Finally – Some Good News for CPAP Users
Lately, the news has not been great for CPAP users and the sleep centers that care for them. The USPSTF recommended against screening of asymptomatic patients and, in doing so, threw some major shade on the use of CPAP.
They wrote: “There is uncertainty about the accuracy or clinical utility of all potential screening tools. Multiple treatments for OSA reduce AHI, ESS scores, and blood pressure. Trials of CPAP and other treatments have not established whether treatment reduces mortality or improves most other health outcomes, except for modest improvement in sleep-related quality of life.” (1, p. 415)
Sleep physicians believe they are helping patients reverse the consequences of OSA when they prescribe CPAP. But clear data in support of this has been lacking.
AASM Practice Parameter
The AASM practice parameter recommends the use of CPAP for treatment of OSA because it reduces apnea. (2) The 2006 paper cites evidence of reduced sleepiness, improved quality of life, reduced blood pressure and minimal side effects as indications for use.
But, as the USPSTF points out, there is little evidence to support increased lifespan or reduced cardiovascular events. And, as data from the recent SAVE study showed, CPAP did not reduce cardiovascular events in patients with moderate-to-severe OSA. (3)
We don’t have much new to say about mortality or other health outcomes, but we have some new evidence to bolster the benefits of CPAP for health-related quality of life (HRQoL).
The Best Apnea Interventions for Research (BestAIR) study was a randomized controlled study with blinded assessment of outcomes. (4) Almost 28,000 patients were screened, 479 consented to participate and 169 with moderate-to-severe OSA and symptoms of cardiovascular disease were randomized for the study. Six month and one year follow ups were planned. There were four arms to the study, but CPAP with and without motivational enhancement were combined and no CPAP with and without a sham treatment were combined for the statistical comparisons. Baseline characteristics of the two groups were comparable.
The Medical Outcomes Study Short Form 36 was used to assess HRQoL. Several measures were significantly better in the CPAP group including general health, physical pain, vitality, and bodily pain. The physical health summary score averaged 42.9 in the control group and 46.2 in the CPAP group at one year follow up (p < .001). The Epworth Sleepiness Scale was significantly improved as well, although the effect size was modest (Cohen’s d = .35).
Let’s not underestimate the value of improved HRQoL. The AASM has included quality of life as one of the outcomes measures for OSA. (5) The improvement in the BestAIR study occurred even with the usual levels of adherence: an average of 3.8 hours of use per night and only 43.4% of patients meeting the arbitrary Medicare criterion of > 4 hours per night for 70% of nights. (4) The reduction in bodily pain was significant at p = .001.
Most of us would strongly consider a treatment even when the only benefit was feeling better, especially when the incidence of side effects is low.
It may be time for sleep professionals to move away from saying, “you have to use CPAP or you will die” to “try some CPAP; it will make you feel better.”
And, in the words of Mary Tyler Moore in the eponymous classic film of 1968, “What’s so bad about feeling good?”
Learn from the Leading Experts in Sleep Technology
American Association of Sleep Technologists
39TH ANNUAL MEETING
June 4-6, 2017 | Boston, Massachusetts
Hear experts discuss the latest trends in sleep technology and research, and discover the emerging roles of the sleep technology professional.
- Jonas DE, Amick HR, Feltner C, Weber RP, Arvanitis M, Stine A, Lux L, Harris RP. Screening for obstructive sleep apnea in adults: Evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2017 Jan 24;317(4):415-433. doi: 10.1001/jama.2016.19635.
- Kushida CA; Littner MR; Hirshkowitz M et al. Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders. SLEEP 2006;29(3):375-380.
- McEvoy RD, Antic NA, Heeley E, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med. 2016 Sep 8;375(10):919-31. doi: 10.1056/NEJMoa1606599.
- Zhao YY, Wang R, Gleason KJ, Lewis EF, Quan SF, Toth CM, Morrical M, Rueschman M, Weng J, Ware JH, Mittleman MA, Redline S, on behalf of the BestAIR Investigators; Effect of continuous positive airway pressure treatment on health-related quality of life and sleepiness in high cardiovascular risk individuals with sleep apnea: Best Apnea Interventions for Research (BestAIR) Trial. Sleep 2017; 40 (4): zsx040. doi: 10.1093/sleep/zsx040
- Aurora RN, Collop NA, Jacobowitz O, Thomas SM, Quan SF, Aronsky AJ. Quality measures for the care of adult patients with obstructive sleep apnea. J Clin Sleep Med 2015;11(3):357–383.