Sunwoo Bernie Y, Light Matthew, Malhotra Atul
Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, CA, USA.
Respirology. 2020 Apr;25(4):363-371. doi: 10.1111/resp.13589. Epub 2019 Jul 3.
Continuous positive airway pressure (CPAP) is highly effective in treating sleep-disordered breathing (SDB). However, unlike surgical interventions, this treatment modality relies heavily on patient acceptance and adherence. The current definition of adherence is largely arbitrary and is mainly used by third-party payers to determine CPAP reimbursement but CPAP adherence remains sub-optimal. Strategies to augment adherence, especially early in the course of a CPAP trial, are needed in the management of SDB. An understanding of the basis for observed differences in CPAP and oral appliance (OA) use is necessary in developing these strategies, but to date no single factor has been consistently identified. Consequently, a multidimensional approach using educational, behavioural, technological and potentially pharmacological strategies to target (i) disease characteristics, (ii) patient characteristics including psychosocial factors, (iii) treatment protocols and (iv) technological devices and side effects that may influence adherence, is likely required to augment the complex behaviour of CPAP and OA use. In the near future, we envision a personalized medicine approach to determine the risk of non-adherence and set individualized adherence goals aimed at treating specific symptoms (e.g. excessive daytime sleepiness) and reducing the risk of patient-specific SDB consequences (e.g. atherosclerosis). Resources for interventions to improve adherence such as educational programmes and telemedicine encounters could then be more efficiently allocated.
持续气道正压通气（CPAP）在治疗睡眠呼吸紊乱（SDB）方面非常有效。然而，与手术干预不同，这种治疗方式在很大程度上依赖于患者的接受度和依从性。目前对于依从性的定义在很大程度上是随意的，主要被第三方支付者用于确定CPAP的报销，但CPAP的依从性仍然不理想。在SDB的管理中，需要采取策略来提高依从性，尤其是在CPAP试验过程的早期。在制定这些策略时，了解观察到的CPAP和口腔矫治器（OA）使用差异的基础是必要的，但迄今为止尚未一致确定单一因素。因此，可能需要一种多维方法，使用教育、行为、技术和潜在的药理学策略来针对（i）疾病特征，（ii）包括心理社会因素在内的患者特征，（iii）治疗方案，以及（iv）可能影响依从性的技术设备和副作用，以增强CPAP和OA使用这种复杂行为。在不久的将来，我们设想采用个性化医疗方法来确定不依从的风险，并设定个性化的依从目标，旨在治疗特定症状（如白天过度嗜睡）并降低患者特定的SDB后果（如动脉粥样硬化）的风险。这样一来，就可以更有效地分配用于改善依从性的干预资源，如教育项目和远程医疗会诊。
