Adherence to positive airway pressure therapy initiated in the early subacute phase of ischemic stroke: a PRESS study follow-up

Abstract

Background Sleep-disordered breathing (SDB) is frequent in stroke patients and negatively affects stroke outcomes. Positive airway pressure (PAP) is the standard first-line treatment for patients with moderate-to-severe SDB. Despite a strong link between PAP adherence and therapeutic response, rates of post-stroke PAP adherence remain underexplored. Our study aimed to determine PAP adherence in patients undergoing comprehensive sleep apnea assessment and in-lab PAP titration in the early subacute phase of stroke. Methods In-hospital screening pulse oximetry was performed in consecutive patients with imaging-confirmed acute ischemic stroke. Subjects with desaturation index ≥ 15.3/h were selected as PAP candidates, and polysomnography was recommended. In a sleep laboratory setting, subjects underwent a diagnostic night followed by a titration night, and PAP therapy was initiated in subjects with apnea–hypopnea index ≥ 15/h. Adherence to PAP therapy was assessed at a 6-month follow-up visit. Results Of 225 consecutive patients with acute ischemic stroke, 116 were PAP candidates and 52 were able to undergo polysomnography. PAP therapy was initiated in 35 subjects. At a 6-month follow-up visit, out of 34 stroke survivors, PAP adherence (PAP use of > 4 h per night) was present in 47%. Except for the significantly lower minimal nocturnal O 2 saturation determined from the polysomnography (74.6 ± 11.7% vs. 81.8 ± 5.2%, p = 0.025), no other significant difference in characteristics of the groups with PAP adherence and PAP non-adherence was found. Conclusions Less than half of the stroke subjects remained adherent to PAP therapy at 6 months post-PAP initiation. Special attention to support adaptation and adherence to PAP treatment is needed in this group of patients.

No Difference in Sleep Desaturations Severity between Patients with Wake-Up and Non-Wake-Up Stroke: A PRESS Study Results

“…Early sleep apnea assessment (nocturnal pulse oximetry evaluation within seven days from the stroke onset) was performed in the current study. It is necessary to admit that Slonková et al previously described spontaneous improvement of sleep apnea in stroke patients [ 36 ], and these findings were supported also by the results of a recent study by Šiarnik et al [ 16 ]. It remains unknown if there is any significant difference in spontaneous OSA improvement between WUS and non-WUS subjects and future research in this field is warranted.…”

“…For these reasons, research into less demanding options for sleep monitoring examinations is ongoing [ 26 , 27 ]. Except for the fact that PSG is a technically demanding and costly examination with limited availability, the feasibility of PSG in acute stroke patients represents one of the most challenging issues even in departments with close cooperation between the stroke unit and sleep laboratory [ 16 , 19 ]. All these issues limit routine polysomnographic assessment in a “real world” population of patients with acute stroke.…”

“…However, later sleep apnea assessment could influence the results of our current study. The optimal timing of sleep apnea assessment post-stroke also needs to be elucidated by future prospective studies, because it can influence further therapeutic approaches and treatment adherence in this high-risk population [ 16 ].…”

“…Several studies proved overnight pulse oximetry is a simple method to evaluate nocturnal desaturations in patients with stroke [ 11 , 12 , 13 ]. This method can be used as a sensitive screening tool in this population [ 14 , 15 , 16 ]. This study aimed to explore and compare the severity of nocturnal desaturations in a “real world” population of patients with acute WUS and non-WUS.…”

Novel Technologies in the Diagnosis and Management of Sleep-disordered Breathing

“…Obstructive sleep apnea (OSA) is a highly prevalent disorder that has major consequences for neurocognitive, cardiovascular, and metabolic health. Unfortunately, the leading therapeutic intervention, continuous positive airway pressure (CPAP), is limited by patient tolerance despite its otherwise excellent efficacy (Lozano et al, 2010;Weaver et al, 2012;Rotenberg et al, 2016;Bakker et al, 2019;Shapiro et al, 2021;NCA-CPAP, 2022;Šiarnik et al, 2022). Of the array of available and experimental non-CPAP interventions-including weight loss (Schwartz et al, 1991), oral appliances (Ng et al, 2003;Chan et al, 2010;Edwards et al, 2016a;Dissanayake et al, 2021;Pattipati et al, 2022), positional therapy , hypoglossal nerve stimulation (Certal et al, 2015;Costantino et al, 2020;Op de Beeck et al, 2021b), pharyngeal surgery [particularly in pediatrics (Schwartz et al, 1992;Joosten et al, 2017;Gozal et al, 2020)], supplemental oxygen (Wellman et al, 2008), pharmacological interventions to: activate dilator muscles (e.g., atomoxetine-plusoxybutynin) Hedner and Zou, 2022a;, decrease arousability from sleep (e.g., eszopiclone) , and stabilize ventilatory control (carbonic anhydrase inhibitors) (Hedner and Zou, 2022a;)-each appears to be efficacious in some patients more than others.…”