Retrospective, nonrandomized controlled study on autoadjusting, dual-pressure positive airway pressure therapy for a consecutive series of complex insomnia disorder patients

Abstract

PurposeEmerging evidence shows that positive airway pressure (PAP) treatment of obstructive sleep apnea (OSA) and upper airway resistance syndrome (UARS) in chronic insomnia patients (proposed “complex insomnia” disorder) leads to substantial decreases in insomnia severity. Although continuous PAP (CPAP) is the pressure mode most widely researched, intolerance to fixed pressurized air is rarely investigated or described in comorbidity patients. This retrospective study examined dual pressure, autoadjusting PAP modes in chronic, complex insomnia disorder patients.Patients and methodsChronic insomnia disorder patients (mean [SD] insomnia severity index [ISI] =19.11 [3.34]) objectively diagnosed with OSA or UARS and using either autobilevel PAP device or adaptive servoventilation (ASV) device after failing CPAP therapy (frequently due to intolerance to pressurized air, poor outcomes, or emergence of CSA) were divided into PAP users (≥20 h/wk) and partial users (<20 h/wk) for comparison. Subjective and objective baseline and follow-up measures were analyzed.ResultsOf the 302 complex insomnia patients, PAP users (n=246) averaged 6.10 (1.78) nightly hours and 42.71 (12.48) weekly hours and partial users (n=56) averaged 1.67 (0.76) nightly hours and 11.70 (5.31) weekly hours. For mean (SD) decreases in total ISI scores, a significant (group × time) interaction was observed (F[1,300]=13.566; P<0.0001) with PAP users (–7.59 [5.92]; d=1.63) showing superior results to partial users (−4.34 [6.13]; d=0.81). Anecdotally, patients reported better tolerability with advanced PAP compared to previous experience with CPAP. Both adaptive servoventilation and autobilevel PAP showed similar ISI score improvement without statistical differences between devices. Total weekly hours of PAP use correlated inversely with change in insomnia symptoms (r=−0.256, P<0.01).ConclusionInsomnia severity significantly decreased in patients using autoadjusting PAP devices, but the study design restricts interpretation to an association. Future research must elucidate the interaction between insomnia and OSA/UARS as well as the adverse influence of pressure intolerance on PAP adaptation in complex insomnia patients. Randomized controlled studies must determine whether advanced PAP modes provide benefits over standard CPAP modes in these comorbidity patients.

Current Treatment of Comorbid Insomnia and Obstructive Sleep Apnea With CBTI and PAP-Therapy: A Systematic Review

“…Three of the six studies that addressed our primary research question and two of the seven studies that analyzed the association between insomnia and adherence to PAP used more eligibility criteria than OSA and insomnia to define their populations. In the former group, one study included only military veterans with a mini mental state ≥24 points and without serious physical or mental health issues ( 24 ), one included only patients with psychophysiological risk factors of insomnia such as poor sleep hygiene ( 25 ), and one excluded other sleep disorders such as narcolepsy ( 26 ). In the latter group, two included only military veterans without previous OSA-surgery or oxygen supplementation ( 27 , 30 ).…”

“…Of the six studies addressing our primary research question, four indeed analyzed the effect of PAP, i.e., OSA-therapy, on insomnia ( 22 , 23 , 25 , 26 ), while two studies analyzed the direct effect of OSA on insomnia comparing two groups without PAP, and with equal CBTI for both groups ( 21 , 24 ). Of the four studies analyzing the effect of PAP on insomnia, three measured the exposure in minutes per night and one used no control.…”

“…Of the four studies analyzing the effect of PAP on insomnia, three measured the exposure in minutes per night and one used no control. Of the former three studies, two used a cut-off, namely 240 min PAP-use per night and 171 min per night ( 22 , 25 ), and the third looked at the exposure continuously ( 23 ). The second only reported results for participants above the cut-off stating that those below were not statistically significant ( 26 ).…”

“…One defined the outcome as improvement of the ISI of 9 points ( 22 ), one defined it as follow-up subscale score of <4 of the ISI ( 23 ), and one reported no definition. The last differentiated between initial, middle, and late insomnia ( 25 ). The first found that adherence to OSA therapy increased the chance of successful insomnia therapy by 1.1 times ( 22 ), the second found that patients with persistent insomnia have 72 min less PAP-use per night ( 23 ), and the study omitting the results for the control found improvements of 0.7 standard deviations in initial, 0.9 in middle, and 0.6 in late insomnia ( 25 ).…”

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

“…When manually titrated, the sleep technologist overrides the aspects of the auto-adjusting algorithms that appear to have responded ineffectually to the dueling problems of residual flow limitation and iatrogenic EPI. 46 , 67 As described elsewhere, this nuanced approach to titrations often requires changes in the 0.2- to 0.4-cm H 2 O range, while adjusting both inspiratory and expiratory settings. 48 Although our experience reflects case series, we have published on this clinical care model, involving 744 OSA/UARS patients, 30 , 46 – 48 , 67 and have treated 3,934 clinical patients in this manner at our sleep center from 2008 to the present.…”