Positive pressure therapy: a perspective on evidence-based outcomes and methods of application

Abstract

The sleep medicine community has increasingly recognized the necessity that clinical care be based on high-quality levels of evidence. Although research supports a favorable influence of positive airway pressure (PAP) therapy on risk for significant adverse outcomes in patients with severe obstructive sleep apnea-hypopnea (OSAH), well-designed trials are still required to elucidate the effect of PAP on health, quality of life, and economic risks in patients with milder OSAH. Similarly, although there is strong evidence supporting various PAP titration strategies and PAP modalities in patients with severe OSAH without significant medical and psychiatric comorbidities, there is insufficient high-level evidence assessing and comparing the clinical efficacy and health care cost implications of various titration paradigms and various PAP modalities in individuals with milder OSAH and those with comorbid conditions. For ethical and other reasons, it may not be possible to apply a randomized controlled design to address all questions. However, whichever design is employed, it must be rigorously developed with attention to all potential confounders with adequate power to provide compelling, high-quality evidence.

Figure 1.

Average (±SD) number of automobile crashes per driver per year over the 3-year interval before initiation of positive airway pressure therapy (solid circles) and during the 3-year interval after initiation of positive airway pressure therapy (open circles) in (A) patients with sleep apnea–hypopnea compared with (B) control subjects over the same time periods. Reprinted by permission from Reference .

Figure 2.

Cumulative survival of patients with obstructive sleep apnea–hypopnea by categories of average daily use of positive airway pressure therapy. Patients with average daily use less than 1 hour had significantly lower cumulative survival than those with an average daily use of 1–6 hours and those with an average daily use exceeding 6 hours. There was no difference in the groups with average daily use of 1–6 hours and more than 6 hours. Reprinted by permission from Reference .