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

In the paper

“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”

What the sources say

• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured

In the paper

“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”

What the sources say

• ?Not checked — no full text of the sourcecites [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
• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured

In the paper

“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.”

What the sources say

• ?Not matched

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

  cites 35,175,177,[179][180][181]
• ?Not checked — no full text of the sourcecites [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
• Supported

  The In-Trial Study Costs section reports that the HOME arm’s costs were 25% lower than the LAB arm’s. This supports the cost finding for a combined home-based diagnostic and treatment pathway; the count of six studies is the citing authors’ synthesis, not a finding attributed to this individual trial. (LLM, conf=0.90)

  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
• ?Not checked — no full text of the sourcecites [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
• Supported

  The relevant attribution is that home automated CPAP titration cost less than in-laboratory titration. The Discussion (p. 4) states that home titration provided equal quality of care at lower cost per patient, and Table 4 lists costs of US$91.3 for home versus US$142.2 for hospital titration. (LLM, conf=0.93)

  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
• Supported

  The Costs section reports lower direct costs per patient for home APAP titration (AU$132.09) than for either laboratory APAP (AU$647.56) or manual titration (AU$817.84). This supports the home-APAP cost finding for which this paper is cited; the sentence attributes the six-study count to the group of citations, not to this paper alone. (LLM, conf=0.93)

  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
• ?Not checked — no full text of the sourcecites [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

In the paper

“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”

What the sources say

• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured

In the paper

“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.”

What the sources say

• Supported

  The Discussion reports that estimated upfront in-trial costs were approximately 25% lower in the HOME arm than in the LAB arm. Diagnostic Testing Completion Rates and AHI Eligibility reports split-night testing for 61 of 92 eligible LAB participants, exceeding 50%. That proportion applies to eligible participants, not all LAB participants who completed diagnostic testing. (LLM, conf=0.90)

  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

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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
• Supported

  The Objective compliance section reports pressure discomfort in 30 patients using fixed-CPAP versus 17 using auto-CPAP (P = 0.013). This source is cited for the pressure-discomfort finding; the sentence assigns nasal irritation and machine noise to other citations. (LLM, conf=0.94)

  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
• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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

In the paper

“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]”

What the sources say

• Supported

  The Methods/Abstract passages describe enrollment of patients who estimated their current CPAP use at under 4 hours nightly; objective monitoring was not required for enrollment. This supports the clause cited to this paper. The comparison with four PAP-naïve studies is attached to other citations, not this one. (LLM, conf=0.90)

  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
• ?Not matched

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

  cites [210][211][212][213]

In the paper

“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.”

What the sources say

• ?Not matched

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

  cites 179,183,186,188,191,[193][194][195][196]198,205
• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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
• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be 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
• ?Not checked — no full text of the sourcecites [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
• Supported

  The Results (page not specified in our copy) report mild nasal symptoms in both the fixed-CPAP and automatic-CPAP groups, supporting this study’s inclusion among those finding no clinically significant side-effect difference. The counts of 11 and 6 studies are the citing paper’s synthesis, not findings attributed to this individual study. (LLM, conf=0.83)

  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
• ?Not checked — no full text of the sourcecites [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

In the paper

“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”

What the sources say

• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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
• Supported

  The Explanatory variables section (p. 2) describes random assignment to intervention groups, and the Results (p. 3) identify a phone-calls group, a literature group, and a control group. The written materials included CPAP information and remedies for common problems (Subjects, p. 2). This paper supports its inclusion as an RCT comparing CPAP-support interventions with usual care; it does not itself establish the review’s totals across studies. (LLM, conf=0.88)

  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
• ?Not checked — no full text of the sourcecites [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
• Supported

  The Methods Participants and randomisation sections identify this paper as a randomised controlled trial comparing an educational video with usual care. The citation supports identifying this study as an educational-intervention RCT; the totals of 7, 6 and 9 trials are the citing authors’ synthesis, not findings attributed to this individual study. Page numbers were not available in our copy. (LLM, conf=0.92)

  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
• Supported

  The citation appears among the studies identified as RCTs comparing an educational intervention with usual care. The Abstract’s Material/Methods and the Study design section describe a randomized comparison of standard support with additional education using patients’ polysomnography charts. This supports identifying this paper as one such trial; it does not, by itself, establish the citing document’s totals across all trials. (LLM, conf=0.90)

  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
• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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
• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured

In the paper

“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”

What the sources say

• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured

In the paper

“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.”

What the sources say

• Partly supported

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

  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): sourceExperimental — accuracy not yet measured

In the paper

“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”

What the sources say

• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured
• Supported

  The Results report that 100 patients were randomized to standard care or telemedicine and compare treatment-related side effects after three months. This supports citing the paper as one of the RCTs assessing that outcome. The statement about whether the two trials’ data could be meta-analyzed is the citing authors’ assessment, not a finding attributed to this individual trial. (LLM, conf=0.90)

  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

In the paper

“Data on adherence for nasal versus oronasal interfaces were also analyzed from 3 non-randomized studies.[249][250][251]”

What the sources say

• Supported

  The Discussion identifies this paper as a prospective observational cohort study comparing CPAP adherence across interfaces and reports lower adherence with oronasal than nasal masks. The citation supports its identification as one of the non-randomized studies in the citing sentence; it need not itself analyze all three studies. (LLM, conf=0.91)

  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
• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [251] Bachour A, Vitikainen P, Virkkula P, Maasilta P CPAP interface: satisfaction and side effects. Sleep Breath. 2013;17(2):667–672 source

In the paper

“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”

What the sources say

• Supported

  The Results report no significant difference in overall nasopharyngeal symptom scores after four weeks (P = .19), but significantly lower dry throat/sore throat scores with heated humidification than without it (P < .001). This matches both parts of the cited sentence. (LLM, conf=0.95)

  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

In the paper

“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”

What the sources say

• Partly supported

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

  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 sourceExperimental — accuracy not yet measured
• Supported

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

  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
• ?Not checked — no full text of the sourcecites [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

In the paper

“Another study reported clinically significant reductions in the incidence of sinus pain/headache, sore throat, hoarse voice, and”

What the sources say

• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured

In the paper

“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.”

What the sources say

• Supported

  The Subjects section states that patients were offered participation only if their post-CPAP-titration questionnaire showed a moderate nasopharyngeal symptom. This confirms that the cited study specifically recruited people with nasal or related symptoms. The citation identifies this study; it does not ask this paper to establish the characteristics of every study in the citing paper's comparison. (LLM, conf=0.90)

  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

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [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
• Supported

  The Discussion reports no clear preference for either therapy. The Results specify that 51% preferred heated humidification, 35% preferred no humidification, and 14% were undecided (p=0.24). This supports the no-clear-preference finding attributed to this study; the count of five studies is the citing paper’s synthesis. (LLM, conf=0.94)

  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
• ?Not checked — no full text of the sourcecites [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

In the paper

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

In the paper

“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.”

In the paper

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

In the paper

“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.”

In the paper

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

In the paper

“Participants were predominantly male, with previously untreated moderate to severe OSA and no major medical comorbidities.”

In the paper

“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.”

In the paper

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

In the paper

“However, the magnitude of any hypothetical costs savings has not been studied.”

In the paper

“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.”

In the paper

“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”

In the paper

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

In the paper

“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”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“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.”

In the paper

“One of these studies used a cross-over design.240”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

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

In the paper

“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.”

In the paper

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

In the paper

“Participants were predominantly male, obese, with moderate to severe OSA, and self-reportedly sleepy.”

In the paper

“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”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“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.”

In the paper

“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 the paper

“Residual AHI was higher with oronasal than nasal interfaces, although this difference was not clinically significant (see supplemental material, Figure S95).”

In the paper

“Overall, there were no clinically significant differences in side effects or in participant preference 188,240 between modified pressure profile PAP and standard PAP.”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be 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
• ?Not checked — no full text of the sourcecites [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

In the paper

“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).”

In the paper

“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.”

In the paper

“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”

What the sources say

• ?Not matched

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

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“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”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“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.”

In the paper

“The duration of treatment for most studies was only 3-4 weeks, although one study did follow participants to 1 year.258”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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

In the paper

“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”

What the sources say

• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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

In the paper

“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.”

In the paper

“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”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

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

In the paper

“QOL was assessed with the FOSQ and no clinically significant difference in QOL was found comparing intra-nasal versus nasal interfaces.208”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“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”

What the sources say

• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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

In the paper

“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.”

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

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

In the paper

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

In the paper

“Potential adverse effects of humidification including”

In the paper

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

In the paper

“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.”

In the paper

“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.”

In the paper

“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.”

In the paper

“Directors approved the final list of PICO questions presented”

In the paper

“Overall, the analyses suggest that PAP is effective in improving sleep-related QOL, but not overall QOL in adults with OSA.”

In the paper

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

In the paper

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

In the paper

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

In the paper

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

In the paper

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

In the paper

“All abstracts were reviewed based on inclusion/ exclusion criteria by two TF members.”

In the paper

“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.”

In the paper

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

In the paper

“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.”

In the paper

“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.”

In the paper

“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.”

In the paper

“The overall quality of evidence was high.”

In the paper

“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.”

In the paper

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

In the paper

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

In the paper

“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.”

In the paper

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

In the paper

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

In the paper

“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.”

In the paper

“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.”

In the paper

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

In the paper

“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.”

In the paper

“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.”

In the paper

“The quality of evidence for this outcome ranged from moderate to high, being downgraded due to imprecision.”

In the paper

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

In the paper

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

In the paper

“The TF therefore concluded that either APAP or CPAP should be used to treat adult OSA.”

In the paper

“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.”

In the paper

“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”

In the paper

“The overall quality of evidence was moderate due to imprecision.”

In the paper

“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.”

In the paper

“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.”