Влияние приверженности длительной ПАП-терапии на психоэмоциональное состояние пациентов с синдромом обструктивного апноэ сна
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Elfimova E.M., Mikhailova O.O., Khachatrian N.T. et al. The effect of adherence with long-term PAP therapy on the psycho-emotional state of patients with obstructive sleep apnea syndrome. Systemic Hypertension. 2020; 17 (2): 56–60.
DOI: 10.26442/2075082X.2020.2.200176
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Материалы и методы. В исследование были включены 80 пациентов, проходивших обследование в лаборатории апноэ сна Института клинической кардиологии им. А.Л. Мясникова ФГБУ «Национальный медицинский исследовательский центр кардиологии» Минздрава России, которые находились на ПАП-терапии более 12 мес. Средний возраст пациентов составил 65,0 года [59,0; 71,0], индекс массы тела – 35,0 кг/м2 [31,0; 38,0], индекс апноэ-гипопноэ сна (ИАГ) – 39,5 соб/ч [31,0; 62,6]. Средняя длительность применения ПАП-терапии составила 3,5 года [2,0; 6,0], при этом минимальное использование было 1 год, максимальное – 15 лет. В выборке пациентов, пришедших на очный прием, процент дней использования ПАП-терапии составил 87,5% [62,0; 98,0] и среднее время использования – 6,3 ч [5,2; 7,3].
Результаты. На фоне длительной ПАП-терапии выявлено стойкое снижение ИАГ в среднем с 39,5 соб/ч [31,0; 62,6] до 2,7 соб/ч [1,2; 6,2], р=0,000. Критериям приверженности ПАП-терапии (использование более 4 ч за ночь, более 70% ночей) соответствовало по проценту дней использования 67,5% пациентов, по среднему времени использования – 87,5% пациентов. Обоим критериям оценки приверженности ПАП-терапии соответствовали 64,8% пациентов. При длительной ПАП-терапии критериям эффективности (ИАГ<5 соб/ч) соответствовали 71,7% пациентов, у 22,9% пациентов сохранялся ИАГ>5 соб/ч и у 5,4% пациентов был средний резидуальный ИАГ≥10 соб/ч. При корреляционном анализе была выявлена ассоциация между параметрами, отражающими использование ПАП-терапии, тяжестью синдрома обструктивного апноэ сна и качеством сна: процент дней использования и ИАГ (r=0,374, p=0,001), среднее время использования и PSQI (r=-0,438, p=0,000). Пациенты с более низкой приверженностью к ПАП-терапии – 63,0% дней [22,0; 96,0] и 3,6 ч [2,4; 4,5] использования – не отличались по уровню дневной сонливости – ESS 5,0 балла [2,0; 9,0] и 5,0 балла [3,0; 8,0], p=0,891, но имели достоверно более низкое качество сна (по данным опросника PSQI): 18,0 балла [14,0; 20,0] против 10,0 балла [7,0; 18,0], р=0,004 – по сравнению с пациентами с высокой приверженностью к ПАП-терапии: 98,0% дней [92,0; 99,0] и 7,9 ч [7,5; 8,2] использования.
Выводы. Пациенты, наиболее приверженные к ПАП-терапии, имели значительно лучшее качество сна. Но даже использование ПАП-терапии менее 4 ч/сут приводило к снижению выраженности дневной сонливости.
Ключевые слова: синдром обструктивного апноэ сна, ПАП-терапия, качество жизни, качество сна, длительное использование, приверженность.
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Aim. To assess the impact of adherence and effectiveness of long-term positive airway pressure therapy (PAP-therapy) on the clinical and psychological characteristics of patients with obstructive sleep apnea syndrome.
Materials and methods. The study included 80 patients who were examined in the sleep apnea laboratory of the Myasnikov Institute of Clinical Cardiology of the National Medical Research Center for Cardiology and who have been on PAP-therapy for more than 12 months. The average age of the patients was 65.0 years [59.0; 71.0], body mass index – 35.0 kg/m2 [31.0; 38.0], sleep apnea-hypopnea index (AHI) – 39.5/h [31.0; 62.6]. The average duration of PAP therapy was 3.5 years [2.0; 6.0], while the minimum use was 1 year, the maximum – 15 years. In the sample of patients who came in person, the percentage of days using PAP-therapy was 87.5% [62.0; 98.0] and the average usage time – 6.3 hours [5.2; 7.3].
Results. On long-term PAP-therapy a persistent decrease in AHI was seen on average from 39.5/h [31.0; 62.6] to 2.7/h [1.2; 6.2], p=0,000. The criteria for good adherence to PAP-therapy (use> 4 hours/night, more than 70% of nights) were met by the percentage of days of use – by 67.5% of patients, the average time of use – by 87.5% of patients. Both criteria for good adherence to PAP-therapy was met by 64.8% of patients. With long-term PAP-therapy, 71.7% of patients met the criteria of effectiveness (AHI<5/h), AHI remained >5/h in 22.9% of patients and the average residual AHI was ≥10/h in 5.4% of patients. Correlation analysis showed associations between the PAP-therapy usage parameters and the severity of obstructive sleep apnea syndrome, and sleep quality: percentage of days of use and AHI (r=0.374, p=0.001), average time of use and PSQI (r=-0.438, p=0.000). Patients with a lower adherence to PAP-therapy (63.0% of days [22.0; 96.0] and 3.6 hours [2.4; 4.5] of use) did not differ in daytime sleepiness (ESS 5.0 points [2.0; 9.0] and 5.0 points [3.0; 8.0 ], p=0.891), but had a significantly lower quality of sleep (PSQI): 18.0 points [14.0; 20.0] versus 10.0 points [7.0; 18.0], p=0.004 compared with patients with high adherence to PAP-therapy (98.0% of the days [92.0; 99.0] and 7.9 hours [7.5; 8.2] of use).
Conclusions. Patients with the higher adherence to PAP-therapy had significantly better sleep quality. But even the use of PAP-therapy for less than 4 hours is associated with a decrease in daytime sleepiness severity.
Key words: obstructive sleep apnea syndrome, PAP-therapy, quality of life, quality of sleep, long-term use, adherence.
2. Greenstone M, Hack M. Obstructive sleep apnoea. BMJ 2014; 348: g3745.
3. Fu Y, Xia Y, Yi H et al. Meta-analysis of all-cause and cardiovascular mortality in obstructive sleep apnea with or without continuous positive airway pressure treatment. Sleep Breath 2017; 21 (1): 181–9.
4. Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc 2008; 5: 173–8.
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[Konovalova K.I., Elfimova E.M., Mikhailova O.O. et al. The dynamics of clinical and psychological characteristics of patients with obstructive sleep apnea syndrome and arterial hypertension after one month of using CPAP therapy. Systemic Hypertension. 2017; 14 (3): 65–71 (in Russian).]
7. Lindberg E, Berne C, Elmasry A et al. CPAP treatment of a population-based sample – what are the benefits and the treatment compliance. Sleep Med 2006; 7: 553–60.
8. Campos-Rodriguez F, Pena-Grinan N, Reyes-Nunez N et al. Mortality in obstructive sleep apnea-hypopnea patients treated with positive airway pressure. Chest 2005; 128: 624–33.
9. McEvoy RD, Banks S, Tarquinio N et al. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med 2004; 170: 656–64.
10. Centers for Medicare and Medicaid Services website. Decision Memo for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093N).
11. Tan B, Tan A, Huak CY et al. Adherence to continuous positive airway pressure therapy in Singaporean patients with obstructive sleep apnea. Am J Otolaryngol 2018; 39 (5): 501–6.
12. Kushida CA, Nichols DA, Holmes TH et al. Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: the Apnea Positive Pressure Long-term Efficacy Study (APPLES). Sleep 2012; 35 (12): 1593–602.
13. Meurice JC, Dore P, Paquereau J et al. Predictive factors of long- term compliance with nasal continuous positive airway pressure treatment in sleep apnea syndrome. Chest 1994; 105: 429–33.
14. McCall WV, Harding D, O'Donovan C. Correlates of depressive symptoms in patients with obstructive sleep apnea. J Clin Sleep Med 2006; 2 (4): 424–6.
15. Weissman MM, Olfson M. Depression in women: implications for health care research. Science 1995; 269: 799–801.
16. Weaver TE, Maislin G, Dinges DF et al. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep 2007; 30 (6): 711.
17. Wang Y, Ai L, Luo J et al. Effect of adherence on daytime sleepiness, fatigue, depression and sleep quality in the obstructive sleep apnea/hypopnea syndrome patients undertaking nasal continuous positive airway pressure therapy. Patient Prefer Adherence 2017; 11: 769–79. https://doi.org/10.2147/PPA.S128217
18. Quan SF, Budhiraja R, Kushida CA. Associations Between Sleep Quality, Sleep Architecture and Sleep Disordered Breathing and Memory After Continuous Positive Airway Pressure in Patients with Obstructive Sleep Apnea in the Apnea Positive Pressure Long-term Efficacy Study (APPLES). Sleep Sci 2018; 11 (4): 231–8. DOI: 10.5935/1984-0063.20180037
19. Stepnowsky C, Zamora T, Edwards C. Does Positive Airway Pressure Therapy Result in Improved Sleep Quality? Health 2014; 6: 2416–24.
20. Loredo JS, Ancoli-Israel S, Kim E-J et al. Effect of Continuous Positive Airway Pressure Versus Supplemental Oxygen on Sleep Quality in Obstructive Sleep Apnea: A Placebo-CPAP−Controlled Study. Sleep 2006; 29 (4): 564–71. https://doi.org/10.1093/sleep/29.4.564
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1. Jordan AS, McSharry DG, Malhotra A. Adult obstructive sleep apnoea. Lancet 2014; 383 (9918): 736–47.
2. Greenstone M, Hack M. Obstructive sleep apnoea. BMJ 2014; 348: g3745.
3. Fu Y, Xia Y, Yi H et al. Meta-analysis of all-cause and cardiovascular mortality in obstructive sleep apnea with or without continuous positive airway pressure treatment. Sleep Breath 2017; 21 (1): 181–9.
4. Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc 2008; 5: 173–8.
5. Zozula R, Rosen R. Compliance with continuous positive airway pressure therapy: assessing and improving treatment outcomes. Curr Opin Pulm Med 2001; 7: 391–8.
6. Konovalova K.I., Elfimova E.M., Mikhailova O.O. et al. The dynamics of clinical and psychological characteristics of patients with obstructive sleep apnea syndrome and arterial hypertension after one month of using CPAP therapy. Systemic Hypertension. 2017; 14 (3): 65–71 (in Russian).
7. Lindberg E, Berne C, Elmasry A et al. CPAP treatment of a population-based sample – what are the benefits and the treatment compliance. Sleep Med 2006; 7: 553–60.
8. Campos-Rodriguez F, Pena-Grinan N, Reyes-Nunez N et al. Mortality in obstructive sleep apnea-hypopnea patients treated with positive airway pressure. Chest 2005; 128: 624–33.
9. McEvoy RD, Banks S, Tarquinio N et al. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med 2004; 170: 656–64.
10. Centers for Medicare and Medicaid Services website. Decision Memo for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093N).
11. Tan B, Tan A, Huak CY et al. Adherence to continuous positive airway pressure therapy in Singaporean patients with obstructive sleep apnea. Am J Otolaryngol 2018; 39 (5): 501–6.
12. Kushida CA, Nichols DA, Holmes TH et al. Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: the Apnea Positive Pressure Long-term Efficacy Study (APPLES). Sleep 2012; 35 (12): 1593–602.
13. Meurice JC, Dore P, Paquereau J et al. Predictive factors of long- term compliance with nasal continuous positive airway pressure treatment in sleep apnea syndrome. Chest 1994; 105: 429–33.
14. McCall WV, Harding D, O'Donovan C. Correlates of depressive symptoms in patients with obstructive sleep apnea. J Clin Sleep Med 2006; 2 (4): 424–6.
15. Weissman MM, Olfson M. Depression in women: implications for health care research. Science 1995; 269: 799–801.
16. Weaver TE, Maislin G, Dinges DF et al. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep 2007; 30 (6): 711.
17. Wang Y, Ai L, Luo J et al. Effect of adherence on daytime sleepiness, fatigue, depression and sleep quality in the obstructive sleep apnea/hypopnea syndrome patients undertaking nasal continuous positive airway pressure therapy. Patient Prefer Adherence 2017; 11: 769–79. https://doi.org/10.2147/PPA.S128217
18. Quan SF, Budhiraja R, Kushida CA. Associations Between Sleep Quality, Sleep Architecture and Sleep Disordered Breathing and Memory After Continuous Positive Airway Pressure in Patients with Obstructive Sleep Apnea in the Apnea Positive Pressure Long-term Efficacy Study (APPLES). Sleep Sci 2018; 11 (4): 231–8. DOI: 10.5935/1984-0063.20180037
19. Stepnowsky C, Zamora T, Edwards C. Does Positive Airway Pressure Therapy Result in Improved Sleep Quality? Health 2014; 6: 2416–24.
20. Loredo JS, Ancoli-Israel S, Kim E-J et al. Effect of Continuous Positive Airway Pressure Versus Supplemental Oxygen on Sleep Quality in Obstructive Sleep Apnea: A Placebo-CPAP−Controlled Study. Sleep 2006; 29 (4): 564–71. https://doi.org/10.1093/sleep/29.4.564
1 ФГБУ «Национальный медицинский исследовательский центр кардиологии» Минздрава России, Москва, Россия;
2 ООО «Клиника ТРИ ПОКОЛЕНИЯ», Москва, Россия;
3 ФГБНУ «Национальный научно-исследовательский институт общественного здоровья им. Н.А. Семашко», Москва, Россия;
4 ФГАОУ ВО «Российский национальный исследовательский медицинский университет им. Н.И. Пирогова» Минздрава России, Москва, Россия
*alelitvin@yandex.ru
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Evgeniia M. Elfimova1, Oksana O. Mikhailova1,Narine T. Khachatrian1, Ivan V. Starostin2,3, Aleksandr Iu. Litvin*1,4, Irina E. Chazova1
1 National Medical Research Center for Cardiology, Moscow, Russia;
2 Three Generations Clinic, Moscow, Russia;
3 Semashko National Research Institute of Public Health, Moscow, Russia;
4 Pirogov Russian National Research Medical University,
Moscow, Russia
*alelitvin@yandex.ru