the current review is to synthesize
the pertinent research base with an eye toward real-
world clinical application. We fi rst review known cor-
relates of PAP therapy adherence and offer clinical
recommendations for overcoming common barriers
to PAP therapy. Next, we explore different strategies
to enhance PAP therapy adherence presented in the
literature, highlighting the strengths and limitations
of each. Throughout the article, we embrace the view
that OSA is a chronic medical condition that requires
long-term follow-up. Finally, we suggest a comprehen-
sive, interdisciplinary, patient-centered approach to
enhancing PAP usage.
Rates of Acceptance and Adherence
Up to 30% of patients prescribed PAP therapy refuse
the treatment from the onset.
1
Of those patients who
agree to a PAP trial, approximately 25% discontinue
PAP therapy within the fi rst year.
2
Among those who
initiate PAP therapy, it is estimated that only 50%
remain adherent long term.
3 - 5
One of the earliest stud-
ies to document objective PAP therapy adherence and
Maximizing Positive Airway Pressure
Adherence in Adults
A Common-Sense Approach
Emerson M. Wickwire , PhD ; Christopher J. Lettieri , MD, FCCP ; Alyssa A. Cairns , PhD ;
and Nancy A. Collop , MD, FCCP
Manuscript received November 1 , 2012 ; revision accepted January 24 ,
2013 .
Affi liations: From the Pulmonary Disease and Critical Care Asso-
ciates (Drs Wickwire and Cairns), Columbia, MD; Department of
Psychiatry and Behavioral Sciences (Dr Wickwire), Johns Hopkins
School of Medicine, Baltimore, MD; Uniformed Services University
and Walter Reed National Military Medical Center (Dr Lettieri),
Bethesda, MD; and the Departments of Medicine and Neurology
(Dr Collop), Emory University, Atlanta, GA.
Correspondence to: Emerson M. Wickwire, PhD, Pulmonary
Disease and Critical Care Associates, 10710 Charter Dr, Ste 310,
Columbia, MD 21044; e-mail: emerson@ewickwire.com
© 2013 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.12-2681
Positive airway pressure (PAP) therapy is considered the most effi cacious treatment of obstruc-
tive sleep apnea (OSA), especially moderate to severe OSA, and remains the most commonly
prescribed. Yet suboptimal adherence presents a challenge to sleep-medicine clinicians. The pur-
pose of the current review is to highlight the effi cacy of published interventions to improve PAP
adherence and to suggest a patient-centered clinical approach to enhancing PAP usage.
CHEST 2013; 144 ( 2 ): 680 – 693
Abbreviations : AASM 5 American Academy of Sleep Medicine ; APAP 5 autotitrating positive airway pressure device ;
BPAP 5 bilevel positive airway pressure ; CBT 5 cognitive behavioral treatment ; HST 5 home sleep testing ; OSA 5 obstructive
sleep apnea ; PAP 5 positive airway pressure ; PSG 5 polysomnography ; RCT 5 randomized controlled trial ; TLC 5 telephone-
linked communication
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the fi rst to use covert monitoring found that only 46%
of patients wore a PAP device . 4 h/night on . 70%
of days,
6
and this rate of adherence continues to
refl ect the majority of published adherence data.
Although the question of how much PAP therapy is
enough remains unanswered, in 2009, the Centers
for Medicare & Medicaid Services adopted a require-
ment of 4 h of PAP use on 70% of nights, or 21 days
in a consecutive 30-day period, to continue medical
coverage for PAP therapy. This cutoff has been criti-
cized as too lenient for accepting a suboptimal level
of use, as well as too stringent as some patients with
OSA benefi t from , 4 h use.
7 , 8
Dose-Response Relationship
A number of investigations have evaluated how much
PAP use is needed to ensure maximal benefi t from the
therapy. In aggregate, results support a dose-response
relationship between hours of PAP use and health-
related outcomes. For example, in a sample of 23 CPAP-
naive patients, Stepnowsky and Dimsdale
9
found PAP
use to be linearly related to signifi cant reduc tions in
respi ratory disturbance index, oxygen desaturation
index, and arousal index. Similarly, PAP use has been
linearly related to increased survival, with signifi cant
differences between patients who use a PAP device
, 1 h/night relative to 1-6 h/night or . 6 h/night.
10
This similar dose-response pattern has also been
observed in terms of functional status, with PAP use
being positively correlated to improvements in both
sleepiness and neurocognitive performance. In a study
using a sham PAP device as a control (N 5 101 men),
hours of PAP use were linearly related to decreases in
subjective and objective sleepiness.
11
Interestingly,
this study found 5 h to be an optimal cutoff to ensure
maximal benefi t. In a study of 58 PAP-naive patients
with memory complaints, Zimmerman et al
12
found
a linear improvement in working memory among
patients who used PAP , 2 h, 2-6 h, or . 6 h/night.
Similarly, Weaver et al
13
identifi ed linear relationships
between PAP use and functional status, self-reported
sleepiness, and objective sleepiness. More recently,
among patients with moderate to severe OSA, hours
of PAP use were linearly related to subjective sleepi-
ness, functional status, and neurocognitive perfor-
mance including executive function and working
memory.
14
Correlates of PAP Use and Barriers
to Adherence
Identifying correlates of PAP use can help over-
come barriers to adherence. Identifying patients at
risk for poor adherence may allow a focused interven-
tion based on specifi c patient characteristics. Beyond
demographic variables, factors have been identifi ed
in three overlapping domains: physiologic/medical,
psychologic/behavioral, and technical/equipment-
related.
Demographic Variables
The impact of demographic variables on PAP use
is not fully understood. The most common variables
studied have been age, sex, and ethnicity. Because
they are at increased risk for OSA, it is notable that
older adults appear to use a PAP device at similar rates
to other age groups.
15 , 16
In terms of sex, some studies
report men are more likely to be adherent and others
that women use PAP therapy more. Four studies have
evaluated PAP therapy adherence and ethnicity, with
results suggesting black patients are less likely to
adhere to PAP use than are whites, a fi nding similar
to other disorders.
17 - 19
However, socioeconomic status
better explains this relationship, and lower socioeco-
nomic status has been associated with reduced PAP
adherence even when the cost of ther apy is taken into
consideration.
20 - 22
Medical and Physiologic Factors
To date, evidence regarding the impact of disease-
related factors such as BMI, apnea-hypopnea index,
oxyhemoglobin desaturations, or sleepiness on adher-
ence suggests that these factors are often related to
PAP therapy adherence, although the strengths of
these associations are generally weaker than perceived
benefi t of therapy or other psychologic variables.
23
However, certain medical conditions impact PAP use
or make PAP use challenging. For example, nocturia,
which increases with age, has been associated with
decreased PAP use among older men.
15
Stroke may
cause upper extremity weakness, and facial droop may
make donning the PAP mask diffi cult. Palombini and
Guielleminault
24
found only seven of 32 stroke patients
with OSA persisted beyond the fi rst week of an 8-week
PAP therapy trial. When treating stroke patients, incor-
porating a caregiver in treatment can be helpful to
increase social support as well as positive reinforce-
ment for PAP use.
Nasal resistance can be another important barrier
to effective PAP use. Numerous studies using acous-
tic rhinometry have found that smaller nasal vol-
umes are negatively associated with adherence to
PAP therapy.
25 - 27
Nakata
28
performed nasal surgery on
12 PAP-resistant patients, and all 12 demonstrated
decreased nasal resistance and were able to acclimate
to PAP therapy. Similarly, among patients with turbi-
nate hypertrophy, Powell et al
29
found temperature-
controlled radiofrequency reduction to be associated
with signifi cant improvements in self-reported CPAP
use ( P 5 .03).
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682
Postgraduate Education Corner
Psychiatric Comorbidity, Psychologic Distress
Perhaps due to a paucity of high-quality studies,
research investigating the relationship between psy-
chologic disorders such as depression and anxiety
and PAP adherence has produced mixed results. Sev-
eral authors have reported that higher premorbid
symp toms of depression are associated with reduced
PAP therapy adherence at clinical follow-up
3 , 30 , 31
while
other studies have not supported this relationship.
32 , 33
Type D personality (negative affectivity and social
inhibition) has also been associated with poorer PAP
adherence at follow-up.
34
Negative health behaviors
such as smoking have also been associated with worse
adherence.
15
Clinicians are well aware of the relationship between
anxiety and claustrophobia and poorer adherence to
PAP use.
35 , 36
Systematic desensitization, a behavioral
intervention developed to treat anxiety disorders, can
effectively treat claustrophobia interfering with using
a PAP device.
37
Similarly, a number of reports have
evidenced high rates of comorbidity between OSA and
chronic insomnia,
38
and patients experiencing insom-
nia symptoms may use PAP therapy less.
39
Cognitive-
behavioral treatment (CBT) of insomnia can effectively
treat insomnia interfering with PAP use.
40
Two studies
of patients experiencing comorbid OSA and post-
traumatic stress disorder have found the latter to be
associated with lower PAP therapy adherence.
41 , 42
Krakow et al
43
reported results of an abbreviated, day-
time sleep study designed to help acclimate patients
with OSA who have insomnia and psychiatric disorders
and/or resistance to PAP therapy. Patients who under-
went the PAP-NAP procedure (n 5 39) were signifi -
cantly more likely than were patients in a matched,
historical, control group (n 5 60) to complete their
titration studies (90% vs 63%, P 5 .003), fi ll their
PAP-device prescriptions (85% vs 35%), and main-
tain regular use of the device (67% vs 23%). Although
hypnotic therapy has not been evaluated in patients
with OSA who have insomnia, the promising fi ndings
of Lettieri et al
44
among unselected patients suggest
that hypnotic sleep aids may help patients with insom-
nia adjust to PAP therapy.
Psychologic and Motivational Variables
Psychologic and social-cognitive variables have proven
to be robust predictors of PAP therapy adherence. For
example, in a small sample of 23 PAP-naive patients,
Stepnowsky et al
45
found neither depression nor anx-
iety predicted adherence, but “active coping” skills
such as openness to lifestyle modifi cation were asso-
ciated with greater PAP use. Additional psychologic
variables such as patient attitudes, beliefs, knowledge,
perceived importance, perceived risks, perceived bene-
fi ts, locus of control, and perceived self-effi cacy have
gained consistent empirical support in understanding
and predicting PAP adherence.
46
Importantly, psycho-
logic variables predict future adherence even when
measured pretitration. Olsen et al
23
found that psycho-
logic variables measured prior to exposure to PAP
use explained 21.8% of the variance in PAP use at
follow-up, whereas biomedical indices alone accounted
for 10% of variance. Similarly, Poulet et al
47
administered
validated psychologic questionnaires to 100 patients
newly diagnosed with OSA who were prescribed PAP
therapy. Using age and two psychologic variables
(emotional reactivity and disease perceptions), these
authors created a decision-tree algorithm to classify
accurately 85.7% of eventual nonadherers.
Importance of Early Experiences
The aforementioned patient characteristics contrib-
ute to patients’ early experiences with PAP therapy,
which can have powerful impact on adaptation to PAP
use. Indeed, long-term PAP therapy adherence is deter-
mined after only 3 nights of use.
9
More impressively,
studies have confi rmed the importance of very initial
exposure to PAP therapy as an important predictor of
future adherence. Drake et al
48
found that objective
improvement in sleep effi ciency between diagnostic and
titration polysomnography (PSG) predicted adherence
at 7-week follow-up ( P , .001, r 5 0.48). Lewis et al
32
found that patients reporting problems during the
fi rst night of autotitrating PAP devices (APAP) used
their PAP device less than patients not reporting ini-
tial problems ( P , .001). van de Mortel et al
49
reported
that relative to nonadherers, adherent patients reported
greater satisfaction with the level of information and
communication from their sleep doctor, were happier
with the PSG experience, and were more satisfi ed
with communication and education from the sleep-
laboratory staff.
In aggregate, these studies support a proactive
approach to maximizing early experiences with PAP
therapy. As evidenced by van de Mortel et al,
49
health-
care providers play an important role in helping patients
transition to PAP, and the role of the sleep specialist
may be particularly important. Pamidi et al
50
found
that patients who underwent sleep consultation prior
to diagnostic PSG used the PAP device 1 h/night
longer than patients referred by nonsleep specialists
( P 5 .002).
Equipment-Related Side Effects
The majority of PAP users report side effects, which
may contribute to PAP discontinuation.
51
Across stud-
ies, the most common patient-reported side effects of
PAP therapy include mask-related problems such as
air leakage, skin abrasion, and mask discomfort; nasal
congestion; dry throat; and frequent awakenings.
51
Not
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surprisingly, equipment manufacturers have invested
much effort to minimize these complaints and improve
patient adherence. We will next review the impact of
equipment and technical factors including mask type,
humidifi cation, test type, pressure relief, and PAP
modality.
Technical Factors
Interface Type: Identifying an appropriately fi tted
interface should improve PAP device comfort, reduce
side leakage and skin abrasion, and ultimately increase
the likelihood of PAP use. However, the data support-
ing this are mixed. Most of the data suggest differences
in reported comfort and side-effect profi le between
interface styles, but no difference in adherence. To our
knowledge, only one study
52
to date has found improved
adherence with nasal vs oronasal styles (1 h/night).
Nasal-pillow styles have generally been rated as more
comfort able and/or having fewer side effects compared
with oronasal styles
53
or standard nasal styles.
54
The main
difference in nasal masks compared with oral masks
(Oracle; Fisher & Paykel Healthcare Ltd) seems to
be in overall preference (nasal over oral
55
) and side-
effect profi le.
56
Overall, as the most common techni-
cal side effects are mask discomfort and mask leak,
mouth breathing, PAP pressure settings, or facial hair
may infl uence mask selection. Otherwise, patient
preference should guide the mask selection process.
Heated Humidifi cation
Data on the use of heated humidifi cation are sup-
portive but mixed. To our knowledge, only one random-
ized controlled trial (RCT) to date has found increased
objective adherence (36 min) with the use of heated
humidifi cation compared with no humidifi cation.
57
Other RCTs suggest that nasopharyngeal side effects
are reduced with humidifi cation, but adherence is vir-
tually unchanged. In addition to nasal stuffi ness caused
by PAP use, rhinitis is common in patients with OSA,
and patients frequently complain PAP use exacer-
bates rhinitis symptoms. Although effective in treat-
ing chronic rhini tis, intranasal steroids have not been
shown to improve PAP therapy adherence.
58
None-
theless, use of nasal steroids remains common in clin-
ical practice. Consistent with the Clinical Guideline
of the American Academy of Sleep Medicine (AASM),
59
all patients should be provided heated humidifi cation
to reduce nasal irritation. Other common strategies
include use of a neti pot or other nasal rinse. In our
centers, we provide nasal-rinse samples as part of stan-
dard clinical practice. It should also be noted that
humidifi cation is unlikely to impact complaints of dry
mouth, which are typically indicative of mouth breath-
ing and thus best resolved through use of a chin strap
or switch to full-face mask.
Split- vs Full-Night Titration
Data on split-night titrations suggest they can be as
effi cacious and lead to similar adherence as full-night
titrations when completed in those with moderate
to severe sleep-disordered breathing.
60 , 61
However,
these fi ndings are limited in that they have yet to be
explored under randomized, controlled conditions.
Out-of-Center Testing for OSA
The use of home sleep testing (HST) is rapidly
becoming a viable alternative to in-laboratory PSG
for diagnosing OSA. Per AASM guidelines, HST is
warranted in individuals with a high pretest proba-
bility for moderate to severe OSA and who have been
evaluated by a board-certifi ed sleep physician.
62
Table 1
depicts the seven studies that have contrasted PAP
adherence based on diagnosis using a type 3 HST device
or in-laboratory PSG. Five of the seven studies found
no difference in PAP therapy adherence between the
two approaches. One study found objective PAP adher-
ence to be approximately 1-h greater in laboratory-
diagnosed patients compared with home-diagnosed
patients,
64
whereas another study found exactly the
opposite.
69
Methodologic rigor varied across studies,
and well-designed studies aimed at exploring the long-
term implications of HST are needed. In addition,
all of these studies were conducted under the super-
vision of a sleep specialist. As a potential benefi t of
HST is increased availability of diagnostic testing,
studies using HST in primary care are needed. In
an observational study conducted by Lettieri and
colleagues,
67
no differences were observed in PAP
adherence between HST administered in a primary-
care setting relative to in-laboratory PSG in an AASM-
accredited sleep-disorders center.
Expiratory Pressure Relief
Expiratory pressure relief refers to the pressure dip
at the beginning of exhalation to allow for lessened
back pressure. This technology is currently available
in ResMed machines (EPR; ResMed Corp) and Philips
Respironics machines (CFlex; Koninklijke Philips Elec-
tronics NV). The majority of studies have been on
CFlex and more data are needed on ResMed’s similar
technology. In general, results suggest that these fea-
tures improve comfort and are preferred by patients.
However, with the exception of one study,
70
pressure
relief has not been shown to improve adherence.
PAP Modality
Bilevel PAP (BPAP ) therapy is a type of PAP ther-
apy that uses two different pressures instead of one
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684
Postgraduate Education Corner
Table 1 — PAP Adherence in HST/APAP Studies
Study Characteristics Design Intervention Follow-up Duration Major Findings
Whittle et al
63
N 5 150 (87% male
patients)
Quasi-experimental
If AHI . 40 during HST
a
: direct to
in-laboratory titration; AHI , 4 0 :
PSG titration.
94 d after
PAP setup
No difference in objective CPAP use between
HST and in-laboratory PSG (4.7 ⫾ 2.4 h/d
vs 5.0 ⫾ 2.4 h/d).
29% HST
56% PSG
Age: 48 ⫾ 13 y
BMI: 31 ⫾ 5 kg/m
2
Means et al
64
98 military veterans
(99% male patients)
Retrospective
chart review
50 patients had split-night PSG; 48 had HST
b
4-6 wk post-
PAP setup
LAB group wore CPAP signifi cantly longer
compared with HST (5.0 ⫾ 2.0 h/night vs 3.9 ⫾
2.0 h/night). No difference in % nights used or
adherence as defi ned by . 4 h on 70% of nights
Age: 55.9 ⫾ 11 y
BMI: 34.2 ⫾ 6.3 kg/m
2
RDI: 36.2 ⫾ 26.2
Berry et al
65
N 5 1 0 6
RCT HOME
c
and 3-night APAP titration with
fi xed 95% pressure
d
vs LAB
6-wk post-PAP
setup at home
No difference in mean adherence in
PM-APAP vs PSG arms (5.20 ⫾ 0.28 h/night
vs 5.25 ⫾ 0.38 h/night, respectively) or ESS,
FOSQ, or PAP satisfaction.
PM-APAP (n 5 5 3 )
PSG (n 5 53; 83% split)
Skomro et al
66
N 5 1 0 2
RCT HOME
e
and 1-wk APAP titration with fi xed
95% pressure
d
vs LAB
4 wk post PAP
setup at home
No difference in mean adherence in LAB
vs HOME arms (5.6 ⫾ 1.7 h/night
vs 5.4 ⫾ 1.0 h/night, respectively).
(62% male patients)
Age: 47.4 ⫾ 11.4 y
BMI: 32.3 ⫾ 6.3 kg/m
2
Mean pressure was 1.3 cm higher in APAP group
vs manual titration.
HOME (n 5 5 1 )
LAB (n 5 51;
77% split)
Lettieri et al
67
N 5 2 1 0
Observational
cohort study
Three groups: group 1, HST
f
and APAP
g
(set
to 95% pressure); group 2, standard PSG and
manual titration; group 3, in-laboratory PSG
and APAP. Group 1 was managed by PCP
and groups 2 and 3 were managed by
sleep-disorders center.
4-6 wk post-PAP
setup at home
No difference in % nights used, mean h used,
or % regular use. Groups 1, 2, 3: % nights used:
70%, 73%, and 72%, respectively; average hours
used: 4.4 ⫾ 2.0, 4.7 ⫾ 1.5, and 4.6 ⫾ 1.5 h/night,
respectively; regular use: 54%, 51%, and 50%,
respectively.
Kuna et al
68
Military veterans
(N 5 296)
RCT HOME
e
and 4-5 d APAP
g
titration
at 90% pressure vs LAB
3 mo following PAP
setup at home
No difference in mean objective use in HOME
vs LAB arms (3.5 ⫾ 2.5 h/night vs 2.9 ⫾
2.3 h/night, respectively; P 5 .08)
(95% male patients)
HOME (n 5 148)
No difference in % adherence in HOME
vs LAB arms (52% ⫾ 34% vs 49% ⫾ 35%,
respectively; P 5 .42).
LAB (n 5 148)
Age: 53.5 ⫾ 10.4 y
BMI: 34.6 ⫾ 6.4 kg/m
2
Mean PAP pressure was higher in HOME
group compared with LAB group (11.1 ⫾
3.2 cm H
2
O vs 9.4 ⫾ 2.9 cm H
2
O; P , .001).
(Continued)
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Study Characteristics Design Intervention Follow-up Duration Major Findings
Rosen et al
69
N 5 1 9 7
HOME (n 5 9 2 )
LAB (n 5 105; % split)
RCT HOME
h
and 1-wk APAP
g
titration with
fi xed 90% pressure vs LAB
1 and 3 mo
following PAP
setup at home
No difference in objective adherence or mean
usage at 1 mo. Acceptance of PAP therapy,
titration pressures, effective titrations, time
to treatment, and ESS score were not
different between arms.
Mean usage was ⵑ 1 h greater in the HOME group
compared with LAB group at 3 mo (4.7 ⫾
2.1 h/night vs 3.7 ⫾ 2.4 h/night, respectively).
Likewise, objective adherence (% night
used ⱖ 4 h) was ⵑ 12.6% greater in HOME
compared with LAB group at 3 mo
(62.8% ⫾ 29.2% vs 49.4% ⫾ 36.1%, respectively).
AHI 5 apnea-hypopnea index; APAP 5 autotitrating positive airway pressure device; ESS 5 Epworth sleepiness scale; FOSQ 5 Functional Outcomes of Sleep Questionnaire; HOME 5 home diagnosis
via portable sleep monitor HST 5 home sleep testing; LAB 5 in-laboratory diagnosis and manual CPAP titration; PAP 5 positive airway pressure; PCP 5 primary care physician; PM-APAP 5 portable
monitoring-autotitrating positive airway pressure device; PSG 5 polysomnography; RDI 5 respiratory disturbance index.
a
Edentrace system; Nellcor Puritan Bennett LLC.
b
Oxford MediLog Inc.
c
Watch PAT100; Itamar Medical Inc.
d
Auto Set; ResMed Corp.
e
Embletta; Embla Systems LLC.
f
Stardust II; Koninklijke Philips Electronics NV.
g
AutoPAP; Koninklijke Philips Electronics NV.
h
Embletta X-30; Embla Systems LLC.
Table 1—Continued
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686
Postgraduate Education Corner
fi xed pressure. A 2009 Cochrane Review
71
of six RCTs
on BPAP compared with CPAP therapy found no dif-
ference in adherence. However, evidence suggests
that a subset of nonadherent patients improve follow-
ing transition to BPAP therapy. Ballard et al
72
recruited
204 patients with OSA who were nonadherent to PAP
therapy and implemented a two-stage adherence
intervention. The fi rst phase included mask optimiza-
tion, heated humidifi cation, topical nasal therapy, and
sleep apnea education. Following this intervention,
an additional (24%) 49 patients improved their average
use ⱖ 4 h/night. Of the remaining 155 nonadherent
patients, 104 agreed to proceed with a second PAP
titration. These patients were randomized to either
CPAP (n 5 53) or BPAP therapy (n 5 51). Patients
randomized to BPAP were signifi cantly more likely
to achieve adherence ( ⱖ 4 h/night; 49% vs 28%;
P 5 .03).
Numerous RCTs have investigated the short- and
long-term adherence associated with home-based
APAP devices relative to in-laboratory manual titra-
tion. A recent meta-analysis of 24 peer-reviewed
RCTs revealed that patients used their APAP devices,
on average, 11 min longer than fi xed CPAP devices.
73
Nonetheless, the data were mixed, with 20 of 24 stud ies
reporting no differences in adherence.
Interventions to Improve PAP Adherence
Education
Although thorough patient education is an essen-
tial component of any chronic-disease management
program, stand-alone educational interventions to
improve PAP adherence have produced disappointing
results. Table 2 highlights fi ndings from educational
interventions. Most stand-alone educational interven-
tions have not been found to improve adherence. In a
study by Jean Wiese et al,
77
a 15-min educational video
did not improve PAP use. However, patients random-
ized to the video condition were signifi cantly more
likely to return for clinical follow-up (72.9% vs 48.9%,
P , .01). An uncontrolled French study (n 5 35) found
a nonsignifi cant trend toward improved adherence
following a comprehensive intervention that included
patient spouses and 1-night hospital exposure to PAP
therapy.
87
Such a resource-intensive intervention is not
feasible in all health-care systems.
Additional Support
A number of interventions have been designed to
test additional support as a means to enhance PAP
use. Interventions have included telephone support,
video education with support, increased interaction
with sleep provider, and telemonitoring of PAP use.
As depicted in Table 2 , only one of seven studies
reported an increase in PAP use following additional
support.
Telemedicine Approaches
Four studies have evaluated computerized or tele-
medicine approaches to improving CPAP adherence,
with mixed but promising results. In a 2-month pilot
study of an automated, computerized intervention
delivered via phone (telephone-linked communica-
tions, or TLC), patients receiving TLC used their
CPAP device 4.4 h/night, whereas patients receiving
standard care used their CPAP device 2.9 h/night
( P 5 .076; 70). In a larger study, TLC was associated
with 1 h/night greater PAP use at 2 months and 2 h/night
greater PAP use at 12 months, relative to control.
81
Both studies reported improved sleep symptoms in
patients assigned to TLC. Stepnowsky et al
92
evalu-
ated the impact of wireless telemonitoring on PAP
adherence in newly diagnosed patients with OSA.
At 2-month follow-up, telemonitoring was associ-
ated with nightly PAP usage of 4.1 h/night, whereas
PAP usage with usual care was 2.8 h/night ( P 5 .07).
Smith et al
80
conducted a study among PAP nonad-
herent patients who had already received supple-
mental education. The 12-week intervention resulted
in increased PAP usage and higher satisfaction than
active control subjects (nine of 10 participants in the
treatment group vs four in the control group using
PAP ⱖ 4 h on nine of the previous 14 nights; x
2
5 4.55;
P 5 .033). This study also reported cost per tele-
phone call ($30 for 20 min) and per patient ($420),
thereby facilitating a cost-benefi t analysis relative to
untreated OSA.
Use of Hypnotic Sleep Aids
Because early experiences with PAP therapy can
shape patient perceptions and infl uence long-term
adherence, several studies have evaluated the impact
of using hypnotic sleep aids during the initial tran-
sition to PAP therapy. Bradshaw et al
78
conducted a
double-blind RCT and found no difference in PAP
therapy adherence following administration of 10 mg
zolpidem during titration and fi rst 14 days of use.
More recently, Lettieri and colleagues
79
conducted a
double-blind, randomized, placebo controlled trial
and found that 3 mg eszopiclone administered during
titration was associated with reduced PAP therapy
refusal and greater PAP use at 6-week follow-up. In a
second study among patients with OSA, 3 mg eszopi-
clone administered during the fi rst 2 weeks of PAP
use was similarly associated with reduced discontinua-
tion and greater adherence and less discontinuation at
6-month follow-up.
46
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Table 2 — Interventions to Increase PAP Adherence
Study Patients, No. Design Intervention Major Findings
Intervention
prior to
PAP titration
Hoy et al
74
80 ND RCT In-home education with spouse; home
visits at days 7, 14, 28, and 120, and 2 extra
nights titration vs TAU
Intensive support resulted in increased nightly use at 6-mo
(5.4 h vs 3.8 h; P 5 .003)
Olsen et al
75
106 ND RCT Three CBT visits w/experienced sleep nurse
closely supervised by psychologist vs TAU
CBT resulted in increased PAP acceptance (96% vs 74%, P 5 .002)
and nightly use at 1-mo (4.63 h vs 3.16 h; P , .001); gains maintained
at 2, 3, and 12 mo.
Richards et al
76
100 ND RCT Two 60-min group cognitive-behavioral
sessions with spouses vs TAU
CBT resulted in increased PAP acceptance and greater nightly use at day
7 (5.9 h vs 2.97 h; P , .0001) and day 28 (5.38 h vs 2.51 h; P , .0001)
Jean Wiese et al
77
100 ND RCT Video on OSA, PAP, and users’ experiences
vs TAU
PAP use not reported. Video education resulted in greater return for
1-mo follow-up visit (72.9% vs 48.9%; P , .02)
Intervention begun
during PAP titration
Bradshaw et al
78
72 men ND RCT Zolpidem 10 mg during in-laboratory titration
and fi rst 14 d of PAP use vs placebo vs TAU
No differences between groups in PAP use at 28-d follow-up.
Lettieri et al
79
117 ND RCT Eszopiclone 3 mg during in-laboratory
titration vs placebo
Oral hypnotic during titration resulted in greater nightly PAP use at 6 wk
(4.8 h vs 3.9 h; P 5 .03)
Smith et al
80
97 ND RCT 20-min audio w/ PAP instructions, relaxation,
and music; and daily PAP journal vs sham
instructions
Audio instructions and music resulted in greater nightly use of
autotitrating PAP at 1 mo ( x
2
5 14.7; P , .01), but not 3 or 6 mo.
Participants did report audiotape was helpful.
Intervention begun
after exposure to PAP
Aloia et al
81
12 ND RCT Motivational enhancement for CPAP (2 45-min
CBT sessions and 15-min telephone call
with nurse) vs wait-list control
CBT (ME-PAP ) begun after 1-wk PAP use resulted in greater use
at 3-mo follow-up (7.8 h vs 4.6 h; P , .03). No differences at
week 1 or week 4.
Aloia et al
82
142 ND RCT Motivational enhancement for CPAP
vs education (2 45-min sessions) vs TAU
CBT (ME-PAP) and education begun after 1 wk of PAP use both
resulted in less PAP discontinuation than TAU (26% and 30%,
respectively, vs 41%; x
2
5 6.61; P 5 .04).
Chervin et al
83
33 (10 ND,
12 experienced
PAP users)
RCT Weekly telephone support vs written fact
sheet vs TAU
No differences at 2 mo (nightly use 5.7 h vs 7.1 h vs 4.4 h).
DeMolles et al
84
30 RCT Telephone support No differences at 2 mo.
Fletcher and Luckett
85
10 Crossover
RCT
Positive reinforcement (weekly calls for
3 wk, then monthly) vs mechanical
troubleshooting (monthly calls)
No differences at 3 mo (nightly use 5.95 h vs 6.04 h).
(Continued)
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688
Postgraduate Education Corner
Study Patients, No. Design Intervention Major Findings
Fuchs et al
86
526 already on PAP RCT Educational lecture with booklet vs TAU
Information resulted in greater nightly use (6.9 h vs 5.7 h; P , .001).
Golay et al
87
35 already on PAP One group
pre-post
Intensive, inpatient, hands-on workshop
with spouse
Intensive education increased average use from 4.4 h/night to
5.1 h/night ( P value not reported) at 3-mo follow-up.
Hui et al
88
108 RCT Video education, telephone support, and extra
follow-up at weeks 1 and 2 vs TAU
No differences in PAP use at 1 and 3 mo. Augmented support
resulted in greater improvement in quality of life at 1 and 3 mo.
Lettieri et al
44
160 RCT Eszopiclone 3 mg during fi rst 14 d of PAP use
vs placebo
Oral hypnotic during fi rst 14 d of PAP use resulted in increased
PAP acceptance and greater nightly use at 1, 3 and 6 mo (3.57 h
vs 2.42 h; P 5 .005)
Likar et al
89
34 veteran users Open-label,
uncontrolled
trial
2-h group educational session on OSA with
video on assembly of PAP
Group education increased average nightly use from 5.2 h to 6.3 h.
Gains maintained at 3 yr.
Meurice et al
90
112 ND RCT 3 educational strategies vs TAU No differences.
Sparrow et al
91
250 RCT Automated telephone responses vs TAU
TLC-CPAP resulted in greater nightly PAP use at 6 mo ( 1 1 h) and
12 mo ( 1 2 h).
Stepnowsky et al
92
45 RCT Telemonitoring of PAP use with support vs TAU No differences in PAP use at 2 mo.
Intervention group reported higher likelihood of continued use
(4.8 vs 4.3; P 5 05).
Wang et al
93
152 RCT
Education vs relaxation vs education 1 relaxation
vs TAU
Education 1 relaxation resulted in greater PAP adherence, less daytime
sleepiness, and better sleep quality than TAU at 4, 8, and 12 wk.
Education alone resulted in greater PAP adherence, less daytime
sleepiness, and better sleep quality than TAU at 4 wk, but not
8 or 12 wk
CBT 5 cognitive behavioral therapy; ME-APAP 5 motivational enhancement therapy for positive airway pressure; ND 5 newly diagnosed; OSA 5 obstructive sleep apnea; RCT 5 randomized controlled
trial; TAU 5 treatment as usual .
Table 2—Continued
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Cognitive Behavioral Treatments
Four studies have evaluated CBTs. Aloia et al
81
deliv-
ered a two-session motivational intervention with a
psychologist and a telephone follow-up with a trained
nurse. No differences in PAP use were observed at
1 or 4 weeks, but at 12 weeks, patients assigned to
CBT used their PAP devices an average of 3.2 h per
night longer than patients who underwent treatment
as usual ( P , .04). In a larger study, these initial posi-
tive results were replicated when contrasted to treat-
ment as usual, but no signifi cant differences were
detected between CBT and an educational control
intervention.
82
This latter fi nding highlights the multi-
faceted nature of PAP therapy and the challenge
of identifying active treatment components. Per-
haps more important, in these studies, CBT was not
begun until 1 week after PAP initiation. More recently,
Richards et al
76
randomized 100 newly diagnosed
patients to a two-session, group-CBT intervention
begun prior to titration. Relative to treatment as
usual, CBT was associated with increased likelihood
of completing the titration study (four vs 15 refused
PAP; not statistically signifi cant) and greater PAP
usage at 4-week follow-up (5.4 h vs 2.5 h; P , .0001).
Similarly, Olsen et al
75
initiated three-session, individual
CBT prior to titration. CBT was associated with six
times greater likelihood of initiating PAP therapy and
signifi cantly greater PAP use at 3-month follow-up
(4.63 h vs 3.16 h; P , .001), with clinically signifi cant
gains maintained at 12 months. Importantly, this study
also demonstrated a possible dissemination pathway
for CBT. All treatment was provided by sleep-trained
nurses who were trained and closely supervised by a
sleep psychologist.
Five Clinical Recommendations
When making clinical recommendations, it is impor-
tant to note that PAP therapy adherence is highly
multifactorial, and a wide variety of approaches might
improve PAP adherence in the real world. Many of
these approaches may be either provider or context
specifi c, such as an effective interpersonal style or
well-run clinical team. Hence, the objectives of the fol-
lowing practical, common-sense, clinical recommen-
dations are to help providers adopt a patient-centered
approach throughout the treatment process and to
maximize PAP therapy adherence regardless of pro-
fessional setting or treatment pathway ( Fig 1 ). We
make these recommendation based on the best avail-
able evidence regarding interventions that have been
shown to be effective or promising as well as clinical
experience in academic, hospital, military, and private
practice settings.
Figure 1. Clinical recommendations pathway. OSA 5 obstructive
sleep apnea; PAP 5 positive airway pressure.
Assess and Enhance Patient Readiness
By any measure, acclimating to PAP therapy requires
substantial behavior change. PAP users will wear a
PAP device nightly, clean PAP supplies daily, replace
fi lters monthly, attend clinical follow-up appointments,
work with a durable-medical-equipment provider,
and so on. It is, thus, essential for clinicians to adopt
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690
Postgraduate Education Corner
a long-term, patient-centered perspective to managing
OSA as a chronic disease.
From a chronic disease perspective, patient readi-
ness is a prerequisite for long-term adherence. Patients
who feel pressured or rushed may resist or abandon
treatment, whereas those who self-select PAP ther-
apy are most likely to persevere and become long-term
users. To increase buy-in, sleep-medicine clinicians
must assess current readiness and resolve ambivalence
toward PAP therapy.
Patients feel most ready when they perceive both
that PAP therapy is important and also that they pos-
sess the skills to use the PAP device successfully. One
of the most effi cient ways to assess perceived impor-
tance and perceived self effi cacy is to ask the patient
directly:
On a scale of 1-10, how important do you think it •
is for you to use the PAP device?
On a scale from 1-10, how confi dent are you in •
your ability to use the PAP device from now until
the next time we meet?
If a patient reports low importance or confi dence,
simply ask, “What might make that number higher?”
To increase perceived importance, providers should
educate patients on the impact of OSA and the bene-
fi ts of treatment. Advanced motivational strategies
include conducting a decisional-balance exercise to
explore with the patient the pros and cons of using PAP
therapy as well as not using it. Strategies to increase
perceived confi dence include lowering the bar (target-
ing daily use, or 2 h nightly use instead of 8 h), recruit-
ing social support, and identifying creative self rewards
for progress. To enhance importance and con fi dence,
clinicians should explicitly reinforce all patient self care.
Map a Plan for Change
Once patients are ready to initiate PAP therapy,
collaborating to set realistic goals will help patients
feel empowered and become active participants in
the treatment process. Providers should manage patient
expectations for acclimating to PAP therapy and col-
laborate with patients to set clear behavioral goals
under their control that are specifi c, motivational,
assessable, realistic, and time based. Finally, to increase
behavioral momentum toward PAP use, patients should
identify concrete rewards for adherence.
94 , 95
Identify and Overcome Potential Barriers to PAP
Clinicians should assess patient characteristics that
may interfere with PAP therapy. Does the patient
suffer insomnia? Anxiety? Claustrophobia? Is rhinitis
or reduced nasal airfl ow suspected? Does the patient
have facial hair or does the patient mouth breathe?
Once identifi ed, each of these common barriers can
be effectively overcome using strategies outlined in
this article. In addition, patients can be asked to iden-
tify potential barriers to PAP use and possible solu-
tions and support, including spouses, bed partners,
and other individuals who can provide encouragement
and help troubleshoot during the transition.
Maximize Early Experiences With PAP
Unfortunately, many patients with OSA are referred
for PAP titration with minimal attention paid to the
patient’s personal goals for treatment, or preparation
for PAP. At a minimum, patients should be educated
about what to expect at the sleep laboratory, what
sleep apnea is, their personal disease consequences
or risks, and the benefi ts of PAP therapy. Printed and
multimedia educational materials can serve as impor-
tant patient-reference guides throughout the evalu-
ation and treatment process. In large centers, group
educational sessions may also be feasible, with the
added social-cognitive benefi ts of vicarious learning
and social support.
In addition to thorough education, particular atten-
tion should be paid to proper mask selection and fi t-
ting. While comfort features like humidifi ers, ramp,
expiratory pressure relief, and varied PAP platforms
have shown only a modest benefi t for enhancing PAP
therapy adherence, they are widely available and should
be used to improve comfort and tolerance when pos-
sible. Because these features increase cost, providers
will need to work within their respective health-care
systems to ensure optimal care for their patients.
Finally, both sedative hypnotic use and CBT have
been shown to improve PAP therapy initiation and
enhance long-term adherence. Sedative hypnotic use
has specifi cally been shown to improve sleep during
titration.
44
For centers with a behavioral sleep spe-
cialist on staff, CBT for PAP can be an essential com-
ponent of a patient-centered approach.
Proactively Follow-up, Trouble Shoot, and Support
Early assessment of response to therapy, trouble-
shooting, and support are essential for PAP therapy
success. Unfortunately, there is a lack of consensus
regarding optimal follow-up intervals for patients with
OSA. As of 2008, the Centers for Medicare & Medic-
aid Services requires an in-person visit with the PAP-
prescribing provider within 90 days to document
effective response to treatment. We strongly recom-
mend follow-up much sooner. In addition to patients’
subjective reports, adherence reports from leading
manufacturers include summary statistics regarding
nights used, hours used per night, and percentage of
nights with ⱖ 4 h use as well as technical data such as
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CHEST / 144 / 2 / AUGUST 2013 691
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number and type of breathing events and mask leak.
Again, clinicians should attend to medical/physio-
logic, behavioral/motivational, and technical aspects
of PAP therapy to optimize treatment outcomes, mit-
igate discontinuation or abandonment of therapy, and
overcome barriers or side effects that emerge as a
result of PAP use.
Conclusions and Future Directions
OSA is a chronic medical condition that requires
patients to engage actively in their treatment. To maxi-
mize outcomes, sleep-medicine clinicians must adopt
a patient-centered approach. Further, providers must
attend to the medical, behavioral, and technical fac-
tors associated with PAP therapy. Specifi c objectives
should be to identify patients at risk for poor adher-
ence or abandonment of therapy, improve education
to ensure patients understand the risk of OSA and
benefi ts of therapy, and develop and implement strat-
egies to increase PAP use. To meet these objectives, an
interdisciplinary team may include physicians, tech-
nologists, PAP-device providers, and increasingly,
behavioral sleep specialists. Finally, clinicians must
consider both objective and subjective patient factors
during the three sensitive periods of diagnostic expe-
rience, transition to therapy, and long-term follow-up
with ongoing support.
Acknowledgments
Financial/nonfi nancial disclosures: The authors have reported
to CHEST the following confl icts of interest: Dr Lettieri has
received research funding from Sepracor Inc. The other authors
have reported to CHEST that no potential confl icts of interest
exist with any companies/organizations whose products or services
may be discussed in this article .
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