Sleep apnea syndrome represents more than 85% of sleep breathing disorders. Obstructive sleep apnea (OSA) is the most common form of sleep apnea syndrome, which is characterized by instability of the upper airway during sleep, resulting in reduction or elimination of airflow, oxyhemoglobin desaturation, and sleep disruption (McEvoy et al., 2016). The prevalence of OSA can reach 4% in men and 2% in women, depending on the populations screened (Jennum & Riha, 2009).
Some of the main symptoms of OSA include excessive daytime sleepiness (EDS), decreased quality of life, depression, anxiety, memory impairment, and attention and concentration problems. In addition, OSA has been found to be an independent risk factor for cardiovascular and cerebrovascular disorders including hypertension, congestive heart failure, myocardial infarction, cardiac arrhythmias, and stroke (Yaggi & Strohl, 2010). Observational clinical studies have shown that the use of CPAP is associated with lower rates of cardiovascular complications and death from cardiovascular causes, especially among patients who are adherent to treatment (Campos-Rodriguez et al., 2012; Gottlieb et al., 2010; Marin et al., 2005).
Daytime sleepiness is a key factor for the quality of life of patients, which plays a greater role than the severity of OSA. Patients with EDS can be severely disabled, as they sometimes fall asleep during a conversation or while eating or driving a car. This has major consequences for public health (e.g., accidents while driving, at work, and home) and the economy of countries (Lacasse & Godbout, 2002).
Although the disorder worsens over time when left untreated (Basoglu, Midilli, Midilli, & Bilgen, 2012), 80%–90% of adults with moderate or severe OSA and EDS are not clinically diagnosed (Young, Evans, Finn, & Palta, 1997). Therefore, expeditious diagnosis and effective treatment of patients with OSA is very important.
Continuous positive airway pressure (CPAP) treatment is the first-line therapeutic option for OSA because of its efficacy in reversing sleep apnea. Antic et al. (2011) obtained a reduction of 2.9 points in the Epworth Sleepiness Scale because of CPAP treatment. However, the adherence rate to CPAP treatment is low. About 75% of patients agree to use CPAP, but after 1 year, only 40%–60% continue to use it (Weaver, 2006). Studies use the cutoff point of at least 4 hours per night on a minimum of 70% of nights to define CPAP adherence. Their results show that 29%–83% of patients are nonadherent. As these findings clearly indicate, effective interventions are needed to improve CPAP compliance among the OSA-diagnosed patient population at large.
Some factors that reduce CPAP treatment adherence are the severity of the disease (measured with the apnea/hypopnea index and oxygen desaturation, with higher figures indicating greater severity), patient characteristics (e.g., age, gender, race, socioeconomic status, body mass index), and features of the CPAP machine (e.g., pressure, heated humidification, mask). All these factors have been evaluated to assess their effect on adherence (Allen, Coon, Uriri‐Glover, & Grando, 2013; Alves, Caminha, da Silva, & Mendonça, 2012). The progress made in CPAP technology has reduced patient complaints about the machine and mask, but adherence to treatment remains a clinically significant problem.
Various interventions have been proposed to promote CPAP adherence including educational, supportive, and behavioral interventions to try to increase the hours of use of CPAP treatment (Basoglu et al., 2012), but their results remain contradictory. The purpose of this review was to evaluate the effectiveness of interventions to improve adherence to CPAP treatment in patients with high daytime sleepiness.
Materials and Methods
We performed a systematic search in MEDLINE, ScienceDirect, and Google Scholar. The keywords were apnea, compliance, CPAP, adherence, and somnolence. We considered only randomized controlled trials published between January 2005 and May 2018, which included interventions to improve CPAP adherence in adult OSA patients with high daytime sleepiness. We limited only control trials in order to include articles with a high methodological quality that would give more truth to our results.
A total of 23,762 studies were identified, of which 21,973 were excluded. One thousand five hundred forty-three were duplicate references, 59 were in another language, 195 did not have the full text available, 18,472 were not according to the topic, and 3,493 did not meet the inclusion criteria. Finally, eight trials were included in this review (Figure 1).
The characteristics of the studies are shown in Table 1.
The interventions can be grouped into four categories: educational, pharmacological, multidimensional, and technological interventions.
The methodological quality of all the studies included was classified according to the Jadad Scale (Halpern & Douglas, 2005; Jadad et al., 1996), also known as Jadad or Oxford score. The Jadad Scale makes it possible to assess the methodological quality of a clinical trial and presents the best evidence of its validity and reliability (Olivo et al., 2008). The Jadad Scale consists of five questions that address issues such as the design and randomization of subjects, monitoring, and masking measures. The score ranges from 0 to 5, with 5 being the highest score. A clinical trial is considered rigorous if the score is between 3 and 5 and not rigorous if the score is <3.
Three trials had scores below 3 points (Bradshaw, Ruff, & Murphy, 2006; Golay et al., 2006; Jurado-Gamez et al., 2015). The rest obtained a score of 3 points (Chen et al., 2015; Delanote, Borzée, Belge, Buyse, & Testelmans, 2018; Meurice et al., 2007; Taylor, Eliasson, Andrada, Kristo, & Howard, 2006; Wang, He, Wang, Liu, & Tang, 2012). None of the trials scored higher than 3 points.
Characteristics of Studies
Of the eight studies, one featured only one intervention group (Golay et al., 2006), three studies included two groups (Chen et al., 2015; Jurado-Gamez et al., 2015; Taylor et al., 2006), two studies included three groups (Bradshaw et al., 2006; Delanote et al., 2018), and the rest included four groups (Meurice et al., 2007). Sample size ranged from 35 (Golay et al., 2006) to 321 (Jurado-Gamez et al., 2015).
All the studies included men and women in the sample except one of them, which included only men (Bradshaw et al., 2006). The mean age of participants included in the studies was 58.25 years. The mean body mass index of participants was 32.253 kg/m2. The mean apnea/hypopnea index was 66.28. In addition, the mean score of the Epworth Sleepiness Scale was 13.23.
The outcome variable to assess the efficacy of the proposed interventions was the number of hours of use of CPAP per night (4 hours/night).
The characteristics of the interventions are shown in Table 2.
After reviewing the trials, the types of interventions to improve adherence to CPAP can be grouped into the following categories.
In this review, we included five educational intervention studies (Chen et al., 2015; Delanote et al., 2018; Golay et al., 2006; Jurado-Gamez et al., 2015; Meurice et al., 2007).
In the study by Golay et al. (2006), the intervention consisted of workshops on the management and usefulness of CPAP led by nurses, a round-table discussion with the spouses of patients, and a night of CPAP therapy in the hospital. The hours of CPAP use were higher in the intervention group than in the control group; nevertheless, they had not found significant differences between groups.
In the study conducted by Meurice et al. (2007), four educational strategies were compared. Variables after 3, 6, and 12 months did not show significant differences between groups in the use of CPAP. The group that had received education reinforced by the prescriber plus standard education and delivery of written support on the use of CPAP showed the best CPAP adherence.
A previous trial (Jurado-Gamez et al., 2015) showed an improvement in adherence in the experimental group after 6 months of treatment. The treatment consisted of the provision of information about the importance of CPAP usage by the nursing staff. In addition, patients could call the nurses on the phone if any problems arose.
Chen and colleagues (2015) conducted a study that compared nurse-led intensive treatment versus standard support in new OSA patients who received CPAP therapy for the first time. Continuous positive airway pressure adherence increased significantly at 1, 3, 6, and 12 months in the intervention group after undergoing educational health and patient self-care interventions for 5 days.
Delanote and colleagues (2018) showed a significant improvement in the time of CPAP treatment. They carried out three different educational programs. In the first group, an individualized approach based on education using a checklist was performed. The second group received the same intervention and an additional phone call asking about the compliance and side effects. Finally, the last group received a combination of individual and group education using a slide presentation open for discussion. The hours of CPAP use improved in all groups. The percentage of patients using their device ≥3 hours per night was significantly higher in Group 3 (85%) versus Groups 1 and 2 (p < .05).
In the study conducted by Wang et al. (2012), subjects were divided into four intervention groups: an educational intervention group, a muscle relaxation intervention group, a group that received a combination of both, and a control group. In the control group, patients received one night of CPAP adjustment at the hospital at baseline. The adherence rate of the combined group was significantly higher than that of the control group at 4, 8, and 12 weeks from the intervention.
Another trial (Taylor et al., 2006) used a personal computer called “HealthBuddy,” where patients were asked to record the hours of CPAP use as well as daytime sleepiness, symptom management, and more. Although the difference in hours of CPAP use was not significant between groups, the results were better in the intervention group.
Only in one study, patients were treated with drugs (Meurice et al., 2007) to increase adherence to CPAP in OSA. There were three groups. The first used the standard treatment without drugs, the second used a placebo, and the third used 30 mg of zolpidem. Zolpidem is a sedative-hypnotic agent commonly prescribed for insomnia complaints and is used in polysomnographies because patient’s sedation improves sleep efficiency and patient tolerance to CPAP. Authors reported that there were no significant differences between groups.
As nurses are the main clinicians responsible for device use for patients, the therapeutic strategies to improve CPAP adherence are of importance in their clinical setting.
Our findings highlight the relevance of education programs carried out by nurses, given the added value of closeness that nurses have with clients, and they rely upon them to provide information that will affect their behavior. Previous studies include education interventions that can be performed individually or in group, including information about the pathology, the importance of adherence, and the procedure of administration. The majority of the educational interventions are carried out in the hospital. Nevertheless, nursing staff are also responsible to the reinforcement by phone calls or face-to-face sessions. In addition, educational treatment should involve the spouses or relatives, which allows a reinforcement of the intervention at home. Moreover, more research is needed about the specific intervention protocols in order to determine which is most effective. Thus, developing intervention programs conducted by nurses to compare their effectiveness could be an essential step in future studies for increasing adherence of patients using CPAP. Therefore, the nursing work related to the use of CPAP has a great impact that can make the difference between life and death in OSA patients.
This review was limited by the quality and volume of current evidence. All the studies retrieved in this review scored 3 points or below on the Jadad Scale. The exclusion of studies in languages and in methodology might result in missing information.
The literature shows different treatments to improve CPAP adherence in OSA patients. This review included educational, pharmacological, technological, and multidimensional treatments. The scientific evidence shows that educational interventions are the most effective at improving adherence to CPAP. Our results agree with those of other reviews, such as that of Smith et al. (2014). Authors of this review revealed that educational programs can increase CPAP adherence. According to scientific evidence, educational interventions conducted by the nursing staff are the most effective treatment to increase the number of hours of CPAP use in adult patients with OSA and EDS.
Key Practice Points
- Sleep apnea syndrome represents more than 85% of sleep breathing disorders, but daytime sleepiness is a key factor for the quality of life of patients that is more important than the severity of obstructive sleep apnea (OSA).
- Continuous positive airway pressure (CPAP) treatment is first-line therapeutic option, but the adherence rate is low.
- Types of interventions to improve adherence to CPAP can be grouped into the following categories: educational, technological, pharmacological, and multidimensional.
- Educational interventions conducted by nurses are more efficient than other interventions.
Conflict of Interest
The authors declare no conflict of interest.
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