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OtherPractice

Continuous positive airway pressure

Peter (Ran) Yang and Christina Korownyk
Canadian Family Physician October 2018, 64 (10) 745;
Peter (Ran) Yang
Medical student at the University of Alberta in Edmonton.
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Christina Korownyk
Associate Professor of the PEER (Patients, Experience, Evidence, Research) group in the Department of Family Medicine at the University of Alberta.
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Clinical question

Does continuous positive airway pressure (CPAP) reduce cardiovascular disease (CVD) or mortality in patients with obstructive sleep apnea (OSA)?

Bottom line

There is a lack of convincing evidence that CPAP reduces CVD or mortality in patients with moderate to severe OSA. Adherence to CPAP treatment in most clinical trials is low (1.4 to 5.8 hours per night at 1 year). Modest clinically important improvements in daytime sleepiness have been demonstrated. Quality-of-life scales have also demonstrated improvement, although the clinical significance is unclear.

Evidence

Three meta-analyses of RCTs have been completed.1–3

Most patients were male, with a mean age older than 60 years and moderate to severe OSA.

  • There was no statistical difference in outcomes for CPAP versus standard care or sham.

    • - Cardiovascular disease1–3: 7% with CPAP versus 8% of controls (7 trials, 4562 patients).1

    • - Cardiovascular death1,2: 9% with CPAP versus 8% of controls (7 trials, 5476 patients).1

    • - Acute coronary syndrome1,2: 3% with CPAP versus 3% of controls (7 trials, 4562 patients).1

    • - Stroke1–3: 4% with CPAP versus 4% of controls (6 trials, 4171 patients).1

  • Post hoc analysis did not identify any significant relationship between CPAP and CVD regardless of apnea severity, length of follow-up, or adherence.1

  • Limitations: Studies were somewhat heterogeneous, with inclusion of central apnea patients in some outcomes and differences in length of follow-up (2 to 68 months) and adherence to CPAP (1.4 to 5.8 hours a night at 1 year).

Context

  • Obstructive sleep apnea is associated with increased risk of CVD and mortality.4,5

  • Use of CPAP modestly improves daytime sleepiness by 1.6 to 3.8 points on a 24-point scale, which is likely clinically detectable.6,7

  • Use of CPAP is associated with modest improvements in quality-of-life measures (eg, about a 3.3- to 9.7-point improvement on a 100-point scale)8 with uncertain clinical relevance.

  • Use of CPAP significantly decreases blood pressure (mean reduction of 2.5 mm Hg systolic and 2.0 mm Hg diastolic, P < .001).9

  • Observational data suggest CPAP use significantly reduces motor vehicle accidents (P < .001).10 A large RCT (2717 patients) reports a non–statistically significant trend toward injury reduction (7.4% vs 8.8%, P = .06).11

Implementation

Laboratory polysomnography (level I study) is the criterion standard for diagnosing OSA.4 If access is a barrier, home apnea testing (level III study) can be considered for symptomatic patients with a high pretest probability of OSA.4 A trial of CPAP might demonstrate benefit in symptomatic patients, although cost can be a barrier.8 A systematic review and meta-analysis of 4 small trials found that exercise training demonstrated similar improvement in clinically important outcomes in patients with OSA (eg, about a 3.1-point improvement on a sleepiness scale out of 24).12 While interventions were diverse, they typically included aerobic and resistance exercise 3 to 4 times per week.12

Notes

Tools for Practice articles in Canadian Family Physician are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in Canadian Family Physician are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to toolsforpractice{at}cfpc.ca. Archived articles are available on the ACFP website: www.acfp.ca.

Footnotes

  • Competing interests

    None declared

  • The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Yu J,
    2. Zhou Z,
    3. McEvoy RD,
    4. Anderson CS,
    5. Rodgers A,
    6. Perkovic V,
    7. et al
    . Association of positive airway pressure with cardiovascular events and death in adults with sleep apnea: a systematic review and meta-analysis. JAMA 2017;318(2):156-66.
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    1. Abuzaid AS,
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    3. Elbadawi A,
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    . Meta-analysis of cardiovascular outcomes with continuous positive airway pressure therapy in patients with obstructive sleep apnea. Am J Cardiol 2017;120(4):693-9. Epub 2017 Jun 1.
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    1. Guo J,
    2. Sun Y,
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    7. et al
    . Effect of CPAP therapy on cardiovascular events and mortality in patients with obstructive sleep apnea: a meta-analysis. Sleep Breath 2016;20(3):965-74. Epub 2016 Feb 12.
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    1. Laratta CR,
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    3. Povitz M,
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    . Diagnosis and treatment of obstructive sleep apnea in adults. CMAJ 2017;189(48):E1481-8.
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    1. Kendzerska T,
    2. Mollayeva T,
    3. Gershon AS,
    4. Leung RS,
    5. Hawker G,
    6. Tomlinson G
    . Untreated obstructive sleep apnea and the risk for serious long-term adverse outcomes: a systematic review. Sleep Med Rev 2014;18(1):49-59. Epub 2013 May 1.
    OpenUrlCrossRefPubMed
  6. 6.↵
    1. Giles TL,
    2. Lasserson TJ,
    3. Smith BH,
    4. White J,
    5. Wright J,
    6. Cates CJ
    . Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 2006;(3):CD001106.
  7. 7.↵
    1. Phillips CL,
    2. Grunstein RR,
    3. Darendeliler MA,
    4. Mihailidou AS,
    5. Srinivasan VK,
    6. Yee BJ,
    7. et al
    . Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med 2013;187(8):879-87.
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  8. 8.↵
    1. Kuhn E,
    2. Schwarz EI,
    3. Bratton DJ,
    4. Rossi VA,
    5. Kohler M
    . Effects of CPAP and mandibular advancement devices on health-related quality of life in OSA: a systematic review and meta-analysis. Chest 2017;151(4):786-94. Epub 2017 Jan 24.
    OpenUrl
  9. 9.↵
    1. Bratton DJ,
    2. Gaisl T,
    3. Wons AM,
    4. Kohler M
    . CPAP vs mandibular advancement devices and blood pressure in patients with obstructive sleep apnea: a systematic review and meta-analysis. JAMA 2015;314(21):2280-93.
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  10. 10.↵
    1. Tregear S,
    2. Reston J,
    3. Schoelles K,
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    . Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis. Sleep 2010;33(10):1373-80.
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  11. 11.↵
    1. McEvoy RD,
    2. Antic NA,
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    6. Zhang X,
    7. et al
    . CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med 2016;375(10):919-31. Epub 2016 Aug 28.
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    6. Vivodtzev I,
    7. et al
    . Obstructive sleep apnea syndrome, objectively measured physical activity and exercise training interventions: a systematic review and meta-analysis. Front Neurol 2018;(9):73.
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Canadian Family Physician: 64 (10)
Canadian Family Physician
Vol. 64, Issue 10
1 Oct 2018
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Continuous positive airway pressure
Peter (Ran) Yang, Christina Korownyk
Canadian Family Physician Oct 2018, 64 (10) 745;

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