Elsevier

Auris Nasus Larynx

Volume 46, Issue 4, August 2019, Pages 548-558
Auris Nasus Larynx

Nasal function and CPAP compliance

https://doi.org/10.1016/j.anl.2018.11.006Get rights and content

Abstract

Objective

Continuous positive airway pressure (CPAP) is the mainstay therapy for patients with obstructive sleep apnea (OSA) however compliance with CPAP is variable. Nasal ailments, such as nasal congestion are frequently mentioned as a cause for CPAP non-compliance, and potentially could be addressed prior to CPAP initiation, however, no specific criteria or recommendations for the evaluation and management of these patients exist. The aim of this retrospective study is to evaluate the effects of nasal anatomic features and disease on adherence to CPAP therapy for patients with OSA and determine the indications for pre-CPAP nasal treatment by using data obtained at clinical examination.

Methods

In total, 711 adult patients with initial diagnosis of OSA and an apnea–hypopnea index of ≥20 who were amenable to CPAP were included. We analyzed nasal parameters, past history of nasal disease, subjective symptoms, and disease severity in addition to whether CPAP therapy had been initiated, rate of CPAP therapy use (initial and 1 year), treatment continuation rate at 2 months and 1 year, and nasal treatments for all patients.

Results

CPAP therapy was initiated in 543 of 711 patients. Nasal resistance was significantly higher in patients who discontinued therapy soon after CPAP initiation. Nasal disease and nasal parameters were not found to be predictors of treatment adherence at 1 year.

Allergic rhinitis, moderate to severe nasal congestion at bedtime, slight or extensive sinus opacification, and a high nasal septum deviation score were found to be independent predictors of nasal treatment, while strong awareness of nasal congestion, a past history of sinusitis, and a total nasal resistance (supine position) of ≥0.35 Pa/cm3/s were independent predictors of surgical treatment.

Conclusion

Long-term CPAP therapy adherence in patients with OSA can be predicted from initial CPAP adherence. Nasal disease and nasal parameters are important factors for early CPAP therapy discontinuation and should be adequately treated before therapy initiation to ensure long-term adherence. Indications for pre-CPAP nasal treatment and nasal surgery for patients with OSA can be predicted from the data obtained at the first examination, and these patients should be treated differently from those without OSA.

Introduction

Continuous positive airway pressure (CPAP) therapy is a standard treatment for patients with moderate to severe obstructive sleep apnea (OSA), however its high efficacy tends to be limited by individual compliance with therapy. In the Apnea Positive Pressure Long-term Efficacy Study cohort, the adherence of patients with OSA to CPAP therapy was favorable on the first day of treatment; worsened with time, and stabilized after 1 or 2 months [1]. In the Home Positive Airway Pressure study, the rate of CPAP therapy use was not more than 50% at 1 and 3 months after the beginning of therapy in OSA patients with an apnea–hypopnea index (AHI) of ≥15 and an Epworth sleepiness scale (ESS) of ≥12 [2].

Several studies have described factors associated with dropout from CPAP therapy. The Sleep Apnea Cardiovascular Endpoints study showed that CPAP therapy use was evidently decreased at 1 year in patients with moderate to severe OSA associated with cardiovascular disease. The authors reported that adherence to CPAP and side effects of the therapy at 1 month (dry mouth, nasal symptoms, eye problems, claustrophobia, hearing problems, facial pain, skin irritation due to the mask, and the mask fit and leakage) were predictors of a decreased rate of CPAP therapy use [3]. Therefore, a high usage rate in the initial introductory period is a key factor for continued adherence to this therapy.

Nasal complaints and findings associated with decreased CPAP compliance have been previously described. Sugiura et al. reported that nasal resistance was significantly increased while AHI was significantly decreased, in patients who complained of discomfort and sleeplessness during CPAP titration [4]. Brander et al. reported that nasal symptoms (nasal obstruction, nasal drainage) were present in 42% of the patients who dropped out within 6 months after the introduction of CPAP therapy [5]. According to a report by Redline et al., a significant improvement in well-being, mood, and functional status was more frequent when there were no sinus problems in patients with sleep respiratory disturbances and a respiratory disturbance index of <30 who were receiving CPAP therapy [6]. Clinical guidelines issued by the American Academy of Sleep Medicine (AASM) in 2006 noted that the treatment of nasal airway problems in the introductory phase of CPAP therapy is important [7]. Guidelines for the long-term management of patients with OSA also indicate that the nasal airway should be the preferred delivery route to CPAP [8]. In addition, the rate of CPAP therapy use at 1 year was 71% for patients who exhibited nose breathing during sleep, whereas it was 30% for those who exhibited mouth breathing during sleep [9]. These findings suggest that oral breathing due to nasal congestion or habitual mouth breathing may be associated with decreased adherence to CPAP therapy.

Therefore, nasal congestion, oral breathing and nasal pathologies are well known risk factors for decreased CPAP usage, however specific nasal findings, disease states, and the impact of treating such conditions on CPAP compliance prior to its initiation is less clear. The aims of this retrospective study are to evaluate nasal disease states and clinical findings that could potentially affect adherence to CPAP therapy for patients with OSA and determine the indications for pre-CPAP nasal treatment for these patients.

Section snippets

Materials and methods

The protocol of the investigation was approved by the Institutional Review Board of Ota General Hospital (No.18013). A retrospective analysis of adult patients who underwent polysomnography (PSG) between April 2014 and March 2016, newly diagnosed with OSA, exhibited an AHI of ≥20 and were amenable to CPAP therapy were selected. All included patients had complete data pertaining to nasal anatomic findings, past history of nasal disease, subjective symptoms, and disease severity. Patients with

Overall patients (Table 1)

A total of 711 patients were included. The background characteristics of these patients are shown in Table 1. The subjective symptom of nasal congestion was biphasic. The median JESS score was 9. Sinus opacification was not observed in 61% of the patients (Fig. 2). The total nasal resistance was greater in the sitting position than in the supine position, however, there was significant correlation between the total nasal resistance in sitting position and that supine positions (correlation

Discussion

In the present study, we found that the initial adherence to CPAP therapy in patients with OSA had a major influence on long-term adherence and that treatment adherence gradually decreases in patients with nasal complaints. Nasal disease and nasal parameters were important factors influencing the early discontinuation of CPAP therapy.

The nasal cavities were reported to exhibit a cycle whereby the morphology of the cavities varies over time [17]. Therefore, we tried our best to perform nasal

Conclusion

We found that long-term CPAP therapy adherence in patients with OSA can be predicted from the status of use (adherence and duration of use) in the early stages of treatment. Nasal disease and nasal parameters are important factors for early CPAP therapy discontinuation and should be adequately treated before therapy initiation.

Acknowledgement

The protocol of the investigation was approved by the Institutional Review Board of Ota General Hospital (No.18013)

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