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[Treatment] Patients with treatment-emergent CSA more likely to terminate therapy
#1
Exclaimation 
Patients with treatment-emergent CSA more likely to terminate therapy
I don't know if this has appeared in the forum previously, but a big data study by Resmed showed that patients with treatment-emergent central apnea (TECA) are twice as likely to abandon their therapy. Given the number of such patients we see here, and the difficulty overcoming TECA, I'm not really surprised at this outcome. However it's something that docs and therapists need to be aware of.

It's also noteworthy that the base data for the study was gathered using Resmed's much-maligned app AirView.

Resmed article

The paper itself is behind a paywall, but the abstract is here.

Resmed Wrote:Big Data Yields Big Insights for Treatment of Central Sleep Apnea
New study of 134,899 patients on PAP therapy shows those with treatment-emergent CSA are nearly two times more likely to terminate therapy

WASHINGTON - May 212 2017 - According to a new ResMed-sponsored (NYSE:RMD) study, people with treatment-emergent central sleep apnea (CSA) have a significantly greater risk of terminating positive airway pressure (PAP) treatment. Researchers found that 3.5 percent of patients had CSA during the first 90 days of PAP therapy. The study, Trajectories of Central Sleep Apnea during Continuous Positive Airway Pressure and Association with Therapy Termination: A Big Data Analysis, was presented today at the 2017 American Thoracic Society International Conference.

This analysis highlights the importance of:

- Regularly monitoring patients to support adherence to treatment

Untreated sleep apnea increases the risk of other chronic diseases known for being prevalent with sleep apnea, including drug-resistant hypertension (83 percent), morbid obesity (77 percent), type 2 diabetes (72 percent) and stroke (62 percent)1.

- Early diagnosis of CSA to minimize risk of therapy termination

Findings from the largest-ever study of patients with treatment-emergent CSA, presented at the April 2017 European Respiratory Society and European Society of Sleep Research conference showed that switching treatment from continuous positive airway pressure (CPAP) to adaptive servo-ventilation (ASV) therapy2 significantly improved the patient’s adherence to therapy. It also showed that those with treatment-emergent CSA who switched from CPAP to ASV used their therapy longer and had significantly fewer apneas (breathing stoppages or reductions) during sleep.

"This study provides the most robust view available on the prevalence of CSA in patients on PAP therapy," said Dr. Carlos Nunez, ResMed’s chief medical officer. "The findings in this new research, combined with the research presented in April 2017, underscore the importance of keeping patients on therapy through regular monitoring, and rethinking the conventional wisdom on therapeutic options based on each patient's disease severity."

The new analysis defined three groups among patients with CSA - emergent, persistent and transient - based on whether the condition was present at the start of therapy or emerged during the first 12 weeks. All three groups showed a significantly higher risk of terminating their therapy than those without CSA. The risk was highest among the emergent group, whose CSA only became apparent during treatment, and were 1.7 times more likely to terminate their therapy than those without the condition.

About the Study

The study authors included: Atul Malhotra, University of California San Diego, United States; Peter Cistulli, University of Sydney, Australia; and Jean-Louis Pépin, Grenoble Alpes University, France.

A retrospective analysis used anonymous, aggregated telemonitoring data from a U.S. positive airway pressure therapy database, (ResMed AirView™) and analyzed it for the presence or absence of CSA during CPAP therapy at baseline (week 1) and after 12 weeks.

Session data included weekly values by averaging within each week for each patient. Defined patient groups were: OSA, emergent CSA, persistent CSA and transient CSA. Groups were compared to identify risk factors for different forms of CSA, and adherence and therapy termination rates were determined.

Patients with any form of CSA during CPAP were at higher risk of terminating therapy in the first 90 days versus those who did not develop CSA (hazard ratio 1.7 for emergent CSA, 1.4 for persistent CSA and 1.3 for transient CSA; all p<0.001).

About Central Sleep Apnea

Obstructive sleep apnea (OSA) and central sleep apnea (CSA) are the two most common types of sleep apnea, a condition that results in repetitive pauses in breathing during sleep. OSA is a sleep disorder in which the throat muscles relax, block the airways and stop the flow of breath during sleep. CSA is a sleep disorder in which the brain does not transmit the "breathe" signal to the muscles that control breathing during sleep. In either situation, the lack of oxygen causes the person to wake up to catch their breath and start breathing again, interrupting continuous sleep. This may occur multiple times in an hour.

In some patients with OSA, CSA may emerge and only become apparent during CPAP therapy. This was recognized in the third edition of the International Classification of Sleep Disorders and called "treatment-emergent CSA".

<snip>

1 References:  Gami AS et al. Circulation 2004,  O’Keefe and Patterson, Obes Surgery 2004, Logan et al. J. Hypertension 2001, O’Keeffe T and Patterson EJ. Obes Surg 2004, Einhorn D et al. Endocr Pract 2007, Bassetti C and Aldrich M. Sleep 1999

2 ASV therapy is contraindicated in patients with chronic, symptomatic heart failure (NYHA 2-4) with reduced left ventricular ejection fraction (LVEF ≤ 45%) and moderate to severe predominant central sleep apnea.
DeepBreathing
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#2
RE: Patients with treatment-emergent CSA more likely to terminate therapy
Thank-you for posting this.  Very interesting, and really (hindsight bias at work here...), it is to be expected.
Serial Tapist
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#3
RE: Patients with treatment-emergent CSA more likely to terminate therapy
'It's also noteworthy that the base data for the study was gathered using Resmed's much-maligned app AirView.'

The amount of data in the Resmed 'AirView' database is substantial, it must be close to being the world's largest respiration database.
Unfortunately rather then use that data to help people they use it to gather compliance data.
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#4
RE: Patients with treatment-emergent CSA more likely to terminate therapy
Treatment for Treatment Emergent Central Apnea (TECA) is typically to avoid the Central Apnea (looking at lowering both PS/EPR/Flex and Pressure) because getting and ASV is VERY difficult, though effective.
As the body adapts over 2-3 months time, the TECA lessens.
The most common cause of this is that the "CPAP" machine, in all its various flavors, Improves the efficiency of breathing resulting in a DECREASE in the concentration of CO2 in our blood.  When this decreases below a threshold it suppresses the drive to breathe.  Lowering PS/EPR/Flex decreases this efficiency resulting in less CO2 washout and decreases this form of Apnea.  A process called Enhanced Expiratory Rebreathing Space (EERS) can also do this by slightly raising the amount of CO2 that is rebreathed.

Read this WIKI http://www.apneaboard.com/wiki/index.php...tral_Apnea
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#5
RE: Patients with treatment-emergent CSA more likely to terminate therapy
The problem is that sleep apnea treatment is all or nothing. It never ceases to amaze me that someone that has an AHI of 30-40 without any treatment is suddenly thrust into a sub 5 AHI treatment plan. Obviously long term/persistent treatment emergent CSA will need to be addressed with another approach, such as an ASV.

But it would be interesting to see the effects of easing into the treatment using less than the optimum initially. It would also be interesting to see if there are any other treatment emergent flow limitations. Few other medical conditions, except imminent life threatening, are approached this way because people need to adjust to medication/treatment.

And there should never be an instance where someone feels more restful without xPAP treatment.

John
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