Hvordan øger vi CPAP compliance Philip Tønnesen, M.D., dr.med. Overlæge Dansk Center for Søvnmedicin Glostrup Hospital Danmark 12.juni 2015.

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1 Hvordan øger vi CPAP compliance Philip Tønnesen, M.D., dr.med. Overlæge Dansk Center for Søvnmedicin Glostrup Hospital Danmark 12.juni 2015

2 CPAP adherence 1. Cochrane meta-analyse 2. Intensiv support 3. Patient –partner inddragelse 4. Patient relateret ”materiale” (video, søvnrapport) Compliance efter 1 år med CPAP: Danmark 2013: 46 % Glostrup Hospital 40% Nordsjællands Apnø Klinik 76%

3 Cochrane meta-analysis 2014, issue 1

4 Cochrane meta-analyse 2014 (30 studier med 2047 deltagere)  Moderat kvalitetsstudier indikerer at kort tids undervisning / information mht. øget CPAP anvendelse medfører en moderat (mindre) øgning af compliance 1. 1. Increased CPAP use 35 minutes per night 2. 2. Increased the number of participants who used their machines for longer than four hours per night from 57 to 70 % 3. 3. Reduced the likelihood of withdrawal from the study (OR 0.67, 95% CI 0.45 to 0.98, N = 683, eight studies; low- quality evidence)

5 Cochrane meta-analyse 2014 (30 studier med 2047 deltagere)  For pt. nystartet med CPAP med moderat/ svær søvnapnø er der lav-kvalitetsstudier der indikerer at diverse tiltag og støtte (support) mht. øget brug af CPAP medfører øget compliance sammenlignet med “usual care” 1. 1. Increased machine usage by about 50 minutes per night 2. 2. Increased the number of participants who used their machines for longer than four hours per night from 59 to 75 % 3. 3. Reduced the likelihood of study withdrawal (OR 0.65, 95% CI 0.44 to 0.97, N = 903, 12 studies; moderate- quality evidence).

6 Cochrane meta-analyse 2014 (30 studier med 2047 deltagere)  Lav kvalitetsstudier indikerer at adfærdsterapi (behavioral support)medfører en stor øgning af compliance 1. 1. Increased CPAP use 1.44 hours per night 2. 2. Increased the number of participants who used their machines for longer than four hours per night from 28 to 47 % 3. 3. Rate of withdrawal with behavioural interventions was imprecise and did not reach statistical significance (OR 0.85, 95% CI 0.57 to 1.25, N = 609, five studies, very low-quality evidence).

7 Cochrane meta-analyse 2014 (30 studier med 2047 deltagere)  Effekten af øget brug på dagtidstræthed, livskvalitet og lang-tids cardio-vasculær risiko er uklar

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9   Standard support. Each patient was given a full explanation of the need for and benefits of CPAP therapy by a sleep physician and a sleep nurse + a 20-min video education program.   CPAP mask from among a range of masks of more than 20 sizes provided by three different manufacturers. The patients were then acclimated to wearing the CPAP mask for at least 20 min during the daytime + a full-night CPAP titration. Any problems with CPAP were addressed by the CPAP nurse.   Home: A 24-h telephone line to the sleep nurses.   Nurse telephone Days 2 and 21.   In the hospital by the CPAP nurse and by a sleep physician at 1, 3, and 6 M.

10   Intensive support. Standard support protocol, plus:   Initial CPAP education was given in the patient's home, with involvement of the patient's partner   The patients had an additional 2 nights (3 nights in total) of CPAP titration in the sleep center in an effort to resolve early problems encountered with CPAP   The sleep nurses home visits to the patient and the patient's partner at 7, 14, and 28 d and at 4 M after CPAP initiation

11 Used CPAP after 6 months 1. Standard: 36 of 40 patients (compliance 90%)  All four stopped CPAP 2. Intensive support:37 of 40 patients (compliance 92.5%)  One died of lung cancer, ones topped CPAP, one did not attend follow-up

12 3 nd 2

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14 Overall findings   CPAP use and outcomes of therapy can be improved by provision of a nurse-led intensive CPAP education and support program.   CPAP use is lower among patients whose partners ask them to seek treatment.

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16   Qualitative study explored patients' and partners' experiences of CPAP and facilitators and barriers to CPAP use, and elicited suggestions for a first-time CPAP user program (N=27).   Qualitative content analysis identified five themes: Knowledge of sleep apnea Effects of sleep apnoea Effects of CPAP Barriers and facilitators of CPAP Ideas for a new user support program.   Patients and partners emphasized the importance of partner involvement in the early CPAP treatment period   These data suggest consideration of a couple-oriented approach to improving CPAP adherence.

17   Barriers and Motivations for CPAP Use   Patients and partners described problems with the equipment, interference with sleep and intimacy, logistical issues, side effects of CPAP, lack of support from health care providers, and initial feelings of shame as barriers to CPAP adherence.   Difficulties adjusting the mask, discomfort and pain from the mask, and incorrect pressure setting were commonly reported barriers to adherence.   Patient: Sometimes it's just so uncomfortable to put that mask on at night and I wake up in the morning with a big mark on my face. Not that the mark bothers me, but it hurts. It's like sleeping, you know, with something pressing into your face all night. It's not worth it.   Patients also expressed frustration with falling asleep with the mask on, difficulties changing sleeping positions or sleeping on one's side or stomach, and annoyance with having to put the mask back on after getting out of bed during the night.   Patient: If you get up [during the night], you don't want to put it back on. I don't want to wake myself up trying to get that thing threaded through there.

18 Study findings   Partners in our study provided support to patients during the early treatment period that was viewed by patients as motivation for continued CPAP use.   Inclusion of partners in a new CPAP user program was identified as a key component.   It is recommended, that future adherence interventions evaluate a couple-oriented approach to improving CPAP adherence.

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20 Cochrane anbefaler flere undersøgelser mht. 1. Studier der matcher individuelle behov og derfor øger effekt og derfor er mere cost-effective 2. Studier med patienter der kæmper med at anvende CPAP 3. Optimal ”timing”, varighed og lang-tids effekt af diverse interventioner for at øge compliance 4. Sammenhæng med øget anvendelse af CPAP og effekt på symptomer og livskvalitet