Cochrane for Clinicians

Putting Evidence into Practice

Interventions to Improve Use of CPAP Machines in Adults with Obstructive Sleep Apnea

 

Am Fam Physician. 2021 Oct ;104(4):356-358.

Author disclosure: No relevant financial affiliations.

Clinical Question

Are educational, supportive, behavioral, or mixed intervention strategies effective at increasing compliance with continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA)?

Evidence-Based Answer

Behavioral interventions increase CPAP use (mean difference [MD] = 1.31 hours per night; 95% CI, 0.95 to 1.66) compared with usual care. These interventions also increase CPAP adherence, measured by participants using their machine four or more hours per night, from 371 to 501 per 1,000 patients (number needed to treat [NNT] = 8; 95% CI, 5 to 23). Supportive interventions may slightly increase CPAP use (MD = 0.70 hours per night; 95% CI, 0.36 to 1.05) vs. usual care, and they increase CPAP adherence from 601 to 717 per 1,000 patients (NNT = 9; 95% CI, 5 to 56). The benefits of educational and mixed interventions are unclear because of low-quality evidence.1 (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)

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SUMMARY TABLE

Comparison of Various Interventions plus CPAP vs. Usual Care plus CPAP

OutcomesAnticipated absolute effects* (95% CI)NNT* (95% CI)Participants (RCTs)Quality of evidence

Risk with usual care plus CPAPRisk with intervention plus CPAP

Educational interventions

Device use

Mean of 1.97 to 5.1 hours per night

MD = 0.85 hours per night (0.32 to 1.39)

1,128 (10)

Very low

N deemed adherent (≥ 4 hours per night)

558 per 1,000

765 per 1,000 (654 to 849)

5 (3 to 10)

1,019 (7)

Very low

Supportive interventions

Device use

Mean of 1.75 to 4.9 hours per night

MD = 0.70 hours per night (0.36 to 1.05)

1,426 (13)

Moderate

N deemed adherent (≥ 4 hours per night)

601 per 1,000

717 per 1,000 (619 to 797)

9 (5 to 56)

376 (2)

Low

Behavioral interventions

Device use

Mean of 1.48 to 5.1 hours per night

MD = 1.31 hours per night (0.95 to 1.66)

578 (8)

High

N deemed adherent (≥ 4 hours per night)

371 per 1,000

501 per 1,000 (414 to 587)

8 (5 to 23)

549 (6)

High

Withdrawal

146 per 1,000

101 per 1,000 (70 to 143)

22 (13 to 33)

939 (10)

High

Mixed interventions

Device use

Mean of 2.6 to 5.5 hours per night

MD = 0.82 hours per night (0.20 to 1.43)

4,509 (11)

Very low

N deemed adherent (≥ 4 hours per night)

741 per 1,000

830 per 1,000 (755 to 886)

11 (7 to 71)

4,015 (9)

Very low

Withdrawal

129 per 1,000

83 per 1,000 (40 to 161)

4,956 (11)

Very low


CPAP = continuous positive airway pressure; MD = mean difference; NNT = number needed to treat; RCT = randomized controlled trial.

*—The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

SUMMARY TABLE

Comparison of Various Interventions plus CPAP vs. Usual Care plus CPAP

OutcomesAnticipated absolute effects* (95% CI)NNT* (95% CI)Participants (RCTs)Quality of evidence

Risk with usual care plus CPAPRisk with intervention plus CPAP

Educational interventions

Device use

Mean of 1.97 to 5.1 hours per night

MD = 0.85 hours per night (0.32 to 1.39)

1,128 (10)

Very low

N deemed adherent (≥ 4 hours per night)

558 per 1,000

765 per 1,000 (654 to 849)

5 (3 to 10)

1,019 (7)

Very low

Supportive interventions

Device use

Mean of 1.75 to 4.9 hours per night

MD = 0.70 hours per night (0.36 to 1.05)

1,426 (13)

Moderate

N deemed adherent (≥ 4 hours per night)

601 per 1,000

717 per 1,000 (619 to 797)

9 (5 to 56)

376 (2)

Low

Behavioral interventions

Device use

Mean of 1.48 to 5.1 hours per night

MD = 1.31 hours per night (0.95 to 1.66)

578 (8)

High

N deemed adherent (≥ 4 hours per night)

371 per 1,000

501 per 1,000 (414 to 587)

8 (5 to 23)

549 (6)

High

Withdrawal

146 per 1,000

101 per 1,000 (70 to 143)

22 (13 to 33)

939 (10)

High

Mixed interventions

Device use

Mean of 2.6 to 5.5 hours per night

MD = 0.82 hours per night (0.20 to 1.43)

4,509 (11)

Very low

N deemed adherent (≥ 4 hours per night)

741 per 1,000

830 per 1,000 (755 to 886)

11 (7 to 71)

4,015 (9)

Very low

Withdrawal

129 per 1,000

83 per 1,000 (40 to 161)

4,956 (11)

Very low


CPAP = continuous positive airway pressure; MD = mean difference; NNT = number needed to treat; RCT = randomized controlled trial.

*—The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

Practice Pointers

OSA causes sleep fragmentation and can lead to excessive daytime sleepiness, mood changes, and impairments in cognition, memory, and driving competence. OSA increases the risk of cardiovascular, cerebrovascular, and metabolic morbidity.2 CPAP is first-line treatment for OSA, and consistent use can improve sleep quality and associated symptoms.3 A large systematic review and meta-analysis showed that CPAP had no effect on cardiovascular outcomes in patients with OSA; however, in most randomized controlled trials, patients used CPAP less than four hours per night.4 The effectiveness of CPAP on OSA symptoms directly correlates to duration

Author disclosure: No relevant financial affiliations.

References

show all references

1. Askland K, Wright L, Wozniak DR, et al. Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev. 2020;(4):CD007736....

2. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(3):479–504.

3. Patil SP, Ayappa IA, Caples SM, et al. Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2019;15(2):335–343.

4. Yu J, Zhou Z, McEvoy RD, et al. Association of positive airway pressure with cardiovascular events and death in adults with sleep apnea: a systematic review and meta-analysis. JAMA. 2017;318(2):156–166.

5. Wang Y, Ai L, Luo J, et al. Effect of adherence on daytime sleepiness, fatigue, depression and sleep quality in the obstructive sleep apnea/hypopnea syndrome patients undertaking nasal continuous positive airway pressure therapy. Patient Prefer Adherence. 2017;11:769–779.

6. The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea Work Group; Department of Veterans Affairs; Department of Defense. VA/DoD clinical practice guideline for the management of chronic insomnia disorder and obstructive sleep apnea. 2019;1–152. Accessed July 20, 2020. https://www.healthquality.va.gov/guidelines/CD/insomnia/VADoDSleepCPGFinal508.pdf

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at https://www.aafp.org/afp/cochrane.

 

 

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