First Indian study on Airview, PAP THERAPY, Remote access cloud management published in the prestigious Indian journal lungindia

 Original Article

A panoramic view of a cohort of obstructive sleep apnea patients on positive airway pressure therapy using cloud based telemonitoring devices

Arup Haldar1, Arpita C Halder2, Somnath Maity3

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	DOI: 10.4103/lungindia.lungindia_531_22

© 2023 Indian Chest Society | Published by Wolters Kluwer - Medknow 

ABSTRACT

Background: Positive airway pressure therapy is mainstay of treatment of obstructive sleep apnea (OSA). But long‑term compliance with is poor with such therapy. A proactive and vigilant management may improve the PAP therapy usage. Cloud‑based telemonitoring PAP devices offer an opportunity for proactive monitoring and prompt interventions related to PAP troubleshooting. This technology is also used in India for adult OSA patients. But we lack our own data on behavior of Indian patients as a cohort on PAP therapy. The present study is an attempt to look at the behavior a cohort of PAP users in OSA. Methodology: This study was planned as a retrospective analysis of data of OSA patients who were using a cloud‑based PAP devices. First 100 patients were chosen for data retrieval that who was on this therapy. The data was obtained for those patients who were on PAP for at least 7 days and maximum follow‑up was available up to 390 days. Descriptive statistical analysis has been carried out in the present study. Results: The number of male and female patients was 75 and 25, respectively. Overall good compliance was present in 66% of patients. 34% of patients were not compliant with PAP during follow‑up. The compliance was statistically same in both the sexes (P = 0.8088). Incomplete data recovery was present in 17 patients and 11 (64.70%) were non‑compliant among them. In the initial, 60 days non‑compliant patients were more than compliant patients. The difference was lost in 60 to 90 days of use. The air leak was present more in the compliant group than non‑compliant group (P = 0.0239). 75.75% of compliant patients had achieved AHI control, whereas 35.29% of non‑compliant patients also achieved AHI control. But overall, AHI control was poor in non‑compliant patients and 61.76% of non‑compliant patients had an AHI uncontrolled. Conclusions: We conclude that 3/4th of the compliant patients achieve AHI control while 1/4th didn’t. This 1/4th population needs further exploration to determine the causes of poor AHI control. Cloud‑based PAP devices give an easy opportunity to monitor patients of OSA. It gives an instant panoramic view of behavior of OSA patients on PAP therapy. The compliant patients can be tracked, and non‑compliant patients can be segregated quickly.

 

KEY WORDS: Air leak, apnea‑hypopnea index, cloud‑based devices, compliance, obstructive sleep apnea, positive airway pressure therapy

 

INTRODUCTION

Obstructive sleep apnea (OSA) is a common disorder manifested with snoring, daytime sleepiness, fatigue, metabolic, and cardiovascular symptoms.[1] It is diagnosed with overnight polysomnography (PSG), either as a full-night or split-night study protocol.[2-7] The treatment of OSA is positive airway pressure (PAP) therapy either by continuous positive airway pressure (CPAP) or automatic positive airway pressure (APAP). But compliance with PAP therapy remains a big issue. A 10-year adherence data to CPAP has shown 31% dropout rate specially in the first year of therapy.[8] A proactive and vigilant management may improve the PAP therapy usage. Cloud-based telemonitoring PAP devices offer an opportunity for proactive monitoring and prompt interventions related to PAP troubleshooting. A cloud-based system is a broad term for anything that involves the delivery of hosted services via the internet. So, the provider can monitor and access the machine if permission had been granted by the user. Instead of the users coming to the provider with the PAP machine for checking adherence and troubleshooting, the same job can be done online, thus saving many efforts and time. Though this technology was available for more than 10 years, it had popularized during COVID-19 pandemic. Studies have shown that this method, as compared to standard methods of PAP monitoring, reduces the termination rate of the PAP therapy and improves the overall compliance.[9] American academy of sleep medicine (AASM) in their recent recommendation also suggested to use these telemonitoring guided interventions during initial period of PAP therapy in adults with OSA (Recommendation 9, Conditional).[10] This technology is also used in India for adult OSA patients. But we lack our own data on behavior of Indian patients as a cohort on PAP therapy. The telemonitoring technology has provided us a unique opportunity to pay a panoramic view on this cohort. The present study is such a glimpse spread across a year.

 

METHODOLOGY

This study was planned as a retrospective analysis of data of OSA patients who were using a cloud-based PAP

devices. The study was carried out in a sleep institute based on Kolkata, India. The devices were either APAP, in the majority or CPAP (Airview, Resmed). The masks used were mainly nasal masks (N20); nasal pillows (P10) or oronasal masks (F30) were used in some. Those patients on these cloud-based devices were being monitored regularly for their PAP usage. In case of inadequate use, they were being intimidated either by email or phone calls and were requested to adhere to PAP therapy. A pressure adjustments or adjustments of comfort setting (expiratory pressure relief, EPR) were done online. A cross-sectional data were obtained for the study. First 100 patients were chosen for data retrieval that who was on this therapy. The data were obtained for those patients who were on PAP for at least 7 days and maximum follow-up was available up to 390 days. A “Compliance” was defined as per Medicare definition of usage of PAP therapy for more than 4 hours per night during sleep for at least 70% of the nights.[11,12] “AHI control” was defined as AHI <5/hour/night. A “leak” was defined by air-leak beyond 24 liters/minute (as defined by the manufacturers and detected by machine).

 

A strict patient confidentiality was maintained, and all subjects were kept anonymous. Ethics committe aproved by 11.01.2020.

 

Descriptive statistical analysis has been carried out in the present study. Results on continuous measurements are presented on Mean ± SD and results on categorical measurements are presented in Number (%). Significance is assessed at a level of 5%. Statistical software: Med Calc Software.[13]

 

RESULTS

The data were analyzed for first 100 patients who were put on cloud based positive airway pressure (PAP) therapies for obstructive sleep apnea (OSA). The number of male and female patients was 75 and 25, respectively. Overall good compliance was present in 66% of patients. 34% of patients were not compliant with PAP during follow-up. The compliance was statistically same in both the gender (P = 0.8088). Incomplete data recovery was present in 17 patients and 11 (64.70%) were non-compliant among them.

Figure 1: PAP compliance with days of use (Y = Number of patients, X = Days of use)

 

An interesting trend was observed with PAP therapy use. In the initial, 60 days non-compliant patients were more than compliant patients [Figure 1]. The difference was lost in 60 to 90 days of use. The compliant patients were more after 90 days. The difference again had narrowed after a year of use.

 

Air leak with PAP therapy is always a concern. 51.6% of patients had increased air leak despite a controlled Apnea Hypopnea Index (AHI) in this study [Figure 2]. 62.12% of compliant patients had air leak, whereas 32.23% of non-compliant had an air leak.

 

The air leak was present more in the compliant group than non-compliant group (P = 0.0239). The air leak was lesser with an increasing day of use of PAP therapy, and this was valid both for compliant and non-compliant patients [Figure 3].

 

75.75% of compliant patients had achieved AHI control, thus 24.24% didn’t achieve an AHI control despite having adequate use, whereas 35.29% of non-compliant patients also achieved AHI control [Figure 4]. But overall, AHI control was poor in non-compliant patients and 61.76% of non-compliant patients had an AHI uncontrolled.

 Figure 2: Air leak in compliant and non‑compliant patients

AHI control was always more predictable and more in compliant patients, whereas non-compliant patients had an unpredictable AHI control, when they were tracked longitudinally [Figure 5].

 

DISCUSSION

The present study gives a panoramic view of a cohort of OSA patients put on PAP therapy. This panoramic view can be obtained easily with the use of cloud-based PAP devices. This cohort can be followed up for a prolonged period till they are using the machine and cloud connected. In non-cloud-based devices such follow-ups are difficult, as patients have to appear themselves periodically for such a data acquisition.

 

The present study gives an insight into PAP usage for a cohort of OSA patients. The data are available for almost more than a year of PAP usage. The overall compliance rate was like other studies done with telemonitoring-based PAP adherence studies. In a study published in respirology 67.1% of patients were adherent with this platform.[14] In our study, 66% of patients were adherent. A 10-year adherence study previously showed that 31% of patients on CPAP dropped out, especially in first year.[8] Here in this study, we were not able to retrieve adequate data in 11 patients and subsequently they were detected non-compliant also. This group can be labeled as dropout. Thus, 11% was the dropout rate while using cloud-based devices. The beauty of such remote monitoring is that these dropouts can be easily tracked and motivated to use PAP.

 

Another insight retrieved from this study is that we don’t have a gender bias in PAP compliance and usage or non-usage were similar in both sexes. The present knowledge also offers similar idea.[15] We had 34% non-compliant patients in this study. The reason for noncompliance was not evaluated here and further exploration of the non-compliant cohort may provide an insight to non-compliant trait. An early sign of noncompliance may be the irretrievable data and 64.70% of such patients were non-compliant.

  

Figure 3: Air leak in compliant and non‑compliant patients with days of use (Y = Percentage of patient with air leak, X = Days of use)

 

The present study also showed that initial noncompliance doesn’t always translate to long-term noncompliance. Though patients may have an initial j

erky start in first 60 days, they gradually become more compliant after 90 days of usage. So, a telemonitoring and teleinterventions to boost up the usage in first 3 months become a critical issue to ensure long-term compliance.

 

The compliance again tends to decrease over 1 year but needs further exploration with long-term follow-ups. A constant and periodic telecounseling may be needed in PAP users to remain motivated to use the machine adequately.

 

Though air leak is a serious problem in PAP users, especially the APAP users, that didn’t interfere with AHI control in this study. Almost half of the patients had air leak, but they still achieved AHI control. Leak was commoner in compliant patients than non-compliant, possibly because of more use in compliant patients. The leak tends to decrease with days of usage and patients probably learn to tie their masks properly.

 

The present study also showed that 3/4th of the compliant patients achieved AHI control while 1/4th didn’t. This1/4th population needs further exploration to determine the causes of poor AHI control. More than of 1/3rd non-compliant patients also achieved AHI control. This group also needs further exploration to determine the causes of poor usage despite having a benefit from the machine. It was obvious from the study that in non-compliant patients AHI control was difficult to achieve.

 

The present study gives us 4 distinct phenotypes of PAP users in OSA-

1.    Compliant and controlled AHI.

2.    Compliant and not controlled AHI.

3.    Non-compliant and controlled AHI.

4.    Non-compliant and not controlled AHI.

 

These 4 phenotypes need an evaluation through continuous follow-ups and enquiries. The distinct behaviors of these 4 groups to a same machine may bring new insights into PAP usage psyche.

 

CONCLUSION

Cloud-based PAP devices give an easy opportunity to monitor patients of OSA. It gives an instant panoramic view of behavior of OSA patients on PAP therapy. The compliant patients can be tracked, and non-compliant patients can be segregated quickly. Thus, the dropout rates can be minimized. The pattern of PAP usage needs some time to adjust, and first 3 months are crucial for long-term compliance. Leak is not a major problem to achieve AHI control. Distinct phenotypes of PAP users may be identified with a longitudinal follow-up of OSA patients.

A constant motivation by healthcare provider helps to improve the adherence to PAP device. These motivational interventions may be tailored to the vulnerable group with telemonitoring through the cloud-based PAP devices.

Figure 5: AHI control in compliant and non‑compliant patients when assessed longitudinally (Y = Percentage of AHI control patients, X = Days

of use)

Financial support and sponsorship

Nil.

 

Conflicts of interest

There are no conflicts of interest.

 

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