INTRODUCTION — Obstructive sleep apnea (OSA) is a disorder that is characterized by obstructive apneas and hypopneas due to repetitive collapse of the upper airway during sleep. Continuous positive airway pressure (CPAP) is an effective therapy for OSA, but adherence is frequently suboptimal [1]. The prevalence, consequences, and risk factors for nonadherence, as well as interventions to improve adherence are reviewed in this topic. Initiation of CPAP therapy is described separately. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea".)
NONADHERENCE
Definition (hours of CPAP use) — In patients with OSA, it is generally accepted that nonadherence be defined as using CPAP for less than an average of four hours per night or less than 70 percent of nights (ie, less than five nights per week). We set expectations with our patients that CPAP should be used for a minimum of four hours per night for five to seven nights a week. However, we encourage a level of adherence greater than the set minimum on an individual basis to determine the appropriate target for nightly usage.
●The four-hour cutoff is typically used since several studies have shown that four or more hours of CPAP use is associated with normalization of daytime sleepiness as well as improvement in quality of life, neurocognitive function, cardiovascular disease, and diabetes [1-7]. Consequently, insurers and The Centers for Medicare and Medicaid Services (CMS) use four hours per night for 70 percent of nights as the cutoff point differentiating adherence and nonadherence.
●However, targeting longer use is appropriate and is dependent upon individual patient goals. For example, if the goal is to improve self-reported sleepiness, it has been shown that four hours of use is sufficient to achieve a normal score on the Epworth Sleepiness Scale [2]. When evaluating fitness for duty in a commercial truck driver, one study showed that six hours was needed to achieve a normal level of objective alertness in the multiple sleep latency test, and 7.5 hours was required to improve to normal daytime functioning on the Functional Outcomes of Sleep Questionnaire [2]. Another study showed that five hours of use improved neurobehavioral performance [3]. Several other studies indicate that greater than six hours per night results in normal levels of objectively measured and self-reported daytime sleepiness, as well as significantly improved memory and daily functioning [2,3,8].
Prevalence — It has been estimated that almost half of patients are nonadherent, when nonadherence is defined as a mean of less than four hours of use per night, but the range is broad (29 to 83 percent) [1,9]. The prevalence when the definition also includes less than 70 percent of nights is unknown.
Overall, the average duration of CPAP use is approximately five to six hours per night across numerous studies [10]. Among those who are nonadherent, the mean duration of use was found in one study to be three hours per night (on those nights when it is used) compared with those who were adherent, in whom the mean duration of CPAP use was typically six hours per night [1].
Sequalae — In patients with OSA who are adherent, there are several benefits associated with CPAP use including improved daytime sleepiness, systemic blood pressure, quality of life, neurobehavioral performance, and a reduced risk of motor vehicle accidents. These effects are typically felt within days to weeks of starting CPAP therapy. Randomized trials have not shown an impact on mortality. One retrospective study showed a dose-response relationship between improved adherence and reduced cardiovascular events [11]. The benefits of CPAP are discussed separately. (See "Management of obstructive sleep apnea in adults".)
Similarly, the impact of nonadherence is typically felt within days to weeks of stopping CPAP therapy [12-15]. This was illustrated by a trial that included 41 patients with OSA who had been using CPAP successfully for at least one year without subjective daytime sleepiness [15]. Subtherapeutic CPAP (“CPAP withdrawal”) led to recurrence of abnormal respiratory events within one night (mean apnea-hypopnea index [AHI] >25 events per hour). Increased morning and evening blood pressure, morning heart rate, and subjective daytime sleepiness were seen within two weeks of withdrawal. Psychomotor performance remained unaffected. (See "Quantifying sleepiness", section on 'Epworth Sleepiness Scale (ESS)'.)
Risk factors — Risk factors for nonadherence have been identified by observational studies and are listed in the table (table 1). Importantly, nonadherence is usually multifactorial [9,16-20]. An adherence index based upon polysomnographic indices has been described but is not validated or routine [21].
Nonadherence is often identified during the first two weeks of CPAP use and predicts long-term nonadherence [20,22]. Consistent among studies is that major predictors of nonadherence during the first two weeks include the following [18,19,23]:
●Higher residual AHI (ie, poor efficacy of CPAP delivery)
●Poor self-efficacy (defined as one's motivation, volition, and confidence to engage in a healthy behavior)
●Younger age (weak association)
●Being African-American (perhaps intertwined with lower socioeconomic status)
The following factors have been associated with long-term nonadherence with CPAP therapy:
●CPAP use <4 hours/night during the first two weeks of therapy [1,24]
●Problems encountered during the first night of use [25]
●Moderate to severe OSA (ie, an AHI >15 events per hour of sleep; weak relationship) [4,9,10,16,26]
●Certain psychological traits:
•Lack of a positive perspective regarding the benefit of CPAP therapy [27,28] and poor self-efficacy [1,26-29]
•Claustrophobic tendencies [30]
•Lack of ability to overcome obstacles and problem-solve [31]
●Unsupportive bed partner [26]
●CPAP affecting sleep of bed partner [18]
●Less severe oxyhemoglobin desaturation during sleep on diagnostic polysomnography [32]
●Poor sleep-efficiency during CPAP titration (ie, time asleep/time in bed) [33]
●Small nasal volume and high nasal resistance [34-36]
●Comorbid insomnia [37]
It is uncertain whether the routine application of heated humidification predicts adherence, since the evidence is conflicting. While some studies indicate that heated humidification enhances adherence [38-42], other studies do not [40,41,43-45]. It has been suggested that humidification affects adherence only in those who experience nasal congestion [39,43]. However, the issue may be moot since most CPAP machines come equipped with a heated humidifier and guidelines encourage routine use of this function [46].
The impact of different methods of CPAP delivery on adherence has been studied. Although auto-titrating CPAP or pressure relief CPAP are often prescribed in patients when nonadherence is due to intolerance of positive pressure, most studies have found that routinely prescribing these measures is not associated with increased adherence rates when compared to conventional CPAP [9,47,48]. In-person set up has also been shown to improve adherence [49].
EVALUATION FOR NONADHERENCE
Frequent provider follow-up during first two weeks — In patients with OSA, we evaluate and manage nonadherence in the first two weeks of CPAP therapy, preferably within the first few days [46]. We also re-evaluate at every follow up visit thereafter. Assessment can be done during in-person visits, or by telephone or telehealth encounters [50]. This is in keeping with the American Academy of Sleep Medicine who recommends follow-up within the first two weeks to optimize adherence, then monthly and yearly, depending on level of adherence and resolution of symptoms [46]. The evaluation should focus on the following:
●Determining whether or not the patient is tolerating CPAP therapy, the level of adherence, and perceived benefits (see 'Clinical assessment' below)
●Identifying and troubleshooting any side effects (see 'Side effect management' below)
●Offering general encouragement and reinforcement of the importance of nightly CPAP use (see 'Behavioral therapy' below)
Early assessment of adherence is based upon data suggesting that patients generally make the decision to adhere to CPAP early during the first week of therapy, usually by the second to fourth day [1,24,51,52]. Those who adhere generally increase their duration of nightly use gradually. As an example, one study demonstrated that patients who used CPAP for more than two years increased their duration of use approximately eight minutes per night during each year of therapy [53].
We adopt a multidisciplinary approach to evaluating and managing nonadherence. Effective teams consist of personnel experienced in sleep medicine including a physician, technologist, advanced practice nurse, and psychologist as well as the bed partner [54,55]. However, the level of support may vary depending on the patients and the institution. For example, patients who have no or minimal issues with adherence and who tolerate CPAP easily need less support than those who struggle during the first few nights with CPAP. In addition, institutions vary in their ability to provide expertise on a frequent basis.
Clinical assessment — We typically evaluate CPAP use using clinical and objective criteria [46,56].
●Clinical - We interview patients and their bed partner who are asked directly about their estimated hours of nightly use, frequency of weekly use, and reasons for nonadherence, if present. We assess for side effects including a sense of claustrophobia, ulceration, nasal or upper airway dryness or congestion, intolerance of the sensation of pressure or noise, frequent awakenings, mask discomfort and leak, and aerophagia or nausea. We also question patients about their perception of CPAP efficacy (eg, quality of sleep with CPAP, daytime sleepiness, general daytime performance, snoring and choking episodes during sleep, mood, motor vehicle accidents), the impact of CPAP on their bed partner (eg, their quality of sleep and intimacy), and any psychosocial issues that may be impeding therapy. We typically also assess the level of sleepiness on CPAP using either a self-report measure such as the Epworth Sleepiness Scale or an objective measure (eg, Psychomotor Vigilance Task).
●Objective – As an objective measure of adherence, we assess downloaded data from the patient’s CPAP device. Most newer devices contain data on hours of “mask-on” use per day, patterns of use (eg, how many nights per week CPAP was used for a certain duration), mask leaks, and efficacy as measured by the device-measured apnea hypopnea index (AHIflow). (See "Downloading data from positive airway pressure devices in adults".)
Electronic resources (telehealth, telemonitoring, active patient engagement) — Newer electronic resources may offer some benefit in the evaluation and management of adherence. As examples:
●Telehealth – Telehealth (eg, virtual visits, web-based educational tools, applications) is increasingly utilized to connect with CPAP users to address symptoms, troubleshoot equipment problems, and provide motivational interviewing-based interventions to enhance adherence [57-61] (see 'Motivational enhancement' below). As an example, in a meta-analysis of seven trials, only two of which were small randomized trials, use of patient-facing applications (PFAs) was associated with improved CPAP adherence for significantly more hours per night (range 0.7 to 1.3 hours more) and for a greater proportion of nights [61].
●Telemonitoring – Telemonitoring involves feedback that is given to the patient based upon data downloaded from the CPAP device. However, studies have yielded conflicting results on the value of telemonitoring alone as a tool to improve patient adherence [58,62,63]. (See "Downloading data from positive airway pressure devices in adults".)
●Combined resources - Combining electronic tools may be beneficial. As an example, in one trial, CPAP use at 90 days was higher in those who received telehealth education and telemonitoring web-based feedback compared with usual care (4.8 versus 3.8 hours of nightly use) [59].
●Active patient engagement (APE) – Several CPAP manufacturers have developed cloud-based technology to promote adherence through patient engagement. This technology provides feedback to the patient on a number of outcomes including hours of CPAP use, presence of a leak, residual AHI, in addition to coaching messages based on cognitive behavioral therapy (see 'Cognitive behavioral therapy' below). One study reported that patients who accessed APE manufacturer cloud-based feedback services used their CPAP one hour longer per night compared with patients who didn’t access APE services (5.9 hours/night versus 4.9 hours/night) [60]. In addition, a greater proportion of the APE group met Medicare adherence requirements (87.3 versus 70.4 percent).
FIRST-LINE INTERVENTIONS — In patients with OSA, we believe in an integrated approach to management that involves behavioral therapy and prompt management of side effects. This approach has been shown to increase CPAP use by about one hour, sometimes more [64].
Behavioral therapy — Consistent with the American Academy of Sleep Medicine recommendation, we suggest that all patients with OSA being treated with CPAP receive behavioral therapy before and during the first few weeks of therapy [46]. Therapies include cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET). Behavioral therapy can be delivered by a psychologist or advanced practice nurse. It can be performed during a telephone call or during an in-person or telehealth visit. However, it is unclear if one form is superior to another or if different behavioral interventions are best for different patient phenotypes. We encourage support from a bed partner or significant other (eg, CPAP “buddy”), especially since it has been shown that bed partner response to CPAP therapy also affects adherence [54,55,65]. Therapy is best administered before and during the first month of starting CPAP but can be offered at any time.
This recommendation is based upon data that suggest behavioral interventions that focus on intensive patient support and reinforcement of positive behaviors, improve CPAP adherence by approximately one hour per night [64,66]. In a meta-analysis that included 41 small randomized trials of CPAP-naïve patients with OSA, behavioral therapies were associated with increased CPAP adherence (mean improvement 50 minutes per night) [64]. Among the high-quality trials, behavioral therapies improved CPAP adherence by a mean of 1.3 hours per night and also increased the number of patients who used their machines for four or more hours/night (371 to 501 per 1000;odds ratio 1.70). However, flaws included significant heterogeneity across studies, the small effect size, and the lack of reporting on the effect of behavioral therapies on daytime sleepiness.
Cognitive behavioral therapy — CBT is a structured psychotherapeutic method used to alter attitudes and behaviors. The positive effect of CBT plus education on adherence with CPAP is likely due to improved self-efficacy (defined as one's motivation, volition, and confidence to engage in a healthy behavior). CBT may take many forms including videos demonstrating CPAP use, electronic or pamphlet information, relaxation techniques, mask fitting sessions, and telephone or telehealth support. CBT usually takes place over several sessions during the first two weeks and is usually delivered by a psychologist or advanced practice nurse.
The efficacy of CBT plus education has been reported in several randomized trials [67-69]. As examples
●One trial randomly assigned 96 men with OSA to either usual treatment with mask-fitting and basic information regarding CPAP (the control group) or two one-hour cognitive behavioral interventions that included a video of real CPAP users and relaxation techniques as well as mask-fitting and basic information regarding CPAP (the CBT group) [67]. After 28 days of treatment, patients in the CBT group were more likely to accept CPAP therapy compared with controls; in addition, patients who underwent CBT had greater hours of nightly use (5.38 versus 2.51 hours/night) and a greater proportion used their CPAP device for four or more hours/night (50 versus 15 percent).
●Another trial utilized an automated telephone-linked communication system adapted for CPAP to provide regular telephone sessions that included assessment of the participant’s experience with CPAP, self-reported machine use, feedback, and counseling [68]. After six months, the median CPAP usage was approximately one hour greater in the 124 patients randomly assigned to the telephone sessions compared with those assigned to an attention control intervention (ie, no feedback was provided).
Motivational enhancement — Motivational enhancement therapy (MET) addresses the components of CPAP adherence that can be modified such as perception and behavior. Aspects of motivational interviewing include interaction with the patient in person (two to three sessions) and by phone during the first month to resolve perceptions, behaviors, and volitions that are barriers to engaging in the treatment. When delivering this therapy, we support an empathic approach that enhances the patient's self-efficacy, is not reactive to resistance, and assists the patient in the identification of specific goals for CPAP use. MET may be administered by nurses or trained psychologists during a telephone, in-person, or telehealth encounter.
Several randomized studies have demonstrated increased CPAP use with motivational interviewing but the effect may be lost once it’s stopped [40,70].
●One randomized study of 106 adults with a new diagnosis of OSA reported that patients who received motivational interview nurse therapy (MINT) with CPAP had improved adherence at three months compared with patients who were treated with CPAP alone (4.6 versus 3.2 hours per night) [40]. However, the effect was lost at 12 months.
●In another randomized trial of 83 patients with moderate to severe OSA, adherence improved by 99 minutes per night in those who received eight months of MET with CPAP compared with CPAP alone [70]. The effect was persistent in those who continued to receive therapy.
●In another study, downloaded CPAP data was used to trigger an intervention designed to improve adherence in 113 patients with OSA and compared with 110 patients who did not receive the intervention. The intervention was two telephone calls per month based on two days with <4 hours/night use or a leak greater than two days of >0.5 L/second. Those who received the intervention demonstrated greater CPAP use (5.3 versus 4.6 hours/night), used their CPAP for a greater number of nights, and had a higher number of nights with four or more hours/night use [63].
Side effect management — We suggest early troubleshooting of side effects, initiated by the provider team within the first few days to two weeks of CPAP use. Prompt intervention should enhance comfort and self-efficacy (defined as one's motivation, volition, and confidence to engage in a healthy behavior), which have been shown to promote CPAP adherence [9,27,28]. A multidisciplinary approach to managing side effects related to CPAP therapy has been developed and is illustrated in the figure (algorithm 1) [16].
In most cases, the assessment and troubleshooting can be done during provider follow-up with the patient at home using telehealth or in-person visits with an experienced sleep technician. (See 'Frequent provider follow-up during first two weeks' above.)
Interface (mask)-related issues — An ill-fitting mask may be responsible for discomfort on the face, pressure ulcers on the nose and cheeks, and air leaks leading to poor efficacy. Ideally, at the initiation of CPAP, time should be spent with the patient educating them regarding the importance of a good seal and optimization of the of mask fit. We believe that patients should be active participants in mask selection and identify a preference for nasal mask, nasal pillows, or full-face mask as well as the specific brand they prefer.
We advocate for an initial acclimatization period where the patient is taught how to place the mask on their face and tolerate the pressure for a short period (eg, while awake or watching TV); the patient slowly increases their time and pressure until their targeted goal is reached.
However, in some cases, patients have trouble tolerating the mask despite acclimatization or have trouble later in their treatment course due to issues such as a change in weight or dentition. Simple solutions involve giving the patient the choice of mask or interface, resizing the existing mask, changing the type of interface (eg, nasal or oronasal mask), or changing the cushioning on the interface. Retitration of CPAP may need to be performed when the interface is changed.
Selecting an appropriate interface and titration of CPAP are discussed separately. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Choosing the correct patient-device interface'.)
Intolerant of pressure — Some patients cannot tolerate fixed-level CPAP due to the feeling of pressure from the device. In such cases, using a flexible pressure device enables the patient to set the initial pressure prior to ramping up to the prescribed pressure before switching to an auto titratable CPAP (APAP) device or to bilevel positive airway pressure (BPAP); the latter may necessitate another in-laboratory titration. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Intolerance of the sensation of pressure'.)
Nasal or upper airway dryness or congestion — Although typically administered routinely, we employ heated humidification in cases where it can alleviate nasal dryness. For those with congestion, several topical agents (eg, antimuscarinic agents, anti-histamines, corticosteroids) or changing the facemask can be attempted. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Nasal congestion' and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Nasal dryness (heated humidification)'.)
Oral air leaks — For patients with air leaks via the mouth, we typically add a chin strap or switch to an oronasal mask and then examine downloaded data during a future visit to ensure a reduction in leak and improvement in apnea-hypopnea (AHIflow) with these maneuvers [71]. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Mouth breathing and air leaks'.)
Others — Identification and management of other issues that may interfere with adherence include the following (see "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Others'):
●Education for issues surrounding intimacy
●Switching to a nasal mask or pillows for aerophagia
PATIENTS WHO FAIL FIRST-LINE INTERVENTIONS — Measures discussed in this topic should improve patient adherence. However, an analysis of 82 articles examining interventions for adherence reported that the overall CPAP nonadherence rate based on a seven hours/night sleep time was stable over the 20 year period at 34 percent [66], indicating the individualized nature of the response. Future research should center on identifying who best responds from which intervention reflecting person-centered health care. In general, for those who fail first-line interventions, we persist with education and behavioral therapy. Pharmacologic therapy in the form of a sedative-hypnotic sleep aid is a last resort but may be attempted on a trial basis.
Pharmacological therapy — We do not suggest routine use of a sedative-hypnotic at the time of CPAP initiation. This recommendation is based on the greater risk of side effects and conflicting data regarding such therapy. However, a short-term trial of sedative hypnotic therapy may be tried in those who fail all other options (eg, one to two weeks).
Randomized studies have yielded conflicting results:
●Single-dose therapy – One trial randomly assigned 117 patients with OSA (mean apnea hypopnea index [AHI] 29 events per hour) to receive premedication with a single dose of eszopiclone (3 mg) or placebo 30 minutes prior to attended polysomnography (PSG) for CPAP titration [72]. Four to six weeks later, the eszopiclone group used their CPAP on more nights (76 versus 60 percent of nights) and for a longer duration (four versus three hours) than the placebo group. However, loss of follow-up was significant among both groups.
In contrast, in a second study of 134 patients with OSA (median AHI 17 events per hour) undergoing initial split-night PSG, there was no difference in the median daily CPAP use at one month among those who were randomly assigned to receive a single dose of zaleplon or placebo (6.5 hours each) [73].
●Two weeks course of therapy – Extended dosing was tested in a trial that randomized 72 male CPAP-naïve patients with OSA (mean AHI 42 events per hour) to zolpidem, placebo, or standard of care for the first 14 days of CPAP therapy [74]. After one month, there was no difference in CPAP adherence among the three groups as measured by average nightly CPAP use (approximately four to five hours) or total days used.
In contrast, in a subsequent trial, 160 patients with newly diagnosed OSA (mean AHI 37 events per hour) were randomly assigned to receive eszopiclone (3 mg) or placebo during the initial 14 nights of CPAP therapy [75]. After six months of follow-up, patients who received eszopiclone used their CPAP device for more nights (64 versus 45 percent of nights) and for a longer duration (four versus three hours), and were less likely to discontinue CPAP therapy (42 versus 58 percent) than the patients taking placebo.
One meta-analysis of eight studies that included over 1000 patients with OSA reported that patients who were treated with nonbenzodiazepine sedative hypnotics had higher rates of adherence than those who did not receive such medication (six studies were placebo controlled) [76]. Patients treated with nonbenzodiazepine sedative hypnotics tolerated CPAP by 0.62 hours more per night and had a 12 percent increase in the number of nights used. After removing one study with significant heterogeneity, patients receiving nonbenzodiazepine sedative hypnotics were more than twice as likely to have good adherence using the definition described above (see 'Definition (hours of CPAP use)' above). The results of this analysis were heavily influenced by trials that used eszopiclone, and larger randomized trials are needed before making firm conclusions regarding the use of sedatives to encourage CPAP adherence.
Other options — If the side effects persist despite adequate intervention, we typically repeat a titration study with fixed-level CPAP or have patients undergo a trial of auto-titrating CPAP (APAP) or bilevel positive airway pressure (BPAP) [77]. Alternatively, other treatments for OSA such as oral appliance, surgery, or hypoglossal nerve stimulation should be considered. (See "Oral appliances in the treatment of obstructive sleep apnea in adults" and "Surgical treatment of obstructive sleep apnea in adults".)
PATIENTS WHO ARE ADHERENT WITH RESIDUAL SLEEPINESS — For patients who are adherent and in whom CPAP is adequate but who remain sleepy, we evaluate for other etiologies of excessive sleepiness and suitability for a wakefulness-promoting agent. (See "Approach to the patient with excessive daytime sleepiness" and "Evaluation and management of residual excessive sleepiness in adults with obstructive sleep apnea".)
USEFUL RESOURCES — Educational materials such as pamphlets and videotapes for both clinicians and patients are available from several sites including The American Academy of Sleep Medicine, The Sleep Foundation, and The American Sleep Apnea Association.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sleep-related breathing disorders in adults".)
SUMMARY AND RECOMMENDATIONS
●Continuous positive airway pressure (CPAP) is an effective therapy for obstructive sleep apnea (OSA), but adherence is suboptimal in over half of patients. (See 'Nonadherence' above.)
•We suggest that a cutoff of less than four hours and/or less than 70 percent of nights (ie, five out of seven nights) be used as a general metric to define nonadherence. However, outcome expectations should be individually defined to determine the appropriate target for nightly usage. (See 'Definition (hours of CPAP use)' above.)
•The benefits of CPAP therapy are generally felt within a few weeks of CPAP therapy (eg, improved daytime sleepiness, systemic blood pressure, quality of life, neurobehavioral performance, and a reduced risk of motor vehicle accidents). (See 'Sequalae' above and "Management of obstructive sleep apnea in adults".)
•Risk factors for nonadherence should be explored and are shown in the table (table 1). (See 'Risk factors' above.)
●Evaluation – We advocate a multidisciplinary approach to the evaluation and management of adherence. Effective teams consist of experienced personnel (eg, physician, technologist, advanced practice nurse, psychologist), and the bed partner. Follow-up consists of in-person or telehealth encounters and telephone contact. (See 'Evaluation for nonadherence' above.)
•Frequent contact and follow-up with a health care provider who has expertise in treating sleep disorders is especially important during the first two weeks of therapy. (See 'Frequent provider follow-up during first two weeks' above.)
•Patients and their bed partner should be asked directly about their estimated hours of nightly use, frequency of weekly use, presence of side effects explaining nonadherence, their perception of CPAP efficacy, the impact of CPAP on their bed partner, and any psychosocial issues that may be impeding therapy. In addition, data should be downloaded from the patients CPAP device that provides information about adherence, mask leaks, and an estimated apnea hypopnea index (AHIflow). (See 'Clinical assessment' above.)
●Interventions to prevent and treat nonadherence – First-line interventions that promote adherence in all patients with OSA who receive CPAP include behavioral therapy and aggressive side effect management (see 'First-line interventions' above):
•Behavioral therapy - For patients with OSA who are prescribed CPAP, we suggest behavioral therapy rather than no behavioral therapy (Grade 2C). This recommendation is based upon evidence from randomized trials that suggest benefit in terms of hours used per night and proportion of patients using CPAP. Therapies include cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET). Therapy is best administered before and during the first month of starting CPAP but can be offered at any time. (See 'Behavioral therapy' above.)
•Side effect management – Simultaneous with behavioral therapy, we also advocate early and aggressive CPAP side effect management (Grade 2C) as illustrated in the figure (algorithm 1). This approach recognizes that most side effects can be corrected by simple interventions.
•Pharmacologic therapy – For patients with OSA who are initiated on CPAP and are nonadherent, we suggest not routinely using of a sedative-hypnotic to encourage adherence (Grade 2C). This recommendation is based upon the risk of adverse effects and conflicting data regarding the benefits of such therapy. However, in patients with OSA on CPAP who are refractory to first-line interventions of behavioral therapy and side effect management, a short trial of a sedative-hypnotic is reasonable (no greater than two weeks). (See 'Pharmacological therapy' above.)
•Other – Failing these measures, a repeat titration study with, for example, fixed-level CPAP, auto-titrating CPAP, or bilevel positive airway pressure (BPAP) is appropriate. Alternatively, therapies such as oral appliance devices or surgery may also be considered. (See 'Patients who fail first-line interventions' above.)
●For patients who are adherent and in whom CPAP is adequate but who remain sleepy, we evaluate for other etiologies of excessive sleepiness and suitability for a wakefulness-promoting agent. (See "Approach to the patient with excessive daytime sleepiness" and "Evaluation and management of residual excessive sleepiness in adults with obstructive sleep apnea".)
