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Cited by 721Obstructive Sleep Apnea ResearchSleep and related disordersRespiratory Support and Mechanisms

Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment

Open access
Patil, Susheel P., Ayappa, Indu A., Caples, Sean M., Kimoff, R. John, Patel, Sanjay R., Harrod, Christopher G.·2019·Journal of Clinical Sleep Medicine
DOI 10.5664/jcsm.7638PMC PMC6374080
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Abstract

Systematic review and meta-analysis supporting positive airway pressure as first-line adult OSA treatment.

Integrity signals

Registry

Crossref · 10.5664/jcsm.7638

Cites

302 of 302 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

66 of 201 cited sources checked · 36 supported · 1 flagged · accuracy not yet measured

  • Findingcitation

    In these non-RCT cohorts, oronasal interfaces were least often chosen by participants for long-term treatment compared with nasal and intra-nasal interfaces.

    “In these non-RCT cohorts, oronasal interfaces were least often chosen by participants for long-term treatment compared with nasal and intra-nasal interfaces.249,250”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [249] Borel JC, Tamisier R, Dias-Domingos S, et al. Type of mask may impact on continuous positive airway pressure adherence in apneic patients. PLoS One. 2013;8(5):e64382 source

      Table 2 (Patients’ characteristics; page not specified in our copy) reports that oronasal masks were used by 26.2% of patients, versus 11.4% for nasal pillows and 62.4% for nasal masks. Oronasal interfaces were therefore not the least-used type in this observational cohort. The paper reports interface use, not which interface participants chose for long-term treatment. (LLM, conf=0.90)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites [250] Beecroft J, Zanon S, Lukic D, Hanly P Oral continuous positive airway pressure for sleep apnea: effectiveness, patient preference, and adherence. Chest. 2003;124(6):2200–2208 source
  • Premisecitation

    Current evidence suggests a continuous dose-response relationship between hours of PAP use and therapeutic response.

    “current evidence suggests a continuous dose-response relationship between hours of use and therapeutic response.22,23”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [22] Antic NA, Catcheside P, Buchan C, et al. The effect of CPAP in normalizing daytime sleepiness, quality of life, and neurocognitive function in patients with moderate to severe OSA. Sleep. 2011;34(1):111–119 source

      The Discussion passage (page not provided) reports a dose-response relationship for many, but not all, behavioral measures: it was clear for posttreatment ESS scores but absent for MWT sleep latency. Thus the paper supports a relationship between hours of CPAP use and some therapeutic outcomes, but not a continuous relationship across therapeutic response generally. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [23] Weaver TE, Maislin G, Dinges DF, et al. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep. 2007;30(6):711–719 source

      The Discussion (page not specified in our copy) reports continuous gains in objective and subjective sleepiness with longer nightly CPAP use. It also says functional status appears to gain no further benefit beyond seven hours, so a continuous dose-response relationship does not apply to every therapeutic outcome studied. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • Findingown data

    Subgroup meta-analyses demonstrated a clinically significant reduction in the risk ratio for mortality of 0.2 (95% CI 0.1 to 0.5) for heart failure participants.

    “meta-analyses demonstrated clinically significant reductions in the risk ratio for mortality of 0.2 (95% CI: 0.1 to 0.5) and 0.4 (95% CI: 0.2 to 0.7) for heart failure 142,146 and no heart failure participants, 137,139,143,144,147 respectively”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [142] Kasai T, Narui K, Dohi T, et al. Prognosis of patients with heart failure and obstructive sleep apnea treated with continuous positive airway pressure. Chest. 2008;133(3):690–696 source
    • cites [146] Wang H, Parker JD, Newton GE, et al. Influence of obstructive sleep apnea on mortality in patients with heart failure. J Am Coll Cardiol. 2007;49(15):1625–1631 source

      The Mortality section (p. 1629) reports fewer deaths among treated heart-failure patients with obstructive sleep apnea than among untreated patients, so this study supplies relevant mortality data. It is an observational study, not a subgroup meta-analysis, and it reports no risk ratio of 0.2 (95% CI 0.1–0.5); its treated-versus-untreated mortality difference was not statistically significant (p = 0.07). (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • Findingcitation

    One study demonstrated an incremental cost-effectiveness ratio of CDN$15,915 per quality-adjusted life year with CPAP therapy.

    “The first study 167 demonstrated an incremental cost-effectiveness ratio (ICER) of CDN$15,915 per quality-adjusted life year (QALY) with CPAP therapy”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [167] Pietzsch JB, Garner A, Cipriano LE, Linehan JH An integrated health-economic analysis of diagnostic and therapeutic strategies in the treatment of moderate-to-severe obstructive sleep apnea. Sleep. 2011;34(6):695–709 source

      The Results report an ICER of $15,915 per QALY gained for CPAP compared with no treatment over a lifetime horizon. The paper specifies that its values are in 2008 U.S. dollars, not Canadian dollars, so the CDN$ designation is unsupported. (LLM, conf=0.94)

      Experimental — accuracy not yet measured
  • Findingown data

    Meta-analysis of RCTs demonstrated no clinically significant difference in sleep-related quality of life when comparing PAP initiation using home APAP versus an in-laboratory titration.

    “A meta-analysis combining 2 RCTs measuring sleep-related QOL with FOSQ, 175,176 2 RCTs measuring sleep-related QOL with SAQLI, 178,182 and one RCT 180 measuring both FOSQ and SAQLI demonstrated no clinically significant difference in sleep-related QOL when comparing PAP initiation using home APAP versus an in-laboratory titration”
    Quote in the paperSubstantial claim2 of 5 sources checked
    • cites [175] Cross MD, Vennelle M, Engleman HM, et al. Comparison of CPAP titration at home or the sleep laboratory in the sleep apnea hypopnea syndrome. Sleep. 2006;29(11):1451–1455 source

      The Three-Month Assessment (p. 2) identifies this as an RCT that measured sleep-related quality of life with FOSQ, and the Results (p. 3) report no statistical difference between home and laboratory titration. The paper measured SF-36, not SAQLI, alongside FOSQ. It reports its own trial, not the cited meta-analysis or a test of clinical significance. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [176] Kuna ST, Gurubhagavatula I, Maislin G, et al. Noninferiority of functional outcome in ambulatory management of obstructive sleep apnea. Am J Respir Crit Care Med. 2011;183(9):1238–1244 source
    • cites [178] Mulgrew AT, Fox N, Ayas NT, Ryan CF Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. Ann Intern Med. 2007;146(3):157–166 source
    • cites [182] Hui DS, Ng SS, Tam WWS Home-based approach is non-inferior to hospital-based approach in managing patients with suspected obstructive sleep apnoea syndrome. Am J Respir Crit Care Med. 2018;197(9):1233–1234 source
    • cites [180] Rosen CL, Auckley D, Benca R, et al. A multisite randomized trial of portable sleep studies and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and treatment of obstructive sleep apnea: the HomePAP study. Sleep. 2012;35(6):757–767 source
  • May combine two claims. 91
  • Classified as probably not a substantial claim. 45
  • The quote only partly states this claim. 5

  • May combine two claims.

    Premisecitation

    Observational data demonstrate that increased knowledge of OSA and its long-term impacts, as well as the beneficial effects of PAP, predict adherence.

    “Observational data have demonstrated that increased knowledge of OSA and its long-term impacts, as well as the beneficial effects of PAP predict adherence, raising interest in educational interventions.26”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [26] Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev. 2011;15(6):343–356 source

      In “Psychological and social factors” (page unavailable), the review reports that beliefs about OSA and CPAP formed during education and early treatment influence CPAP use; it also describes nonadherent patients identifying few CPAP benefits. But “Educational strategies” (page unavailable) says that knowledge influencing adherence is an assumption and that educational studies had not measured knowledge as a mediator. The review therefore does not establish the claimed prediction by increased knowledge of OSA’s long-term impacts and PAP benefits. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Interpretationcitation

    Two reasons for the lower adherence in RCTs may be the inclusion of less symptomatic/sleepy participants and exclusion of participants with the most severe disease.

    “Two reasons for the lower adherence in RCTs may be the inclusion of less symptomatic/sleepy participants and exclusion of participants with the most severe disease 116given that symptoms and OSA severity are predictors of PAP adherence.163”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [116] McEvoy RD, Antic NA, Heeley E, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med. 2016;375(10):919–931 source
    • cites [163] Weaver TE, Grunstein RR Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;5(2):173–178 source

      The Disease Severity passage supports the proposed role of sleepiness: it associates greater daytime sleepiness with long-term CPAP use and reports low use among patients with severe sleep apnea but little sleepiness. It describes only a weak relationship between disease severity and adherence, and it does not say that RCTs exclude the most severe patients or attribute lower RCT adherence to either enrollment pattern. Page numbers are unavailable in our copy. (LLM, conf=0.82)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Six studies evaluated cost, of which three reported a slightly reduced cost for a combined home-based diagnostic and treatment pathway, and three reported a lower cost for home APAP compared to in-laboratory titrations.

    “Six studies evaluated cost, 35,175,177,[179][180][181] of which three 35,180,181 reported a slightly reduced cost for a combined home-based diagnostic and treatment pathway, and three 175,177,179 reported a lower cost for home APAP compared to in-laboratory titrations.”
    Quote in the paperSubstantial claim3 of 7 sources checked
    • cites 35,175,177,[179][180][181]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [35] Antic NA, Buchan C, Esterman A, et al. A randomized controlled trial of nurse-led care for symptomatic moderate-severe obstructive sleep apnea. Am J Respir Crit Care Med. 2009;179(6):501–508 source
    • cites [180] Rosen CL, Auckley D, Benca R, et al. A multisite randomized trial of portable sleep studies and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and treatment of obstructive sleep apnea: the HomePAP study. Sleep. 2012;35(6):757–767 source
    • cites [181] Chai-Coetzer CL, Antic NA, Rowland LS, et al. Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life: a randomized trial. JAMA. 2013;309(10):997–1004 source
    • cites [175] Cross MD, Vennelle M, Engleman HM, et al. Comparison of CPAP titration at home or the sleep laboratory in the sleep apnea hypopnea syndrome. Sleep. 2006;29(11):1451–1455 source
    • cites [177] McArdle N, Singh B, Murphy M, et al. Continuous positive airway pressure titration for obstructive sleep apnoea: automatic versus manual titration. Thorax. 2010;65(7):606–611 source
    • cites [179] Planes C, D'Ortho MP, Foucher A, et al. Efficacy and cost of home-initiated auto-nCPAP versus conventional nCPAP. Sleep. 2003;26(2):156–160 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Many studies utilized 24-hour (or 48-hour) ambulatory blood pressure measurements, considered to be the most accurate method to diagnose hypertension and the best predictor of future cardiovascular risk.

    “Many studies utilized 24-hour (or 48-hour) ambulatory BP measurements, considered to be the most accurate method to diagnose hypertension and the best predictor of future cardiovascular risk.154”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [154] Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the subcommittee of professional and public education of the American Heart Association Council on high blood pressure research. Hypertension. 2005;45(1):142–161 source

      The Types of Monitor section (page not available) describes ambulatory monitoring as a research technique typically used for 24 hours. The Prognostic Significance section says ambulatory blood pressure predicts morbid events better than clinic blood pressure. It does not establish that 24- or 48-hour monitoring is the most accurate method for diagnosing hypertension or the best predictor among all methods; it notes that nighttime blood pressure may be the best predictor of risk. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    One study demonstrated lower cost using a home-based pathway compared to the laboratory pathway where > 50% of the studies were split-night studies.

    “Of note, one study 180 demonstrated lower cost using a home-based pathway compared to the laboratory pathway where > 50% of the studies were split-night studies.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [180] Rosen CL, Auckley D, Benca R, et al. A multisite randomized trial of portable sleep studies and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and treatment of obstructive sleep apnea: the HomePAP study. Sleep. 2012;35(6):757–767 source

  • May combine two claims.

    Findingcitation

    In 4 studies, there was less pressure discomfort with APAP than CPAP, and in at least 2 studies, less nasal irritation or machine noise with APAP than CPAP.

    “In 4 of these studies, 186,193,198,208 there was less pressure discomfort with APAP than CPAP, and in at least 2 of the studies, less nasal irritation 186,205 or machine noise 193,205 with APAP than CPAP.”
    Quote in the paperNot a substantial claim1 of 5 sources checked
    • cites [186] Hukins C Comparative study of autotitrating and fixed-pressure CPAP in the home: a randomized, single-blind crossover trial. Sleep. 2004;27(8):1512–1517 source
    • cites [193] Nussbaumer Y, Bloch KE, Genser T, Thurnheer R Equivalence of autoadjusted and constant continuous positive airway pressure in home treatment of sleep apnea. Chest. 2006;129(3):638–643 source
    • cites [198] To KW, Chan WC, Choo KL, Lam WK, Wong KK, Hui DS A randomized cross-over study of auto-continuous positive airway pressure versus fixed-continuous positive airway pressure in patients with obstructive sleep apnoea. Respirology. 2008;13(1):79–86 source
    • cites [208] Massie CA, Hart RW Clinical outcomes related to interface type in patients with obstructive sleep apnea/hypopnea syndrome who are using continuous positive airway pressure. Chest. 2003;123(4):1112–1118 source
    • cites [205] Massie CA, McArdle N, Hart RW, et al. Comparison between automatic and fixed positive airway pressure therapy in the home. Am J Respir Crit Care Med. 2003;167(1):20–23 source

  • May combine two claims.

    Findingcitation

    Only one study included participants who had previously showed nonadherence with CPAP (< 4 h/night), whereas the other 4 studies included PAP naïve participants.

    “Only one study included participants who had previously showed nonadherence with CPAP (< 4 h/ night), 209 whereas the other 4 studies included PAP naïve participants.[210][211][212][213]”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [209] Ballard RD, Gay PC, Strollo PJ Interventions to improve compliance in sleep apnea patients previously non-compliant with continuous positive airway pressure. J Clin Sleep Med. 2007;3(7):706–712 source
    • cites [210][211][212][213]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Findingown data

    A total of 11 studies reported data on side effects, with 6 of the studies reporting no clinically significant differences in side effects between APAP and CPAP.

    “A total of 11 studies reported data on side effe cts, 179,183,186,188,191,[193][194][195][196]198,205 with 6 of the studies 179,183,188,191,195,196 reporting no clinically significant differences in side effects between APAP and CPAP.”
    Quote in the paperNot a substantial claim1 of 7 sources checked
    • cites 179,183,186,188,191,[193][194][195][196]198,205

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [179] Planes C, D'Ortho MP, Foucher A, et al. Efficacy and cost of home-initiated auto-nCPAP versus conventional nCPAP. Sleep. 2003;26(2):156–160 source
    • cites [183] d'Ortho MP, Grillier-Lanoir V, Levy P, et al. Constant vs. automatic continuous positive airway pressure therapy: home evaluation. Chest. 2000;118(4):1010–1017 source
    • cites [188] Kushida CA, Berry RB, Blau A, et al. Positive airway pressure initiation: a randomized controlled trial to assess the impact of therapy mode and titration process on efficacy, adherence, and outcomes. Sleep. 2011;34(8):1083–1092

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [191] Nolan GM, Doherty LS, Mc Nicholas WT Auto-adjusting versus fixed positive pressure therapy in mild to moderate obstructive sleep apnoea. Sleep. 2007;30(2):189–194 source
    • cites [195] Resta O, Carratu P, Depalo A, et al. Effects of fixed compared to automatic CPAP on sleep in obstructive sleep apnoea syndrome. Monaldi Arch Chest Dis. 2004;61(3):153–156 source
    • cites [196] Senn O, Brack T, Matthews F, Russi EW, Bloch KE Randomized short-term trial of two autoCPAP devices versus fixed continuous positive airway pressure for the treatment of sleep apnea. Am J Respir Crit Care Med. 2003;168(12):1506–1511 source

  • May combine two claims.

    Findingcitation

    Only one study, which assessed participants that were CPAP intolerant, suggests that BPAP might improve adherence, although the precision in this study was very low and precluded any definitive statements.

    “Only one study, which assessed participants that were CPAP intolerant, suggests that BPAP might improve adherence, although the precision in this study was very low and precluded any definitive statements.209”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [209] Ballard RD, Gay PC, Strollo PJ Interventions to improve compliance in sleep apnea patients previously non-compliant with continuous positive airway pressure. J Clin Sleep Med. 2007;3(7):706–712 source

      In Phase 2 (page not provided), previously CPAP-noncompliant patients assigned to BiFlex had higher adherence than those continuing CPAP (49% versus 28%). The Discussion notes the study’s relatively small size, but its caution against definitive conclusions concerns BiFlex versus standard bilevel PAP, which was not tested; it does not describe the adherence result as having very low precision. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    Overall, there were 7 RCTs identified that compared a pure educational intervention versus usual care, 6 RCTs that compared a behavioral intervention versus usual care, and 9 RCTs that compared a troubleshooting with education intervention versus usual care.

    “Overall, there were 7 RCTs 207,214,215,220,221,229,230 identified that compared a pure educational intervention versus usual care, 6 RCTs 214-219 that compared a behavioral intervention versus usual care, and 9 RCTs 207,220,222-228 that compared a troubleshooting with education intervention versus usual care.”
    Quote in the paperSubstantial claim4 of 10 sources checked
    • cites [207] Meurice JC, Ingrand P, Portier F, et al. A multicentre trial of education strategies at CPAP induction in the treatment of severe sleep apnoeahypopnoea syndrome. Sleep Med. 2007;8(1):37–42 source
    • cites [214] Aloia MS, Smith K, Arnedt JT, et al. Brief behavioral therapies reduce early positive airway pressure discontinuation rates in sleep apnea syndrome: preliminary findings. Behav Sleep Med. 2007;5(2):89–104 source
    • cites [215] Aloia MS, Arnedt JT, Strand M, Millman RP, Borrelli B Motivational enhancement to improve adherence to positive airway pressure in patients with obstructive sleep apnea: a randomized controlled trial. Sleep. 2013;36(11):1655–1662 source
    • cites [220] Chervin RD, Theut S, Bassetti C, Aldrich MS Compliance with nasal CPAP can be improved by simple interventions. Sleep. 1997;20(4):284–289 source
    • cites [221] Wang W, He G, Wang M, Liu L, Tang H Effects of patient education and progressive muscle relaxation alone or combined on adherence to continuous positive airway pressure treatment in obstructive sleep apnea patients. Sleep Breath. 2012;16(4):1049–1057 source
    • cites [229] Guralnick AS, Balachandran JS, Szutenbach S, et al. Educational video to improve CPAP use in patients with obstructive sleep apnoea at risk for poor adherence: a randomised controlled trial. Thorax. 2017;72(12):1132–1139 source
    • cites [230] Sarac S, Afsar GC, Oruc O, Topcuoglu OB, Salturk C, Peker Y Impact of patient education on compliance with positive airway pressure treatment in obstructive sleep apnea. Med Sci Monit. 2017;23 1792–1799 source
    • cites [216] Deng T, Wang Y, Sun M, Chen B Stage-matched intervention for adherence to CPAP in patients with obstructive sleep apnea: a randomized controlled trial. Sleep Breath. 2013;17(2):791–801 source
    • cites [217] Lai AY, Fong DY, Lam JC, Weaver TE, Ip MS The efficacy of a brief motivational enhancement education program on CPAP adherence in OSA: a randomized controlled trial. Chest. 2014;146(3):600–610 source
    • cites [218] Parthasarathy S, Wendel C, Haynes PL, Atwood C, Kuna S A pilot study of CPAP adherence promotion by peer buddies with sleep apnea. J Clin Sleep Med. 2013;9(6):543–550 source

      The Design and Setting passage identifies this as a randomized trial of a peer-buddy intervention versus usual care, supporting its inclusion among behavioral-intervention trials. It does not support counting the study as a pure educational intervention versus usual care: both groups received usual care, and the intervention group additionally interacted with peer buddies. The paper does not establish the sentence’s overall counts of 7, 6, and 9 RCTs. (LLM, conf=0.90)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Both studies demonstrated no clinically significant difference in the frequency of PAP-related side effects, with the exception of one study which suggested that telemonitoring was associated with fewer complaints of a dry mouth.

    “Both studies demonstrated no clinically significant difference in the frequency of PAP-related side effects, with the exception of one study which suggested that telemonitoring was associated with fewer complaints of a dry mouth (see supplemental material, Table S10).228”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [228] Fox N, Hirsch-Allen AJ, Goodfellow E, et al. The impact of a telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial. Sleep. 2012;35(4):477–481 source

      The Results (Table 3) show more favorable dry-mouth scores in the telemedicine group (5.81 versus 4.16; P = 0.01), and the Results text says no other side-effect difference was statistically significant. The study measured side-effect ratings, not the frequency of complaints, and it does not establish that the other differences were clinically insignificant. This paper also cannot substantiate the claim about both studies. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    In the other RCT study, participants in the telemonitoring group reported low to moderate overall satisfaction compared to those in the usual care arm (26% versus 4% respectively) with additional concerns about privacy when being identified as being nonadherent or that non-hospital personnel had access to their PAP data.

    “In the other RCT study, participants in the telemonitoring group reported low to moderate overall satisfaction compared to those in the usual care arm (26% versus 4% respectively) with additional concerns about privacy when being identified as being nonadherent or that non-hospital personnel had access to their PAP data.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [235] Turino C, de Batlle J, Woehrle H, et al. Management of continuous positive airway pressure treatment compliance using telemonitoring in obstructive sleep apnoea. Eur Respir J. 2017;49(2): source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Two RCTs assessed the impact of telemonitoring-guided PAP adherence interventions on PAP-induced side effects, but data were not reported in a sufficiently standardized format to allow for meta-analysis.

    “Two RCTs were identified that assessed the impact of a telemonitoring guided PAP adherence intervention on PAP-induced side effects; however, data were not reported in a sufficiently standardized format to allow for a meta-analysis.228,235”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [228] Fox N, Hirsch-Allen AJ, Goodfellow E, et al. The impact of a telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial. Sleep. 2012;35(4):477–481 source

      The Methods (Protocol) and Results (Table 3) show that this randomized trial assessed PAP-related side effects under telemedicine monitoring. The paper reports side-effect scores as means and standard deviations, but it does not address whether its data could be combined with another trial in a meta-analysis. It also cannot establish the citing document's count of two RCTs. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [235] Turino C, de Batlle J, Woehrle H, et al. Management of continuous positive airway pressure treatment compliance using telemonitoring in obstructive sleep apnoea. Eur Respir J. 2017;49(2): source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Data on adherence for nasal versus oronasal interfaces were also analyzed from 3 non-randomized studies.

    “Data on adherence for nasal versus oronasal interfaces were also analyzed from 3 non-randomized studies.[249][250][251]”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [249] Borel JC, Tamisier R, Dias-Domingos S, et al. Type of mask may impact on continuous positive airway pressure adherence in apneic patients. PLoS One. 2013;8(5):e64382 source
    • cites [250] Beecroft J, Zanon S, Lukic D, Hanly P Oral continuous positive airway pressure for sleep apnea: effectiveness, patient preference, and adherence. Chest. 2003;124(6):2200–2208 source
    • cites [251] Bachour A, Vitikainen P, Virkkula P, Maasilta P CPAP interface: satisfaction and side effects. Sleep Breath. 2013;17(2):667–672 source

  • May combine two claims.

    Findingcitation

    In one study, while overall nasopharyngeal scores were not significantly different, complaints of dry or sore throat were significantly less with humidified than non-humidified PAP.

    “In one study, while overall nasopharyngeal scores were not significantly different, complaints of dry or sore throat were significantly less with humidified than non-humidified PAP.266”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [266] Soudorn C, Muntham D, Reutrakul S, Chirakalwasan N Effect of heated humidification on CPAP therapy adherence in subjects with obstructive sleep apnea with nasopharyngeal symptoms. Respir Care. 2016;61(9):1151–1159 source

  • May combine two claims.

    Findingown data

    Meta-analyses of 2 RCTs demonstrated clinically significant reduction in the odds of nasal discharge, dry nose, epistaxis, and dry mouth/throat with the use of humidified PAP while meta-analyses of 3 RCTs demonstrated clinically significant reduction in the odds of nasal congestion and dry mouth with the use of humidified PAP.

    “Meta-analyses of 2 RCTs 260,262 demonstrated clinically significant reduction in the odds of nasal discharge, dry nose, epistaxis, and dry mouth/throat with the use of humidified PAP while meta-analyses of 3 RCTs 260,262,263 demonstrated clinically significant reduction in the odds of nasal congestion and dry mouth with the use of humidified PAP (see supplemental material, Figure S102 through”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [260] Neill AM, Wai HS, Bannan SP, Beasley CR, Weatherall M, Campbell AJ Humidified nasal continuous positive airway pressure in obstructive sleep apnoea. Eur Respir J. 2003;22(2):258–262 source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
    • cites [262] Salgado SM, Boleo-Tome JP, Canhao CM, et al. Impact of heated humidification with automatic positive airway pressure in obstructive sleep apnea therapy. J Bras Pneumol. 2008;34(9):690–694 source
    • cites [263] Sommer JU, Kraus M, Birk R, Schultz JD, Hormann K, Stuck BA Functional short- and long-term effects of nasal CPAP with and without humidification on the ciliary function of the nasal respiratory epithelium. Sleep Breath. 2014;18(1):85–93 source

  • May combine two claims. The quote only partly states this claim.

    Findingcitation

    Another study reported clinically significant reductions in the incidence of sinus pain/headache, sore throat, hoarse voice, and smell with odds ratios of 0.4 (95% CI: 0.1 to 1.4), 0.3 (95% CI: 0.1 to 1.6), 0.8 (95% CI: 0.2 to 3.2), and 0.7 (95% CI: 0.2 to 2.3) with humidification, respectively.

    “Another study reported clinically significant reductions in the incidence of sinus pain/headache, sore throat, hoarse voice, and”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [260] Neill AM, Wai HS, Bannan SP, Beasley CR, Weatherall M, Campbell AJ Humidified nasal continuous positive airway pressure in obstructive sleep apnoea. Eur Respir J. 2003;22(2):258–262 source

      Table 3 (Discussion; page unavailable) shows lower symptom frequencies with heated humidification for all four named symptoms, and the Discussion describes the overall effect as clinically relevant. However, the table does not report the four odds ratios or confidence intervals quoted in the claim; it reports different values, and the individual symptom differences did not reach statistical significance. (LLM, conf=0.89)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingnone given

    The studies assessed only participants with newly diagnosed OSA with no prior history of treatment and only one study specifically recruited individuals with nasal symptoms.

    “The studies assessed only participants with newly diagnosed OSA with no prior history of treatment and only one study 266 specifically recruited individuals with nasal symptoms.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [266] Soudorn C, Muntham D, Reutrakul S, Chirakalwasan N Effect of heated humidification on CPAP therapy adherence in subjects with obstructive sleep apnea with nasopharyngeal symptoms. Respir Care. 2016;61(9):1151–1159 source

  • May combine two claims.

    Findingcitation

    Five studies reported on participant preference or satisfaction with the use of humidification, with participants on average either preferring heated humidification or expressing no clear preference for heated humidification.

    “Five studies [259][260][261][262]264 reported on participant preference or satisfaction with the use of humidification, with participants on average either preferring heated humidification 260,264 or expressing no clear preference 261,262 for heated humidification.”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [259] Massie CA, Hart RW, Peralez K, Richards GN Effects of humidification on nasal symptoms and compliance in sleep apnea patients using continuous positive airway pressure. Chest. 1999;116(2):403–408 source
    • cites [260] Neill AM, Wai HS, Bannan SP, Beasley CR, Weatherall M, Campbell AJ Humidified nasal continuous positive airway pressure in obstructive sleep apnoea. Eur Respir J. 2003;22(2):258–262 source
    • cites [261] Ryan S, Doherty LS, Nolan GM, McNicholas WT Effects of heated humidification and topical steroids on compliance, nasal symptoms, and quality of life in patients with obstructive sleep apnea syndrome using nasal continuous positive airway pressure. J Clin Sleep Med. 2009;5(5):422–427 source

  • May combine two claims.

    Findingown data

    The literature search resulted in 336 studies that met inclusion criteria, and 184 studies provided data suitable for meta-analyses.

    “The literature search resulted in 336 studies that met inclusion criteria; 184 studies provided data suitable for meta-analyses.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In non-sleepy adults with OSA, PAP compared with control reduces ESS by -1.0 points (95% CI: -0.7 to -1.4 points), which the task force judged not clinically significant.

    “A sub-analysis of the 5 studies 63,85,86,106,112 recruiting only non-sleepy participants with OSA demonstrated an ESS reduction of -1.0 points (95% CI: -0.7 to -1.4 points) that the TF judged to not be clinically significant.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The control interventions used in the included RCTs (sham CPAP, conservative measures, no intervention, sham surgery, placebo tablet, nasal dilator strips) are equivalent to no treatment.
    • Rests on an assumption: The study populations in the included studies are representative of typical adult patients with OSA.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Participants were randomized to CPAP versus APAP for at least 1 month up to a maximum of 6 months (median 2 months).

    “Participants were randomized to CPAP versus APAP for at least 1 month up to a maximum of 6 months (median 2 months).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    In that study, 62% of participants randomized to the in-laboratory pathway would have preferred home management, compared to 6% of participants in the ambulatory group who would have preferred in-laboratory based management.

    “In that study, 62% of participants randomized to the in-laboratory pathway would have preferred home management, compared to 6% of participants in the ambulatory group who would have preferred inlaboratory based management.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    There was no evidence of poor treatment efficacy based on AHI or reduced PAP adherence in the home APAP arm.

    “There was no evidence of poor treatment efficacy (based on AHI) or reduced PAP adherence in the home APAP arm”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Participants in APAP versus CPAP studies were predominantly male, with previously untreated moderate to severe OSA and no major medical comorbidities.

    “Participants were predominantly male, with previously untreated moderate to severe OSA and no major medical comorbidities.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The present meta-analyses demonstrated no clinically significant differences in most of the critical outcomes assessed between APAP and CPAP, and no substantial harm was identified for APAP compared with CPAP.

    “The present meta-analyses demonstrated no clinically significant differences in most of the critical outcomes assessed between APAP and CPAP, and no substantial harm was identified for APAP compared with CPAP.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The proportion of participants favoring APAP varied considerably between studies, with no consistent pattern of preference emerging.

    “The proportion of participants favoring APAP (see supplemental material, Figure S74) varied considerably between studies, with no consistent pattern of preference emerging.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The magnitude of any hypothetical costs savings has not been studied.

    “However, the magnitude of any hypothetical costs savings has not been studied.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Participants in BPAP versus CPAP studies were predominantly male, middle aged, referred to sleep clinics without concomitant medical or psychiatric disorders with moderate to severe OSA, randomized to CPAP versus BPAP for durations of either 1 month, 3 months, or 12 months of PAP use.

    “Participants were predominantly male, middle aged, referred to sleep clinics without concomitant medical or psychiatric disorders with moderate to severe OSA, randomized to CPAP versus BPAP for durations of either 1 month, 3 months, or 12 months of PAP use.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Meta-analyses demonstrated no clinically significant differences in quality of life as measured by the combined SAQLI/FOSQ, or by the SF-36 physical component summary, mental component summary, or vitality scores.

    “Meta-analyses demonstrated no clinically significant differences in QOL as measured by the combined SAQLI/ FOSQ, or by the SF-36 physical component summary, mental component summary, or vitality scores”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The average therapeutic pressure reported in the studies was ~10 cm H2O and none of the studies specifically selected participants with high PAP requirements.

    “The average therapeutic pressure reported in the studies was ~10 cm H2O and none of the studies specifically selected participants with high PAP requirements.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    The one RCT of CPAP versus BPAP that reported side effects followed participants for 1 year and reported no clinically significant difference in side effects with similar complaints in both groups with regard to mask discomfort, machine noise, and nasal stuffiness.

    “Participants in the one RCT of CPAP versus BPAP that reported side effects followed participants for 1 year. 212his study reported no clinically significant difference in side effects with similar complaints in both groups with regard to mask discomfort, machine noise, and nasal stuffiness.212”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [212] Reeves-Hoche MK, Hudgel DW, Meck R, Witteman R, Ross A, Zwillich CW Continuous versus bilevel positive airway pressure for obstructive sleep apnea. Am J Respir Crit Care Med. 1995;151(2 Pt 1):443–449 source

  • May combine two claims.

    Findingnone given

    All studies included in this assessment compared at least one of these interventions to a standard of care which varied substantially across studies in terms of the level and intensity of care provided, resulting in heterogeneity across studies.

    “All studies included in this assessment compared at least one of these interventions to a standard of care which varied substantially across studies in terms of the level and intensity of care provided, resulting in heterogeneity across studies.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    One of the included studies used a cross-over design.

    “One of these studies used a cross-over design.240”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [240] Leidag M, Hader C, Keller T, Meyer Y, Rasche K Mask leakage in continuous positive airway pressure and C-Flex. J Physiol Pharmacol. 2008;59 Suppl 6 401–406

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The intervention was administered for a period of at least 1 month (range: 1-6 months).

    “The intervention was administered for a period of at least 1 month (range: 1-6 months).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Some telemonitoring studies triggered interventions based only on low PAP usage, while other studies also triggered interventions for high mask leak, high delivered pressures, and/or high residual AHI.

    “Some studies only triggered interventions based on low usage while other studies also triggered interventions for high mask leak, high delivered pressures, and/or high residual AHI.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    One of the studies reviewed suggested that telemonitoring may be a more cost-effective approach with an ICER of €17,359 per QALY.

    “One of the studies reviewed suggested that telemonitoring may be a more cost-effective approach with an ICER of €17,359 per QALY.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Participants in the modified pressure profile studies were predominantly male, obese, with moderate to severe OSA, and self-reportedly sleepy.

    “Participants were predominantly male, obese, with moderate to severe OSA, and self-reportedly sleepy.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    One of the included studies allowed participants after the RCT ended to cross-over to using a modified pressure profile PAP in an open-label study for 3 months and demonstrated an increase in adherence in those participants that had had low adherence on standard PAP (< 4 h/night).

    “One of the included studies allowed participants after the RCT ended to cross-over to using a modified pressure profile PAP in an open-label study for 3 months and demonstrated an increase in adherence in those participants that had had low adherence on standard PAP (< 4 h/night), suggesting that participants with poor adherence might increase their PAP use once transitioned to modified pressure P”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [239] Pepin JL, Muir JF, Gentina T, et al. Pressure reduction during exhalation in sleep apnea patients treated by continuous positive airway pressure. Chest. 2009;136(2):490–497 source

  • May combine two claims.

    Findingcitation

    In another trial, clinically significant improvements in QOL with CPAP were observed in both telemonitoring and control groups, but there was no difference in the magnitude of improvement between groups.

    “Clinically significant improvements in QOL with CPAP were observed in both telemonitoring and control groups; however, there was no difference in the magnitude of improvement between those who received telemonitoring and those who did not.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    In one study, participants in the telemonitoring group indicated a greater likelihood of continuing to use CPAP compared to the usual care group, while both groups were highly satisfied with their care and were not concerned about being wirelessly monitored.

    “In one study, participants in the telemonitoring group indicated a greater likelihood of continuing to use CPAP compared to the usual care group, while both groups were highly satisfied with their care and were not concerned about being wirelessly monitored.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Residual AHI was higher with oronasal than nasal interfaces, although this difference was not clinically significant.

    “Residual AHI was higher with oronasal than nasal interfaces, although this difference was not clinically significant (see supplemental material, Figure S95).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Overall, there were no clinically significant differences in side effects or in participant preference between modified pressure profile PAP and standard PAP.

    “Overall, there were no clinically significant differences in side effects or in participant preference 188,240 between modified pressure profile PAP and standard PAP.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [188] Kushida CA, Berry RB, Blau A, et al. Positive airway pressure initiation: a randomized controlled trial to assess the impact of therapy mode and titration process on efficacy, adherence, and outcomes. Sleep. 2011;34(8):1083–1092

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [240] Leidag M, Hader C, Keller T, Meyer Y, Rasche K Mask leakage in continuous positive airway pressure and C-Flex. J Physiol Pharmacol. 2008;59 Suppl 6 401–406

  • May combine two claims.

    Findingown data

    Meta-analysis demonstrated a clinically significant standardized mean difference of 0.3 (95% CI: 0.0 to 0.6) in PVT reaction time in favor of standard PAP over modified pressure profile and a clinically significant standardized mean difference in PVT lapses of 0.2 (95% CI: -0.2 to 0.7).

    “Meta-analysis demonstrated a clinically significant standardized mean difference of 0.3 (95% CI: 0.0 to 0.6) in PVT reaction time in favor of standard PAP over modified pressure profile and a clinically significant standardized mean difference in PVT lapses of 0.2 (95% CI: -0.2 to 0.7) (see supplemental material, Figure S89 and Figure S90).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Participants in the 8 RCTs were predominantly middle-aged males without major medical comorbidities with moderate to severe OSA who were treated with each interface for at least 1 and up to 8 weeks (median duration of 4 weeks) in either parallel or crossover designs.

    “Participants in the 8 RCTs were predominantly middle-aged males without major medical comorbidities with moderate to severe OSA who were treated with each interface for at least 1 and up to 8 weeks (median duration of 4 weeks) in either parallel or crossover designs.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    There were no differences in mask comfort between the groups; however, there was a trend in sleep quality being worse in the modified pressure profile PAP group at 90 and 180 days after the start of therapy.

    “There were no differences in mask comfort between the groups; however, there was a trend in sleep quality being worse in the modified pressure profile PAP group at 90 and 180 days after the start of therapy.188”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [188] Kushida CA, Berry RB, Blau A, et al. Positive airway pressure initiation: a randomized controlled trial to assess the impact of therapy mode and titration process on efficacy, adherence, and outcomes. Sleep. 2011;34(8):1083–1092

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Findingcitation

    Participants were previously untreated except for one study in which participants established on PAP treatment for > 6 months were randomized to intra-nasal versus nasal treatment.

    “Participants were previously untreated except for one study 243 in which participants established on PAP treatment for > 6 months were randomized to intra-nasal versus nasal treatment.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [243] Zhu X, Wimms AJ, Benjafield AV Assessment of the performance of nasal pillows at high CPAP pressures. J Clin Sleep Med. 2013;9(9):873–877 source

  • May combine two claims.

    Findingcitation

    Generally, participants in these studies were not selected based on specific side effects (eg, nasal congestion, oral dryness) or mask interface intolerance, except for one study where participants with significant nasal resistance were excluded.

    “Generally, participants in these studies were not selected based on specific side effects (eg, nasal congestion, oral dryness) or mask interface intolerance, except for one study where participants with significant nasal resistance were excluded.248”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [248] Rowland S, Aiyappan V, Hennessy C, et al. Comparing the efficacy, mask leak, patient adherence, and patient preference of three different CPAP interfaces to treat moderate-severe obstructive sleep apnea. J Clin Sleep Med. 2018;14(1):101–108 source

  • May combine two claims.

    Findingown data

    Participants in the non-randomized studies were predominantly male without major medical comorbidities, with previously untreated moderate to severe OSA, and were treated for at least 3 weeks up to 24 months.

    “Participants were predominantly male without major medical comorbidities, with previously untreated moderate to severe OSA, and were treated for at least 3 weeks up to 24 months.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    The duration of treatment for most studies was only 3-4 weeks, although one study did follow participants to 1 year.

    “The duration of treatment for most studies was only 3-4 weeks, although one study did follow participants to 1 year.258”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [258] Mador MJ, Krauza M, Pervez A, Pierce D, Braun M Effect of heated humidification on compliance and quality of life in patients with sleep apnea using nasal continuous positive airway pressure. Chest. 2005;128(4):2151–2158 source

  • May combine two claims.

    Findingcitation

    In one study, overall mask satisfaction scores were significantly higher for intra-nasal interfaces while in the other 2 studies which determined participant preference, there was no clinically significant difference between intra-nasal versus nasal interfaces either for newly treated or previously treated participants.

    “In one study, 208 overall mask satisfaction scores were significantly higher for intra-nasal interfaces while in the other 2 studies 242,243 which determined participant preference, there was no clinically significant difference between intra-nasal versus nasal interfaces either for newly treated or previously treated participants.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [208] Massie CA, Hart RW Clinical outcomes related to interface type in patients with obstructive sleep apnea/hypopnea syndrome who are using continuous positive airway pressure. Chest. 2003;123(4):1112–1118 source
    • cites [242] Ryan S, Garvey JF, Swan V, Behan R, McNicholas WT Nasal pillows as an alternative interface in patients with obstructive sleep apnoea syndrome initiating continuous positive airway pressure therapy. J Sleep Res. 2011;20(2):367–373 source
    • cites [243] Zhu X, Wimms AJ, Benjafield AV Assessment of the performance of nasal pillows at high CPAP pressures. J Clin Sleep Med. 2013;9(9):873–877 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    Most studies utilized heated humidification, except for 2 studies where one study compared both heated and cold pass-over humidification to no humidification and one study that did not specify the form of humidification used.

    “Most studies utilized heated humidification, except for 2 studies where one study 259 compared both heated and cold pass-over humidification to no humidification and one study 263 that did not specify the form of humidification used.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [259] Massie CA, Hart RW, Peralez K, Richards GN Effects of humidification on nasal symptoms and compliance in sleep apnea patients using continuous positive airway pressure. Chest. 1999;116(2):403–408 source
    • cites [263] Sommer JU, Kraus M, Birk R, Schultz JD, Hormann K, Stuck BA Functional short- and long-term effects of nasal CPAP with and without humidification on the ciliary function of the nasal respiratory epithelium. Sleep Breath. 2014;18(1):85–93 source

  • May combine two claims.

    Findingcitation

    An overall multi-item side effect score favored intra-nasal interfaces in one study of newly treated participants, but there were no clinically significant differences in overall side effects between interfaces for the other 2 studies.

    “An overall multi-item side effect score favored intra-nasal interfaces in one study of newly treated participants, 208 but there were no clinically significant differences in overall side effects between interfaces for the other 2 studies.242,243”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [208] Massie CA, Hart RW Clinical outcomes related to interface type in patients with obstructive sleep apnea/hypopnea syndrome who are using continuous positive airway pressure. Chest. 2003;123(4):1112–1118 source
    • cites [242] Ryan S, Garvey JF, Swan V, Behan R, McNicholas WT Nasal pillows as an alternative interface in patients with obstructive sleep apnoea syndrome initiating continuous positive airway pressure therapy. J Sleep Res. 2011;20(2):367–373 source
    • cites [243] Zhu X, Wimms AJ, Benjafield AV Assessment of the performance of nasal pillows at high CPAP pressures. J Clin Sleep Med. 2013;9(9):873–877 source

  • May combine two claims.

    Findingown data

    Individual side effects including pressure sensation on the face, skin irritation, claustrophobia and obtrusiveness were in general less for intra-nasal interfaces in the 3 studies, while nasal interfaces were scored as being less obtrusive.

    “Individual side effects including pressure sensation on the face, skin irritation, claustrophobia and obtrusiveness were in general less for intra-nasal interfaces in the 3 studies, while nasal interfaces were scored as being less obtrusive.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    In one study in which participants selected mask interface for initial titration and later long-term use, 27% chose oral versus 66% nasal initially, while long-term, after 6 months, 43% of those who initially selected an oral interface switched to nasal, while no one who initially selected a nasal interface switched masks.

    “In one study in which participants selected mask interface for initial titration and later long-term use, 27% chose oral versus 66% nasal initially, while long-term, after 6 months, 43% of those who initially selected an oral interface switched to nasal, while no one who initially selected a nasal interface switched masks.250”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [250] Beecroft J, Zanon S, Lukic D, Hanly P Oral continuous positive airway pressure for sleep apnea: effectiveness, patient preference, and adherence. Chest. 2003;124(6):2200–2208 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The mean AHI in nearly all studies was in the severe range.

    “The mean AHI in nearly all studies was in the severe range.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    QOL was assessed with the FOSQ and no clinically significant difference in QOL was found comparing intra-nasal versus nasal interfaces.

    “QOL was assessed with the FOSQ and no clinically significant difference in QOL was found comparing intra-nasal versus nasal interfaces.208”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [208] Massie CA, Hart RW Clinical outcomes related to interface type in patients with obstructive sleep apnea/hypopnea syndrome who are using continuous positive airway pressure. Chest. 2003;123(4):1112–1118 source

  • May combine two claims.

    Findingcitation

    For both RCTs, oral interfaces were associated with more oral dryness, excess salivation, lip and gum discomfort, while nasal interfaces were associated with more self-reports of air leaks, nasal dryness and strap/mask discomfort, with no differences in interface dislodgement.

    “For both RCTs, oral interfaces were associated with more oral dryness, excess salivation, lip and gum discomfort, while nasal interfaces were associated with more self-reports of air leaks, nasal dryness and strap/mask discomfort, with no differences in interface dislodgement.246,247”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [246] Anderson FE, Kingshott RN, Taylor DR, Jones DR, Kline LR, Whyte KF A randomized crossover efficacy trial of oral CPAP (Oracle) compared with nasal CPAP in the management of obstructive sleep apnea. Sleep. 2003;26(6):721–726 source
    • cites [247] Khanna R, Kline LR A prospective 8 week trial of nasal interfaces vs. a novel oral interface (Oracle) for treatment of obstructive sleep apnea hypopnea syndrome. Sleep Med. 2003;4(4):333–338 source

  • May combine two claims.

    Findingown data

    Higher scores for nasal and throat dryness but not nasal stuffiness were clinically significant with the nasal interface while higher scores of self-reported mask leak, sore eyes, claustrophobia and difficulty exhaling were clinically significant with the oronasal interface.

    “Higher scores for nasal and throat dryness but not nasal stuffiness were clinically significant with the nasal interface while higher scores of self-reported mask leak, sore eyes, claustrophobia and difficulty exhaling were clinically significant with the oronasal interface.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    In another cross-over RCT, mask noise and leak were greater with oronasal masks which were also reported to be harder to fit and hold in place, while other side effects did not differ.

    “In another cross-over RCT, 248 mask noise and leak were greater with oronasal masks which were also reported to be harder to fit and hold in place, while other side effects did not differ.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [248] Rowland S, Aiyappan V, Hennessy C, et al. Comparing the efficacy, mask leak, patient adherence, and patient preference of three different CPAP interfaces to treat moderate-severe obstructive sleep apnea. J Clin Sleep Med. 2018;14(1):101–108 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    All participants chose the nasal interface for long-term treatment.

    “All participants chose the nasal interface for long-term treatment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    All of the included studies assessed self-reported sleepiness using the ESS.

    “All of the included studies assessed self-reported sleepiness using the ESS.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based). The quote only partly states this claim.

    Findingnone given

    Potential adverse effects of humidification including rainout (condensation) of water into the PAP circuit or participants' face, nose or mouth with excessive humidity settings, or the inconvenience of purchasing distilled water and additional cleaning requirements were not reported on.

    “Potential adverse effects of humidification including”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Findingnone given

    Significant progress has been made in examining educational, behavioral, troubleshooting, and telemonitoring strategies that can improve adherence to PAP.

    “Significant progress has been made in examining educational, behavioral, troubleshooting, and telemonitoring strategies that can improve adherence to PAP.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Although the quality of evidence for neurocognitive outcomes was rated as moderate, the number of studies available for review was small and these studies focused on participants without baseline deficits in neurocognitive function.

    “Although the quality of evidence for neurocognitive outcomes was rated as moderate, the number of studies available for review was small and these studies focused on participants without baseline deficits in neurocognitive function.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Overall, the analyses support the conclusion that treatment of OSA with CPAP results in clinically significant improvements in self-reported sleepiness and the ability to maintain wakefulness, particularly in sleepy patients with OSA.

    “Overall, the analyses support the conclusion that treatment of OSA with CPAP results in clinically significant improvements in selfreported sleepiness and the ability to maintain wakefulness, particularly in sleepy patients with OSA.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The control interventions used in the included RCTs (sham CPAP, conservative measures, no intervention, sham surgery, placebo tablet, nasal dilator strips) are equivalent to no treatment.
    • Rests on an assumption: The study populations in the included studies are representative of typical adult patients with OSA.

  • May combine two claims.

    Interpretationown data

    The quality of evidence for blood pressure in all participant types with OSA ranged from moderate to high, depending on the time and type of blood pressure measured, and was downgraded due to imprecision.

    “The quality of evidence for BP in all participant types with OSA ranged from moderate to high, depending on the time and type of BP measured, and was downgraded due to imprecision.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The AASM Board of Directors approved the final list of PICO questions before the literature search was performed.

    “Directors approved the final list of PICO questions presented”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Overall, the analyses suggest that PAP is effective in improving sleep-related quality of life, but not overall quality of life, in adults with OSA.

    “Overall, the analyses suggest that PAP is effective in improving sleep-related QOL, but not overall QOL in adults with OSA.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The control interventions used in the included RCTs (sham CPAP, conservative measures, no intervention, sham surgery, placebo tablet, nasal dilator strips) are equivalent to no treatment.
    • Rests on an assumption: The study populations in the included studies are representative of typical adult patients with OSA.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The task force set a clinical significance threshold for each outcome to determine whether the mean changes in the outcomes assessed were clinically significant.

    “The TF set a clinical significance threshold for each outcome to determine whether the mean changes in the outcomes assessed were clinically significant.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Any discrepancies between the reviewers were discussed and resolved by the Chair.

    “Any discrepancies between the reviewers were discussed and resolved by the Chair.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The quality of evidence for quality of life ranged from moderate to high, depending on the measure employed, and was downgraded due to imprecision.

    “The quality of evidence for QOL ranged from moderate to high, depending on the measure employed, and was downgraded due to imprecision.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The assessment of evidence quality was performed according to the GRADE process.

    “The assessment of evidence quality was performed according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Overall, the analyses suggest that PAP use reduces blood pressure in adults with OSA, particularly in participants with moderate to severe OSA.

    “Overall, the analyses suggest that PAP use reduces BP in adults with OSA, particularly in participants with moderate to severe OSA.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    All abstracts were reviewed based on inclusion/exclusion criteria by two task force members.

    “All abstracts were reviewed based on inclusion/ exclusion criteria by two TF members.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The analyses are inconclusive regarding the effects of PAP in reducing all-cause mortality in adults with OSA, in part related to differences in patient populations studied and PAP adherence between randomized and non-randomized studies.

    “Like the evidence review for cardiovascular events, the analyses are inconclusive regarding the effects of PAP in reducing all-cause mortality in adults with OSA, in part related to differences in patient populations studied and PAP adherence between randomized and non-randomized studies.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The quality of evidence for neurocognitive function ranged from low to high and was downgraded due to imprecision in certain domains.

    “The quality of evidence for neurocognitive function ranged from low to high and was downgraded due to imprecision in certain domains.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The potential benefits of CPAP based on the meta-analyses performed include reduction in OSA severity, improvement in patient symptoms, particularly sleepiness, sleep-related QOL, MVCs, and reduction in blood pressure.

    “The potential benefits of CPAP based on the meta-analyses performed include reduction in OSA severity, improvement in patient symptoms, particularly sleepiness, sleep-related QOL, MVCs, and reduction in BP.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The quality of evidence for cardiovascular event rate ranged from low to moderate, based on the types of studies pooled for meta-analysis, and was downgraded due to study type and imprecision.

    “The quality of evidence for cardiovascular event rate ranged from low to moderate, based on the types of studies pooled for meta-analysis, and was downgraded due to study type and imprecision.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    PAP initiation in adults with OSA using home APAP or in-laboratory titration have similar effects on both sleep-related and general quality of life.

    “Overall, the analysis suggests that PAP initiation in adults with OSA using a home APAP or in-laboratory titration have similar effects on both sleep-related and general QOL.”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Study design and conductnone given

    The overall quality of evidence for the comparison of home APAP versus in-laboratory titration was high.

    “The overall quality of evidence was high.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    The TF judged that resource use is justified for home APAP titration in the initiation of therapy for patients without significant comorbidities with established diagnoses of OSA, while recognizing that in some regions due to patient access and patient preference that in-laboratory CPAP titration may be a more effective use of resources.

    “The TF judged that resource use is justified for home APAP titration in the initiation of therapy for patients without significant comorbidities with established diagnoses of OSA, while recognizing that in some regions due to patient access and patient preference that in-laboratory CPAP titration may be a more effective use of resources.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Results of meta-analyses should not be extrapolated to participants with OSA and these comorbidities or situations.

    “Thus, results of meta-analyses should not be extrapolated to participants with OSA and these comorbidities or situations.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Studies that did not describe a systematic method of blood pressure ascertainment were excluded from the meta-analyses.

    “Studies that did not describe a systematic method of BP ascertainment were excluded from the meta-analyses.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationnone given

    Potential benefits of PAP initiation using home APAP over in-laboratory titration include reduced time to initiation of therapy, reduced time away from home, lower overall cost, and greater access to care.

    “The potential benefits of PAP initiation using home APAP over in-laboratory titration are a reduced time to initiation of therapy, particularly in areas with limited laboratory resources, reduced time away from home, lower overall cost, and greater access to care.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The outcomes of adherence to PAP therapy, sleepiness, and quality of life were determined by the TF to be critical for decisionmaking.

    “The outcomes of adherence to PAP therapy, sleepiness, and QOL were determined by the TF to be critical for decisionmaking.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Similar issues with mask fit or leak could occur with an in-laboratory titration approach once the patient is using PAP in the home setting.

    “However, similar issues could occur with an in-laboratory titration approach once the patient is using PAP in the home setting.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationnone given

    There are some concerns about the development of treatment-emergent central sleep apnea associated with PAP in general, however, patient harm has yet to be demonstrated.

    “There are some concerns about the development of treatment-emergent central sleep apnea associated with PAP in general, however, patient harm has yet to be demonstrated.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The TF determined that the majority of well-informed patients would most likely choose the more convenient, accessible, and cost-effective intervention, particularly when adequate education on PAP with mask fittings and daytime acclimatization by trained staff are available.

    “Given this discussion, the TF determined that the majority of well-informed patients would most likely choose the more convenient, accessible, and cost-effective intervention, particularly when adequate education on PAP with mask fittings and daytime acclimatization by trained staff are available.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Initiating therapy with APAP at home may delay or obscure recognition of mask fit or leak problems and reduce adherence to therapy.

    “In such instances, initiating therapy with APAP at home may delay or obscure recognition of these conditions and reduce adherence to therapy.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    A potential benefit of APAP over CPAP is the ability to automatically adjust therapeutic pressures as OSA severity changes with weight fluctuations, nighttime alcohol consumption, body position, seasonal variations, and changes in upper airway anatomy.

    “A potential benefit of APAP over CPAP is the ability to automatically adjust therapeutic pressures as OSA severity changes with weight fluctuations, nighttime alcohol consumption, body position, seasonal variations (eg, upper respiratory tract infections), and changes in upper airway anatomy.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationnone given

    Potential disadvantages of APAP include sleep disruption from pressure fluctuations or the return of sleep disordered breathing events when the PAP level is lowered by internal device algorithms.

    “Potential disadvantages of APAP, which may be observed for some patients, include sleep disruption from pressure fluctuations or the return of sleep disordered breathing events when the PAP level is lowered by internal device algorithms.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    The quality of evidence for adherence in the APAP versus CPAP comparison ranged from moderate to high, being downgraded due to imprecision.

    “The quality of evidence for this outcome ranged from moderate to high, being downgraded due to imprecision.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    The overall quality of evidence for quality of life in the APAP versus CPAP comparison ranged from moderate to high and was downgraded due to imprecision.

    “The overall quality of evidence for QOL ranged from moderate to high and was downgraded due to imprecision.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    The overall quality of evidence for sleepiness in the APAP versus CPAP comparison ranged from moderate to high and was downgraded due to imprecision.

    “The overall quality of evidence for sleepiness ranged from moderate to high and was downgraded due to imprecision.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Either APAP or CPAP should be used to treat adult OSA.

    “The TF therefore concluded that either APAP or CPAP should be used to treat adult OSA.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationreasoning

    Over the long-term, APAP therapy may reduce costs due to reduced need for patient visits and in-laboratory titrations as pressure requirements change over time.

    “Over the long-term, APAP therapy may reduce costs due to reduced need for patient visits and in-laboratory titrations as pressure requirements change over time.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Differences in side effects between APAP and CPAP in adults with OSA were minor and were judged by the TF to not be clinically significant.

    “Overall, differences in side effects between APAP and CPAP in adults with OSA were minor and were judged by the TF to not be clinically significant”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Study design and conductown data

    The overall quality of evidence for the APAP versus CPAP comparison was moderate due to imprecision.

    “The overall quality of evidence was moderate due to imprecision.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    In some regions of the world, market and other factors may lead to differences in cost between APAP and fixed CPAP, which may impact the feasibility of APAP-based treatment.

    “However, in some regions of the world, market and other factors may lead to differences in cost between APAP and fixed CPAP (as discussed in the section on APAP at home versus in-laboratory PAP titration for initiation of PAP for the treatment of adults with OSA), which may therefore impact the feasibility of APAP-based treatment.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationnone given

    Inappropriate or inadvertent increases in pressure may result in the development of treatment-emergent central sleep apnea or periodic breathing in certain patients, however, patient harm has yet to be demonstrated.

    “Furthermore, inappropriate or inadvertent increases in pressure may result in the development of treatment-emergent central sleep apnea or periodic breathing in certain patients, however, patient harm has yet to be demonstrated.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    In these situations, BPAP devices may be needed for optimal treatment and can be utilized during an initial or subsequent in-laboratory PAP titration study.

    “In these situations, BPAP devices may be needed for optimal treatment and can be utilized during an initial or subsequent in-laboratory PAP titration study.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    BPAP may be of benefit in some CPAP intolerant patients, despite the use of modified pressure profile.

    “However, the TF also recognized that BPAP may be of benefit in some CPAP intolerant patients, despite the use of modified pressure profile.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Some patients may require BPAP when therapeutic pressure settings are higher than what can be delivered by a CPAP device.

    “In addition, some patients may require BPAP when therapeutic pressure settings are higher than what can be delivered by a CPAP device.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The majority of patients would prefer their OSA be treated with CPAP rather than BPAP based on the similar benefits of treatment with BPAP and CPAP, and the potential for increased cost of BPAP, risk for incomplete treatment, and the availability of modest expiratory pressure reduction in most CPAP devices manufactured today.

    “The TF determined that the majority of patients would prefer their OSA be treated with CPAP rather than BPAP based on the similar benefits of treatment with BPAP and CPAP, and the potential for increased cost of BPAP, risk for incomplete treatment, and the availability of modest expiratory pressure reduction in most CPAP devices manufactured today.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    In general, clinicians should use CPAP over BPAP in the routine initiation of treatment of adults with OSA.

    “Therefore, the TF concluded that in general, clinicians should use CPAP over BPAP in the routine initiation of treatment of adults with OSA.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    BPAP conferred no clinically significant advantage over CPAP in adults with OSA in improving adherence, except potentially as rescue therapy for participants nonadherent to CPAP.

    “Overall, the analyses suggest that BPAP conferred no clinically significant advantage over CPAP in adults with OSA in improving adherence, except potentially as rescue therapy for participants' nonadherent to CPAP.”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Study design and conductown data

    The overall quality of evidence for the BPAP versus CPAP comparison was downgraded to very low due to imprecision and potential bias due to industry funding.

    “The overall quality of evidence was downgraded to very low due to imprecision and potential bias due to industry funding.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    There is no expected advantage of BPAP over CPAP in reducing OSA severity, which was confirmed in the meta-analysis of the limited studies available.

    “There is no expected advantage of BPAP over CPAP in reducing OSA severity, which was confirmed in the meta-analysis of the limited studies available.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    There are significant differences in the cost of BPAP and CPAP devices between countries and medical systems, with small differences in some regions and larger differences in others.

    “The TF recognized that there are significant differences in the cost of BPAP and CPAP devices between countries and medical systems, with small differences in some regions and larger differences in others.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Potential harms of BPAP are, in general, like CPAP with a few notable additional considerations including the potential for suboptimal improvement in the residual AHI from an inappropriately low expiratory pressure setting and the substantially higher cost of BPAP devices.

    “Potential harms of BPAP are, in general, like CPAP with a few notable additional considerations including the potential for suboptimal improvement in the residual AHI from an inappropriately low expiratory pressure setting and the substantially higher cost of BPAP devices.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationreasoning

    The cost of BPAP could result in greater resource use.

    “While the TF did not identify cost-effectiveness studies and did not undertake a comprehensive cost comparison of BPAP versus CPAP devices, the TF determined based on its collective clinical experience that the cost of BPAP could result in greater resource use.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    A potential benefit of BPAP over CPAP is improved comfort due to a lower pressure during exhalation, which may then improve patient adherence and consequentially improve OSA-related outcomes.

    “A potential benefit of BPAP over CPAP is improved comfort due to a lower pressure during exhalation, which may then improve patient adherence and consequentially improve OSA-related outcomes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationreasoning

    The potential benefit of a lower expiratory pressure may be less relevant since modified pressure profiles in current PAP devices perform a similar function.

    “The potential benefit of a lower expiratory pressure may be less relevant since modified pressure profiles in current PAP devices perform a similar function.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    Educational interventions, which are typically one-time sessions providing information about OSA and PAP therapy, have minimal burden and are relatively easy to implement in virtually all healthcare settings.

    “Educational interventions, which are typically one-time sessions providing information about OSA and PAP therapy have minimal burden and are relatively easy to implement in virtually all healthcare settings.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    The TF judged that the benefits of an educational intervention strongly outweigh any potential harms or burdens, while the benefits of a behavioral and/or troubleshooting intervention likely outweigh the harms and burdens of such interventions in most patients.

    “Overall, the TF judged that the benefits of an educational intervention strongly outweigh any potential harms or burdens, while the benefits of a behavioral and/or troubleshooting intervention likely outweigh the harms and burdens of such interventions in most patients.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    These interventions require development of infrastructure and expertise that may not be readily available in some healthcare settings.

    “Finally, these interventions require development of infrastructure and expertise that may not be readily available in some healthcare settings.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    The behavioral and troubleshooting interventions may cause a sense of loss of privacy or discomfort to patients.

    “In addition, the behavioral and troubleshooting interventions may cause a sense of loss of privacy or discomfort to patients.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Increased knowledge and mastery of CPAP therapy would lead to improvements in psychological well-being.

    “In addition, increased knowledge and mastery of CPAP therapy would lead to improvements in psychological well-being.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The benefits of a telemonitoring-guided adherence intervention are improvements in PAP adherence to improve control of OSA symptoms and reduce the need for office visits, which might reduce healthcare costs.

    “The benefits of a telemonitoring guided adherence intervention are improvements in PAP adherence to improve control of OSA symptoms and reduce the need for office visits, which might reduce healthcare costs.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    For some patients, increased communication with a health care provider or healthcare medical equipment company may be perceived as intrusive or seem more impersonal, which could result in reduced patient satisfaction.

    “Furthermore, for some patients, increased communication with a health care provider or healthcare medical equipment company may be perceived as intrusive or seem more impersonal which could result in reduced patient satisfaction.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    The benefits of all three types of interventions include increased adherence with PAP therapy along with the presumed downstream effects of increased adherence, such as better control of OSA symptoms.

    “The benefits of all three types of interventions include increased adherence with PAP therapy along with the presumed downstream effects of increased adherence, such as better control of OSA symptoms.181”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [181] Chai-Coetzer CL, Antic NA, Rowland LS, et al. Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life: a randomized trial. JAMA. 2013;309(10):997–1004 source

  • May combine two claims.

    Interpretationcitation

    Analyses from at least one study suggest that certain patient populations, particularly poorly adherent patients, may benefit from modified pressure profile PAP, though this requires further investigation.

    “Nevertheless, analyses from at least one study 239 suggest that certain patient populations, particularly poorly adherent patients, may benefit from modified pressure profile PAP, though this requires further investigation.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [239] Pepin JL, Muir JF, Gentina T, et al. Pressure reduction during exhalation in sleep apnea patients treated by continuous positive airway pressure. Chest. 2009;136(2):490–497 source

  • May combine two claims.

    Interpretationreasoning

    For individual patients there may be clinically important differences in side effects with oral compared with nasal interfaces, which on average lead patients to select nasal over oral interfaces.

    “For individual patients there may be clinically important differences in side effects with oral compared with nasal interfaces, which on average lead patients to select nasal over oral interfaces, but ultimately interface selection should be based on individual patient preference and tolerance.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The increased side effects appear to result in a patient preference for nasal over oronasal interfaces and translate into a clinically significant reduction in adherence with oronasal compared to nasal PAP.

    “The increased side effects appear to result in a patient preference for nasal over oronasal interfaces and translate into a clinically significant reduction in adherence with oronasal compared to nasal PAP (see Adherence above).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Effects may be synergistic between anti-hypertensive medications and PAP.

    “effects may be synergistic between anti-hypertensive medications and PAP”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [159] Pepin JL, Tamisier R, Barone-Rochette G, Launois SH, Levy P, Baguet JP Comparison of continuous positive airway pressure and valsartan in hypertensive patients with sleep apnea. Am J Respir Crit Care Med. 2010;182(7):954–960 source
    • cites [160] Thunstrom E, Manhem K, Rosengren A, Peker Y Blood pressure response to losartan and continuous positive airway pressure in hypertension and obstructive sleep apnea. Am J Respir Crit Care Med. 2016;193(3):310–320 source

  • May combine two claims.

    Study design and conductreasoning

    Current RCTs of PAP for cardiovascular events are limited by the extent of PAP adherence obtained (e.g., 3-4 h/night), the severity of OSA in the patient sample, and restriction of recruitment to non-sleepy patients.

    “current RCTs are limited by several factors: the extent of PAP adherence obtained (eg, 3-4 h/night of PAP use), the severity of OSA in the patient sample, and restriction of recruitment to non-sleepy patients”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Overall, review of the data suggests a clinically significant reduction in the incidence of CPAP-related side effects with humidification, which together with the widespread availability of integrated humidifiers on current PAP devices, favors the routine use of humidification.

    “Overall, review of the data suggests a clinically significant reduction in the incidence of CPAP-related side effects with humidification, which together with the widespread availability of integrated humidifiers on current PAP devices, favors the routine use of humidification.”
    Quote in the paperSubstantial claim
128 of 128

  • The authors state this as an assumption.

    For the OSA severity meta-analysis, AHI and RDI are equivalent measures.

    “For this analysis, the two measures were considered equivalent.”

  • The paper relies on this without support.

    The control interventions used in the included RCTs (sham CPAP, conservative measures, no intervention, sham surgery, placebo tablet, nasal dilator strips) are equivalent to no treatment.

    “The control interventions utilized included sham CPAP (n = 5), 34,66,74,84,93 conservative measures (advice on weight loss or good sleep habit counseling), no intervention (n = 3), 78,82,92 sham surgery (n = 1), 90 placebo tablet (n = 1), 65 and nasal dilator strips (n = 1) 61 .”

  • The paper relies on this without support.

    The study populations in the included studies are representative of typical adult patients with OSA.

    “Particpants in the studies were from clinic-based populations and were predominantly male, obese, with moderate to severe OSA and self-reported sleepiness.”

  • The paper relies on this without support.

    The studies pooled in each meta-analysis are sufficiently similar in populations, interventions, and outcome definitions to justify combining their results.

    “many trials studied heterogeneous populations with respect to characteristics that may differentially influence the BP-lowering response to PAP therapy.”

  • The paper relies on this without support.

    The control conditions used in the trials (sham PAP, usual care, oral placebo, no treatment) are appropriate comparators for estimating the effect of PAP.

    “Several control conditions were utilized, ranging from sham PAP, 63,66,68,75,86,89,94,[100][101][102]104,120 to usual care, 36,82,97,98,112,116,148 to an oral placebo tablet 64,65 to no treatment while maintaining antihypertensive medications 79,95,96,105,117 for comparison to PAP.”

  • The paper relies on this without support.

    Home APAP setup requires one step after diagnosis of OSA, while in-laboratory PAP titration typically requires two steps.

    “From a logistical standpoint, home APAP setup requires one step after diagnosis of OSA-a visit to educate on APAP use and provision of the APAP device.In-laboratory PAP titration typically requires two steps-one visit for the titration study and another for PAP education and provision of the PAP device.”

  • The paper relies on this without support.

    Regional variations in the time to schedule an additional sleep study for PAP titration and to navigate the healthcare system for PAP setup after titration can be substantial, generally favoring home APAP.

    “Regional variations in the time to get scheduled for an additional sleep study for PAP titration and navigating the healthcare system for PAP setup after titration can be substantial, which would generally favor home APAP.”

  • The paper relies on this without support.

    In some regions, the health care system creates barriers that make APAP difficult to implement and may take longer to perform than an in-laboratory titration strategy followed by PAP setup.

    “On the other hand, in some regions, the health care system creates barriers that make APAP difficult to implement and may take longer to perform than an in-laboratory titration strategy followed by PAP setup.”

  • The paper relies on this without support.

    The motivation to address OSA symptoms is greatest when patients first seek OSA evaluation.

    “The motivation to address OSA symptoms is greatest when patients first seek OSA evaluation.”

  • The paper relies on this without support.

    Delays in initiating PAP therapy can substantially increase chances of loss to follow-up or poor adherence due to loss of engagement and motivation.

    “Delays in initiating PAP therapy can substantially increase chances of loss to followup or poor adherence due to loss of engagement and motivation.”

  • The paper relies on this without support.

    In-laboratory titration costs include infrastructure and overnight staffing, while resources for education and training of patients are required for APAP initiation.

    “While in-laboratory titration costs include infrastructure and overnight staffing, resources for education and training of patients are required for APAP initiation.”

  • The paper relies on this without support.

    The availability of resources and cost of each strategy may vary by region.

    “The availability of resources and cost of each strategy may vary by region.”

  • The paper relies on this without support.

    Side effects have been reported with the use of both BPAP and CPAP, including nasal dryness or irritation, dry mouth, sore throat, sinus infection, and poor sleep quality.

    “Side effects have been reported with the use of both BPAP and CPAP.These include but are not limited to nasal dryness or irritation, dry mouth, sore throat, sinus infection, and poor sleep quality.”

  • The paper relies on this without support.

    These side effects can impact patient adherence with PAP.

    “These side effects can impact patient adherence with PAP and should be carefully monitored.”

  • The paper relies on this without support.

    There are significant differences in the cost of BPAP and CPAP devices between countries and medical systems.

    “The TF recognized that there are significant differences in the cost of BPAP and CPAP devices between countries and medical systems, with small differences in some regions and larger differences in others.”

  • The paper relies on this without support.

    Randomized trials in the area of PAP and motor vehicle crashes are not feasible.

    “Although randomized trials in this area are not feasible”

  • The paper relies on this without support.

    The current evidence base has been used to set public policy on driving restrictions for drivers at the state level and for safety-sensitive personnel at the federal level.

    “The current evidence base has been used to set public policy on driving restrictions for drivers on the state level and safety-sensitive personnel (eg, commercial motor vehicle drivers, pilots, railroad workers, etc.) at a federal level.”

  • The paper relies on this without support.

    Non-randomized cohort studies are known to over-estimate therapy-related effects compared to randomized controlled designs.

    “non-randomized cohort studies are known to over-estimate therapy-related effects compared to randomized controlled designs”
18 of 18

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • A meta-analysis of patients with obstructive sleep apnea reported that CPAP did not have significant effects on either left ventricular ejection fraction or hospitalization rates.

    “Although several small-scale studies have reported benefits associated with CPAP, including improved left ventricular function, reduced sympathetic tone and myocardial oxygen consumption, and lower rates of HF hospitalization and mortality, a meta-analysis of patients with OSA reported that CPAP did not have significant effects on either left ventricular ejection fraction or hospitalization rates.”

    From Obstructive Sleep Apnea and Cardiovascular Disease: A Scientific Statement From the American Heart Association (2021) · cites this paper as [30]

  • In observational studies, PAP was associated with significant mortality reduction, with greater risk reduction among patients with heart failure.

    “In observational studies that examined several modalities of PAP, a significant mortality reduction was observed with PAP, with greater risk reduction observed among patients with HF. 30”

    From Obstructive Sleep Apnea and Cardiovascular Disease: A Scientific Statement From the American Heart Association (2021) · cites this paper as [30]

  • Large randomized controlled trials have not yet shown an effect of PAP, including CPAP, on survival.

    “However, large randomized controlled trials have not yet shown an effect of PAP, including CPAP, on survival.13,30”

    From Obstructive Sleep Apnea and Cardiovascular Disease: A Scientific Statement From the American Heart Association (2021) · cites this paper as [30]

  • The AHI decrease with tirzepatide is clinically relevant, as it exceeds the American Academy of Sleep Medicine clinical significance threshold of 15 or more events per hour and the proposed 50% improvement in AHI.

    “This change is considered clinically relevant; the American Academy of Sleep Medicine defines the clinical significance threshold for the AHI as 15 or more events per hour, 25 and other sources have proposed a 50% improvement in AHI as clinically relevant. 26,27”

    From Tirzepatide for the Treatment of Obstructive Sleep Apnea and Obesity (2024) · cites this paper as [25]

  • On the basis of the current evidence regarding PAP treatment, the American Academy of Sleep Medicine guidelines prioritize treatment with PAP for patients with symptoms of obstructive sleep apnea.

    “On the basis of the current evidence regarding PAP treatment, the American Academy of Sleep Medicine guidelines prioritize treatment with PAP for patients with symptoms of obstructive sleep apnea. 25”

    From Tirzepatide for the Treatment of Obstructive Sleep Apnea and Obesity (2024) · cites this paper as [25]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • The 24-hour systolic effect falls below the stated clinical threshold

    Major

    The reported 1.5 mmHg reduction in 24-hour systolic blood pressure is called clinically significant, although the paper sets a 2 mmHg threshold for that outcome.

  • The two lists of non-sleepy studies differ

    Minor

    The initial list of five non-sleepy studies includes study 76; the later description of a five-study non-sleepy subanalysis substitutes study 86.

  • Behavioral adherence subgroup cites a study outside its six trials

    Minor

    The five-trial behavioral adherence subgroup is described as a subset of studies 214-219, yet its citations include study 86.

  • Driving-simulator control citations exceed the stated four trials

    Minor

    The driving-simulator analysis identifies four RCTs, but its account of their control interventions cites six distinct studies, including studies 64 and 85, which are absent from the four-trial list.

  • Blood-pressure trial count changes from 26 to 27

    Minor

    The blood-pressure section first reports 26 RCTs, but each subsequent subgroup section describes its trials as part of a set of 27 RCTs.

5 of 5

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. Cohen J. Statistical Power Analysis for the Behavior Sciences. 1988 Hillsdale, NJ L. Eribaum Associates
  2. Canadian Agency for Drugs and Technologies in Health. CPAP Treatment for Adults with Obstructive Sleep Apnea: Review of the Clinical and Cost-Effectiveness and Guidelines. 2013 Ottawa, ON Canadian Agency for Drugs and Technologies in Health

Cited by

Sorted by citations

Related

Authors
Patil, S. P., Ayappa, I. A., Caples, S. M., Kimoff, R. J., Patel, S. R., & Harrod, C. G.
Affiliations
  • Johns Hopkins University (US)
  • Icahn School of Medicine at Mount Sinai (US)
  • Mayo Clinic (US)
  • McGill University Health Centre (CA)
  • University of Pittsburgh (US)
  • American Academy of Sleep Medicine (US)
ORCID
Venue
Journal of Clinical Sleep Medicine
Publisher
Springer Science and Business Media LLC
Published
2019-02-15
Volume
15
Issue
2
Pages
301-334
ISSN
  • 1550-9389 (ISSN-L)
  • 1550-9397
DOI
10.5664/jcsm.7638
PMC
PMC6374080
OpenAlex
W2914973997
Semantic Scholar
75ae818dc65acd24ce27dd866dd880b9a2db39a1
Cited by
721
References
301
Citations by year
2026: 80 · 2025: 107 · 2024: 101 · 2023: 116 · 2022: 113 · 2021: 109 · 2020: 75 · 2019: 18 · 2018: 1
FWCI
9.34
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Clinical Sleep Medicine (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory Support and Mechanisms
Keywords
obstructive sleep apnea, positive airway pressure, continuous positive airway pressure, auto-titrating CPAP, PAP adherence, remote patient monitoring, behavioral interventions, heated humidification, daytime sleepiness, blood pressure, motor vehicle accidents, sleep-related quality of life
MeSH terms
GRADE Approach, Adult, Equipment Design, Humans, Patient Compliance, Positive-Pressure Respiration, Treatment Outcome, Practice Guidelines as Topic, Sleep Apnea, Obstructive

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-11.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-11.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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