The clinical efficiency of positive airway pressure treatment.
Positive airway pressure (PAP) is the first line treatment of moderate and severe obstructive sleep apnea syndrome (OSAS). Disturbance of sleep quality, excessive daytime sleepiness, apnea, deterioration of life quality, and also the presence of cardiovascular, metabolic, neuropsychiatric, and urogenital disorders such as hypertension, diabetes mellitus, dislipidemia, metabolic syndrome, panic attack, depression, stroke, and erectil dysfunction show the importance of the treatment [1-7]. Previous studies showed that PAP treatment improves the symptoms of OSAS, rate of comorbid disorders, cardiovascular morbidity, and mortality. The positive consequences of PAP treatment result higher compliance of patients [1-6, 8].
PAP compliance is the ratio of the patients that use the treatment regularly to the total number. Compliance problem is frequently encountered in OSAS patients. Some publications notified that 29-48.2% of the patients do not use the PAP treatment [8, 9]. The adverse effects such as difficulty to exhale against positive pressure, skin reactions, unfit or very tight mask, nasal blockage, dryness of throat, and aerophagia are among the factors that affect the compliance negatively .
The aim of this study was to evaluate the knowledge of patients about the usage of device, problems encountered during the usage of device, Epworth sleepiness scale (ESS), comparison of the complaints of the patients before and after the usage of device, and the alterations of nocturia by questionnaires.
2. Materials and Methods
This study was conducted on moderate-severe OSAS patients who admitted to Ankara Numune Education and Research Hospital Sleep Center between 2008 and 2012. Patients with apnea hypopnea index (AHI) above 15 measured by all night polysomnographic studies (PSG) were enrolled to the study. PSG was performed during patients' spontaneous sleep with the supervision of a technician. Electroencephalogram (EEG), electromyogram (EMG-submental and left-right tibialis anterior), electrooculogram (EOG, left-right), nasal airflow, thoracic and abdominal respiratory effort, blood oxygen saturation (by pulse oximetry), and body positions were recorded all night long. These data were also scored manually by using Alice PSG system by an ENT physician with a sleep certificate.
Moderate-severe OSAS patients with AHI > 15 were informed in detail about the risk of their disease, possible morbidity and mortality, and the importance of treatment before titration. This information was given by the experienced ENT physicians who performed the PSG scoring.
Among these, 153 of patients performed automatic positive airway pressure titration all night long. Titration data was scored manually. Automatic positive airway pressure (APAP) device was given to supine-dependent and/or rapid-eye-movement-(REM-) dependent patients, and bilevel positive airway pressure (BiPAP) device was given to patients with pressure above 12 cm [H.sub.2]O in automatic PAP titration, chronic obstructive lung disease, and/or obesity hypoventilation syndrome, and (continuous positive airway pressure) CPAP was given to other patients.
As 35 of the patients could not be reached, they were excluded from the study. Total 118 patients were reached, and informed consent were taken.
43 patients (43/118, 36.5%) did not use PAP treatment. 75 patients (75/118, 63.5%) kept going on with PAP treatment.
75 patients who were using PAP treatment regularly were enrolled in the study. Patient's usage data, ESS scores, and the differences in complaints of OSAS were recorded (Table 1).
Control examination of patients was performed, and the routines of device usage and usage time (Table 1), problems encountered during the usage of device (Table 2), Epworth sleepiness scale (ESS), and comparison of the discrepancy of complaints before and after the usage of device were evaluated with questionarries. In Table 3, patients were asked to score the discrepancies of their complaints considering their state prior to treatment with worse (-2), bad (0), good (+1), or better (+2).
49 (65.3%) of the 75 patients were males and 26 (34.7%) were females. Their mean age was 54.2 [+ or -] 6.1 (35-84).
The mean usage time of device was 15.1 [+ or -] 6.03 (6-30) months. Mean orientation time of the patients to the device was detected as 10.5 days (1-90 day). The mean usage time of the device was 6.3 days (4-7). The mean daily usage time was 6.7 (4-10) hours.
Patients were asked if the device pressure was sufficient or not, and it was revealed that 65 of the patients (86.6%) found it sufficient, 8 (10.6%) of them found more, and 2 (2.6%) of them found less.
The ratio of the patients and bed partners who were disturbed from the voice of the device was found to be 24/75 (32%).
It was seen that nocturia was reduced in 36 (48%) of the patients, no change in 38 (50.6%) patients, and increased in 1 (1.3%) patient after starting to use the device.
Problems encountered while using the device were investigated. According to this, most common complaint was dryness of throat (34/75) and then leakage from mask (22/75), nasal blockage (21/75), and excessive noise arising from device (17/75). The problems the patients encountered during the usage of device were summarized in Figure 1.
ESS scores of the enrolled patients were shown in Figure 2. When the patients were evaluated according to their mean ESS score, it was found as 5.4. Excessive daytime sleepiness was finished according to ESS.
Symptoms of patients going on PAP treatment were evaluated before and after the treatment. The results were shown in Figure 3. The overall complaints were improved comparing to pretreatment period. The symptoms with apparent improvement and number of patients were shown in Figure 4. Particularly there was improvement in apnea, snoring, excessive daytime sleepiness, fatigue, and sleep quality.
PAP treatment is a golden standard therapy method of moderate and severe OSAS . The compliance is low although the results of the treatment are very good. There are variable compliance ratios reported in PAP treatment studies for compliance. In recent studies, it was seen that the compliance increased , but in long-term follow-up studies, it was revealed that the compliance decreased . In this study the compliance ratio was found as 63.5% and the mean usage time as 15.1 months.
The daily usage time among the patients who are going on PAP treatment is reported as 4.7-5.6 h/d [14,15]. In this study, it was found as 6.7 h/d.
Throat dryness, leakage from mask, rubbing, nasal blockage, and the noise of the device are the most common problems of the patients who are going on treatment . Also, in this study, throat dryness was found to be the most common adverse effect of the treatment.
It was reported that psychiatric problems such as depression incidence are low in long-term usage . Also, in this study, there was improvement in depression and anxiety in 18 (24%) of the patients.
It was known that the blood pressure is reduced with CPAP treatment in hypertension and OSAS patients . In this study, it was detected that blood pressure levels were better with PAP treatment in 26 (34.6%) of the patients.
ESS is a common method to evaluate the excessive daytime sleepiness all around the world. Ozcan et al. revealed that although ESS is not beneficial to determine the excessive daytime sleepiness, the answers of patients can be influenced by the differences between the socioculturel and economic conditions. Therefore, the necessity to create new forms for each country according to their sociocultural and economic conditions was emphasized . Overall, scores below 10 were accepted as normal, above 10 as excessive daytime sleepiness, and above 16 as severe excessive daytime sleepiness . In this study, mean ESS score of the patients was found to be 5.4, so it was concluded that no one has excessive daytime sleepiness.
It was reported that there was a reduction in chronic fatigue and nocturia and improvement in sexual function and life quality [19, 20]. In this study, there was a reduction in snoring (58, 77.3%), reduction in fatigue (47, 62%), and reduction in nocturia (36, 48%). It was detected that there was an improvement in sexual function (23, 30%) and sleep quality (56, 74.6%). When compared to pretreatment period, significant improvement and recovery were observed in most of the symptoms.
As a result, PAP treatment has recoverable and tolerable adverse effects. PAP treatment maintain a significant improvement in sleep and life quality. It was revealed that PAP treatment has a significant recovery on the symptoms of OSAS and related diseases. To inform the patients with details and the creation of strategies for close followup are necessary for improving the compliance of the patients.
 N. S. Marshall, K. K. H. Wong, P. Y. Liu, S. R. J. Cullen, M. W. Knuiman, and R. R. Grunstein, "Sleep apnea as an independent risk factor for all-cause mortality: the busselton health study," Sleep, vol. 31, no. 8, pp. 1079-1085, 2008.
 J. M. Marin, S. J. Carrizo, E. Vicente, and A. G. N. Agusti, "Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study," The Lancet, vol. 365, no. 9464, pp. 1046-1053, 2005.
 M. Fusetti, A. B. Fioretti, M. Valenti et al., "Cardiovascular and metabolic comorbidities in patients with obstructive sleep apnoea syndrome," Acta Otorhino-Laryngologica Italica, vol. 32, no. 5, pp. 320-325, 2012.
 Y. Takaesu, Y. Inoue, Y. Komada et al., "Effects of nasal continuous positive airway pressure on panic disorder comorbid with obstructive sleep apnea syndrome," Sleep Medicine, vol. 13, no. 2, pp. 156-160, 2012.
 M. A. Martinez-Garcia, J. J. Soler-Cataluna, L. Ejarque-Martinez et al., "Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea: a 5-year follow-up study," American Journal of Respiratory and Critical Care Medicine, vol. 180, no. 1, pp. 36-41, 2009.
 T Santos, M. Drummond, and F Botelho, "Erectile dysfunction in obstructive sleep apnea syndrome--prevalence and determinants," Revista Portuguesa de Pneumologia, vol. 18, no. 2, pp. 64-71, 2012.
 J. D. Edinger, S. Carwile, P. Miller, V Hope, and C. Mayti, "Psychological status, syndromatic measures, and compliance with nasal CPAP therapy for sleep apnea," Perceptual and Motor Skills, vol. 78, no. 3, pp. 1116-1118, 1994.
 S. Olsen, S. Smith, and T. P. S. Oei, "Adherence to continuous positive airway pressure therapy in obstructive sleep apnoea sufferers: a theoretical approach to treatment adherence and intervention," Clinical Psychology Review, vol. 28, no. 8, pp. 1355-1371, 2008.
 M. Uyar, O. Elbek, A. Mete et al., "Factors influencing compliance with continuous positive airway pressure ventilation in obstructive sleep apnea syndrome," Tuberkuloz ve Toraks, vol. 60, pp. 47-51, 2012.
 J. L. Pepin, P. Leger, D. Veale, B. Langevin, D. Robert, and P. Levy, "Side effects of nasal continuous positive airway pressure in sleep apnea syndrome: study of 193 patients in two French sleep centers," Chest, vol. 107, no. 2, pp. 375-381, 1995.
 D. I. Loube, P. C. Gay, K. P. Strohl, A. I. Pack, D. P. White, and N. A. Collop, "Indications for positive airway pressure treatment of adult obstructive sleep apnea patients: a consensus statement," Chest, vol. 115, no. 3, pp. 863-866, 1999.
 D. Ghosh,V. Allgar, and M. W. Elliott, "Identifying poor compliance with CPAP in obstructive sleep apnoea: a simple prediction equation using data after a two week trial," Respiratory Medicine, 2012.
 C. Alves, J. M. P. C. Caminha, A. M. da Silva, and D. Mendonca, "Compliance to continuous positive airway pressure therapy in a group of Portuguese patients with obstructive sleep apnea syndrome," Sleep and Breathing, vol. 16, no. 2, pp. 555-562, 2011.
 W. Galetke, L. Puzzo, C. Priegnitz, N. Anduleit, and W. J. Randerath, "Long-term therapy with continuous positive airway pressure in obstructive sleep apnea: Adherence, side effects and predictors of withdrawal-a "real-life" study," Respiration, vol. 82, no. 2, pp. 155-161, 2011.
 S. Yurtlu, N. Sariman, E. Levent et al., "Short-term positive airway pressure therapy response in obstructive sleep apnea patients: impact of treatment on the quality of life," Tuberkuloz ve Toraks, vol. 60, no. 4, pp. 327-335, 2012.
 F. Campos-Rodriguez, J. Perez-Ronchel, A. Grilo-Reina, J. Lima-Alvarez, M. A. Benitez, and C. Almeida-Gonzalez, "Long-term effect of continuous positive airway pressure on BP in patients with hypertension and sleep apnea," Chest, vol. 132, no. 6, pp. 1847-1852, 2007.
 K. M. Ozcan, T. Ozdas, F. Ozdogan et al., "Inconsistency of the Epworth sleepiness scale results with the polysomnography findings in patients with sleep-disordered breathing," Kulak Burun BogazIhtis Derg, vol. 22, no. 4, pp. 195-199, 2012.
 J. Rey de Castro and E. Rosales-Mayor, "Clinical and polysom-nographic differences between OSAH patients with/without excessive daytime sleepiness," Sleep Breath. In press.
 I. A. C. Cruz, M. Drummond, and J. C. Winck, "Obstructive sleep apnea symptoms beyond sleepiness and snoring: effects of nasal APAP therapy," Sleep and Breathing, vol. 16, no. 2, pp. 361366, 2012.
 H. M. Engleman, R. N. Kingshott, P. K. Wraith, T. W. Mackay, I. J. Deary, and N. J. Douglas, "Randomized placebo-controlled crossover trial of continuous positive airway pressure for mild sleep apnea/hypopnea syndrome," American Journal of Respiratory and Critical
Care Medicine, vol. 159, no. 2, pp. 461-467, 1999.
Sabri Koseoglu, (1) Aykut Ikinciogullari, (1) Mehmet Ali Cetin, (1) Gokce Saygi Uysal, (2) Rauf Oguzhan Kum, (1) and Berna Arli (3)
(1) Ankara Numune Education and Research Hospital, ENT Clinic, 06640 Ankara, Turkey
(2) Kulu State Hospital, ENT Clinic, Konya, Turkey
(3) Ankara Numune Education and Research Hospital, Neurology Clinic, 06640 Ankara, Turkey
Correspondence should be addressed to Sabri Koseoglu; firstname.lastname@example.org
Received 4 March 2013; Accepted 28 March 2013
Academic Editors: S. Cureoglu, I. Ozcan, K. M. Ozcan, and A. Selcuk
TABLE 1: Definition of usage time of PAP device and habits of the patients. Usage time (month) Adaptation time to sleep with the device (day) Mean usage time per week (day) Mean usage time per day (hour) Device pressure (less-more-sufficient) TABLE 2: Definition of evaluation of the problems that can be occur during the usage of CPAP. Complaints Positive Negative Nasal blockage Redness and pain of eyes Throat dryness Leakage from mask Cold airstream Nose bleeding Rubbing of mask Wake up more frequently than before Excessive noise of device Flatulence Wheezing Claustrophobia TABLE 3: Definition of alteration of complaints after PAP treatment. Complaints Much worse Worse No change Better Much better (-2) (-1) (0) (+1) (+2) Snoring Apnea Daytime sleepiness Quality of sleep Fatigue Ability of concentration Productivity Sweeting during sleep Sexual Performance Restless leg General health status Chest pain at night Palpitation Blood pressure status Regurgitation in supine position Amnesia Habit of nocturia FIGURE 4: Symptoms which improved after PAP treatment Excellent Good Snoring 24 34 Apnea 21 36 Daytime 19 37 sleepiness Fatigue 9 38 Concentrating 8 36 ability Work 3 32 efficiency General health 5 32 status Level of blood 2 24 pressure Sexual 3 21 performance Note: Table made from bar graph.
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Clinical Study|
|Author:||Koseoglu, Sabri; Ikinciogullari, Aykut; Cetin, Mehmet Ali; Uysal, Gokce Saygi; Kum, Rauf Oguzhan; Ar|
|Publication:||The Scientific World Journal|
|Date:||Jan 1, 2013|
|Previous Article:||Optical limiting using the two-photon absorption electrical modulation effect in HgCdTe Photodiode.|
|Next Article:||Acute toxicity and genotoxic activity of avocado seed extract (Persea americana Mill., c.v. hass).|