Meral UYAR1, Osman ELBEK1, Ahmet METE2, Nazan BAYRAM1, Nilüfer ÇİFÇİ1, Nevhiz GÜNDOĞDU1, Öner DİKENSOY1
1Gaziantep Üniversitesi Tıp Fakültesi, Göğüs Hastalıkları Anabilim Dalı, Gaziantep,
2Gaziantep Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Gaziantep.
ÖZET
Obstrüktif uyku apne sendromunda sürekli pozitif hava yolu basıncı tedavisine uyumu etkileyen faktörler
Giriş:Pozitif basınçlı tedavi obstrüktif uyku apne sendromunda birinci basamak tedavi olarak bilinmekle birlikte uyum birçok faktörden etkilenmektedir. Biz bu çalışmada uyumu etkileyen muhtemel faktörleri değerlendirmeyi hedefledik.
Materyal ve Metod:Haziran 2006-Haziran 2008 tarihleri arasında obstrüktif uyku apne sendromu tanısıyla pozitif basınçlı ventilasyon tedavisi 140 hastaya başlanmıştı. Bu hastalardan %77 (n= 108)’sine telefonla ulaşılarak tedavi uyumu ile ilgi- li anket yapıldı. Hava yolu pasajı lateral kafa grafileriyle değerlendirildi.
Bulgular:Ortalama yaş 52.2 ± 12.3 yıl idi. Hastaların %71 (n= 77)’i cihazı temin etmişti. Cihazı temin eden ve etmeyenler ara- sında cinsiyet, yaş, medeni durum, eğitim seviyesi, semptomlar, eşlik eden hastalıklar ve sosyal güvenlik açısından fark yok- tu (p> 0.05). İki grup arasında Epworth uykululuk ölçeği (ESS) ve apne hipopne indeksi (AHİ) de benzerdi. Günlük ortala- ma cihaz kullanımı 6.3 ± 2.3 saat idi. Cihaz kullanım uyumunun yaş, cinsiyet, eğitim düzeyi, eşlik eden hastalıklar, ESS sko- ru, AHİ, hava yolu pasaj ölçümleri, nemlendirici varlığı ve cihazla ilgili eğitim verilmesinden etkilenmediği tespit edildi (p>
0.05). Hasta (p= 0.057) ve yatak partnerinin (p= 0.001) cihazla ilgili memnuniyetinin cihaz uyumunu artırdığı tespit edildi.
Sonuç:Obstrüktif uyku apne sendromunda hasta ve yatak partnerinin cihazla ilgili memnuniyetleri cihaz kullanımında- ki uyumu artırıyor görünmekte olup, C2 vertebra düzeyi ve hava pasajının en dar yerinden alınan ölçümlerle uyum ilişki- li görünmemektedir.
Anahtar Kelimeler: Lateral kafa grafisi, üst hava yolu, uykuda solunum bozukluğu.
SUMMARY
Factors influencing compliance with continuous positive airway pressure ventilation in obstructive sleep apnea syndrome
Meral UYAR1, Osman ELBEK1, Ahmet METE2, Nazan BAYRAM1, Nilüfer ÇİFÇİ1, Nevhiz GÜNDOĞDU1, Öner DİKENSOY1
Yazışma Adresi (Address for Correspondence):
Dr. Meral UYAR, Gaziantep Üniversitesi Tıp Fakültesi, Göğüs Hastalıkları Anabilim Dalı, GAZİANTEP - TURKEY
e-mail: meraluyar1@yahoo.com
INTRODUCTION
Obstructive sleep apnea syndrome (OSAS) is a dise- ase with repeated apneic events and oxygen desatura- tion episodes which affects multiple systems (1,2).
Continuous positive airway pressure (CPAP) ventilation is the leading treatment option in OSAS however compliance with the device affects treatment success (1). Several approaches including use of different devi- ce modalities and heated humidification have been un- dertaken to increase treatment compliance (3-5). Ho- wever, the available data concerning impact of upper airway dimensions on treatment compliance is lacking.
Therefore, we aimed to evaluate impact of upper air- way dimensions and possible factors influencing pati- ent compliance with CPAP usage in OSAS.
MATERIALS and METHODS Patients
Study population consisted of patients admitted to Sleep Laboratory during June 2006 and June 2008.
Subjects older than 18 years of age who were prescri- bed a device for OSAS were included. The study pro- tocol was approved by University Ethics Committee.
Data Collection
Sleep studies were performed according to the guideli- nes of American Academy of Sleep Medicine (6). Ap- nea hypopnea index (AHI) was total number of apneas
or hypopneas per hour. Epworth sleepiness scale (ESS) score were recorded for each patient (7). A qu- estionnaire was prepared including information about the time of the device procurement, the type of the de- vice and mask, the duration of usage, problems invol- ving the device, satisfaction status, patients bed part- ner’s opinion about the device. The questionnaire was filled out by telephone interview between June 2009 and November 2009. Lateral skull radiographs from patient files were obtained for each patient. Each radi- ograph was taken with the patient standing in neutral head position after swallowing. C2 vertebrae level was accepted as a landmark for airway calibre measure- ments. Airway calibres were obtained from the level of C2 vertebrae and narrowest airway passage. Neck and waist circumference was measured and body mass in- dex (kg/m2) was calculated for each patient.
Statistical Analysis
Data was analyzed with using Statistical Package for Social Science 9.0 computer software. Comparisons between groups were performed by chi square and stu- dent’s t test. p< 0.05 was accepted as significant.
RESULTS
The total number of patients who had been prescribed CPAP was 140. Of these patients, 77% (n= 108) were attained by telephone for assessment of compliance.
Seventy two of the subjects were male and 88.9% (n=
1Department of Chest Diseases, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey,
2Department of Radiology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey.
Introduction:Positive pressure ventilation is considered first line therapy in obstructive sleep apnea syndrome however compliance is limited by various factors. We aimed to investigate possible factors influencing compliance.
Materials and Methods: One hundred and forty patients were prescribed positive pressure ventilation for obstructive sleep apnea during June 2006-June 2008. Of these patients, 77% (n= 108) were reached by telephone and a questionnaire was administered regarding factors influencing treatment compliance. Airway passage was measured with C2 vertebrae level and narrowest airway passage on lateral skull radiographs.
Results:The mean age was 52.2 ± 12.3 years. Seventy one percent (n= 77) of subjects obtained the prescribed device. The- re was no difference in sex, age, marital status, educational level, symptoms, co-morbid conditions, and social security co- verage between the subjects who have received the prescribed devices and who have not (p> 0.05). No difference was de- tected between these two groups of patients in view of Epworth sleepiness scale (ESS) and apnea hypopnea index (AHI).
Mean duration of device usage was 6.3 ± 2.3 hours. The device use compliance was not affected by any of the following factors: age, gender, level of education, co-morbid diseases, ESS score, AHI, airway passage measurements, application of humidification and education concerning the device (p> 0.05). Patient (p= 0.057) and bed partners (p= 0.001) satisfaction about the device yielded higher compliance rates.
Conclusion:Factors influencing compliance rates in obstructive sleep apnea syndrome seems to be related to satisfaction about the device use however upper airway morphology measured with C2 vertebrae level and narrowest airway passa- ge has no impact on treatment compliance.
Key Words: Lateral skull radiography, upper airway, sleep disordered breathing.
96) were married. Mean age was 52.23 ± 12.37 years.
Mean airway diameters at C2 vertebrae level in males and females were 11.36 ± 3.00 cm, and 12.35 ± 3.16 cm, respectively (p= 0.23). The narrowest airway pas- sage measurements were 9.09 ± 2.45 cm, in males and 10.05 ± 2.56 cm in females (p= 0.15).
Device procurement rate was 71.3% (n= 77) while 70%
of male subjects (n= 57) and 74.1% (n= 20) of female subjects obtained their device (p= 0.71). Characteristics of patients with respect to device procurement are shown in Table 1. Seventy two percent of married sub- jects and sixty seven percent of single subjects had ob- tained their device (p= 0.74). There were 13 illiterate
subjects in the study population (12%) however educa- tional status was not a factor influencing device procu- rement (61.5% for illiterates vs 72.6% for literates, p=
0.51). Regarding complaints concerning snoring, dayti- me sleepiness, witnessed apnea, dyspnea or headache we did not detect differences between these two groups of patients (p> 0.05). Co-morbid diseases were not sta- tistically different with respect to device procurement.
Reasons for not procuring devices are shown in Table 2.
Fifty three of 77 patients who obtained devices were current users. Mean daily duration of device use was 6.26 ± 2.26 hours and mean total duration of device usage was 9.44 ± 6.66 months. Characteristics of pati- ents with respect to compliance are presented in Table 3. Sixty seven percent of patients using nasal mask and fifty seven percent of those patients who had full face mask were still using their devices (p= 0.68). Baseline ESS score in current device users was 11.59 ± 5.16 and decreased to 5.48 ± 4.73 with treatment (p= 0.00).
We did not detect any difference between marital status and current device usage (p> 0.05). Sixty three percent of illiterates and 64% of literates were still using their devices (p> 0.05). We did not detect difference betwe- en sleep apnea symptoms, OSAS severity, co-morbid conditions and device usage (p> 0.05). Humidifier was present in 68.8% (n= 33) of current device users while
AHI 61.57 ± 27.57 56.26 ± 24.13 0.35
BMI: Body mass index, ESS: Epworth sleepiness scale, AHI: Apnea hypopnea index.
Table 3. Characteristics of patients with respect to device usage (n= 77).
Current device user (n= 53) Device abandoners (n= 24) p
Age (year) 52.04 ± 12.32 50.56 ± 13.69 0.91
ESS score 11.31 ± 4.99 11.43 ± 5.63 0.84
Air passage at C2 level (mm) 11.37 ± 2.39 13.00 ± 3.55 0.11
Narrowest air passage (mm) 9.40 ± 2.20 10.13 ± 2.55 0.32
AHI 61.12 ± 27.49 62.36 ± 28.20 0.98
ESS: Epworth sleepiness scale, AHI: Apnea hypopnea index.
Table 2. Reasons of not obtaining prescribed device (n= 31).
Reason N
Do not want to use it 16
Expensive 10
Resolving complaints 2 (surgery)
Bureaucratic procedures 2
No education from the medical firm 1
60% (n= 15) of current device user had no humidifier (p= 0.45). Only 64% (n= 32) of current device users (p= 0.05) and 78% (n= 36) of bed partners (p= 0.00) expressed satisfaction with therapy. Reasons of stop- ping device use were as follows: high pressure (n= 10), noise (n= 7), no need to use because of decreasing complaints (n= 2), nasal decubitus (n= 2), dry mouth (n= 2), and mask leak (n= 1). There was no relation between airway calibre measurements obtained from C2 vertebrae and narrowest airway level with gender, body mass index, neck and waist circumference, ESS score, mean pressure and AHI (p> 0.05). Device usa- ge period and measurements of airway calibrations including C2 vertebrae and the narrowest level were not different between compliant and non compliant group (p> 0.05).
DISCUSSION
We found that factors influencing compliance with po- sitive airway pressure ventilation among subjects with OSAS were mainly related to the satisfaction rate of patients and their bed partners. It has been revealed that device satisfaction enhances CPAP use regularly (8). A previous study indicated improvement of ESS score, anxiety and depression scores after CPAP usage and concluded that significant benefits in health status in both patient and partner have a positive correlation with device usage (9). A study revealed that half of the bed partners of patients with sleep disordered breat- hing were disturbed by snoring (10). It was also shown that bed partners of this patient population had worse sleep efficiency, increased arousals and a greater per- centage of light sleep (11). Other studies showed that CPAP therapy improved bed partner’s sleep quality, subjective sleepiness, mood and quality of life indepen- dent from the duration of the treatment (12-16). A pi- lot study which evaluated treatment adherence in mar- ried men revealed that it was related to the frequency with which his partner sleeps with him (17).
We did not find any relationship between airway passa- ge measurements and device use. Craniofacial morp- hology in OSAS has been widely studied however the- re is no data regarding its relationship with compliance to positive pressure ventilation device use. A study evaluating craniofacial phenotyping revealed that neck, waist and body mass index measurements were higher in patients with OSAS while a correlation exists between OSAS severity and neck perimeter (18).
Another study revealed that hyoid bone had a low po- sition in OSAS patients in lateral cephalogram (19). A study evaluating role of craniofacial structures in pre- dicting optimal CPAP pressures in OSAS patients sho-
wed that posterior airway space was not different bet- ween control and patient group (20). In our study the- re was no correlation between neck size and gender as well as upper airway diameter measurements. Tsai et al. demonstrated that male patients with risk factors such as increased neck size, inferiorly positioned hyo- id bone and greater anterior lower facial height are li- kely to have more severe type OSAS. Posterior facial height and anteriorly positioned hyoid bone were risk factors related to the severity of OSAS in female pati- ents (21).
We found that device procurement did not take place in around a quarter of our patients. In another study this rate was detected as 31% (8). We found that 68.8% of our study population was regularly using the- ir devices. The compliance rate in the present study was higher than a previous study by Wolkove et al.
(68% vs. 54%) (8). The reason for this could be due to a longer period of follow up in their study after the di- agnosis (64 ± 3.7 months). It has been previously sug- gested that older individuals might have poor compli- ance rate however, we found no statistically significant difference between age distribution of patients who were using their device or not (52.04 ± 12.32 vs.
50.56 ± 13.69; respectively) (22).
Co-morbidity was not found to be related to the comp- liance rate of CPAP. Similarly symptoms concerning OSAS such as snoring, daytime sleepiness and apnea had no effect on compliance. Our results showing that humidification did not add to the compliance rates we- re also compatible with previous data (5).
We did not find association between disease severity which was calculated with AHI and device compliance.
This is in accordance with a previous study as disease severity has not been found to be related to complian- ce rates (23). In a study comparing regular CPAP users with irregular users, the tendency of CPAP usage was highest among severe sleep apneic patients (23). In the present study, sleepiness state which was evaluated with ESS score was decreased after device use, com- patible with literature findings (8,24-26).
There are some limitations to the present study: the da- ta used to evaluate compliance rate were subjective. It would be better to evaluate satisfaction status of pati- ents and bed partners with quality of life questionna- ires. We were able to interview three fourths of our pa- tient population mainly because of insufficient contact information. We could not evaluate the effect of diffe- rent masks and devices on the compliance rate beca- use of the limited number of cases.
compliance should be increased, thus bed partner moti- vation is necessary for better compliance.
ACKNOWLEDGEMENT
We would like to thank Dr. Neriman Aydın for statistical evaluation of the data.
CONFLICT of INTEREST None declared.
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