What are the indications for Continuous Positive Airway Pressure (CPAP) therapy?

Indications for CPAP Therapy

CPAP therapy is strongly recommended as the initial treatment for patients diagnosed with obstructive sleep apnea (OSA), particularly those with moderate to severe OSA and excessive daytime sleepiness. 1

Primary Indications for CPAP Therapy

• Diagnosed OSA with an Apnea-Hypopnea Index (AHI) ≥ 15 events/hour (moderate to severe OSA), regardless of symptoms 1
• Mild OSA (AHI 5-15 events/hour) with symptoms such as excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia 1
• Mild OSA with comorbid conditions including hypertension, coronary artery disease, or history of stroke 1
• OSA with excessive daytime sleepiness that affects quality of life or increases risk of accidents 1

Specific Clinical Scenarios Warranting CPAP

• Patients at high risk for motor vehicle accidents due to OSA-related sleepiness 1
• Patients with cardiovascular comorbidities including:
  • Hypertension, especially resistant or poorly controlled 1, 2
  • History of myocardial infarction 1, 2
  • Atrial fibrillation or other cardiac arrhythmias 1, 2
  • Stroke or increased stroke risk 1, 2
• Patients with pulmonary hypertension associated with OSA 1, 2
• Patients with metabolic disorders such as type 2 diabetes with poor glycemic control 2

Factors Associated with Better CPAP Adherence

• Higher AHI and ESS (Epworth Sleepiness Scale) scores - patients with more severe OSA tend to adhere better to CPAP therapy 1, 3
• Younger age, presence of snoring, lower CPAP pressure settings, higher BMI, and greater mean oxygen saturation are associated with better adherence 1
• Early intervention for CPAP intolerance issues (within 7-90 days) improves long-term adherence 1, 2

Alternative Treatments When CPAP is Not Tolerated

• Mandibular advancement devices (MADs) can be considered for:
  • Patients who prefer MADs over CPAP 1
  • Patients experiencing adverse effects with CPAP 1
  • Patients with mild to moderate OSA who cannot tolerate CPAP 1
• Weight loss interventions should be encouraged for all overweight and obese patients with OSA, though typically as an adjunct to CPAP rather than a replacement 1

Monitoring and Adherence Considerations

• Minimum effective CPAP usage is generally considered to be at least 4 hours per night on 70% of nights, though there is evidence of a dose-response relationship with benefits seen even at 2 hours of use 1
• Regular monitoring of CPAP adherence is essential for optimal outcomes, with early follow-up (7-90 days after initiation) recommended to address any issues 1
• Telemonitoring care may help improve adherence to CPAP therapy 1

Common Pitfalls in CPAP Management

• Failing to address early adherence issues such as mask fit, pressure settings, or side effects can lead to treatment abandonment 1, 2
• Underestimating the importance of CPAP in asymptomatic patients with moderate to severe OSA can lead to increased cardiovascular risk 1, 2
• Discontinuing CPAP monitoring after initial setup can lead to suboptimal outcomes and decreased adherence 1
• Not recognizing the rapid return of symptoms and physiological consequences when CPAP is discontinued, which can occur after just one night without therapy 1, 2

Clinical Outcomes of CPAP Therapy

• Improved daytime sleepiness as measured by ESS scores 1
• Reduced AHI and arousal index scores 1
• Increased oxygen saturation during sleep 1
• Decreased risk of motor vehicle accidents 1, 2
• Reduction in blood pressure compared to no treatment 1, 4
• Improved cognitive function in patients with OSA 5, 4