Comparative Study on CPAP Compliance: PAP-NAP followed by CPAP Trial vs. CPAP Trial Alone

• Abstract
• Introduction
• Materials and Methods
• Study Population and Participants
• Polysomnogram
• Arm 1: PAP-NAP followed by CPAP Trial
• Arm 2: Home-Based CPAP Trial
• Ethical Approval and Statistical Analysis
• Results
• Participants (Table 1)
• Primary Outcome Measure (Table 2)
• Primary Outcome Measure (Table 2, Figure 2)
• Masks Used and Other Secondary Outcomes
• Discussion
• References

Abstract

Objective

To assess the effectiveness of allocating positive airway pressure nap (PAP-NAP) prior to continuous positive airway pressure (CPAP) trial compared with CPAP trial alone in improving CPAP therapy adherence among individuals diagnosed with obstructive sleep apnea (OSA) in our Southeast Asian cohort.

Materials and Methods

A total of 133 adults with OSA were divided into 2 groups: 1 received PAP-NAP before a CPAP trial, and the other underwent a CPAP trial alone. The correlation between CPAP adherence and polysomnographic data was investigated.

Results

The PAP-NAP group showed better CPAP compliance (above 90%) and adherence (66.64% ± 31.96%) compared with the CPAP-only group (57.90% ± 34.86%). Both groups experienced reductions in apnea hypopnea index (AHI), with the PAP-NAP group having lower residual AHI. Compliance was defined as usage of CPAP > 4H in 14 days.

Conclusion

Positive airway pressure naps prior to a CPAP trial increases short-term CPAP adherence and influences mask selection. Personalized CPAP approaches like PAP-NAP can enhance patient acceptance and motivation. Further research is recommended to investigate long-term adherence.

Introduction

Obstructive sleep apnea (OSA) is a prevalent sleep-related breathing disorder characterized by recurrent episodes of partial or complete airflow obstruction during sleep. It is associated with numerous adverse health outcomes, including excessive daytime sleepiness, impaired cognitive function, cardiovascular disease, and decreased quality of life.[1] [2] Continuous positive airway pressure (CPAP) therapy is the primary treatment for OSA and involves the use of a device that delivers a constant flow of pressurized air to maintain an open airway during sleep. Despite the proven efficacy of CPAP in managing OSA, treatment adherence remains a significant challenge.[3] [4] Many patients experience difficulties tolerating CPAP due to factors such as mask discomfort, claustrophobia, anxiety, and air pressure-related side effects. Non-adherence to CPAP therapy can lead to inadequate symptom relief, increased risk of comorbidities, and decreased treatment effectiveness.[5] [6]

To address these challenges, interventions aimed at improving CPAP compliance have been explored. One such intervention is the positive airway pressure nap (PAP-NAP), which is a daytime study in which patients work one-on-one with a sleep technologist to overcome anxieties, claustrophobia, and discomfort associated with CPAP therapy.[7] [8] The session incorporates relaxation techniques and desensitization strategies to help patients become more comfortable with PAP therapy. By providing personalized coaching and support, PAP-NAP aims to increase patient acceptance and adherence to CPAP therapy.

The rationale behind investigating the effectiveness of PAP-NAP is rooted in the need for strategies to enhance CPAP compliance and improve treatment outcomes for individuals with OSA.[5] [6] Previous research has suggested that patient education, support, and close follow-up are critical factors in promoting CPAP adherence.[5] Positive airway pressure nap offers a targeted intervention that addresses the specific concerns and challenges patients may have regarding CPAP therapy. By providing a supportive environment and teaching coping mechanisms, PAP-NAP aims to improve patient acceptance and confidence in using CPAP, potentially leading to greater adherence and improved treatment outcomes.

While there is some evidence supporting the efficacy of PAP-NAP in improving CPAP compliance and patient acceptance, further investigation is needed to establish its effectiveness compared with a standard CPAP trial alone. A retrospective comparative study allows for the assessment of existing data to compare CPAP compliance rates between patients who underwent PAP-NAP followed by a CPAP trial and those who underwent a CPAP trial alone. By evaluating CPAP compliance, the present study aims to contribute to the growing body of literature on interventions to enhance CPAP adherence and improve outcomes for individuals with sleep-related breathing disorders.

Materials and Methods

Study Population and Participants

This is a retrospective cohort study where adults aged 18 to 85 years, diagnosed with obstructive sleep apnea and having undergone diagnostic polysomnogram, were recruited from the University of Malaya Medical Center (UMMC) Otorhinolaryngology Sleep Clinic, Department of Otorhinolaryngology, Kuala Lumpur, Malaysia. Both arms were conducted in a ward for close monitoring privacy to ensure good quality sleep. They were prospectively screened for inclusion. Two groups of participants were randomly recruited through convenience sampling, based on the availability of staff and facilities for PAP-NAP services. Both arms were conducted in a ward for close monitoring privacy to ensure good quality sleep. Patients who had undergone PAP-NAP, followed by a CPAP trial, were recruited from August 2022 to February 2023, while patients who had undergone a CPAP trial alone were recruited from March 2023 to August 2023. Exclusion criteria included: 1) patients with incomplete or insufficient medical records, 2) severe medical or psychiatric conditions that may interfere with the study outcomes, 3) incomplete CPAP adherence data, 4) Upper Airway Resistance Syndrome (UARS).

Polysomnogram

Every recruited patient underwent a detailed sleep history taking and examination, including a flexible nasopharyngoscopy assessment of the upper airway. A polysomnogram was then performed to confirm the diagnosis of obstructive sleep apnea prior to the study. An in-laboratory level 1 Compumedics Grael 4k polysomnogram was conducted in addition to clinical correlation to patient symptoms and signs for the diagnosis of OSA. Results were generated according to patient identifiers and reviewed by qualified clinicians. When obstructive sleep apnea was diagnosed, counseling was provided to the participants, and treatment options were discussed. Patients were given the option of continuous positive airway pressure (CPAP) as their first choice of treatment if there were no contraindications.

Arm 1: PAP-NAP followed by CPAP Trial

For the first arm, PAP-NAP candidates underwent a sleep interview, in which education was delivered to the participants, and an emotional state assessment was conducted before the commencement of PAP-NAP to ensure sufficient motivation for positive airway pressure (PAP) therapy. We randomly prescribed either ResMed AirSense 10 or Phillips DreamStation (Philips Respironics, Murrysville, PA, USA) for the project. The participant was then admitted as an in-patient and exposed to multiple mask types (nasal mask, nasal pillow, and oronasal mask) in various sizes (S, M, L). The participant then selected their appropriate mask and was appropriately fitted. Mask desensitization began without pressurized air for 20 minutes to desensitize, followed by pressurized air under auto-PAP with a minimum setting of 4 cmh20 and maximum setting of 15 cmH20 for 60 to 120 minutes. Manual titration may also be used to adjust appropriate pressure settings for the best comfort level throughout the PAP-NAP session. After the PAP-NAP session, the participant was asked to proceed with a home-based CPAP trial for 2 weeks and was monitored for comfort and compliance with CPAP therapy. Total compliance was calculated as the percentage of times the CPAP was used by a participant for more than 4 hours over a period of 2 weeks.

Arm 2: Home-Based CPAP Trial

For the second arm, the home-based CPAP trial was performed without a prior PAP-NAP session. The participants were randomly prescribed either ResMed AirSense 10 or Phillips DreamStation for the trial. The CPAP trial was prescribed by the attending clinician, and health staff were dispatched to the participant's residence. The participant was then exposed to multiple mask types (nasal mask, nasal pillow, and oronasal mask) in various sizes (S, M, L), similar to what was seen in arm 1, and the participant was fitted with their most comfortable mask. The participant was then given 30 to 90 minutes to adapt to CPAP pressure with the mask on. Auto-PAP mode was used for all participants throughout the study with a minimum setting of 4 cmH20 and maximum setting of 15 cmh20. The CPAP was loaned to the participants for a total of 2 weeks, and it was retrieved from the participants 2 weeks after the trial. Data was extracted and analyzed by the attending clinician.

Ethical Approval and Statistical Analysis

The current project was approved by the University of Malaya Research Ethics Committee (UMREC) (2023714–12669). All participants provided signed informed consent to participate in this project. A statistical analysis was performed using SPSS Statistics for Windows, (IBM Corp., Armonk, NY, USA) version 23. Descriptive statistics were presented as mean ± standard deviation or frequency (percentage). For the primary analysis, compliance between arms 1 (PAP-NAP + CPAP trial) and 2 (CPAP trial alone) was first analyzed separately. Compliance with CPAP at the end of the 2-week trial in percentage was compared between both arms. Both variables were evaluated using the Chi-squared analysis, for the measure of statistical significance, and Cramer's V, for the measure of substantive significance. For the secondary analysis, a comparison between arms 1 and 2 was made for sample characteristics, clinical features, and CPAP settings. The paired t-test was used to compare continuous numerical variables, while the Chi-squared analysis was used to compare categorical variables. A p-value of 0.05 was considered statistically significant for all analysis.

For the proposed study, the sample size was determined through a power analysis using a web-based sample size calculator (http://www.stat.ubc.ca/~rollin/stats/ssize/n2a.html). This tool is highly effective in medical and biological research for determining sample sizes. We aimed for a minimum of 65 participants per group, considering a power of 90% and a 5% margin of error (α = 0.05), based on the mean and standard deviation reported by Krakow et al.

Results

Participants ([Table 1])

Data were available for 65 participants in arm 1 (PAP-NAP + CPAP trial) and 68 participants in arm 2 (CPAP alone) (see [Fig. 1]). Baseline characteristics are presented in [Table 1]. Across both groups (n = 133), the mean age was 48.8 ± 14.0 years, with 84 (65.4%) being male, 70 (52.6%) being Malays, 38 (28.6%) being Chinese, and 21 (15.8%) being Indian, whereby ethnicities were self-reported. The mean body mass index was 34.0 ± 10.2. Regarding the total diagnostics used for the project, 112 (84%) participants had undergone in-laboratory level 1 polysomnogram, and 21 (16%) patients had undergone level 3 home sleep apnea testing (HSAT). Overall, the diagnosis of OSA severity based on the apnea-hypopnea index (AHI) was as follows: 10 (7.5%) mild, 32 (24.1%) moderate, and 91 (68.4%) severe OSA.

Primary Outcome Measure ([Table 2])

Primary Outcome Measure ([Table 2], [Figure 2])

Among the participants who had undergone the PAP-NAP + CPAP trial (arm 1), the overall compliance was 66.64% ± 31.96%, while in the CPAP trial alone (arm 2), the compliance was 57.90% ± 34.86%, suggesting better overall compliance in arm 1. When categorizing compliance as above 90%, there was a statistically significant difference (p < 0.05) between arms 1 and 2, with 23 participants in arm 1 (63.9%) achieving better compliance compared with 13 in arm 2 (36.1%). The AHI was significantly reduced in both groups, with the residual AHI for arm 1 (3.98 ± 4.94) being lower than that of arm 2 (5.41 ± 7.51). Additionally, arm 1 (14.3 ± 13.7 L/min) was associated with slightly higher overall mask leakage compared with arm 2 (13.6 ± 11.6 L/min).

Masks Used and Other Secondary Outcomes

Participants were given the liberty to choose the most appropriately fitting mask type and size based on their own comfort and tolerance. In arm 1, participants were more likely to use nasal masks (43; 66.2%), while in arm 2, participants were more likely to choose between nasal masks (33; 48.5%) and nasal pillows (31; 45.6%). Participants were less likely to select oronasal masks over other choices. Other secondary outcome measures were also used to compare both groups and are summarized in [Table 3].

Discussion

The results from the current project demonstrate a significant increase in short-term adherence to CPAP (2 weeks) when PAP-NAP is done before a CPAP trial. In-patient PAP-NAP prior to a 2-week CPAP trial was effective in increasing adherence and motivation among participants to start CPAP, especially in achieving adherence rates above 90%. Additionally, participants were more likely to confidently choose nasal masks over a split decision between nasal masks and nasal pillows when an in-patient PAP-NAP was performed before a home-based CPAP trial.

Our results are also consistent with those of other studies from neighboring countries.[8] [9] However, the authors were unable to retrieve additional data from mainstream indexing sites about studies involving PAP-NAP prior to CPAP trials in studies conducted by other Southeast Asian countries.[7] It has been published in the literature that low arousal threshold in OSA is highly prevalent in Asian countries[10] and is often associated with older, non-obese patients and females.[10] [11] In a study by Lam et al., when comparing craniofacial profiles between Caucasian and Chinese Asian patients, it was found that Asians that tend to have steeper thyromental angles and more crowded oropharynx, which may contribute to the severity of OSA.[12] While our study included a large number of obese individuals, there was poor adherence to CPAP seen in both obese and non-obese participants, as similarly observed by Lee et al.[13] This may suggest contributions from other factors, such as a low arousal threshold, which was fairly consistent in the literature. As a result, Asian populations with OSA have additional challenges to overcome aside from obesity, which includes craniofacial factors and low arousal threshold. Therefore, new strategies such as PAP-NAP may be attempted to improve compliance with CPAP.

Positive airway pressure nap was first introduced by Krakow et al., in 2008, as a strategy to desensitize patients to the mask interface and to overcome aversive emotional reactions to CPAP installation.[7] It is described as a “test drive” before long-term CPAP trials for vulnerable patients with fears of pressurized air.[13] It was also reported to have better CPAP adherence and is regularly utilized in many other centers.[13] However, there is a lack of data on its usage, especially in the Southeast Asian community. In our study, we investigated the universal application of PAP-NAP before the start of formal CPAP trials and were met with promising results. While PAP-NAP served us well, the authors acknowledge the existence of other strategies to increase long-term adherence, such as telemedicine and the use of sedatives.[14] Still, we found that PAP-NAP posed minimal health risks and had more predictable outcomes compared with CPAP trial alone.

Several factors help determine good long-term compliance, one of which is the selection of the proper mask interface.[15] Among the different types of mask interfaces, the nasal mask tends to be associated with better adherence and lower residual AHI.[16] While the evidence on mask interface selection has been unclear,[17] current practice recommends initiating nasal masks and nasal pillows over oronasal masks as these tend to be less comfortable, cost more, and are associated with poor adherence.[18] [19] There was a statistically significant difference in the selection of nasal masks and nasal pillows in our cohort. It is generally accepted that nasal pillows and nasal masks are equally effective in reducing AHI and achieving optimum CPAP pressures.[20] However, it should be noted that more participants were likely to choose a nasal interface rather than oronasal masks after PAP-NAP in our cohort. Therefore, PAP-NAP followed by a CPAP trial could potentially play an important role in the personalized approach to mask interface selection as well.

The present study has several limitations. First, as a retrospective cohort study, there is an inherent risk of selection bias. The participants were recruited based on convenience sampling and the availability of staff and facilities, which might not fully represent the broader population of individuals with OSA. Secondly, the study focused on short-term CPAP adherence over a two-week period. While this provides initial insights into the effectiveness of PAP-NAP, it does not account for long-term adherence, which is crucial for managing OSA. Third, CPAP compliance was primarily measured based on usage hours recorded by the CPAP device. While this is a standard method, it does not capture the qualitative aspects of patient experience, such as comfort and perceived benefits, which are also critical for long-term adherence. Incorporating patient-reported outcomes and satisfaction measures would provide a more comprehensive assessment of PAP-NAP's effectiveness. Fourth, different CPAP devices (ResMed AirSense 10 and Phillips DreamStation) were used in the study, which could introduce variability in adherence rates due to differences in device features and patient preferences. Standardizing the CPAP equipment across study participants could help mitigate this issue. Finally, participants were enrolled into arm 1 first and then arm 2 once sufficient arm 1 numbers were reached, that is, there was no overlap in the time periods participants were studied in the two arms, which may have influenced the results in addition to the other limitations mentioned.

In conclusion, the results of this study demonstrate the role of PAP-NAP prior to a CPAP trial on CPAP adherence and mask interface selection in our Southeast Asian cohort. In our cohort, participants who underwent a PAP-NAP before a CPAP trial showed better CPAP adherence over a two-week period. Positive airway pressure naps also contributed to a clearer choice of mask selection, favoring nasal masks and nasal pillows over oronasal masks when participants were asked to select masks independently. Since this study focuses on a short duration of CPAP adherence, future studies should investigate the role of PAP-NAP in long-term adherence to CPAP. Additionally, a prospective study design should be employed to ensure better control of confounding factors and provide higher-quality monitoring during CPAP titration.

Conflict of Interests

The authors have no conflict of interests to declare.

Acknowledgment

The authors would like to thank the Department of Otorhinolaryngology and the Respiratory Unit from the Faculty of Medicine, Universiti Malaya, for their support.

• References

• 1 Goyal M, Johnson J. Obstructive Sleep Apnea Diagnosis and Management. Mo Med 2017; 114 (02) 120-124
  PubMedSearch in Google Scholar
• 2 Maspero C, Giannini L, Galbiati G, Rosso G, Farronato G. Obstructive sleep apnea syndrome: a literature review. Minerva Stomatol 2015; 64 (02) 97-109
  PubMedSearch in Google Scholar
• 3 Batool-Anwar S, Goodwin JL, Kushida CA, Walsh JA, Simon RD, Nichols DA, Quan SF. Impact of continuous positive airway pressure (CPAP) on quality of life in patients with obstructive sleep apnea (OSA). J Sleep Res 2016; 25 (06) 731-738
  CrossrefPubMedSearch in Google Scholar
• 4 Mehrtash M, Bakker JP, Ayas N. Predictors of Continuous Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea. Lung 2019; 197 (02) 115-121
  CrossrefPubMedSearch in Google Scholar
• 5 Ballard RD, Gay PC, Strollo PJ. Interventions to improve compliance in sleep apnea patients previously non-compliant with continuous positive airway pressure. J Clin Sleep Med 2007; 3 (07) 706-712
  PubMedSearch in Google Scholar
• 6 Shaukat R, Gamal Y, Ali A, Mohamed S. Adherence to Positive Airway Pressure Therapy in Patients With Obstructive Sleep Apnea. Cureus 2022; 14 (06) e25946
  CrossrefPubMedSearch in Google Scholar
• 7 Krakow B, Ulibarri V, Melendrez D, Kikta S, Togami L, Haynes P. A daytime, abbreviated cardio-respiratory sleep study (CPT 95807-52) to acclimate insomnia patients with sleep disordered breathing to positive airway pressure (PAP-NAP). J Clin Sleep Med 2008; 4 (03) 212-222
  CrossrefPubMedSearch in Google Scholar
• 8 Syed Z, Mehta I, Hella JR, Barber K, Khorfan F. Implementing a sleep technician-supervised and personalized APAP interface fitting session prior to initiation of home APAP therapy improves adherence in patients with obstructive sleep apnea. J Clin Sleep Med 2021; 17 (10) 2057-2065
  CrossrefPubMedSearch in Google Scholar
• 9 Ulibarri VA, Krakow B, McIver ND. The PAP-NAP one decade later: patient risk factors, indications, and clinically relevant emotional and motivational influences on PAP use. Sleep Breath 2020; 24 (04) 1427-1440
  CrossrefPubMedSearch in Google Scholar
• 10 Hang LW, Huang CS, Cheng WJ. Clinical characteristics of Asian patients with sleep apnea with low arousal threshold and sleep structure change with continuous positive airway pressure. Sleep Breath 2021; 25 (03) 1309-1317
  CrossrefPubMedSearch in Google Scholar
• 11 Zinchuk A, Edwards BA, Jeon S, Koo BB, Concato J, Sands S. et al. Prevalence, associated clinical features, and impact on continuous positive airway pressure use of a low respiratory arousal threshold among male United States veterans with obstructive sleep apnea. J Clin Sleep Med 2018; 14 (05) 809-817
  CrossrefPubMedSearch in Google Scholar
• 12 Lam B, Ip MS, Tench E, Ryan CF. Craniofacial profile in Asian and white subjects with obstructive sleep apnoea. Thorax 2005; 60 (06) 504-510
  CrossrefPubMedSearch in Google Scholar
• 13 Lee RWW, Sutherland K, Sands SA, Edwards BA, Chan TO, Ng SSS. et al. Differences in respiratory arousal threshold in Caucasian and Chinese patients with obstructive sleep apnoea. Respirology 2017; 22 (05) 1015-1021
  CrossrefPubMedSearch in Google Scholar
• 14 Wang D, Tang Y, Chen Y, Zhang S, Ma D, Luo Y. et al. The effect of non-benzodiazepine sedative hypnotics on CPAP adherence in patients with OSA: a systematic review and meta-analysis. Sleep 2021; 44 (08) zsab077
  CrossrefPubMedSearch in Google Scholar
• 15 Sunwoo BY, Light M, Malhotra A. Strategies to augment adherence in the management of sleep-disordered breathing. Respirology 2020; 25 (04) 363-371
  CrossrefPubMedSearch in Google Scholar
• 16 Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE. A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev 2011; 15 (06) 343-356
  CrossrefPubMedSearch in Google Scholar
• 17 Goh KJ, Soh RY, Leow LC, Toh ST, Song PR, Hao Y. et al. Choosing the right mask for your Asian patient with sleep apnoea: A randomized, crossover trial of CPAP interfaces. Respirology 2019; 24 (03) 278-285
  CrossrefPubMedSearch in Google Scholar
• 18 Giles TL, Lasserson TJ, Smith BH, White J, Cates CJ. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 2006; (01) CD001106
  CrossrefPubMedSearch in Google Scholar
• 19 Genta PR, Kaminska M, Edwards BA, Ebben MR, Krieger AC, Tamisier R. et al. The Importance of Mask Selection on Continuous Positive Airway Pressure Outcomes for Obstructive Sleep Apnea. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2020; 17 (10) 1177-1185
  CrossrefPubMedSearch in Google Scholar
• 20 Deng B, Lai F, Zhang M, Xiong C, Chen F, Zhang H. et al. Nasal pillow vs. standard nasal mask for treatment of OSA: a systematic review and meta-analysis. Sleep Breath 2023; 27 (04) 1217-1226
  CrossrefPubMedSearch in Google Scholar

Address for correspondence

Publication History

Received: 13 August 2024

Accepted: 18 February 2025

Article published online:
12 June 2025

© 2025. Brazilian Sleep Academy. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Revinter Publicações Ltda.
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• References

• 1 Goyal M, Johnson J. Obstructive Sleep Apnea Diagnosis and Management. Mo Med 2017; 114 (02) 120-124
  PubMedSearch in Google Scholar
• 2 Maspero C, Giannini L, Galbiati G, Rosso G, Farronato G. Obstructive sleep apnea syndrome: a literature review. Minerva Stomatol 2015; 64 (02) 97-109
  PubMedSearch in Google Scholar
• 3 Batool-Anwar S, Goodwin JL, Kushida CA, Walsh JA, Simon RD, Nichols DA, Quan SF. Impact of continuous positive airway pressure (CPAP) on quality of life in patients with obstructive sleep apnea (OSA). J Sleep Res 2016; 25 (06) 731-738
  CrossrefPubMedSearch in Google Scholar
• 4 Mehrtash M, Bakker JP, Ayas N. Predictors of Continuous Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea. Lung 2019; 197 (02) 115-121
  CrossrefPubMedSearch in Google Scholar
• 5 Ballard RD, Gay PC, Strollo PJ. Interventions to improve compliance in sleep apnea patients previously non-compliant with continuous positive airway pressure. J Clin Sleep Med 2007; 3 (07) 706-712
  PubMedSearch in Google Scholar
• 6 Shaukat R, Gamal Y, Ali A, Mohamed S. Adherence to Positive Airway Pressure Therapy in Patients With Obstructive Sleep Apnea. Cureus 2022; 14 (06) e25946
  CrossrefPubMedSearch in Google Scholar
• 7 Krakow B, Ulibarri V, Melendrez D, Kikta S, Togami L, Haynes P. A daytime, abbreviated cardio-respiratory sleep study (CPT 95807-52) to acclimate insomnia patients with sleep disordered breathing to positive airway pressure (PAP-NAP). J Clin Sleep Med 2008; 4 (03) 212-222
  CrossrefPubMedSearch in Google Scholar
• 8 Syed Z, Mehta I, Hella JR, Barber K, Khorfan F. Implementing a sleep technician-supervised and personalized APAP interface fitting session prior to initiation of home APAP therapy improves adherence in patients with obstructive sleep apnea. J Clin Sleep Med 2021; 17 (10) 2057-2065
  CrossrefPubMedSearch in Google Scholar
• 9 Ulibarri VA, Krakow B, McIver ND. The PAP-NAP one decade later: patient risk factors, indications, and clinically relevant emotional and motivational influences on PAP use. Sleep Breath 2020; 24 (04) 1427-1440
  CrossrefPubMedSearch in Google Scholar
• 10 Hang LW, Huang CS, Cheng WJ. Clinical characteristics of Asian patients with sleep apnea with low arousal threshold and sleep structure change with continuous positive airway pressure. Sleep Breath 2021; 25 (03) 1309-1317
  CrossrefPubMedSearch in Google Scholar
• 11 Zinchuk A, Edwards BA, Jeon S, Koo BB, Concato J, Sands S. et al. Prevalence, associated clinical features, and impact on continuous positive airway pressure use of a low respiratory arousal threshold among male United States veterans with obstructive sleep apnea. J Clin Sleep Med 2018; 14 (05) 809-817
  CrossrefPubMedSearch in Google Scholar
• 12 Lam B, Ip MS, Tench E, Ryan CF. Craniofacial profile in Asian and white subjects with obstructive sleep apnoea. Thorax 2005; 60 (06) 504-510
  CrossrefPubMedSearch in Google Scholar
• 13 Lee RWW, Sutherland K, Sands SA, Edwards BA, Chan TO, Ng SSS. et al. Differences in respiratory arousal threshold in Caucasian and Chinese patients with obstructive sleep apnoea. Respirology 2017; 22 (05) 1015-1021
  CrossrefPubMedSearch in Google Scholar
• 14 Wang D, Tang Y, Chen Y, Zhang S, Ma D, Luo Y. et al. The effect of non-benzodiazepine sedative hypnotics on CPAP adherence in patients with OSA: a systematic review and meta-analysis. Sleep 2021; 44 (08) zsab077
  CrossrefPubMedSearch in Google Scholar
• 15 Sunwoo BY, Light M, Malhotra A. Strategies to augment adherence in the management of sleep-disordered breathing. Respirology 2020; 25 (04) 363-371
  CrossrefPubMedSearch in Google Scholar
• 16 Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE. A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev 2011; 15 (06) 343-356
  CrossrefPubMedSearch in Google Scholar
• 17 Goh KJ, Soh RY, Leow LC, Toh ST, Song PR, Hao Y. et al. Choosing the right mask for your Asian patient with sleep apnoea: A randomized, crossover trial of CPAP interfaces. Respirology 2019; 24 (03) 278-285
  CrossrefPubMedSearch in Google Scholar
• 18 Giles TL, Lasserson TJ, Smith BH, White J, Cates CJ. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 2006; (01) CD001106
  CrossrefPubMedSearch in Google Scholar
• 19 Genta PR, Kaminska M, Edwards BA, Ebben MR, Krieger AC, Tamisier R. et al. The Importance of Mask Selection on Continuous Positive Airway Pressure Outcomes for Obstructive Sleep Apnea. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2020; 17 (10) 1177-1185
  CrossrefPubMedSearch in Google Scholar
• 20 Deng B, Lai F, Zhang M, Xiong C, Chen F, Zhang H. et al. Nasal pillow vs. standard nasal mask for treatment of OSA: a systematic review and meta-analysis. Sleep Breath 2023; 27 (04) 1217-1226
  CrossrefPubMedSearch in Google Scholar