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I Keep Meeting People Who Don't Use Their Machines
DC, perhaps RTs and docs in Scottland operate differently than here in the U.S. Dont-know
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Dreamcatcher, wearing a mask is a life changing event ONLY when it works for you. If it isn't working or can't tolerate the therapy, you aren't going to continue the therapy for long unless you can get the help you need. The fact that so many people come here looking for that help, begs the question why they aren't contacting their doctor or therapist, first.

Those that don't come to Apnea Board or call their doctor for help aren't necessarily the uncomitted. After all, they were comitted enough to go to the sleep lab and go to the therapist to get their machine to begin with, weren't they? Most of them did this because they were all tired of being tired and wanted to feel better, didn't they?

I am not faulting the education regarding the machines and masks we were given. Most of us were showed how to use them. I am faulting the quick cure expectations that may be implied, and the follow up that isn't consistently done. If it were, more of these machines wouldn't be sitting idle in closets. After all, if you were feeling better with your therapy, why wouldn't you choose to keep using it?
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(06-20-2012, 04:36 PM)SuperSleeper Wrote: DC, perhaps RTs and docs in Scottland operate differently than here in the U.S. Dont-know

Most probably and babydoc's statement is also probably correct for the states and I dont mean any disrespect towards him. Most of us went through a real tuff time to get where we are but again it was a choice. maybe willpower has alot to do with it and other things but I just dont think its to do with education alone, I think there are many other factors to consider.

Babydoc you could have a valid point but I also think there are other factors that should be taken into account but you know what I think people should be forwarned about how difficult it can be to adjust.

and again welcome to the master members were only crazy a couple of days in the week Too-funny

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(06-20-2012, 05:53 PM)Dreamcatcher Wrote: and again welcome to the master members were only crazy a couple of days in the week Too-funny

And then again, others are crazy 24/7. Bigwink

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I don't think there's anything a doctor can do if a patient doesn't want to comply. I agree that the doctor can make a difference in many cases, but in many others it just can't be done.

Here's an example. A person gets a prescription for 30 pills to lower his blood pressure. He takes one every day until they're gone and they work! His blood pressure drops into the safe range. Then, he doesn't refill the prescription and the blood pressure goes back up where it was.

What can anyone, a doctor included, tell this idiot that will make any difference?
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I was chatting with a neighbor a couple of weeks ago and happened to mention I was scheduled for a sleep study and would probably end up with a CPAP machine. He chuckled and said, "oh, I have one of those but never use it". This guy had a STROKE a year ago, and had to give up fly fishing and a lot of other things he liked to do. And he still doesn't use his CPAP! Oh-jeez That's more than non-compliant... that's a death wish!
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(06-19-2012, 09:52 PM)Itsadryheat Wrote: I am another one of those that has been a life time LOUD snorer. I have been in denial about the sleep apnea, told myself that it wasnt bad when i slept on my side. Just turned 51 and this year started noticing cognitive deficits, trouble finding words and things like that, going down rabbit trails in my mind, trouble focusing. I knew what was wrong. Got my sleep study and diagnosed with severe apnea (when on my back, yes, still some denial here, but just a tiny bit)

Geez... you just described me!

I knew what was wrong for about 5 years before I finally decided that falling asleep at my desk 10 to 15 times a day - and thats only the ones I was aware of - was actually enough to make me suffer through a few doctor visits.

If I'd been able to perceive how bad I was getting during the day as instantly as I perceived how much better I felt after the first 9 hours on CPAP I wouldn't have waited.
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I tend to think it is in part neglect on the doctors and staffs' part. I don't think people realize how serious sleep apnea is and how important it is to get fitted right and try to get the c-pap to work for you. There isn't enough follow up. No one followed up with me I had to call them and I even got a better upgrade c-pap after reading here. Without this forum, I would not have known about a better machine and I would have struggled along at 7 pressure steady and never gotten enough pressure and for sure not an Auto pap. I never minded the machine but I also paid a lot out of pocket then with no insurance and I think that too helped me adjust in a few days to the new way of sleeping. Next time I will offer to take the machine and find someone who can benefit from it. I don't have any way to contact that woman and have no name. I had hoped I would be like the nurse who helped someone on here. I didn't push it but did say her fears of a hear attack etc are more at risk without using the c-pap. We talked about politics atc. or should I say she talked, I listened. About Prs candidates etc.
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(06-20-2012, 08:43 PM)cherylgrrl Wrote: I was chatting with a neighbor a couple of weeks ago and happened to mention I was scheduled for a sleep study and would probably end up with a CPAP machine. He chuckled and said, "oh, I have one of those but never use it". This guy had a STROKE a year ago, and had to give up fly fishing and a lot of other things he liked to do. And he still doesn't use his CPAP! Oh-jeez That's more than non-compliant... that's a death wish!

Its a choice, a personal one or maybe an educated one but either way its a choice. When I dont wear my, I dont think that I wont wake up. I think the big problem with sleep apnea is that its made out to be a condition when really it should be labeled a killer.

One other thing Welcome to the Forum cherylgrrl

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The below is the most comprehensive study I've found on compliance. It really seems that follow up is the key!

Long-term Compliance Rates to Continuous Positive Airway Pressure in Obstructive Sleep Apnea*
A Population-Based Study
Don D. Sin, MD, Irvin Mayers, MD, FCCP, Godfrey C. W. Man, MBBS, FCCP and Larry Pawluk, MD
+ Author Affiliations

*From the Departments of Pulmonary Medicine (Drs. Sin, Mayers, and Man) and Psychiatry (Dr. Pawluk), University of Alberta, Edmonton, AB, Canada.
Correspondence to: Don D. Sin, MD, 2E4.29 Walter C. Mackenzie Center, University of Alberta, Edmonton, AB, Canada, T6G 2B7; e-mail: don.sin@ualberta.ca
Next SectionAbstract
Study objectives: To determine long-term compliance rates to continuous positive airway pressure (CPAP) therapy in patients with obstructive sleep apnea enrolled in a comprehensive CPAP program in the community.

Design: Prospective cohort longitudinal study.

Setting: University sleep disorders center.

Patients: Two hundred ninety-six patients with an apnea-hypopnea index (AHI) ≥ 20/h on polysomnography.

Interventions: A CPAP device equipped with a monitoring chip was supplied. Within the first week, daily telephone contacts were made. Patients were seen at 2 weeks, 4 weeks, 3 months, and 6 months.

Results: Of the 296 subjects enrolled, 81.1% were males. Mean ± SD AHI was 64.4 ± 34.2/h of sleep; age, 51 ± 11.7 years; and body mass index, 35.2 ± 7.9 kg/m2. The mean duration of CPAP use was 5.7 h/d at 2 weeks, 5.7 h/d at 4 weeks, 5.9 h/d at 3 months, and 5.8 h/d at 6 months. The percentage of patients using CPAP ≥ 3.5 h/d was 89.0% at 2 weeks, 86.6% at 4 weeks, 88.6% at 3 months, and 88.5% at 6 months. There was a decrease in the Epworth Sleepiness Scale (ESS) score of 44% by 2 weeks of therapy. The patients continue to improve over the follow-up period, with the lowest mean ESS score observed at 6 months. With multiple regression analysis, three variables were found to be significantly correlated with increased CPAP use: female gender, increasing age, and reduction in ESS score.

Conclusion: A population-based CPAP program consisting of consistent follow-up, “troubleshooting,” and regular feedback to both patients and physicians can achieve CPAP compliance rates of> 85% over 6 months.

compliance rate continuous positive airway pressure obstructive sleep apnea
Obstructive sleep apnea (OSA) is a common condition affecting 2% of adult female and 4% of adult male populations,1 and close to 20% of the elderly population.2 OSA results in excess daytime sleepiness and decreased health-related quality of life.3

Continuous positive airway pressure (CPAP) is an effective therapy for OSA, significantly reducing OSA symptoms in a vast majority of cases.4 Successful application of CPAP can dramatically improve the health-related quality of life of patients and transform somnolent individuals into energetic and more productive people.5 Moreover, the use of CPAP can decrease systemic BP and improve cardiovascular performance, thereby decreasing cardiovascular morbidity and mortality associated with OSA.5

However, CPAP therapy is often difficult to tolerate and patients frequently stop using it because of discomfort. The nasal mask interface may cause pressure sores, persistent air leakage, claustrophobia, nasal congestion, and other side effects that may lead to suboptimal compliance.6 One study7 suggests that CPAP compliance might be improved with intensive CPAP support, where these problems can be addressed through a multidisciplinary team approach. However, as these results were produced in a clinical trial setting, it remains uncertain whether high CPAP compliance rates can also be achieved in the community using a similar CPAP program.

Using data from a comprehensive CPAP program implemented in Northern Alberta (population 1.3 million persons) beginning in July of 1999, the aims of this study were to determine: (1) short-term and long-term CPAP compliance rates in the community, (2) baseline predictors for long-term CPAP compliance, and (3) whether CPAP use is associated with sustained improvements in daytime sleepiness in OSA patients with moderate-to-severe disease.

Previous SectionNext SectionMaterials and Methods
General Program Description
This study was conducted at the University of Alberta Hospital (UAH) Sleep Disorders Laboratory, in Edmonton, AB, which is the only accredited sleep facility to conduct supervised polysomnography in Northern Alberta. Funding for the CPAP devices were provided by the Alberta Aids to Daily Living, a government agency that oversees the provision of Respiratory Health Services and respiratory equipment to the citizens of Alberta. Funding was also provided for hiring a dedicated CPAP clinic nurse with the specific role of educating and following these patients on a regular basis.

Recruitment and Consent
Between July 1999 and March 2000, all patients undergoing diagnostic polysomnography at the UAH Sleep Disorders Laboratory were considered as potential recruits for this study. All patients were referred for clinical evaluation of possible sleep disorders.

Patients with an AHI ≥ 20/h were considered to be eligible candidates to receive a CPAP device provided by Alberta Aids to Daily Living without any cost to the patient. Some subjects with an AHI < 20/h also received CPAP therapy if there were significant clinical indications for CPAP therapy. All patients receiving CPAP devices were asked to sign a consent form indicating their willingness to comply with CPAP therapy, and their explicit understanding that the CPAP device must be returned if their compliance was deemed unsatisfactory, as measured through a pressure-sensing chip included in each CPAP unit.

The diagnostic polysomnographic studies were performed at the UAH Sleep Disorders Laboratory. Recordings were performed overnight with continuous monitoring of EEG, electro-oculogram, chin electromyogram, oronasal airflow (by thermistor), chest and abdominal respiratory movements, oximetry, anterior tibialis electromyogram, body position sensor, and snoring noise sensor. Digitized signals were stored on optical disk and analyzed using software (Sandman Elite Version 5.0; Nellcor Puritan Bennett [Melville] Ltd., Ottawa, ON, Canada). Manual scoring was done by trained, certified technologist to verify the automated scoring system in every case. All sleep recordings were verified by American Board of Sleep Medicine-certified sleep specialists who provided descriptive diagnostic interpretation of the polysomnographic studies.

Scoring of sleep staging was done using published criteria.8 An apnea episode was defined as a cessation of oronasal airflow for > 10 s. An hypopnea episode was defined as a diminution of the amplitude of respiratory signals by > 50% for> 10 s, with or without desaturation. An obstructive respiratory event was scored when there was evidence of paradoxical chest and abdomen movement. A central respiratory event was scored when both the chest and abdominal respiratory movements were diminished.

Follow-up Protocol
All CPAP subjects underwent an educational session prior to commencement of CPAP therapy, which included a 26-min video presentation (produced locally by the Sleep Apnea Society of Alberta) and a one-on-one discussion session with a qualified CPAP clinic nurse. The videotape presented information on OSA, including symptoms, health consequences, and pathophysiology, and a detailed explanation on the use of the CPAP device. The key concepts from this videotape was subsequently reinforced by a CPAP nurse who had prior training and experience in polysomnographic studies and in basic respiratory therapy principles relevant to the care of the CPAP devices. Reading materials were given to each subject, with a pamphlet on OSA, CPAP devices, suggestions for troubleshooting and remedies, as well as a follow-up schedule.

Subjects were instructed to contact the CPAP clinic nurse daily by telephone within the first week. Subsequently, the subjects were seen at 2 weeks, 4 weeks, 3 months, and 6 months after starting CPAP therapy. At each visit, the compliance data were downloaded from the CPAP device and reviewed by the CPAP clinic nurse together with the subjects. Any concerns or questions were addressed immediately by the CPAP clinic nurse, and changes in the CPAP setting, nose/face mask, or circuit were made after consultation with the responsible sleep physician if necessary. If nasal complaints were significant, either topical steroid spray or anticholinergic nasal spray was prescribed. If these failed, a heated humidifier was then made available. During the study period, only 15 patients required a heated humidifier. Each follow-up visit lasted 15 to 30 min.

The compliance data from each visit were tabulated and reported to the referring sleep physician. If there were doubts about a patient’s compliance or willingness to continue with the program, the referring physician made personal contacts with the patient by telephone or through direct in-person interviews to resolve barriers to adequate compliance. Through a collaborative team effort, patient problems were addressed and resolved.

CPAP Device
The CPAP device used was the Aria LX model (Respironics; Pittsburgh, PA). There were various nose masks, face masks, nasal pillows, and head-harnesses used, depending on individual facial structure and preference. Passive humidifiers were routinely used. Heated humidifiers were used when necessary. In all CPAP devices, there was a built-in monitoring chip for collection and storage of CPAP usage data. The monitoring chip only registers use when the set pressure was maintained, not just when the CPAP device was turned on. The monitoring device provided time of days used, hours of daily use, and days used per month. From these data, we calculated: Percentage of days CPAP was used Mean daily use (hours) Mean daily use on days CPAP was used
At the start of the CPAP program, and during each follow-up visit, subjects were asked to complete a questionnaire regarding the degree of daytime sleepiness (the Epworth Sleepiness Scale[ ESS]).9

Statistical Analysis
The means and SDs of continuous variables were compared using Student’s two-tailed t test. Nonnormally distributed variables were compared using the Wilcoxon rank-sum test. Ordinal and binary variables were compared using a χ2 test. A trend test was used to determine significance of temporal relationships in the use of CPAP over the 6 months of follow-up. To determine important predictors of 6-month compliance to CPAP, we used a multiple logistic regression model. We employed a step-wise regression model to select out significant variables; only those variables that produced a p value < 0.05 were included in the final model. Odds ratios are presented with 95% confidence intervals, and reported p values are two-tailed. All p values < 0.05 were considered statistically significant. All analyses were performed with statistical software (SAS release 8.1; SAS Institute; Cary, NC).

Previous SectionNext SectionResults
Study Cohort
During the study period, 1,007 patients underwent diagnostic polysomnography for a suspected sleep disorder. Of these, 296 patients (29.4%) had an AHI ≥ 20/h and were invited to join the CPAP program. No patients refused, and all were followed up for the duration of the study period. We did not lose any patients during follow-up. The baseline demographic and sleep study features for patients with and without OSA are shown in Table 1 . Patients with OSA were slightly older, more obese, and more likely to be men than those without OSA. Moreover, OSA patients displayed increased fragmentation of sleep as evidenced by lower sleep efficiency and increased representation of stages 1 and 2 sleep than those without OSA. As expected, OSA patients had a higher AHI and lower mean arterial oxygen saturation (Sao2) compared to those without OSA.

View this table:
In this window In a new window Table 1.
Baseline Demographics and Sleep Characteristics of Patients With and Without OSA*

Compliance to CPAP Therapy for OSA Patients
The average CPAP setting at initiation was 11.6 ± 2.7 cm H2O (mean ± SD). The use of CPAP over the first 6 months of therapy is shown in Table 2 . The average hours of CPAP use during the study period was well maintained; however, there was a slight decline in the total percentage of days that CPAP was used over the first 6 months of therapy.

View this table:
In this window In a new window Table 2.
CPAP Utilization Data Over 6 Months of Follow-up*

Because there is no universally accepted definition of CPAP compliance, CPAP compliance was defined in multiple ways in Table 3 using mean hours of daily CPAP use. Even using a very stringent definition of CPAP compliance (ie, ≥ 4.5 h/d), 83% and 79% of the patients in this program were compliant with their CPAP therapy at 3 months and 6 months, respectively.

View this table:
In this window In a new window Table 3.
Percentage of Total Patients With OSA Who Complied With CPAP Therapy According to Different Definitions of Compliance*

ESS scores at baseline and during the follow-up period are plotted in Figure 1 . By 2 weeks of therapy, there was a dramatic decrease in the subjective feeling of sleepiness as measured by the ESS (44% relative reduction). The ESS scores at baseline, 2 weeks, 4 weeks, 3 months, and 6 months of therapy were 14.1 ± 5.6, 7.9 ± 5.3, 7.1 ± 4.7, 6.0 ± 4.5, and 5.5 ± 4.4, respectively. The test for trend (toward decreasing ESS scores with increased follow-up time) was significant (p = 0.001), suggesting an inverse monotonic relationship between elapsed time since the start of CPAP therapy (up to 6 months) and daytime sleepiness.

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Download as PowerPoint Slide Figure 1.
Mean ESS scores at baseline and during follow-up at 2 weeks, 4 weeks, 3 months, and 6 months. Error bars represent SEM.

Predictors of CPAP Use
Using a step-wise approach, we determined the important clinical predictors of CPAP use at 6 months after CPAP initiation. In our initial model, we included changes in ESS score at 6 months compared to baseline, total sleep time, sleep efficiency, AHI, mean Sao2 during sleep, gender, age, body mass index, periodic leg movement index, and various sleep stages, and correlated these variables to the mean hours of daily use of CPAP. In our final multiple regression model, only three variables were found to be significantly correlated with CPAP use: change in ESS scores (p = 0.003), gender (p = 0.020), and age (p = 0.021). There was a negative association between the magnitude of ESS score change and CPAP use, such that a 10-U decrease in ESS score was associated with a 0.76 ± 0.11-h increase in the amount of CPAP used per day of follow-up. Age, however, was positively associated with CPAP use; a 10-year increment in age was associated with 0.24 ± 0.11-h increase in CPAP use (Fig 2 ). Women, on average, used CPAP more frequently than men by 0.76 ± 0.32 h.

View larger version:
In this page In a new window
Download as PowerPoint Slide Figure 2.
Left panel: Relationship between the use of CPAP (No. of hours per day) and change in actual ESS score from baseline to 6 months. Right panel: Relationship between the use of CPAP (No. of hours per day) and age. Dotted lines represent 95% confidence limits.

Previous SectionNext SectionDiscussion
This population-based CPAP program produced several interesting findings. First, we observed that > 92% of OSA patients in this program used CPAP for > 2.5 h/night on average for the first 6 months of the program. Even using a more stringent criterion for compliance (ie, ≥ 4 h of CPAP use per night), 84% of the eligible CPAP recipients were compliant with CPAP over the first 6 months of the program. Second, as expected, with the application of and compliance with CPAP therapy, there was a marked improvement in the patients’ daytime sleepiness as measured by the ESS. In just 2 weeks following initiation of CPAP therapy, we observed a 44% relative reduction in the average daytime sleepiness for our cohort of patients. More importantly, this improvement was sustained for the duration of the 6-month follow-up period, suggesting that continued compliance with CPAP provides long-term benefits for patients with OSA. Third, women, older patients, and those who experienced marked improvements in their daytime sleepiness were more likely to be compliant with CPAP at 6 months than those without these parameters.

Several large studies10111213 have been previously published concerning CPAP compliance in the community, which have shown compliance rates ranging from 65 to 80%. Such a wide variation in the reported compliance rates may in part be related to the way in which compliance has been measured. For instance, McArdle and coworkers14 reported a 6-month compliance rate of 85% using a program similar to ours. However, their definition of compliance was > 2 h/night of CPAP use.14 Moreover, they used built-in counters on CPAP devices to capture utilization data; however, these devices tend to overestimate actual compliance as measured by pressure-actuated devices such as the one we used.1516 In an earlier work, Kribbs and coworkers15 used a microprocessor to measure“ actual” compliance and reported an average duration of CPAP use of 4.9 ± 2.0 h (on days that CPAP was used) over a 3-month period. In our program, we observed an average duration of CPAP use of 6.2 ± 1.8 h over a similar time frame. In a more recent study, Pepin and coworkers16 reported a 3-month compliance rate of 74% using criteria of > 4 h of use per day. Even using very stringent criteria for compliance in our study (≥ 4 h of use), we found that 87% and 84% of patients were compliant at 3 months and 6 months, respectively, suggesting our program was effective in securing adequate compliance in most OSA patients.

We believe that several factors were important in producing good CPAP compliance among our cohort of patients. First, we carefully selected patients with “objective” documentation of OSA (using an AHI of≥ 20/h) for our program and systematically treated all of them with CPAP. Patients with an AHI < 20/h were enrolled on a case-by-case basis (data not included in this analysis). Second, we designed our program to maximize the compliance rate in our participants. We incorporated the elements that have been suggested by previous investigators6 to be important for improving CPAP compliance over the long term. These measures included intense patient education, use of a dedicated CPAP nurse to ensure close follow-up of patients (particularly during the first 2 weeks of therapy), troubleshooting when necessary, and rapid involvement of sleep physicians to solve compliance issues for difficult-to-manage patients. Third, we provided the CPAP device and ancillary services free of charge to the patients, removing significant financial concerns for patients.

Our findings that increasing age, female sex, and changes in ESS scores from baseline were associated with CPAP compliance are consistent with findings by McArdle and coworkers14 but dissimilar to those from Janson and coworkers.17 However, the latter study employed a case-control design (which is prone to more biases),18 had smaller study sample, and, most importantly, used only oximetric results for OSA diagnosis, which may have led to a diagnostic misclassification.

The present study has certain limitations. First, while good CPAP compliance was achieved in a vast majority of OSA patients in our program, due to the nature of the study design, it remains uncertain which elements or components of the program were responsible for this success. Indeed, the uncontrolled protocol used in this study makes it difficult to attribute the excellent CPAP compliance rates directly to the comprehensive CPAP program. Nevertheless, the totality of evidence from our study, as well as those of others,715 suggests that high compliance rates to CPAP can be achieved in a environment that fosters patient education, comprehensive follow-up, and integrated care. Second, before we started the program, we decided collectively to use the criteria of an AHI ≥ 20/h as the treatment threshold. This decision is partly based on previous report of increased mortality in OSA subjects with an AHI ≥ 20/h who are untreated.19 There is evidence that some patients with an AHI < 20/h may also benefit symptomatically from nasal CPAP, but the results are not definitive and it is not possible at the moment to clearly identify the subjects (with an AHI < 20/h) who might benefit. We do not wish to imply that OSA patients with an AHI < 20/h should not be treated. Our study did not include these subjects, and therefore we cannot report on the CPAP compliance rate in these subjects. Further studies will be necessary to determine the treatment threshold and compliance rate in OSA subjects with mild disease.

In summary, our study findings suggest that high CPAP compliance rates are achievable in the community through a comprehensive CPAP program that provided free CPAP devices, extensive education, and follow-up services for symptomatic OSA patients with moderate-to-severe disease through a multidisciplinary team approach. Future studies are needed to determine which of the components of the program are the critical pieces in effecting excellent long-term CPAP compliance rates in the community.

Previous SectionNext SectionAcknowledgments
The authors acknowledge the technical assistance of Rhoda Schreiner, Doreen Kelsey, and Doug Willms at the University of Alberta Hospital Sleep Disorders Laboratory; Dianne Chaba for preparation of the article; and Rod Rousseau from Alberta Aids to Daily Living Program, Alberta Health and Welfare.

Previous SectionNext SectionFootnotes
Abbreviations: AHI = apnea-hypopnea index; CPAP = continuous positive airway pressure; ESS = Epworth Sleepiness Scale; OSA = obstructive sleep apnea; Sao2 = arterial oxygen saturation; UAH = University of Alberta Hospital
Dr. Sin is supported by a New Investigator Award from the Canadian Institutes of Health Research.

Received May 17, 2001. Accepted August 8, 2001. Previous Section References
↵ Young, T, Palta, M, Dempsey, J, et al (1993) The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 328,1230-1235CrossRefMedlineWeb of Science↵ Phillips, BA, Berry, DT, Schmitt, FA, et al Sleep-disordered breathing in healthy aged persons: two- and three-year follow-up. Sleep 1994;17,411-415Medline↵ Jenkinson, C, Davies, RJ, Mullins, R, et al Comparison of therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomised prospective parallel trial. Lancet 1999;353,2100-2105CrossRefMedlineWeb of Science↵ Sullivan, CE, Issa, FG, Berthon-Jones, M, et al Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet 1981;1,862-865MedlineWeb of Science↵ Chokroverty, S Editor’s corner. Sleep Med 2000;1,173Medline↵ Berry, RB Improving CPAP compliance: man more than machine. Sleep Med 2000;1,175-178CrossRefMedline↵ Hoy, CJ, Vennelle, M, Kingshott, RN, et al Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome? Am J Respir Crit Care Med 1999;159,1096-1100Abstract/FREE Full Text↵ Rechtschaffen A, Kales A. A manual of standardized terminology, techniques and scoring system for sleep stages of human subjects. Los Angeles, CA: Brain Information Service/Brain Research Institute, University of California, 1968
↵ Johns, MW Sleepiness in different situations measured by the Epworth sleepiness scale. Sleep 1994;17,703-710MedlineWeb of Science↵ Hoffstein, V, Viner, S, Mateika, S, et al Treatment of obstructive sleep apnea with nasal continuous positive airway pressure: patient compliance, perception of benefits, and side effects. Am Rev Respir Dis 1992;145,841-845MedlineWeb of Science↵ Krieger, J Long-term compliance with nasal continuous positive airway pressure (CPAP) in obstructive sleep apnea patients and non-apneic snorers. Sleep 1992;15,S42-S46MedlineWeb of Science↵ Rauscher, H, Formanek, D, Popp, W, et al Self-reported vs measured compliance with nasal CPAP for obstructive sleep apnea. Chest 1993;103,1675-1680Abstract/FREE Full Text↵ Rolfe, I, Olson, LG, Saunders, NA Long-term acceptance of continuous positive airway pressure in obstructive sleep apnea. Am Rev Respir Dis 1991;144,130-133
↵ McArdle, N, Devereux, G, Heidarnejad, H, et al Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med 1999;159,1108-1114Abstract/FREE Full Text↵ Kribbs, NB, Pack, AI, Kline, LR Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis 1993;147,887-895MedlineWeb of Science↵ Pepin, JL, Krieger, J, Rodenstein, D, et al Effective compliance during the first 3 months of continuous positive airway pressure: a European prospective study of 121 patients. Am J Respir Crit Care Med 1999;160,124-129
↵ Janson, C, Noges, E, Svedberg-Randt, S, et al What characterizes patients who are unable to tolerate continuous positive airway pressure (CPAP) treatment? Respir Med 2000;94,145-149CrossRefMedlineWeb of Science↵ Davies, HT, Crombie, IK Bias in case-control studies. Hosp Med 2000;61,279-281Medline↵ He, J, Kryger, MH, Zorick, FJ, et al Mortality and apnea index in obstructive sleep apnea: experience in 385 male patients. Chest 1988;94,9-14Abstract/FREE Full Text
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