Therapieadhärenz 3 Monate nach Einleitung einer nichtinvasiven CPAP-Therapie bei 1078 Patienten mit obstruktiver Schlafapnoe (OSA)^[*]

Zusammenfassung

Einleitung Die nächtliche kontinuierliche positive Überdruckatmung (CPAP) gilt als therapeutischer Goldstandard einer obstruktiven Schlafapnoe (OSA). Die CPAP-Therapie stellt zumeist eine Dauertherapie mit geringen Nebenwirkungen dar. Trotzdem ist die Therapietreue unbefriedigend. In dieser Arbeit wurden die Therapietreue betrachtet und typische Probleme katalogisiert.

Methode 1078 OSA-Patienten wurden nach diagnostischer Polygrafie (PG) oder Polysomnografie (PSG) auf eine CPAP-Therapie eingestellt. Die Therapietreue wurde nach 3 Monaten nachverfolgt. Folgende Therapieadhärenz-Gruppen wurden festgelegt: 1. gute CPAP-Einstellung und Nutzung, 2. CPAP-Abbruch nach anfänglicher Nutzung, 3. mangelnde CPAP-Nutzung wegen Nebenwirkungen, 4. Abbruch aufgrund fehlender Motivation/geringem Leidensdruck, 5. Masken-Unverträglichkeit, 6. CPAP-Versagen aufgrund fehlenden Therapieeffekts, 7. Umstellung auf anderes Beatmungsverfahren, 8. keine Kontrolle erfolgt.

Ergebnisse Von 1078 CPAP-Patienten erschienen 830 Patienten (77 %) zur Therapiekontrolle. Hiervon waren 450 Patienten (54,2 %) in Gruppe 1, 216 Patienten (26 %) in Gruppe 2, 71 Patienten (8,5 %) in Gruppe 3, 35 Patienten (4,2 %) in Gruppe 4, 14 Patienten (1,7 %) in Gruppe 5, 3 Patienten (0,4 %) in Gruppe 6 und 41 Patienten (4,9 %) in Gruppe 7. Ein geringer obstruktiver Ereignisindex, niedriger CPAP-Druck und tendenziell auch ein geringer Epworth-Sleepiness-Score waren Prädiktoren für CPAP-Versagen. Für die Therapietreue konnten keine signifikanten Prädiktoren dargestellt werden.

Diskussion Eine effektive Therapienutzung von 54 % nach 3 Monaten ist ein suboptimales Ergebnis. Prädiktoren für CPAP-Versagen waren Parameter, die vor Therapie auf geringen Leidensdruck der Patienten deuteten. Trotz großer Patientenkohorte konnten keine signifikanten CPAP-Adhärenz-Prädiktoren durch anthropometrische oder PSG-Daten dargestellt werden. Vielmehr könnten Erfahrungen in den ersten Therapietagen ausschlaggebend sein. CPAP-Geräte bieten Komforteinstellungen, die kenntnisgerecht auf den Patienten individualisiert werden müssen. Eine große Auswahl an unterschiedlichen Maskenformen erfordert Erfahrung und Training bei der patientenorientierten Maskenanpassung. Eine 3-monatige Wiedervorstellung erscheint zu lang, um Therapieprobleme zeitnah mit dem Patienten zu besprechen. Telemedizinische Möglichkeiten oder kurzfristige telefonische Beratungsoptionen sollten in Betracht gezogen werden.

Abstract

Introduction Nocturnal Continuous Positive Airway Pressure (CPAP) is considered the gold standard treatment for obstructive sleep apnoea (OSA). The CPAP therapy is a long-term treatment but does come with few possible side effects. The adherence to the therapy is frequently suboptimal. In this paper, adherence to therapy was assessed and typical problems were classified.

Methods 1078 OSA patients received CPAP therapy after a diagnostic polygraphy (PG) or polysomnography (PSG). Adherence to therapy was followed up three months after treatment induction. The following therapy adherence groups were defined: 1. correctly calibrated CPAP and good adherence, 2. CPAP non-acceptance, after initial use, 3. CPAP intolerance use due to side effects, 4. discontinuation due to lack of motivation/low rates of symptoms. 5. mask intolerance, 6. CPAP failure due to a lack of perceived treatment effect, 7. Change to another non-invasive ventilation method, 8. No control carried out.

Results Out of 1078 OSA patients a therapy control was performed in 830 patients (77 %). Of these, 450 patients (54.2 %) were placed in group 1, 216 patients (26 %) in group 2, 71 patients (8.5 %) in group 3, 35 patients (4.2 %) in group 4, 14 patients (1.7 %) in group 5, 3 patients (0.4 %) in group 6 and 41 patients (4.9 %) in group 7. A mild obstructive index, low CPAP pressure and, as a trend, a low Epworth- Sleepiness score were predictors of CPAP failure. No significant predictors could be shown for adherence to therapy.

Discussion An effective treatment use of 54 % after 3 months is a suboptimal result. Predictors of CPAP failure were parameters that indicated that the patient was less symptomatic prior to therapy. Despite a large patient cohort, neither anthropometric nor PSG-data provided any significant CPAP adherence predictors. Rather, experiences in the first nights of use could be decisive. CPAP devices offer comfort settings that have to be personalised to patients’ needs and wants. A large selection of different mask shapes requires experience and training in patient-centred mask fitting. A three-month follow-up appointment seems too long to discuss therapy problems with the patient in a timely manner. Telemedical options or short-term telephone appointments should be considered.

^* Die vorgestellten Daten der Publikation sind Inhalt der Promotion von Julian Koehler.

Publikationsverlauf

Eingereicht: 28. Mai 2021

Angenommen nach Revision: 02. September 2021

Artikel online veröffentlicht:
29. November 2021

• Literatur

• 1 Sin DD, Mayers I, Man GC. et al. Long-term compliance rates to continuous positive airway pressure in obstructive sleep apnea: a population-based study. Chest 2002; 121: 430-435
• 2 Dodds S, Williams LJ, Roguski A. et al. Mortality and morbidity in obstructive sleep apnoea-hypopnoea syndrome: results from a 30-year prospective cohort study. ERJ Open Res 2020; 6: 00057-2020
• 3 Osman AM, Carter SG, Carberry JC. et al. Obstructive sleep apnea: current perspectives. Nat Sci Sleep 2018; 10: 21-34
• 4 Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc 2008; 5: 173-178
• 5 Wang Y, Gao W, Sun M. et al. Adherence to CPAP in Patients With Obstructive Sleep Apnea in a Chinese Population. Respir Care 2012; 57: 238-243
• 6 Patel SR, Bakker JP, Stitt CJ. et al. Age and Sex Disparities in Adherence to CPAP. Chest 2021; 159: 382-389
• 7 Mehrtash M, Bakker JP, Ayas N. Predictors of Continuous Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea. Lung 2019; 197: 115-121
• 8 Riachy M, Najem S. et al. Factors predicting CPAP adherence in obstructive sleep apnea syndrome. Sleep Breath 2017; 21: 295-302
• 9 Burnier M. Drug adherence in hypertension. Pharmacol Res 2017; 125: 142-149
• 10 Polonsky WH, Henry RR. Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Patient Prefer Adherence 2016; 10: 1299-1307
• 11 Sullivan CE. Nasal positive airway pressure and sleep apnea: reflection on an experimental method that became a therapy. Am J Respir Crit Care Med 2018; 198: 581-587
• 12 Fietze I, Ficker JH, Heiser C. et al. Wenn CPAP nicht genutzt oder nicht vertragen wird – Vorschlag für eine standardisierte Terminologie. Somnologie 2020; 24: 102-105
• 13 Baratta F, Pastori D, Bucci T. et al. Long-term prediction of adherence to continuous positive air pressure therapy for the treatment of moderate/severe obstructive sleep apnea syndrome. Sleep Med 2018; 43: 66-70
• 14 Campos-Rodriguez F, Martinez-Alonso M, Sanchez-de-la-Torre M. et al. Long-term adherence to continuous positive airway pressure therapy in non-sleepy sleep apnea patients. Sleep Med 2016; 17: 1-6
• 15 Wickwire EM, Jobe SL, Oldstone LM. et al. Lower socioeconomic status and co-morbid conditions are associated with reduced contiunuous positive airway pressure adherence among older adult medicare beneficiaries with obstructive sleep apnea. Sleep 2020; 43: zsaa122
• 16 Schwartz M, Acosta L, Hung YL. Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnea patients: a systematic review and meta-analysis. Sleep Breath 2018; 22: 555-568
• 17 Xu L, Xie D, Griffin KS. et al. Objective adherence to dental device versus positive airway pressure treatment in adults with obstructive sleep apnea. J Sleep Res 2021; 30: e13240 DOI: 10.1111/jsr.13240.
• 18 Chai-Coetzer CL, Luo Y-M, Antic NA. et al. Predictors of long-term adherence to continuous positive airway pressure therapy in patients with obstructive sleep apnea and cardiovascular disease in the SAVE study. Sleep 2013; 36: 1929-1937
• 19 Rotty MC, Suehs CM, Mallet JP. et al. Mask side-effects in long-term CPAP-patients impact adherence and sleepiness: the InterfaceVent real-life study. Respir Res 2021; 22: 1-13
• 20 Cistulli PA, Sullivan CE. In search of a good fit: CPAP therapy mask selection for obstructive sleep apnoea. Respirology 2019; 24: 199-200
• 21 Genta PR, Kaminska M, Edwards BA. et al. The Importance of Mask Selection on Continuous Positive Airway Pressure Outcomes for Obstructive Sleep Apnea. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2020; 17: 1177-1185
• 22 Goh K, Soh RY, Chai L. et al. Choosing the right mask for your Asian patient with sleep apnoea: a randomized, crossover trial of CPAP interface. Respirology 2018; 24: 278-285
• 23 Andrade RGS, Viana FM, Nascimento JA. et al. Nasal vs oronasal CPAP for OSA-treatment: a meta-analysis. Chest 2018; 153: 665-674
• 24 Pepin JLD, Langevin B, Robert D. et al. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome: study of 193 patients in two French sleep centers. Chest 1995; 107: 375-381
• 25 Lasters F, Mallegho C, Boudewyns A. et al. Nasal symptoms in patients with obstructive sleep apnea and their impact on the therapeutic compliance with continuous positive airway pressure. Acta Clinica Belg 2014; 69: 87-91
• 26 Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg 2016; 45: 43
• 27 Ryswyk E, Anderson CS, Antic NA. et al. Predictors of long-term adherence to continuous positive airway pressure in patients with obstructive sleep apnea and cardiovascular disease. Sleep 2019; 42: zsz152
• 28 Ritter J, Geißler K, Schneider G. et al. Influence of a structured follow-up on CPAP adherence in patients with an OSAS. Laryngo-Rhino-Otol 2018; 97: 615-623
• 29 Malhotra A, Crocker ME, Willes L. et al. Patient Engagement Using New Technology to Improve Adherence to Positive Airway Pressure Therapy. Chest 2018; 153: 843-850
• 30 Hoet F, Libert W, Sanida C. et al. Telemonitoring in continuous positive airway pressure-treated patients improves delay to first intervention and early compliance: a randomized trial. Sleep Med 2017; 39: 77-83
• 31 Hwang D, Chang JW, Benjafield AV. et al. Effect of telemedicine education and telemonitoring on continuous positive airway pressure adherence. The tele-OSA randomized trial. Am J Respir Crit Care Me 2018; 197: 117-126