Journal of Research in Medical Sciences

: 2017  |  Volume : 22  |  Issue : 1  |  Page : 114-

Compliance with continuous positive airway pressure in persian patients with obstructive sleep apnea

Forogh Soltaninejad1, Ali Sadeghi2, Babak Amra3,  
1 Department of Pulmonary Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
3 Bamdad Respiratory Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Correspondence Address:
Ali Sadeghi
Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan


Background: Obstructive sleep apnea (OSA) is defined by recurrent apnea and hypopnea during sleep. The main treatment of OSA is continuous positive airway pressure (CPAP). Adherence to CPAP is challenging and depends on multiple factors. This study was designed to evaluate the compliance with CPAP in patients with OSA. Materials and Methods: This was a prospective observational study including 106 patients with confirmed OSA by a standard polysomnography. We recorded CPAP usage hours after 7 and 90 days by a smart card. We compared the adherence of the patients with respect to body mass index (BMI), gender, smoking status, living area, and education level. Results: Patients in the 18–45 years' age group had higher compliance in mean (standard deviation) daily use of CPAP (0.93 [0.40] h) compared to the other age groups (P < 0.001). Patients with BMI >35 had better compliance (1.13 [0.44]) than the other patients (P < 0.001). Furthermore, nonsmokers and highly educated patients had better compliance compared to the others (P < 0.001). Conclusion: Age, BMI, education, and smoking are important factors in adherence to CPAP in patients with OSA.

How to cite this article:
Soltaninejad F, Sadeghi A, Amra B. Compliance with continuous positive airway pressure in persian patients with obstructive sleep apnea.J Res Med Sci 2017;22:114-114

How to cite this URL:
Soltaninejad F, Sadeghi A, Amra B. Compliance with continuous positive airway pressure in persian patients with obstructive sleep apnea. J Res Med Sci [serial online] 2017 [cited 2020 Dec 3 ];22:114-114
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Full Text


Obstructive sleep apnea (OSA) syndrome is characterized by repeated cessations of breathing during sleep, which lead to the fragmentation of sleep and repeated hypoxia.[1] The prevalence of OSA among adult male and female is 4% and 2%, respectively, and 20% among the elderly population.[1],[2],[3] Different studies have shown that people with OSA have an increased risk for traffic accidents,[4],[5],[6],[7],[8] hypertension, cardiovascular morbidity, and impaired health-related quality of life.[9],[10],[11],[12]

Continuous positive airway pressure (CPAP) is the choice of treatment for OSA. This treatment improves the quality of life and decreases cardiovascular morbidity and mortality.[13] However, a significant proportion of patients do not use their CPAP properly.[14] Poor compliance is associated with a decrease of treatment efficacy.[14]

Although some studies are available about factors that influence CPAP compliance,[15],[16],[17] in this study, we evaluated the compliance with CPAP in patients with OSA with respect to different variables including body mass index (BMI), gender, smoking status, living area, and education level.

 Materials and Methods

This study was a prospective, observational study conducted at Bamdad Respiratory Research Center, Isfahan. Between March 2015 and November 2016, 106 patients with confirmed OSA were enrolled in our study. The inclusion criteria were as follows: (i) Patients with apnea-hypopnea index (AHI) >15 in polysomnography and (ii) age ≥18 years. Patients with central sleep apnea syndrome (≥50% of apneas were central) and with a history of sedative or narcotic drugs use were not included.

Patients had been referred to Bamdad Respiratory Research Center due to clinical suspicion of OSA. We performed a standard attended overnight polysomnography by a polysomnography device (SOMNO medics GmbH, Randersacker, Germany). In standard polysomnography, electroencephalogram, electrocardiogram, electrooculogram, chin electromyogram, oronasal airflow, oxygen saturation by pulse oximetry, and thoracic, abdominal, and leg movements were recorded. Scoring was done according to the American Association of Sleep Medicine 2015 guideline.[18]

In patients with moderate and severe OSA (AHI >15), CPAP titration test was performed another night. CPAP treatment with defined pressure was started in patients.

All patients used the device with nasal mask and masks were comfortable. Patients' demographics as well as information about the living area (urban or rural), BMI, education level, and smoking were recorded. Then, after 7 and 90 days, we recorded CPAP usage daily according to the memory card. CPAP compliance was compared between patients according to their BMI, gender, smoking status, living area, and education level.

Statistical analyses were carried out using Statistical Package for the Social Sciences software (version 19.0.0, SPSS Inc., Chicago, IL, USA). The repeated analysis of variance test and the independent-t test were used to determine significant differences. All tests were two-tailed, and P < 0.05 was considered statistically significant.

The study protocol was approved by Ethical Committee of Isfahan University of Medical Sciences (Research Project Number 394822), and informed written consent was obtained from all patients included in this study. The results are presented as mean (standard deviation [SD]) or number (percent) where applicable.


We evaluated 106 patients including 59 men and 47 women, with a mean age of 53.7 (12.7) years. The demographic characteristics of patients are shown in [Table 1]. The mean daily use of CPAP after 7 and 90 days was recorded and compared in all patients.{Table 1}

Patients in the 18–45 years' age group had higher compliance in mean (SD) daily use compared to other age groups (P < 0.001). In addition, patients with BMI >35 had better compliance (P < 0.001). CPAP compliance in all patients was higher after 90 days compared with 7 days (P < 0.001).

Nonsmokers and highly educated patients had better compliance compared to others (P < 0.001). The CPAP compliance for age group, BMI, gender, education, and smoking is shown in [Table 2] and [Table 3]. Patients with at least 4 h usage of the device are considered to have good compliance.[19] After 7 days, none of the patients had good compliance; however, after 90 days, 32.1% of patients had good compliance.{Table 2}{Table 3}


In our observational study, nonsmoker, educated, and younger patients had better compliance. Also, BMI >35 was associated with higher adherence to treatment. However, there was no significant difference in compliance among patients with respect to gender and living area. Furthermore, 90-day mean daily CPAP usage was more than 7-day mean daily CPAP usage in all patients.

Better adherence to treatment in educated patients may be due to greater insight into the disease and improved quality of life. In addition, the awareness about the complication of untreated OSA is another important factor. The effect of motivation on treatment adherence was mentioned in the study of Bakker et al.[20] In another study, the patients who were requested to be treated by their partners had lower compliance that emphasizes the role of motivation.[21] Also, an association of education with better CPAP compliance was reported previously.[14]

The greater CPAP usage in patients with high BMI is probably related to more subjective benefit and symptom control. Better compliance in higher BMI was reported in previous studies.[22]

We also found that older patients had lower compliance, unlike the results of other studies.[23],[24] These differences might be due to a lack of training and support of older patients in their families. In addition, education may have a role in this difference.

The association of smoking with poor adherence may be due to their lower attention toward health risk factors.

In our study, gender had no significant association with compliance, while in another study female gender was associated with more compliance.[23] The difference may be related to the different levels of education of patients in studies.

In addition, we found better compliance at 90 days in patients compared to 7 days, which is due to the patients' perception of subjective benefit of treatment during this time.

Limitations of this study are lack of data about patients' symptoms, effect of treatment on symptoms and association with CPAP compliance, and limited number of patients. However, the study should be done using a larger number of population and including detailed data about patients' symptoms at the initiation of the treatment and follow-up.


The present study showed that education and understanding the benefits of treatment are important factors in increasing CPAP compliance.

Financial support and sponsorship


Conflicts of interest

The authors have no conflicts of interest.


1Amra B, Farajzadegan Z, Golshan M, Fietze I, Penzel T. Prevalence of sleep apnea-related symptoms in a Persian population. Sleep Breath 2011;15:425-9.
2Quintana-Gallego E, Carmona-Bernal C, Capote F, Sánchez-Armengol A, Botebol-Benhamou G, Polo-Padillo J, et al. Gender differences in obstructive sleep apnea syndrome: A clinical study of 1166 patients. Respir Med 2004;98:984-9.
3Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-5.
4Amra B, Dorali R, Mortazavi S, Golshan M, Farajzadegan Z, Fietze I, et al. Sleep apnea symptoms and accident risk factors in Persian commercial vehicle drivers. Sleep Breath 2012;16:187-91.
5Masa JF, Rubio M, Findley LJ. Habitually sleepy drivers have a high frequency of automobile crashes associated with respiratory disorders during sleep. Am J Respir Crit Care Med 2000;162(4 Pt 1):1407-12.
6Mozafari A, Zand N, Abyar Hoseini SA, Mohebi S, Gholabchi Fard R, Rasouli A, et al. Relationship between road accidents with sleep apnea and sleep quality among truck drivers in Iran. Eur Respir J 2014;44 Suppl 58:2296.
7Vorona RD, Ware JC. Sleep disordered breathing and driving risk. Curr Opin Pulm Med 2002;8:506-10.
8Terán-Santos J, Jiménez-Gómez A, Cordero-Guevara J. The association between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos-Santander. N Engl J Med 1999;340:847-51.
9Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA 2000;283:1829-36.
10Peker Y, Hedner J, Norum J, Kraiczi H, Carlson J. Increased incidence of cardiovascular disease in middle-aged men with obstructive sleep apnea: A 7-year follow-up. Am J Respir Crit Care Med 2002;166:159-65.
11Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Nieto FJ, et al. Sleep-disordered breathing and cardiovascular disease: Cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 2001;163:19-25.
12Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med 2005;353:2034-41.
13Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: An observational study. Lancet 2005;365:1046-53.
14Afsharpaiman S, Shahverdi E, Vahedi E, Aqaee H. Continuous positive airway pressure compliance in patients with obstructive sleep apnea. Tanaffos 2016;15:25-30.
15Uematsu A, Akashiba T, Kumasawa F, Akahoshi T, Okamoto N, Nagaoka K, et al. Factors influencing adherence to nasal continuous positive airway pressure in obstructive sleep apnea patients in Japan. Sleep Biol Rhythms 2016;14:339-49.
16Verbraecken J. Telemedicine applications in sleep disordered breathing: Thinking out of the box. Sleep Med Clin 2016;11:445-59.
17Wolkove N, Baltzan M, Kamel H, Dabrusin R, Palayew M. Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea. Can Respir J 2008;15:365-9.
18Berry RB, Gamaldo CE, Harding SM, Brooks R, Lloyd RM, Vaughn BV, et al. AASM scoring manual version 2.2 updates: New chapters for scoring infant sleep staging and home sleep apnea testing. J Clin Sleep Med 2015;11:1253-4.
19Wang Q, Ou Q, Tian XT, Chen YC, Nie ZQ, Gao XL. Analysis of long-term compliance to continuous positive airway pressure in patients with obstructive sleep apnea. Zhonghua Yi Xue Za Zhi 2016;96:2380-4.
20Bakker JP, Wang R, Weng J, Aloia MS, Toth C, Morrical MG, et al. Motivational Enhancement for increasing adherence to CPAP: A randomized controlled trial. Chest 2016;150:337-45.
21Hoy CJ, Vennelle M, Kingshott RN, Engleman HM, Douglas NJ. 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(4 Pt 1):1096-100.
22Gagnadoux F, Le Vaillant M, Goupil F, Pigeanne T, Chollet S, Masson P, et al. Influence of marital status and employment status on long-term adherence with continuous positive airway pressure in sleep apnea patients. PLoS One 2011;6:e22503.
23Sin DD, Mayers I, Man GC, Pawluk L. Long-term compliance rates to continuous positive airway pressure in obstructive sleep apnea: A population-based study. Chest 2002;121:430-5.
24Collen J, Lettieri C, Kelly W, Roop S. Clinical and polysomnographic predictors of short-term continuous positive airway pressure compliance. Chest 2009;135:704-9.