Positive airway pressure adherence and subthreshold adherence in posttraumatic stress disorder patients with comorbid sleep apnea

Abstract

Study objectivesPatients with comorbid posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) manifest low adherence to continuous positive airway pressure (CPAP) due to fixed, pressure-induced expiratory pressure intolerance (EPI), a subjective symptom and objective sign aggravated by anxiety sensitivity and somatosensory amplification. As advanced PAP therapy modes (ie, auto-bilevel PAP [ABPAP] or adaptive servo-ventilation [ASV]) may address these side effects, we hypothesized such treatment would be associated with decreased expiratory intolerance and increased adherence in posttraumatic stress patients with co-occurring OSA.MethodsWe reviewed charts of 147 consecutive adult patients with moderately severe posttraumatic stress symptoms and objectively diagnosed OSA. All patients failed or rejected CPAP and were manually titrated on auto-adjusting, dual-pressure ABPAP or ASV modes in the sleep laboratory, a technique to eliminate flow limitation breathing events while resolving EPI. Patients were then prescribed either mode of therapy. Follow-up encounters assessed patient use, and objective data downloads (ODDs) measured adherence.ResultsOf 147 charts reviewed, 130 patients were deemed current PAP users, and 102 provided ODDs: 64 used ASV and 38 used ABPAP. ODDs yielded three groups: 59 adherent per insurance conventions, 19 subthreshold compliant partial users, and 24 noncompliant. Compliance based on available downloads was 58%, notably higher than recently reported rates in PTSD patients with OSA. Among the 19 partial users, 17 patients were minutes of PAP use or small percentages of nights removed from meeting insurance compliance criteria for PAP devices.ConclusionResearch is warranted on advanced PAP modes in managing CPAP failure in PTSD patients with comorbid OSA. Subthreshold adherence constructs may inform clinical care in a patient-centric model distinct from insurance conventions. Speculatively, clinical application of this transitional zone (“subthreshold” number of hours) may increase PAP use and eventual adherence.

Aetiology and treatment of nightmare disorder: State of the art and future perspectives

“…More precise knowledge is needed regarding the effects of pharmaceutical treatments, which will enable the formulation of more precise recommendations. Furthermore, RCTs should be developed to explore how PAP therapy provides clinical improvement in nightmare disorder (Bahammam et al., ; Krakow et al., ), especially against the background that many patients do not tolerate PAP therapy (Jaoude et al., ); nonetheless, a recent study showed higher than usual adherence rates in PTSD patients using advanced PAP modes such as auto‐bilevel or adaptive servo‐ventilation (Krakow, Obando, Ulibarri, & Mciver, ). Furthermore, the possibilities of lucid dreaming as treatment deserve more attention.…”

Changes in insomnia severity with advanced PAP therapy in patients with posttraumatic stress symptoms and comorbid sleep apnea: a retrospective, nonrandomized controlled study

“…Since 2008, compared to CPAP, we have noted that ABPAP or ASV devices have a much greater ability to smooth the airflow curve [37] on both inspiration and expiration, the latter among patients meeting complex sleep apnea diagnosis (central apnea index (CAI) > 5; CAI/AHI > 50%). In fact, we recently demonstrated higher than usual adherence rates (58%) in PTSD patients using these advanced PAP modes [38] in contrast to commonly reported lower compliance rates (~ 30%) [39] in this vulnerable population. Therefore, we have speculated that a major advantage of ASV or ABPAP over CPAP is the capacity for advanced modes to prevent or eradicate EPI, a principal cause of CPAP rejection [40, 41].…”

“…In a recently published study, we describe our use of advanced PAP therapy devices in PTSD patients who often fail the fixed CPAP mode of treatment primarily due to expiratory pressure intolerance (EPI) or iatrogenic central apneas or both [38]. Many patients fail at initial exposure during the titration itself or even earlier during the desensitization procedure conducted at the presleep portion of overnight polysomnography [46, 47].…”

“…Regardless of how the experience of discomfort or intolerance emerges in psychiatric patients, this discomfort or intolerance may deteriorate to panic or frank claustrophobic feelings where patients report they are “drowning in air” [57, 58]. In some situations, we are aware of OSA or UARS patients having been pushed to continue attempting CPAP in a lab environment or at home, which then elicited further adverse emotional responses, including frustration, anger, discouragement, anxiety and fear; less commonly, but not rarely, a patient may report the experience as traumatizing, albeit the sleep literature regrettably has never established a prevalence for this most severe form of CPAP rejection [38, 59]. For these reasons, discretion has guided us to switch individuals to an expiratory relief mode, which may rapidly enhance comfort and evoke a more positive attitude and outcome [46, 47].…”

Hypoglossal Nerve Stimulation: Outcomes in Veterans with Obstructive Sleep Apnea and Common Comorbid Post‐traumatic Stress Disorder

“…In addition, reductions in SI and depression, mental health issues commonly comorbid with PTSD, were noted after 3 months of PAP 27 . Unfortunately, poor adherence to PAP is a well‐documented problem in both civilian and veteran populations, with partial use of PAP more common in patients with a psychiatric comorbidity than among the general population 28 . Studies of regular PAP use in active duty military patients and veterans with OSA report that only 25% to 41% of patients with PTSD used PAP regularly compared to 58% to 70% of those without PTSD 21,26,29,30 , with reported reasons for nonadherence including mask discomfort, claustrophobia, and air hunger 29 .…”