Adherence to CPAP: What Should We Be Aiming For, and How Can We Get There?

The purpose of this review was to summarize what is currently known regarding two important questions facing the field of sleep medicine today: (1) How many hours of CPAP use per night are necessary to improve daytime symptoms and reduce cardiovascular risk associated with OSA?; and (2) What strategies could be implemented to optimize adherence in clinical settings? Despite the widespread adoption of a threshold approach to CPAP management, the literature to date suggests a dose-response relationship between CPAP usage and a range of outcomes, including sleepiness, functional status, and BP; the data also suggest that the optimal adherence level differs depending on the outcome in question. Over the years, psychological measures of behavior change constructs have been increasingly recognized as the most consistent predictors of CPAP adherence, and, as such, the most successful interventions for optimizing adherence have been behavioral in nature. Unfortunately, behavioral therapies have not been translated from highly controlled research settings to comparative-effectiveness studies and finally into routine care, mainly due to feasibility and cost issues. More recently, theory-driven telemedicine adherence interventions have emerged, which take advantage of the framework that already exists in the United States and elsewhere for real-time remote-monitoring of CPAP. Combining theory-driven behavioral approaches with telemedicine technology could hold the answer to increasing real-world CPAP adherence rates, although randomized studies are still required, and socioeconomic barriers to telemedicine will need to be addressed to promote health equity.