Mouth Breathing Compromises Adherence to Nasal Continuous Positive Airway Pressure Therapy

doi:10.1378/chest.126.4.1248

Chest

Volume 126, Issue 4, October 2004, Pages 1248-1254

https://doi.org/10.1378/chest.126.4.1248 Get rights and content

Study objectives:

Mouth leak compromises nasal continuous positive airway pressure (CPAP) therapy. We hypothesized that patients who breathe mainly through their mouths during sleep, compared to those who breathe mainly through their noses, would have more mouth leak during CPAP and therefore lower adherence to CPAP.

Design:

A case-control study to compare adherence to CPAP at 1 year in mouth breathers (MBs) with nose breathers (NBs).

Setting:

University teaching hospital with a sleep laboratory.

Patients:

Fifty-one CPAP-naive patients (4 women), with a respiratory disturbance index (RDI) > 15/h. Of the 51 patients, 30 patients breathed through their mouths (mouth breathing > 70% of total sleep time [TST]), and 21 patients breathed through their noses (mouth breathing < 30% of TST). MBs between 30% and 70% of TST were excluded.

Interventions:

Overnight polysomnography was performed at baseline, during CPAP titration, and at 3 months. Patients were followed up for 1 year after beginning CPAP.

Measurements and results:

To measure mouth breathing, nasal and oral thermistors during polysomnography were separated by a 3 × 6-cm silicon transverse diaphragm. RDI decreased from (mean ± SD) 37.8 ± 21.5 to 1.8 ± 2.6/h at 3 months. Throughout the study, adherence to CPAP (mean daily CPAP use in hours) was better in NBs. Most NBs (71%) but only 30% of MBs used CPAP daily for > 4 h at 1-year follow-up. Mouth breathing decreased significantly from 84 ± 8.9% at baseline to 22 ± 14.4% at 3 months.

Conclusion:

Patients with moderate-to-severe sleep-disordered breathing and a high percentage of mouth breathing during sleep were less adherent to CPAP therapy than patients exhibiting a low percentage of mouth breathing.

Section snippets

Patients

From 231 consecutive CPAP-naive patients referred for snoring and a variable degree of daytime sleepiness, 119 patients were excluded because their respiratory disturbance index (RDI) was < 15/h. We also excluded 19 patients: 3 patients with a stroke < 1 year previously, 2 patients with severe psychiatric illness, 5 patients with a prior uvulopalatopharyngoplasty, 3 patients with persistent nasal symptoms, 1 patient who refused CPAP, and 5 patients to whom nasal surgical intervention was

Baseline Demographics and Sleep Characteristics

We studied 51 patients (4 women). MBs and NBs did not differ with respect to age, sex, body mass index (BMI), neck circumference (NC), ESS, AUDIT score, TST, TST while supine, rapid eye movement (REM) sleep, wakefulness after sleep onset (WASO), sleep efficiency, RDI while supine, or pulse oxygen saturation (Spo₂) awake. Meanwhile, total arousal, respiratory arousal, RDI, and an oxygen desaturation index of 4% (ODI₄) were higher in MBs, but the amount of delta sleep was lower. By design, the

Discussion

The main finding of this study is that in patients with SDB, a high percentage of mouth breathing during sleep represents a risk for low adherence to CPAP. Furthermore, although mouth breathing decreases considerably when patients are put on nasal CPAP, MBs still have considerably more mouth breathing on CPAP than do NBs. We also found a significant correlation in all patients between use of CPAP at 1 month and its long-term use. These findings are consistent with others, that mouth leak may

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In an open-label single center prospective cohort study, data from files and full night polysomnography on NM and OM were collected for patients wearing OM and presenting an UAO index ≥15/h despite an EPAP level ≥ 10 cmH20.
Forty-four patients were included in the study. In 31 patients (74 %), switching to a NM reduced UAOi to ≥10/h. Interestingly, 92 % of these patients still had NM at 3 to 12 months of follow-up. Switching to a NM was also associated with a trend in paCO2 reduction and significant improvements in Epworth, sleep quality and NIV compliance. Successful interface switching was significantly associated with female gender, and a trend was observed in non-smokers.
As for CPAP, switching to a NM improved NIV efficacy in a selected group of patients presenting residual UAO events despite high EPAP levels. Additionally, this switch has an impact on compliance and subjective sleepiness. Thus, in patients with persisting UAO on OM, switching to a NM could be a first-line intervention before considering further investigation such as polygraphy or video laryngoscopy. We also derive an algorithm for mask allocation and adaptation in acute and chronic NIV use.
Outcome of nasal measurements in patients with OSA – Mounting evidence of a nasal endotype
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Increased nasal resistance as measured by 4-phase rhinomanometry is associated with a paucity of apneas relative to hypopneas in obstructive sleep apnea (OSA) patients. The ratio of hypopneas to apneas for a given apnea hypopnea index (AHI) may influence treatment choice. This study aimed to investigate if OSA patients with an elevated hypopnea apnea ratio are associated with differences in acoustic rhinometry measurements.
One hundred and thirty-nine (n = 139) OSA patients (AHI >5) were enrolled in this prospective case-control study (all male). OSA Diagnosis was established through a type three sleep study. Both acoustic rhinometry and 4-phase rhinomanometry were performed on all patients at baseline and after decongestion. Possible associations between apnea-hypopnea index, oxygen desaturation index, nadir oxygen saturation, apnea index, hypopnea index, hypopnea to apnea ratio and body mass index and were analysed using multiple logistic and linear regression models.
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Sept patients ont été étudiés. Bien que l’oxymétrie nocturne était similaire avec les 2 types de masques, l’index d’obstruction des VAS sans diminution de la commande ventilatoire était significativement inférieur lors de VNI avec le masque Amara View™ (p = 0,01).
La VNI nocturne avec masque Amara View™ peut éviter des obstructions des VAS sans diminution de la commande ventilatoire.
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This retrospective study assessed the impact of the Amara View™ mask on UA. The study was conducted on patients with chronic respiratory failure treated by home NIV with standard facial mask. Replacement of the standard facial mask by an Amara View™ mask was performed when the residual apnea hypopnea index recorded from the ventilator software exceeded 5/h. All patients underwent nocturnal respiratory polygraphy when on NIV with a standard facial mask and with an Amara View™ mask. Respiratory polygraphic traces were interpreted following the analysis methods published by the SomnoNIV Group.
Seven patients were studied. Although nocturnal oxygen saturation was similar between both masks, the index of UA obstruction without ventilatory blunting was significantly lower during NIV with the Amara View™ mask compared to the standard facial mask (P = 0.01).
Nocturnal NIV using an Amara View™ facial interface may avoid UA obstruction without ventilatory command blunting.
Transmission of Oral Pressure Compromises Oronasal CPAP Efficacy in the Treatment of OSA
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Nasal function and CPAP compliance
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Continuous positive airway pressure (CPAP) is the mainstay therapy for patients with obstructive sleep apnea (OSA) however compliance with CPAP is variable. Nasal ailments, such as nasal congestion are frequently mentioned as a cause for CPAP non-compliance, and potentially could be addressed prior to CPAP initiation, however, no specific criteria or recommendations for the evaluation and management of these patients exist. The aim of this retrospective study is to evaluate the effects of nasal anatomic features and disease on adherence to CPAP therapy for patients with OSA and determine the indications for pre-CPAP nasal treatment by using data obtained at clinical examination.
In total, 711 adult patients with initial diagnosis of OSA and an apnea–hypopnea index of ≥20 who were amenable to CPAP were included. We analyzed nasal parameters, past history of nasal disease, subjective symptoms, and disease severity in addition to whether CPAP therapy had been initiated, rate of CPAP therapy use (initial and 1 year), treatment continuation rate at 2 months and 1 year, and nasal treatments for all patients.
CPAP therapy was initiated in 543 of 711 patients. Nasal resistance was significantly higher in patients who discontinued therapy soon after CPAP initiation. Nasal disease and nasal parameters were not found to be predictors of treatment adherence at 1 year.
Allergic rhinitis, moderate to severe nasal congestion at bedtime, slight or extensive sinus opacification, and a high nasal septum deviation score were found to be independent predictors of nasal treatment, while strong awareness of nasal congestion, a past history of sinusitis, and a total nasal resistance (supine position) of ≥0.35 Pa/cm³/s were independent predictors of surgical treatment.
Long-term CPAP therapy adherence in patients with OSA can be predicted from initial CPAP adherence. Nasal disease and nasal parameters are important factors for early CPAP therapy discontinuation and should be adequately treated before therapy initiation to ensure long-term adherence. Indications for pre-CPAP nasal treatment and nasal surgery for patients with OSA can be predicted from the data obtained at the first examination, and these patients should be treated differently from those without OSA.

View all citing articles on Scopus

: Financial support provided by Helsinki University Hospital Special Funds.

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Chest

Clinical InvestigationsSLEEP AND BREATHINGMouth Breathing Compromises Adherence to Nasal Continuous Positive Airway Pressure Therapy

Study objectives:

Design:

Setting:

Patients:

Interventions:

Measurements and results:

Conclusion:

Section snippets

Patients

Baseline Demographics and Sleep Characteristics

Discussion

Lancet

Chest

Chest

Sleep Med

Chest

Chest

Chest

Chest

Chest

Sleep Med

Chest

Effect of continuous positive airway pressure on sleep architecture in the sleep apnea-hypopnea syndrome: a randomized controlled trial

Am J Respir Crit Care Med

Night to night variability in CPAP use over the first three months of treatment

Sleep

Nasal CPAP: an objective evaluation of treatment compliance

Am J Respir Crit Care Med

Clinical Investigations
SLEEP AND BREATHING
Mouth Breathing Compromises Adherence to Nasal Continuous Positive Airway Pressure Therapy