OSAS – CPAP behandling Hvor meget er nok? Ole Hilberg Lungemedicinsk afdeling Århus Universitetshospital Evolutionen Adherence - historie • Hippokrates tid: Effekten af diverse miksturer bliver noteret! • 1979: Første workshop om monitorering af medicincompliance. Adherence - baggrund • I USA anslås mangelfuld adherence at koste 300 millioner dollars per år. • I medicinske forsøg, har personer med dårlig adherence dårligere prognose end dem med god adherence. (gælder både for aktiv medicin og placebo). Adherence – sygdom • Størst ved akut sygdom! • Drastisk fald ved kronisk sygdom til ca. 50% (WHO). • Lung Health Study – 60% efter 1 år, 50% efter 5 år. Fordelingen af adherence Adherent Partial Adherent Non-adherent 1/3 1/3 1/3 Ley’s model for patient compliance (1989). Bourbeau J et al. Patient adherence in COPD. Thorax 2008;63:831 LÆGEN • Retningslinjer – Diagnosticere - hvad er indiceret til hvem • Medicin/behandling – Hvordan tages og virker det/og virker det? • Pris – Hvad koster det – er der alternativer PATIENTEN • Hvorfor og hvordan skal jeg tage min medicin/behandling – Vide og forstå • Hvornår skal jeg gå til læge eller tage ekstra – Mestring/Selvmedicineringsplaner • Hvad kan jeg forvente af min sygdom – Uddannelse i sygdom og egenomsorg Can Respir J Vol 15 No 7 October 2008 (64 måneder) Long-term CPAP Compliance in Women (705) with Obstructive Sleep Apnoea ERJ Express. Published on February 8, 2013 The median CPAP use was 6 (IQR 4-7)hours/day. Sleep Medicine 12 (2011) 1034–1036 CPAP-behandling varighed CPAP therapy for ≥4 hours/night experienced significant reductions in: systolic and diastolic blood pressure (P=0.001 and P=0.006, respectively); global cardiovascular disease risk (P=0.001); total cholesterol (P=0.002); insulin resistance (P=0.031); oxidative stress (P=0.004); and inflammation (P=0.037). Arias MA, Garcia-Rio F, Alonso-Fernandez A, et al. CPAP decreases plasma levels of soluble tumour necrosis factor-alpha receptor 1 in obstructive sleep apnoea. Eur Respir J. 2008;32:1009-1015. Patients with OSA who used CPAP therapy for <4 hours/night did not experience significant improvements Dorkova Z, Petrasova D, Molcanyiova A, Popovnakova M, Tkacova R. Effects of continuous positive airway pressure on cardiovascular risk profile in patients with severe obstructive sleep apnea and metabolic syndrome. Chest. 2008;134:686-692. Am J Respir Crit Care Med Vol 181. pp 718–726, 2010 Prognosis of Patients With Heart Failure and Obstructive Sleep Apnea Treated With Continuous Positive Airway Pressure 32 patients were classified as more compliant (average usage, 6.0 h), and 33 patients were classified as less compliant (average usage, 3.5 h). CHEST 2008; 133:690–696) Am J Physiol Heart Circ Physiol 282: H110–H121, 2002. Compliant>3 timer, Non-compliant<3timer 133 ptt 3 mdr efter opstart SLEEP 2007;30(6):711-719. Psychosomatic Medicine 69:449–454 (2007) Improvements in OSA symptoms, as measured by the FOSQ, were associated with higher CPAP adherence (r .50; p .0001). (1) poor users (n 14), who used PAP an average of 2 h per night; (2) ) moderate users (n 25), who used PAP an average of 2 to 6 h per night; (3) optimal users (n 19), who used PAP an average of 6 h per night. (CHEST 2006; 130:1772–1778) 475 CPAP patients questionnaire There was a negative correlation of the ESS score with daily CPAP usage (r = –0.33, p < 0.001), indicating that patients with longer daily CPAP usage tended to report less daytime sleepiness. <6.5 h/day (n = 228) >6.5 h/day (n = 249) <6.5 h/day showed a significantly higher ESS score (median = 10; IQR: 7–13 vs. median = 7; IQR: 4–10; p < 0.001). Respiration 2010;80:32–37 Konklusion • • • • • Ingen ‘high grade’ evidens for ‘hvor meget er nok’ Ingen større undersøgelser ift % af søvn 5 timer synes at være mest anbefalet Formentlig stor individuel variation Behov for undersøgelser Hvorfor? Campos-Rodriguez F, Pena-Grinan N, ReyesNunez N, De la Cruz-Moron I, Perez-Ronchel J, De la Vega-Gallardo F, et al. Mortality in obstructive sleep apnea-hypopnea patients treated with positive airway pressure. Chest. 2005 Aug; 128(2):624–33. [PubMed: 16100147] 15. Zimmerman ME, Arnedt JT, Stanchina M, Millman RP, Aloia MS. Normalization of memory performance and positive airway pressure adherence in memory-impaired patients with obstructive sleep apnea. Chest. 2006 Dec; 130(6):1772–8. [PubMed: 17166995] 16. Weaver T, Maislin G, Dinges D, Bloxham T, George C, Greenberg H, et al. Relationship Between Hours of CPAP Use and Achieving Normal Levels of Sleepiness and Daily Functioning. Sleep. 2007; 30:711–9. [PubMed: 17580592]