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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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ESS with APAP versus fixed CPAP: meta-analysis, with subgroup analyses by minimum AHI threshold. See Figure 2 legend. Note that studies favoring APAP are to the left of the vertical 0 line. Senn A and Senn B, and Sériès A and Sériès B, were comparisons of two different APAP devices versus fixed CPAP reported in the same study, respectively. Base AHI: baseline apnea-hypopnea index (events/hour) in fixed CPAP group; base ESS: baseline Epworth Sleepiness Scale (no units) in fixed CPAP group; fixed: fixed CPAP.
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Figure 4: ESS with APAP versus fixed CPAP: meta-analysis, with subgroup analyses by minimum AHI threshold. See Figure 2 legend. Note that studies favoring APAP are to the left of the vertical 0 line. Senn A and Senn B, and Sériès A and Sériès B, were comparisons of two different APAP devices versus fixed CPAP reported in the same study, respectively. Base AHI: baseline apnea-hypopnea index (events/hour) in fixed CPAP group; base ESS: baseline Epworth Sleepiness Scale (no units) in fixed CPAP group; fixed: fixed CPAP.

Mentions: Twenty-two trials reported ESS after treatment (Figure 4) [10-27,29,30,32,33]. No statistically significant differences in ESS were observed between APAP and CPAP in 20 trials, while two studies reported a significant decrease in ESS favoring APAP [23,30]. The mean net difference in ESS across all studies ranged from -3.3 to 2.0, where negative values favor less sleepiness with APAP. Eighteen trials provided sufficient data for meta-analysis, which yielded a statistically significant difference between APAP and CPAP of -0.48 (95% CI, -0.81 to -0.15; P = 0.005), favoring APAP. Despite the broad range of severity of OSA across studies, there was no statistically significant heterogeneity within the overall meta-analysis. Meta-regression stratified by minimum AHI threshold or by study design revealed no apparent differences across subgroups in relative effects of APAP and CPAP.


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)

ESS with APAP versus fixed CPAP: meta-analysis, with subgroup analyses by minimum AHI threshold. See Figure 2 legend. Note that studies favoring APAP are to the left of the vertical 0 line. Senn A and Senn B, and Sériès A and Sériès B, were comparisons of two different APAP devices versus fixed CPAP reported in the same study, respectively. Base AHI: baseline apnea-hypopnea index (events/hour) in fixed CPAP group; base ESS: baseline Epworth Sleepiness Scale (no units) 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 4: ESS with APAP versus fixed CPAP: meta-analysis, with subgroup analyses by minimum AHI threshold. See Figure 2 legend. Note that studies favoring APAP are to the left of the vertical 0 line. Senn A and Senn B, and Sériès A and Sériès B, were comparisons of two different APAP devices versus fixed CPAP reported in the same study, respectively. Base AHI: baseline apnea-hypopnea index (events/hour) in fixed CPAP group; base ESS: baseline Epworth Sleepiness Scale (no units) in fixed CPAP group; fixed: fixed CPAP.
Mentions: Twenty-two trials reported ESS after treatment (Figure 4) [10-27,29,30,32,33]. No statistically significant differences in ESS were observed between APAP and CPAP in 20 trials, while two studies reported a significant decrease in ESS favoring APAP [23,30]. The mean net difference in ESS across all studies ranged from -3.3 to 2.0, where negative values favor less sleepiness with APAP. Eighteen trials provided sufficient data for meta-analysis, which yielded a statistically significant difference between APAP and CPAP of -0.48 (95% CI, -0.81 to -0.15; P = 0.005), favoring APAP. Despite the broad range of severity of OSA across studies, there was no statistically significant heterogeneity within the overall meta-analysis. Meta-regression stratified by minimum AHI threshold or by study design revealed no apparent differences across subgroups in relative effects of APAP and CPAP.

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