Original articleA multicentre trial of education strategies at CPAP induction in the treatment of severe sleep apnoea–hypopnoea syndrome
Introduction
Obstructive sleep apnoea syndrome (OSAS) is a common condition [1] with symptoms of daytime somnolence, fatigue, irritability [2], [3], depression and impaired cognitive function [4]. OSA is associated with high risk of systemic hypertension [5] and increased risk of road traffic accidents [6], [7].
Continuous positive airway pressure (CPAP) has been found to be effective treatment for OSAS, improving symptoms [8], reducing accidents [7] and improving quality of life [9], [10]. CPAP treatment can, however, have disagreeable side effects [11] which can lead to refusal or cessation of treatment [12]. Thus, the initial acceptance rate of CPAP is around 70% after titration for effective pressure by polysomnography (PSG). Once patients have been established on CPAP, acceptance of the treatment is good, with 80–90% of subjects still continuing treatment after several years [13]. However, overall compliance can vary considerably. It is recommended that the machine be used every night for a minimum of 5–6 h. This level of compliance is obtained in patients managed by the ANTADIR network of homecare associations in France in over 80% of the patients [14]. Compliance is somewhat less in the USA [15], [16], where only 55–75% of patients have good compliance.
Factors influencing the level of compliance include measures of the initial severity of OSAS, such as the apnoea–hypopnoea index (AHI), or daytime somnolence at the time of diagnosis as well as subjective improvement under nasal CPAP [13]. One factor of importance for compliance with this demanding treatment is the initial level of involvement and education by healthcare professionals at the time of initiation of treatment. Several single-centre studies have demonstrated improved compliance with increased patient education input [17], [18]. Thus, patient education is becoming an important issue for CPAP treatment, and one issue is the degree of complexity required in such education. Will explanation and written material be sufficient to ensure compliance or will it be necessary to set up formal in-depth education programmes with multiple sessions for the vast numbers of patients requiring CPAP treatment? The answer to this specific problem is not quite clear and requires further investigation.
The overall purpose of treating OSAS is to improve patients’ quality of life. Previous studies using generic instruments have shown that quality of life is improved by CPAP despite its difficulties [9], [14], but the role of educational input in the improvement of quality of life has been little studied [17], [18]. Thus, it is important that the effects of different strategies of treatment initiation and education be examined in a multi-centre setting so that the conclusions can be more widely applicable.
Most CPAP treatment in France is managed by the federated respiratory homecare system (ANTADIR). This federation of homecare associations ensures close medical, paramedical and technical follow-up [19]. The ANTADIR structure allows us to examine different strategies of reinforced intervention that could improve compliance or quality of life to a greater degree than the standard level of care. Thus, we have set out to see if different strategies of educational input can lead to different levels of compliance and improved quality of life in OSAS patients treated in a number of centres.
Section snippets
Patients
Patients were consecutively recruited from seven centres and were randomised into the four educational strategies. Each patient had full PSG confirming an AHI greater than 30/h of sleep, in accordance with French reimbursement procedures (TIPS) that usually need the confirmation of an initial AHI greater than 30/h. No patient had prior sleep apnoea treatment. All patients were treated with constant pressure CPAP. The choice of the machine used by the patients corresponded to the wishes of the
Results
One hundred thirty-three patients were initially scheduled. However, complete initial data were obtained in only 112 patients who were definitively included in the study. Demographic characteristics and diagnostic data at initial evaluation are shown in Table 1. The four groups had severe OSAS with no difference between groups as regards AHI and ESS. Initially, the SF-36 quality of life index was reduced in all domains and in all groups, compared to normal values, especially in the domain of
Discussion
We have shown that with standard input by prescribers and homecare workers compliance with CPAP in France was very good, close to 5 h per night confirming previous results from the ANTADIR network [14], [19], [23]. This good compliance obtained in the short and long term is associated with improvement in symptoms and in quality of life scores. We have not shown a significant difference in compliance with CPAP treatment in OSAS, nor a difference in improvement in symptoms between groups of
Acknowledgements
The authors acknowledge the invaluable help of the regional associations of the ANTADIR network that participated in the study. We also thank Ms Coisy Vialette Mariette, ANTADIR, Béatrice Rival ARC CHU Grenoble.
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