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Auto-titrating versus fixed continuous positive airway pressure for the treatment of obstructive sleep apnea: a systematic review with meta-analyses.

Ip S, D'Ambrosio C, Patel K, Obadan N, Kitsios GD, Chung M, Balk EM - Syst Rev (2012)

Bottom Line: Random effects model meta-analyses were performed for selected outcomes.No study reported on objective clinical outcomes.Statistically significant differences were found but clinical importance is unclear.

View Article: PubMed Central - HTML - PubMed

Affiliation: Institute of Clinical Research and Health Policy Studies, Tufts University School of Medicine, Tufts Medical Center, Boston, MA, USA.

ABSTRACT

Background: Obstructive sleep apnea is a relatively common disorder that can lead to lost productivity and cardiovascular disease. The form of positive airway treatment that should be offered is unclear.

Methods: MEDLINE and the Cochrane Central Trials registry were searched for English language randomized controlled trials comparing auto-titrating positive airway pressure (APAP) with continuous positive airway pressure (CPAP) in adults with obstructive sleep apnea (inception through 9/2010). Six researchers extracted information on study design, potential bias, patient characteristics, interventions and outcomes. Data for each study were extracted by one reviewer and confirmed by another. Random effects model meta-analyses were performed for selected outcomes.

Results: Twenty-four randomized controlled trials met the inclusion criteria. In individual studies, APAP and fixed CPAP resulted in similar changes from baseline in the apnea-hypopnea index, most other sleep study measures and quality of life. By meta-analysis, APAP improved compliance by 11 minutes per night (95% CI, 3 to 19 minutes) and reduced sleepiness as measured by the Epworth Sleepiness Scale by 0.5 points (95% CI, 0.8 to 0.2 point reduction) compared with fixed CPAP. Fixed CPAP improved minimum oxygen saturation by 1.3% more than APAP (95% CI, 0.4 to 2.2%). Studies had relatively short follow-up and generally excluded patients with significant comorbidities. No study reported on objective clinical outcomes.

Conclusions: Statistically significant differences were found but clinical importance is unclear. Because the treatment effects are similar between APAP and CPAP, the therapy of choice may depend on other factors such as patient preference, specific reasons for non-compliance and cost.

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CPAP compliance (hour/night) with APAP versus fixed CPAP: meta-analysis, with subgroup analyses by minimum AHI threshold. Estimates and 95% CIs by study subgrouped by minimum AHI threshold used in each study. The overall random effects model meta-analysis is displayed by the black diamond, which spans the width of the 95% CI. Each subgroup meta-analysis, by AHI threshold, is shown by the open diamonds. Grey boxes are proportional to the weight of each study in the overall meta-analysis. For each meta-analysis the I2 statistic and the P value for heterogeneity is displayed. The P value for the summary estimate is displayed next to the black diamond. Note that studies favoring APAP are to the right of the vertical 0 line. Base AHI: baseline apnea-hypopnea index (events/hour) in fixed CPAP group; compliance fixed: compliance (hour/night) in fixed CPAP group; fixed: fixed CPAP.
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Figure 2: CPAP compliance (hour/night) with APAP versus fixed CPAP: meta-analysis, with subgroup analyses by minimum AHI threshold. Estimates and 95% CIs by study subgrouped by minimum AHI threshold used in each study. The overall random effects model meta-analysis is displayed by the black diamond, which spans the width of the 95% CI. Each subgroup meta-analysis, by AHI threshold, is shown by the open diamonds. Grey boxes are proportional to the weight of each study in the overall meta-analysis. For each meta-analysis the I2 statistic and the P value for heterogeneity is displayed. The P value for the summary estimate is displayed next to the black diamond. Note that studies favoring APAP are to the right of the vertical 0 line. Base AHI: baseline apnea-hypopnea index (events/hour) in fixed CPAP group; compliance fixed: compliance (hour/night) in fixed CPAP group; fixed: fixed CPAP.

Mentions: All 24 included trials reported data on compliance. The number of hours used per night was derived from machine-recorded compliance data. No statistically significant differences were observed in device usage (hours used per night) between APAP and CPAP in 20 of the trials, while four reported a significant increase in the use of APAP compared with CPAP [17,18,22,30]. Twenty-two trials provided sufficient data for meta-analysis, which showed a statistically significant difference of 11 minutes per night favoring APAP (difference = 0.18 hours; 95% CI, 0.05 to 0.31 minutes; P = 0.006), without statistical heterogeneity (Figure 2).


Auto-titrating versus fixed continuous positive airway pressure for the treatment of obstructive sleep apnea: a systematic review with meta-analyses.

Ip S, D'Ambrosio C, Patel K, Obadan N, Kitsios GD, Chung M, Balk EM - Syst Rev (2012)

CPAP compliance (hour/night) with APAP versus fixed CPAP: meta-analysis, with subgroup analyses by minimum AHI threshold. Estimates and 95% CIs by study subgrouped by minimum AHI threshold used in each study. The overall random effects model meta-analysis is displayed by the black diamond, which spans the width of the 95% CI. Each subgroup meta-analysis, by AHI threshold, is shown by the open diamonds. Grey boxes are proportional to the weight of each study in the overall meta-analysis. For each meta-analysis the I2 statistic and the P value for heterogeneity is displayed. The P value for the summary estimate is displayed next to the black diamond. Note that studies favoring APAP are to the right of the vertical 0 line. Base AHI: baseline apnea-hypopnea index (events/hour) in fixed CPAP group; compliance fixed: compliance (hour/night) in fixed CPAP group; fixed: fixed CPAP.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3351715&req=5

Figure 2: CPAP compliance (hour/night) with APAP versus fixed CPAP: meta-analysis, with subgroup analyses by minimum AHI threshold. Estimates and 95% CIs by study subgrouped by minimum AHI threshold used in each study. The overall random effects model meta-analysis is displayed by the black diamond, which spans the width of the 95% CI. Each subgroup meta-analysis, by AHI threshold, is shown by the open diamonds. Grey boxes are proportional to the weight of each study in the overall meta-analysis. For each meta-analysis the I2 statistic and the P value for heterogeneity is displayed. The P value for the summary estimate is displayed next to the black diamond. Note that studies favoring APAP are to the right of the vertical 0 line. Base AHI: baseline apnea-hypopnea index (events/hour) in fixed CPAP group; compliance fixed: compliance (hour/night) in fixed CPAP group; fixed: fixed CPAP.
Mentions: All 24 included trials reported data on compliance. The number of hours used per night was derived from machine-recorded compliance data. No statistically significant differences were observed in device usage (hours used per night) between APAP and CPAP in 20 of the trials, while four reported a significant increase in the use of APAP compared with CPAP [17,18,22,30]. Twenty-two trials provided sufficient data for meta-analysis, which showed a statistically significant difference of 11 minutes per night favoring APAP (difference = 0.18 hours; 95% CI, 0.05 to 0.31 minutes; P = 0.006), without statistical heterogeneity (Figure 2).

Bottom Line: Random effects model meta-analyses were performed for selected outcomes.No study reported on objective clinical outcomes.Statistically significant differences were found but clinical importance is unclear.

View Article: PubMed Central - HTML - PubMed

Affiliation: Institute of Clinical Research and Health Policy Studies, Tufts University School of Medicine, Tufts Medical Center, Boston, MA, USA.

ABSTRACT

Background: Obstructive sleep apnea is a relatively common disorder that can lead to lost productivity and cardiovascular disease. The form of positive airway treatment that should be offered is unclear.

Methods: MEDLINE and the Cochrane Central Trials registry were searched for English language randomized controlled trials comparing auto-titrating positive airway pressure (APAP) with continuous positive airway pressure (CPAP) in adults with obstructive sleep apnea (inception through 9/2010). Six researchers extracted information on study design, potential bias, patient characteristics, interventions and outcomes. Data for each study were extracted by one reviewer and confirmed by another. Random effects model meta-analyses were performed for selected outcomes.

Results: Twenty-four randomized controlled trials met the inclusion criteria. In individual studies, APAP and fixed CPAP resulted in similar changes from baseline in the apnea-hypopnea index, most other sleep study measures and quality of life. By meta-analysis, APAP improved compliance by 11 minutes per night (95% CI, 3 to 19 minutes) and reduced sleepiness as measured by the Epworth Sleepiness Scale by 0.5 points (95% CI, 0.8 to 0.2 point reduction) compared with fixed CPAP. Fixed CPAP improved minimum oxygen saturation by 1.3% more than APAP (95% CI, 0.4 to 2.2%). Studies had relatively short follow-up and generally excluded patients with significant comorbidities. No study reported on objective clinical outcomes.

Conclusions: Statistically significant differences were found but clinical importance is unclear. Because the treatment effects are similar between APAP and CPAP, the therapy of choice may depend on other factors such as patient preference, specific reasons for non-compliance and cost.

Show MeSH
Related in: MedlinePlus