Increasing adherence to obstructive sleep apnea treatment with a group social cognitive therapy treatment intervention: a randomized trial. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Comparison of the effects of continuous positive airway pressure, oral appliance and exercise training in obstructive sleep apnea syndrome Oral Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial Randomized crossover trial of two treatments for sleep apnea/hypopnea syndrome: continuous positive airway pressure and mandibular repositioning splint. Randomised study of three non-surgical treatments in mild to moderate obstructive sleep apnoea Obstructive Sleep apnea Therapy Effect of oral appliance therapy on upper airway collapsibility in obstructive sleep apnea. A short-term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea. Mandibular advancement device and CPAP upon cardiovascular parameters in OSA A crossover study comparing the efficacy of continuous positive airway pressure with anterior mandibular positioning devices on patients with obstructive sleep apnea. Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: a randomized cross-over trial. Evidence of the effectiveness of continuous positive airway pressure in the treatment of sleep apnea/hypopnea syndrome. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea.
OBJECTIVE To examine whether a social cognitive therapy ( SCT ) intervention increases continuous positive airway pressure ( CPAP ) use compared to equivalent social interaction ( SI ) time . PARTICIPANTS Individuals with obstructive sleep apnea ( OSA ) referred for CPAP therapy . INTERVENTION Participants received a 30-min group education session regarding OSA and CPAP . Groups of three to four participants were then r and omly assigned to an SCT session or social interaction . MEASUREMENTS CPAP usage was assessed at 7 nights , then 1 , 3 , and 6 months . The two primary outcomes were adherence , usage ≥ 4 h per night at 6 months , and uptake of CPAP . Question naires were given pretreatment and posttreatment . RESULTS Two hundred six individuals were r and omized to SI ( n = 97 ) or SCT ( n = 109 ) . CPAP uptake was not different between groups ( 82 % in SI , 88 % in SCT groups , P = 0.35 ) . There were no differences between groups in adherence : 63 - 66 % at 1 week , and at 6 months 55 - 47 % ( P = 0.36 ) . Higher pretreatment apnea-hypopnea index , higher baseline self-efficacy , and use of CPAP ( ≥ 4 h ) at 1 week were independent predictors of CPAP adherence at 6 months . CPAP adherence increased by a factor of 1.8 ( odds ratio = 1.8 , 95 % confidence interval 1.1 - 3.0 ) for every one-unit increase in self-efficacy . There was no difference between groups postintervention in self-efficacy scores , sleepiness , mood , or sleep quality . CONCLUSIONS In this r and omized trial , a single SCT application did not increase adherence when compared with SI time . Although self-efficacy scores prior to CPAP predicted adherence , self-efficacy was not increased by the interventions . Increasing intensity and underst and ing of SCT interventions may be needed to improve CPAP adherence . CLINICAL TRIALS REGISTRATION Australian New Zeal and Clinical Trials Registry , ACTRN12607000424404 RATIONALE Continuous positive airway pressure ( CPAP ) and m and ibular advancement device ( MAD ) therapy are commonly used to treat obstructive sleep apnea ( OSA ) . Differences in efficacy and compliance of these treatments are likely to influence improvements in health outcomes . OBJECTIVES To compare health effects after 1 month of optimal CPAP and MAD therapy in OSA . METHODS In this r and omized crossover trial , we compared the effects of 1 month each of CPAP and MAD treatment on cardiovascular and neurobehavioral outcomes . MEASUREMENTS AND MAIN RESULTS Cardiovascular ( 24-h blood pressure , arterial stiffness ) , neurobehavioral ( subjective sleepiness , driving simulator performance ) , and quality of life ( Functional Outcomes of Sleep Question naire , Short Form-36 ) were compared between treatments . Our primary outcome was 24-hour mean arterial pressure .  A total of 126 patients with moderate-severe OSA ( apnea hypopnea index [ AHI ] , 25.6 [ SD 12.3 ] ) were r and omly assigned to a treatment order and 108 completed the trial with both devices . CPAP was more efficacious than MAD in reducing AHI ( CPAP AHI , 4.5 ± 6.6/h ; MAD AHI , 11.1 ± 12.1/h ; P < 0.01 ) but reported compliance was higher on MAD ( MAD , 6.50 ± 1.3 h per night vs. CPAP , 5.20 ± 2 h per night ; P < 0.00001 ) . The 24-hour mean arterial pressure was not inferior on treatment with MAD compared with CPAP ( CPAP-MAD difference , 0.2 mm Hg [ 95 % confidence interval , -0.7 to 1.1 ] ) ; however , overall , neither treatment improved blood pressure . In contrast , sleepiness , driving simulator performance , and disease-specific quality of life improved on both treatments by similar amounts , although MAD was superior to CPAP for improving four general quality -of-life domains . CONCLUSIONS Important health outcomes were similar after 1 month of optimal MAD and CPAP treatment in patients with moderate-severe OSA . The results may be explained by greater efficacy of CPAP being offset by inferior compliance relative to MAD , result ing in similar effectiveness . Clinical trial registered with https://www.anzctr.org.au ( ACTRN 12607000289415 ) OBJECTIVE : There are several treatments for obstructive sleep apnea syndrome , such as weight loss , use of an oral appliance and continuous positive airway pressure , that can be used to reduce the signs and symptoms of obstructive sleep apnea syndrome . Few studies have evaluated the effectiveness of a physical training program compared with other treatments . The aim of this study was to assess the effects of physical exercise on subjective and objective sleep parameters , quality of life and mood in obstructive sleep apnea patients and to compare these effects with the effects of continuous positive airway pressure and oral appliance treatments . METHODS : Male patients with moderate to severe obstructive sleep apnea and body mass indices less than 30 kg/m2 were r and omly assigned to three groups : continuous positive airway pressure ( n = 9 ) , oral appliance ( n = 9 ) and physical exercise ( n = 7 ) . Polysomnographic recordings , blood sample s and daytime sleepiness measurements were obtained prior to and after two months of physical exercise or treatment with continuous positive airway pressure or an oral appliance . Clinical trials.gov : NCT01289392 RESULTS : After treatment with continuous positive airway pressure or an oral appliance , the patients presented with a significant reduction in the apnea-hypopnea index . We did not observe changes in the sleep parameters studied in the physical exercise group . However , this group presented reductions in the following parameters : T leukocytes , very-low-density lipoprotein and triglycerides . Two months of exercise training also had a positive impact on subjective daytime sleepiness . CONCLUSIONS : Our results suggest that isolated physical exercise training was able to modify only subjective daytime sleepiness and some blood measures .  Continuous positive airway pressure and oral appliances modified the apnea-hypopnea index Background : Previous r and omized controlled trials have addressed the efficacy of m and ibular advancement devices ( MADs ) in the treatment of obstructive sleep apnea ( OSA ) . Their common control condition , nasal continuous positive airway pressure ( nCPAP ) , was frequently found to be superior to MAD therapy . However , in most of these studies , only nCPAP was titrated objective ly but not MAD . To enable an unbiased comparison between both treatment modalities , the MAD should be titrated objective ly as well . Objective : The aim of the present study was to compare the treatment effects of a titrated MAD with those of nCPAP and an intra-oral placebo device . Methods : Sixty-four mild/moderate patients with obstructive sleep apnea ( OSA ; 52.0 ± 9.6 years ) were r and omly assigned to three parallel groups : MAD , nCPAP and placebo device . From all patients , two polysomnographic recordings were obtained at the hospital : one before treatment and one after approximately 6 months of treatment . Results : The change in the apnea-hypopnea index ( ΔAHI ) between baseline and therapy evaluation differed significantly between the three therapy groups ( ANCOVA ; p = 0.000 ) . No differences in the ΔAHI were found between the MAD and nCPAP therapy ( p = 0.092 ) , whereas the changes in AHI in these groups were significantly larger than those in the placebo group ( p = 0.000 and 0.002 , respectively ) . Conclusion : There is no clinical ly relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objective ly M and ibular repositioning splints ( MRSs ) and continuous positive airway pressure ( CPAP ) are used to treat the sleep apnea/hypopnea syndrome ( SAHS ) . There are some data suggesting that patients with milder symptoms prefer MRS , but there are few comparative data on outcomes . Therefore , we performed a r and omized crossover trial of 8 weeks of CPAP and 8 weeks of MRS treatment in consecutive new out patients diagnosed with SAHS ( apnea/hypopnea index [ AHI ] > or= 5/hour , and > or= 2 symptoms including sleepiness ) . Assessment s at the end of both limbs comprised home sleep study , subjective ratings of treatment value , sleepiness , symptoms , and well-being , and objective tests of sleepiness and cognition .  Forty-eight of 51 recruited patients completed the trial ( 12 women ; age [ mean + /- SD ] , 46 + /- 9 years ; Epworth 14 + /- 4 ; median AHI , 22/hour ; interquartile ratio [ IQR ] , 11 - 43/hour ) . Significant ( p < or= 0.01 ) differences between MRS and CPAP were observed for 7 of 21 variables ( effect sizes , 0.3 - 0.6 SDs ) , all favoring CPAP , including AHI ( 15 + /- 16 and 8 + /- 6/hour , respectively ) , effectiveness rating , symptoms , Epworth ( 12 + /- 5 and 8 + /- 5 , respectively ) , functional outcomes of sleepiness question naire , short-form 36 health survey mental component , and health transition scores . Objective sleepiness , cognitive performance , and preference for treatments were not different . In patients experiencing a mild form of the syndrome ( AHI < 15 , n = 18 ) , symptoms , treatment efficacy and satisfaction , and subjective sleepiness were also better with CPAP than with MRS ( effect sizes , 0.7 - 1.1 SDs ) . These results do not support these MRS devices as first-line treatment for sleepy patients with SAHS Background : Patients with mild to moderate obstructive sleep apnoea ( OSA ) may be managed with different treatment options . This study compared the effectiveness of three commonly used non-surgical treatment modalities . Methods : Subjects with mild to moderate OSA were r and omised to one of three treatment groups for 10 weeks : conservative measures ( sleep hygiene ) only , continuous positive airways pressure ( CPAP ) in addition to conservative measures or an oral appliance in addition to conservative measures .  All overweight subjects were referred to a weight-reduction class . OSA  was assessed by polysomnography .  Blood pressure was recorded in the morning and evening in the sleep laboratory . Daytime sleepiness was assessed with the Epworth Sleepiness Scale . Health-related quality of life ( HRQOL ) was assessed with the 36-Item Short-Form Health Survey ( SF-36 ) and Sleep Apnoea Quality of Life Index ( SAQLI ) . Results : 101 subjects with a mean ( SEM ) apnoea – hypopnoea index ( AHI ) of 21.4 ( 1.1 ) were r and omised to one of the three groups . The severity of sleep-disordered breathing was decreased in the CPAP and oral appliance groups compared with the conservative measures group , and the CPAP group was significantly better than the oral appliance group . Relief from sleepiness was significantly better in the CPAP group . CPAP was also better than the oral appliance or conservative measures in improving the “ bodily pain ” domain , and better than conservative measures in improving the “ physical function ” domain of SF-36 . Both CPAP and the oral appliance were more effective than conservative measures in improving the SAQLI , although no difference was detected between the CPAP and oral appliance groups . CPAP and the oral appliance significantly lowered the morning diastolic blood pressure compared with baseline values , but there was no difference in the changes in blood pressure between the groups . There was also a linear relationship between the changes in AHI and body weight . Conclusion : CPAP produced the best improvement in terms of physiological , symptomatic and HRQOL measures , while the oral appliance was slightly less effective . Weight loss , if achieved , result ed in an improvement in sleep parameters , but weight control alone was not uniformly effective In clinical practice , oral appliances are used primarily for obstructive sleep apnea patients who do not respond to continuous positive airway pressure ( CPAP ) therapy . We hypothesized that an oral appliance is not inferior to CPAP in treating obstructive sleep apnea effectively . We r and omly assigned 103 individuals to oral-appliance or CPAP therapy .  Polysomnography after 8–12 weeks indicated that treatment was effective for 39 of 51 persons using the oral appliance ( 76.5 % ) and for 43 of 52 persons using CPAP ( 82.7 % ) . For the difference in effectiveness , a 95 % two-sided confidence interval was calculated . Non-inferiority of oral-appliance therapy  was considered to be established when the lower boundary of this interval exceeded −25 % . The lower boundary of the confidence interval was −21.7 % , indicating that oral-appliance therapy was not inferior to CPAP for effective treatment of obstructive sleep apnea . However , subgroup analysis revealed that oral-appliance therapy was less effective in individuals with severe disease ( apnea-hypopnea index > 30 ) . Since these people could be at particular cardiovascular risk , primary oral-appliance therapy appears to be supported only for those with non-severe apnea Oral appliance therapy is emerging as an alternative to continuous positive airway pressure for the treatment of obstructive sleep apnea ( OSA ) . However , its precise mechanisms of action are yet to be defined . We examined the effect of a m and ibular advancement splint ( MAS ) on upper airway collapsibility during sleep in OSA . Ten patients with proven OSA had a custom-made MAS incrementally adjusted during an acclimatization period until the maximum comfortable limit of m and ibular advancement was reached .  Polysomnography  with the splint was then performed . After a 1-week washout period , upper airway closing pressures during sleep ( with and without MAS ) were determined . Significant improvements with MAS therapy were seen in the apnea/hypopnea index ( 25.0 + /- 3.1 vs. 13.2 + /- 4.5/hour , p < 0.03 ) and upper airway closing pressure in Stage 2 sleep ( -1.6 + /- 0.4 vs. -3.9 + /- 0.6 cm H2O , p < 0.01 ) and in slow wave sleep ( -2.5 + /- 0.7 vs. -4.7 + /- 0.6 cm H2O , p < 0.02 ) compared with no therapy . These preliminary data indicate that MAS therapy is associated with improved upper airway collapsibility during sleep . The mediators of this effect remain to be determined BACKGROUND Although oral appliances are effective in some patients with obstructive sleep apnoea ( OSA ) , they are not universally effective . A novel anterior m and ibular positioner ( AMP ) has been developed with an adjustable hinge that allows progressive advancement of the m and ible . The objective of this prospect i ve crossover study was to compare efficacy , side effects , patient compliance , and preference between AMP and nasal continuous positive airway pressure ( nCPAP ) in patients with symptomatic mild to moderate OSA . METHODS Twenty four patients of mean ( SD ) age 44.0 ( 10.6 ) years were recruited with a mean ( SD ) body mass index of 32.0 ( 8.2 ) kg/m2 , Epworth sleepiness score 10.7 ( 3.4 ) , and apnoea/hypopnoea index 26.8 (11.9)/hour . There was a two week wash-in and a two week wash-out period and two treatment periods ( AMP and nCPAP ) each of four months . Efficacy , side effects , compliance , and preference were evaluated by a question naire and home sleep monitoring . RESULTS One patient dropped out early in the study and three refused to cross over so treatment results are presented on the remaining 20 patients . The apnoea/hypopnoea index ( AHI ) was lower with nasal CPAP 4.2 (2.2)/hour than with the AMP 13.6 (14.5)/hour ( p < 0.01 ) . Eleven of the 20 patients ( 55 % ) who used the AMP were treatment successes ( reduction of AHI to < 10/hour and relief of symptoms ) , one ( 5 % ) was a compliance failure ( unable or unwilling to use the treatment ) , and eight ( 40 % ) were treatment failures ( failure to reduce AHI to < 10/hour and /or failure to relieve symptoms ) . Fourteen of the 20 patients ( 70 % ) who used nCPAP were treatment successes , six ( 30 % ) were compliance failures , and there were no treatment failures . There was greater patient satisfaction with the AMP ( p < 0.01 ) than with nCPAP but no difference in reported side effects or compliance . CONCLUSIONS AMP is an effective treatment in some patients with mild to moderate OSA and is associated with greater patient satisfaction than nCPAP Purpose This study aims to compare the effects of a m and ibular advancement device ( MAD ) with continuous positive airway pressure ( CPAP ) treatment for obstructive sleep apnea ( OSA ) on blood pressure ( BP ) , oxidative stress , and heart rate variability ( HRV ) in a r and omized , crossed-over , single-blind , and controlled trial . Methods Twenty-nine moderate-to-severe adult OSA patients underwent  MAD , CPAP , and placebo oral appliance treatment .  Polysomnography , Epworth sleepiness scale , 24-h ambulatory BP monitoring , oxidative stress parameters ( malondialdehyde , catalase , superoxide dismutase , vitamins C , E , B6 , B12 , folate , homocysteine , uric acid ) , and HRV were assessed at baseline and after 1 month of each treatment . Diaries were used to evaluate compliance for devices and a pressure – time meter for CPAP . Results Both active treatments result ed in decreases in apnea and hypopnea index and Epworth sleepiness scale ; CPAP showed a greater effect . Frequency of diastolic BP dipping was higher in the MAD group compared with the CPAP group . A significant drop from baseline levels for catalase activity was observed after MAD . For HRV , there was a significant decrease in total power at night with CPAP and MAD compared with POA , and a decrease in index of sleep autonomic variation with MAD compared with baseline levels . Compliance rates were higher with MAD rather than CPAP . Conclusions Even though CPAP proved to be more effective at attenuating OSA , better compliance with MAD favored the reduction of one of the enzymes which participates in oxidative stress and better autonomic modulation during sleep OBJECTIVE This study compared the efficacy of a removable anterior m and ibular positioning ( AMP ) device to continuous positive airway pressure ( CPAP ) in patients with obstructive sleep apnea ( OSA ) using a fully balanced crossover design . DESIGN Twenty-three male subjects with confirmed OSA were recruited from the Technion Sleep Laboratory in Haifa , Israel , from February 18 , 1991 to December 17 , 1992 . Twenty-one of the 23 subjects enrolled completed all aspects of the study . RESULTS The mean apnea-hypopnea index ( AHI ) before treatment was 33.86 + /- 14.30 . The mean AHI decreased with CPAP to 59.50 % , but decreased only 38.91 % with the AMP device . The lowest mean recorded oxygen saturation level for the 21 subjects was 84.30 before treatment , 91.10 after CPAP treatment , and 90.20 after AMP treatment . Sleep data revealed a significant decrease in stage 1 and 2 ( p=0.0088 ) and an increase in rapid eye movement percent ( p=0.0066 ) for both treatments when compared with baseline . Three- to 10-month posttreatment phone interviews showed that 1 subject was not using either device , 1 subject was using CPAP , and 2 subjects were using the AMP device intermittently due to occasional temporom and ibular joint pain symptoms . The remaining 17 subjects were all using the AMP device nightly . The symptoms of excessive daytime sleepiness also decreased significantly by both AMP and CPAP . CONCLUSIONS The AMP device achieved substantial success in most cases , but was less effective than CPAP , especially for the more severe cases . In general , the AMP device was strongly preferred over the CPAP by the subjects of this study This prospect i ve , r and omized , cross-over trial was design ed to compare the efficacy of a m and ibular advancement splint ( MAS ) with that of nasal continuous positive airway pressure ( nCPAP ) in patients with obstructive sleep apnoea ( OSA ) . Twenty-four patients ( 20 males and four females ) with mild to moderate OSA ( AHI between 10 and 49 events per hour ) were enrolled in the study . Each patient used both MAS and nCPAP , with the initial therapy being allocated at r and om . Treatment periods lasted for two months with a two-week wash-out interval between .  Polysomnography  was performed prior to the study and after each clinical intervention . Patient and partner question naires were used to assess changes in general health and daytime somnolence . The AHI decreased from 22.2 to 3.1 using nCPAP , and to 8.0 using the MAS ( P < 0.001 for both devices ) and there was no statistically significant difference between the two treatments . The Epworth Sleepiness Score ( ESS ) fell from 13.4 to 8.1 with nCPAP , and to 9.2 with MAS ( P < 0.001 ) , again with no differences between the use of MAS or nCPAP . The question naire data showed an improvement in general health scores ( P < 0.001 ) after both treatments , but daytime sleepiness only improved significantly using nCPAP ( P < 0.001 ) . Despite this , 17 out of the 21 subjects who completed both arms of the study preferred the MAS . The splints were well tolerated and their efficacy suggests that the MAS may be a suitable alternative to nCPAP in the management of patients with mild or moderate OSA Continuous positive airway pressure ( CPAP ) is worldwide considered as the st and ard treatment of sleep apnea/hypopnea syndrome ( SAHS ) although studies on the effectiveness of this treatment are limited . The aim of our study was to evaluate the effectiveness of CPAP in improving SAHS-related symptoms , daytime function , perceived health status , and quality of life in patients with moderate to severe SAHS . The effect of conservative treatment ( CT ) measures -sleep hygiene and weight loss- was compared with CT + CPAP . We included 105 consecutive patients ( 13 females , age 53 + /- 10 yr , body mass index [ BMI ] = 32 + /- 6 kg/m2 , apnea/hypopnea index [ AHI ] = 56 + /- 20 , Epworth sleepiness scale [ ESS ] = 12 + /- 5 ) who met our criteria for CPAP treatment . Patients were r and omly allocated in two groups of similar characteristics . Group 1 ( n = 37 ) was asked to improve sleep hygiene and started a weight loss program . Group 2 ( n = 68 ) received , in addition , treatment with CPAP . Both groups were followed through weekly telephone calls and appointments . Sleepiness , other symptoms related to SAHS , daytime function , perceived health status , and quality of life were assessed through question naires at inclusion and after 3 mo of treatment . The relief of sleepiness and other SAHS-related clinical symptoms and improvement in perceived health status was much greater in Group 2 receiving CT + CPAP compared with Group 1 , only receiving CT . The odds of experiencing a treatment response with CPAP + CT compared with CT alone was 6.52 ( odds ratio [ OR ] = 2.51 to 17.6 , 95 % confidence interval [ 95 % CI ] ) . CPAP is currently the treatment of choice . At this time , the indication of CPAP treatment in moderate to severe SAHS is adequately supported The efficacy of currently recommended treatments is uncertain in patients with mild to moderate obstructive sleep apnea ( apnea-hypopnea index [ AHI ] , 5 - 30 ) . A group of 114 sleep clinic patients with an AHI of 5 - 30 have participated in a r and omized controlled crossover trial of 3 months of treatment with each of nasal continuous positive airway pressure ( CPAP ) , a m and ibular advancement splint , and a placebo tablet . Outcomes were sleep fragmentation and hypoxemia , daytime sleepiness , quality of life , neurobehavioral function , and blood pressure . Both active treatments improved sleep outcomes , but positive airway pressure had a greater effect . The quality of life , symptoms , and subjective but not objective sleepiness improved to a similar degree with both treatments ; however , many of the improvements seen in neuropsychologic function and mood were not better than the placebo effect . Some aspects of nocturnal blood pressure were improved with the splint but not with CPAP . This study has shown that although both CPAP and m and ibular advancement splint effectively treated sleep-disordered breathing and sleepiness , the expected response in neurobehavioral function was incomplete . This may be due to the splint having a lesser therapeutic effect and CPAP being poorly tolerated and therefore used less in this patient group
The purpose of this review is to conduct a systematic review and meta- analysis comparing the effects of continuous positive airway pressure ( CPAP ) with a m and ibular advancement device ( MAD ) in improving the quality of life ( sleepiness , cognitive , and functional outcomes ) in patients diagnosed with obstructive sleep apnea ( OSA ) .