A Pilot Randomized Trial of Combined Cognitive-Behavioral Therapy and Exercise Training Versus Exercise Training Alone for the Management of Chronic Insomnia in Obstructive Sleep Apnea.

Insomnia treatment among individuals with comorbid insomnia and obstructive sleep apnea is suboptimal. In a pilot randomized controlled trial, 19 individuals with comorbid insomnia and obstructive sleep apnea were allocated to one of two arms: EX + EX, consisting of two 8-week phases of exercise training (EX), or RE + CBTiEX, encompassing 8 weeks of relaxation training (RE) followed by 8 weeks of combined cognitive-behavioral therapy and exercise (CBTiEX). Outcomes included Insomnia Severity Index (ISI), polysomnography, and cardiorespiratory fitness measures. A mixed-model analysis of variance revealed a Group × Time interaction on peak oxygen consumption change, F(1, 14) = 10.1, p = .007, and EX increased peak oxygen consumption (p = .03, g' = -0.41) and reduced ISI (p = .001, g' = 0.82) compared with RE (p = .49, g = 0.16) post-8 weeks. Post-16 weeks, there was a significant Group × Time interaction (p = .014) driven by RE + CBTiEX yielding a larger improvement in ISI (p = .023, g' = 1.48) than EX + EX (p = .88, g' < 0.1). Objective sleep was unchanged. This study showed promising effects of regular EX alone and combined with cognitive-behavioral therapy for insomnia on ISI in comorbid insomnia and obstructive sleep apnea.

Randomized Trial of Nocturnal Oxygen in Chronic Obstructive Pulmonary Disease.

BACKGROUND: Long-term oxygen therapy improves survival in patients with chronic obstructive pulmonary disease (COPD) and chronic severe daytime hypoxemia. However, the efficacy of oxygen therapy for the management of isolated nocturnal hypoxemia is uncertain. METHODS: We designed this double-blind, placebo-controlled, randomized trial to determine, in patients with COPD who have nocturnal arterial oxygen desaturation without qualifying for long-term oxygen therapy, whether nocturnal oxygen provided for a period of 3 to 4 years would decrease mortality or the worsening of disease such that patients meet current specifications for long-term oxygen therapy. Patients with an oxygen saturation of less than 90% for at least 30% of the recording time on nocturnal oximetry were assigned, in a 1:1 ratio, to receive either nocturnal oxygen or ambient air from a sham concentrator (placebo). The primary outcome was a composite of death from any cause or a requirement for long-term oxygen therapy as defined by the Nocturnal Oxygen Therapy Trial (NOTT) criteria in the intention-to-treat population. RESULTS: Recruitment was stopped prematurely because of recruitment and retention difficulties after 243 patients, of a projected 600, had undergone randomization at 28 centers. At 3 years of follow-up, 39.0% of the patients assigned to nocturnal oxygen (48 of 123) and 42.0% of those assigned to placebo (50 of 119) met the NOTT-defined criteria for long-term oxygen therapy or had died (difference, -3.0 percentage points; 95% confidence interval, -15.1 to 9.1). CONCLUSIONS: Our underpowered trial provides no indication that nocturnal oxygen has a positive or negative effect on survival or progression to long-term oxygen therapy in patients with COPD. (Funded by the Canadian Institutes of Health Research; INOX ClinicalTrials.gov number, NCT01044628.).

Should testing for obstructive sleep apnea be offered routinely to older family medicine patients? A prospective cohort study.

In our previous studies, we offered older family medicine patients testing for obstructive sleep apnea (OSA) and discovered that 80% of patients who accepted, were later diagnosed with unsuspected OSA. In the present study, we followed such patients for 3 years of usual treatment. The goals were to (1) observe whether wider testing for OSA would increase case recognition and treatment uptake; (2) identify symptom and health characteristics associated with diagnosis and treatment efficacy. 101 women and 75 men (>45 years) recruited from family medicine clinics completed questionnaires, polysomnography and consented to chart review (Time 1). Participants with OSA were offered treatment and follow-up with a sleep medicine specialist. All were re-evaluated after 3 years (Time 2). At Time 1, 93% of participants received a diagnosis of OSA. Of these, 53 initiated treatment (46 PAP therapy); at Time 2, 24 PAP users met criteria for adherence. PAP-adherent participants had worse OSA and worse reported symptoms at Time 1 than non-adherent participants. At Time 2, PAP-adherent participants improved on insomnia and daytime symptoms compared to non-adherent participants who showed no change. Adherent and non-adherent participants showed no difference in health indices at Time 1 and no change at three-year follow-up. Benefits of treatment included improvements in co-morbid insomnia and daytime functioning; however, offering wider testing for OSA to older, family medicine patients yielded a high rate of diagnosis but low treatment adoption and adherence. Therefore, a cost-effective strategy would identify and support those likely to adopt and adhere to treatment.

The challenge of identifying family medicine patients with obstructive sleep apnea: addressing the question of gender inequality.

Purpose: The purpose of this study was to examine the sleep characteristics, metabolic syndrome disease and likelihood of obstructive sleep apnea in a sample of older, family medicine patients previously unsuspected for sleep apnea. Methods: A total of 295 participants, minimum age 45, 58.7% women, were recruited from two family medicine clinics. None previously had been referred for sleep apnea testing. All participants completed a sleep symptom questionnaire and were offered an overnight polysomnography study, regardless of questionnaire results. 171 followed through with the sleep laboratory component of the study. Health data regarding metabolic syndrome disease (hypertension, hyperlipidemia, diabetes and obesity) were gathered by chart review. Results: Overall, more women than men enrolled in the study and pursued laboratory testing. Of those who underwent polysomnography testing, 75% of the women and 85% of the men were diagnosed with sleep apnea based on an apnea/hypopnea index of 10 or greater. Women and men had similar polysomnography indices, the majority being in the moderate to severe ranges. In those with OSA diagnosis, gender differences in sleep symptom severity were not significant. Conclusions: We conclude that greater gender equality in sleep apnea rates can be achieved in family practice if sleep apnea assessments are widely offered to older patients.

Manifestations of Insomnia in Sleep Apnea: Implications for Screening and Treatment.

The aims of this study were to examine the presence, type, and severity of insomnia complaints in obstructive sleep apnea (OSA) patients and to assess the utility of the Sleep Symptom Checklist (SSC) for case identification in primary care. Participants were 88 OSA patients, 57 cognitive-behavioral therapy for insomnia (CBT-I) patients, and 14 healthy controls (Ctrl). Each completed a sleep questionnaire as well as the SSC, which includes insomnia, daytime functioning, psychological, and sleep disorder subscales. Results showed that OSA patients could be grouped according to 3 insomnia patterns: no insomnia (OSA), n = 21; insomnia (OSA-I), n = 30, with a subjective complaint and disrupted sleep; and noncomplaining poor sleepers (OSA-I-NC), n = 37. Comparisons among the OSA, CBT-I, and Ctrl groups demonstrate distinct profiles on the SSC subscales, indicating its potential utility for both case identification and treatment planning.

Prevalence and regional distribution of obstructive sleep apnea in Canada: Analysis from the Canadian Longitudinal Study on Aging.

OBJECTIVES: Obstructive sleep apnea (OSA) is a common chronic condition that is often undiagnosed or diagnosed after many years of symptoms and has an impact on quality of life and several health factors. We estimated the Canadian national prevalence of OSA using a validated questionnaire and physical measurements in participants in the Canadian Longitudinal Study on Aging (CLSA). METHODS: The method used individual risk estimation based upon the validated STOP-BANG scale developed for OSA. This stratified population sample spans Canada to provide regional estimates. RESULTS: In this sample of adults aged 45 to 85 years old, the overall prevalence in 2015 of combined moderate and severe OSA in the 51,337 participants was 28.1% (95% confidence intervals, 27.8‒28.4). The regional prevalence varied statistically between Atlantic Canada and Western Canada (p < 0.001), although clinically the variations were limited. The provincial prevalence for moderate and severe OSA ranged from 27.5% (New Brunswick and British Columbia) to 29.1% (Manitoba). Body mass index (BMI) was the dominant determinant of the variance between provinces (ß = 0.33, p < 0.001). Only 1.2% of participants had a clinical diagnosis of OSA. CONCLUSION: The great majority (92.9%) of the participants at high risk of OSA were unrecognized and had no clinical diagnosis of OSA.

RéSUMé: OBJECTIFS: Le syndrome de l'apnée du sommeil (SAS) est une maladie chronique courante qui est souvent non diagnostiquée ou diagnostiquée plusieurs années après l'apparition de symptômes et qui a un impact sur la qualité de vie ainsi que plusieurs autres facteurs de santé. Nous avons estimé la prévalence nationale canadienne du SAS à l'aide d'un questionnaire validé et de mesures physiques chez les participants de l'Étude longitudinale canadienne sur le vieillissement (ÉLCV). MéTHODES: L'étude mesure l'estimation du risque individuel du SAS basée sur l'échelle validée STOP-BANG qui a été développée pour l'évaluation du SAS. Cet échantillon de population stratifié couvre tout le Canada et permet de fournir des estimations régionales. RéSULTATS: Dans cet échantillon d'adultes âgés de 45 à 85 ans, la prévalence globale du SAS modéré et sévère chez les 51 337 participants était de 28,1 % en 2015 (intervalles de confiance à 95 %: 27,8‒28,4). La prévalence régionale variait statistiquement entre le Canada atlantique et l'ouest du Canada (p < 0,001), bien que les variations cliniques soient limitées. La prévalence provinciale du SAS modéré et sévère variait entre 27,5 % (Nouveau-Brunswick et Colombie-Britannique) et 29,1 % (Manitoba). L'indice de masse corporelle représentait le facteur dominant de la variance entre les provinces (ß = 0,33, p < 0,001). Seulement 1,2 % des participants avaient un diagnostic clinique du SAS. CONCLUSION: La grande majorité (92,9 %) des participants présentant un risque élevé du SAS n'étaient pas identifiés auparavant et n'avaient aucun diagnostic clinique du SAS.

Short-Term Oxygen Therapy Outcomes in COPD.

Rationale: Short-term oxygen therapy (STOT) is often prescribed to allow patients with chronic obstructive pulmonary disease (COPD) to be discharged safely from hospital following an acute illness. This practice is widely accepted without being based on evidence. Purpose: Our objective was to describe the characteristics and outcomes of patients with COPD who received STOT. Patients and Methods: The study was a secondary analysis of the INOX trial, a 4-year randomised trial of nocturnal oxygen in COPD. The trial indicated that nocturnal oxygen has no significant effect on survival or progression to LTOT, allowing our merging of patients who received nocturnal oxygen and those who received placebo into a single cohort to study the predictors and outcomes of STOT regardless of the treatment received during the trial. Results: Among the 243 participants in the trial, 60 required STOT on at least one occasion during follow-up. Patients requiring STOT had more severe dyspnoea and lung function impairment, and lower PaO2 at baseline than those who did not. STOT was associated with subsequent LTOT requirement (hazard ratio [HR]: 4.59; 95% confidence interval [CI]: 2.98-7.07) and mortality (HR: 1.93; 95% CI: 1.15-3.24). The association between STOT and mortality was confounded by age, disease severity and comorbidities. Periods of STOT of more than one month and/or repeated prescriptions of STOT increased the probability of progression to LTOT (OR: 5.07; 95% CI: 1.48-18.8). Conclusion: Following an acute respiratory illness in COPD, persistent hypoxaemia requiring STOT is a marker of disease progression towards the requirement for LTOT.

A portrait of obstructive sleep apnea risk factors in 27,210 middle-aged and older adults in the Canadian Longitudinal Study on Aging.

Determining the prevalence and characteristics of individuals susceptible to present with obstructive sleep apnea (OSA) is essential for developing targeted and efficient prevention and screening strategies. We included 27,210 participants aged ≥45 years old (50.3% women) from the Canadian Longitudinal Study on Aging. Using the STOP questionnaire combined to the percentage of body fat (%BF), we estimated the prevalence of individuals at high-risk for OSA in a sex and age-specific manner, and tested the relation with comorbidities, menopause and systemic inflammation. The prevalence was 17.5%, and was lower in women (13.1%) than in men (21.9%). A high level of high-sensitivity C-reactive protein was the strongest factor associated with OSA risk and this association was 1.3-2.3 times higher in women than in men. OSA risk increased with age, cardiovascular diseases, diabetes mellitus, anxio-depressive symptoms, asthma and arthritis. In women, post-menopausal status was associated with a high OSA risk. Nearly 1 adult out of 5 older than 45 is at risk for OSA in Canada. Comorbidities, menopause and systemic inflammation, more than age, explain increased OSA prevalence. Considering this high prevalence and associations with medical and mental comorbidities, health care practitioners should incorporate systematic OSA screening in their clinical procedures.

Association between risk of obstructive sleep apnea, inflammation and cognition after 45 years old in the Canadian Longitudinal Study on Aging.

BACKGROUND: The association between obstructive sleep apnea and cognitive functioning is not yet fully understood and could be influenced by factors such as sex, age and systemic inflammation. We determined the sex- and age-specific association between obstructive sleep apnea risk and cognitive performance, and the influence of systemic inflammation on this association. METHODS: We included 25,899 participants from the Canadian Longitudinal Study of Aging comprehensive cohort, aged 45-85 years (51% women). We conducted sex- and age-specific (45-59; 60-69; ≥70) general linear models between obstructive sleep apnea risk and cognitive scores, and tested the moderating and mediating effects of high-sensitivity C-reactive protein levels. Obstructive sleep apnea risk was estimated by combining the STOP and whole-body fat percentage. Cognitive tests assessed episodic verbal memory, executive functions and psychomotor speed. Levels of high-sensitivity C-reactive protein were obtained through blood samples. RESULTS: Higher obstructive sleep apnea risk was associated with poorer episodic memory in women aged 45-59 years, and poorer executive function (p < 0.05 on multiple tests) in women aged 45-59 and 60-69 years. No such association was found in men. High-sensitivity C-reactive protein levels mediated some associations between obstructive sleep apnea risk and executive function in women and men aged <70 years. CONCLUSIONS: Being at high-risk for obstructive sleep apnea is associated with poorer cognition in women aged <70 years. These associations were partly mediated by systemic inflammation. These results underscore the importance of obstructive sleep apnea diagnosis, treatment and appropriate follow-up, particularly in middle-aged women who might already show signs of early cognitive impairments.

Combining both generic and disease-specific properties: development of the McGill COPD quality of life questionnaire.

UNLABELLED: Presently, a generic and a disease-specific questionnaire are often co-administered to capture the different domains of quality of life in chronic obstructive pulmonary disease (COPD) subjects. A health-related-quality of life (HRQL) questionnaire in COPD combining both generic and disease-specific properties is needed. OBJECTIVE: To develop a new, hybrid-HRQL questionnaire, the McGill-COPD-questionnaire, with qualities of both generic and disease-specific instruments. Using pre-defined criteria, we selected items from the SF-36 to complement the items from a COPD-specific-module to create the new hybrid-HRQL-questionnaire. Domains were identified via confirmatory factor analysis. The McGill COPD questionnaire is available in English and French; it assesses three domains: symptoms, physical-function and feelings, has 29 items: 17 from the COPD-specific-module and 12 from the SF-36. The symptom sub-scale has 6 items, all from the COPD-specific-module; the feelings sub-scale has 10 items, 5 each from COPD-specific-module and SF-36 and the physical-function sub-scale has 13 items, 6 from COPD-specific-module and 7 from SF-36. The McGill COPD questionnaire was developed using a novel method of combining items from the SF-36 and a COPD-specific-module. Thus, this new questionnaire has items from a generic-questionnaire and a disease-specific-module and, hence, is promising to be a stand alone quality-of-life questionnaire for COPD subjects.

Impact of the COVID-19 pandemic on obstructive sleep apnea: recommendations for symptom management.

STUDY OBJECTIVES: In the context of the current COVID-19 pandemic situation, we address the following important questions: (1) How can patients be identified for possible OSA while sleep clinic testing is temporarily unavailable or limited? and (2) What measures can be suggested to improve sleep health until proper diagnosis and treatment become safe and available again? METHODS: As a proxy for home or in-laboratory testing, validation of a symptom-based measure of OSA risk is presented, based on an ongoing larger prospective study of 156 family medicine patients with OSA (88 women, 68 men; mean age, 57 years) and 60 control participants (36 women, 24 men; mean age, 54 years) recruited from the community. Participants completed the Sleep Symptom Checklist (SSC) and a range of other self-report measures; primary care patients also underwent a polysomnographic sleep study. RESULTS: Results showed that (1) individuals with OSA reported more symptoms on the SSC related to insomnia, daytime symptoms, sleep disorders, and psychological maladjustment than did the control group (all P < .001), and (2) their sleep-related symptoms were significantly more severe than those of the control patients. In addition, several polysomnographic indices in recently diagnosed untreated individuals with OSA were significantly correlated with SSC measured sleep disorder symptoms, and SSC scores significantly distinguished participants with OSA from control participants. CONCLUSIONS: Our findings suggest that family practitioners can effectively prescreen patients for possible OSA by inquiring about 5 items that form the SSC sleep disorders subscale. If OSA is suspected, then we can recommend a range of behavioral techniques to improve symptoms. The current pandemic causes us to reflect that the provisional targeting of symptoms and guidance regarding mitigation strategies while waiting for specialist care could serve patients well at any time.

Dream enactment behavior: review for the clinician.

NONE: Dream enactment behavior commonly occurs on occasion in normal children and adults. Disruptive and frequent dream enactment behavior may come to the attention of the clinician either as the primary reason for consultation or as a prominent characteristic of a patient with other sleep disorders. Questioning patients with chronic neurologic and psychiatric disorders may also reveal previously unrecognized behavior. In the absence of sleep pathology, process of dream enactment likely begins with active, often emotionally charged dream content that may occasionally break through the normal REM sleep motor suppressive activity. Disrupted sleep resulting from many possible causes, such as circadian disruption, sleep apnea, or medications, may also disrupt at least temporarily the motor-suppressive activity in REM sleep, allowing dream enactment to occur. Finally, pathological neurological damage in the context of degenerative, autoimmune, and infectious neurological disorders may lead to chronic recurrent and severe dream enactment behavior. Evaluating the context, frequency, and severity of dream enactment behavior is guided first and foremost by a structured approach to the sleep history. Physical exam and selected testing support the clinical diagnosis. Understanding the context and the likely cause is essential to effective therapy.

Sleep disorder symptoms are common and unspoken in Canadian general practice.

OBJECTIVE: Primary care patients were surveyed for what sleep disorder symptoms they discussed with their physicians. Their responses were compared with those of new Sleep clinic patients. The goal was to discover what symptom presentation leads to a successful referral to a sleep clinic. METHODS: We recruited two samples: 191 older Primary care patients and 138 Sleep clinic patients. Participants completed the Sleep Symptom Checklist (SSC). This consists of 21 symptoms in four domains: insomnia, sleep disorder, daytime symptoms and psychological distress. All respondents indicated which symptoms had been discussed with their physician in the past year. Primary care subjects were designated as Decliners (completed SSC, refused further evaluation), Dropouts [completed some evaluation steps, but not polysomnography (PSG)] and Completers (completed PSG). RESULTS: Primary care participants frequently had symptoms but relatively few had discussed them with their doctor. Sleep clinic participants discussed significantly more symptoms with their referring physician than did Primary care Dropouts or Decliners in all categories except psychological distress. Primary care Completers, 88.5% of whom were ultimately diagnosed with sleep apnoea/hypopnoea syndrome and/or periodic limb movement disorder, also discussed their sleep disorder symptoms less frequently than did Sleep clinic patients but tended to give more prominence to symptoms of insomnia and impaired daytime function. CONCLUSIONS: The findings suggest that Primary care patients often have symptoms they do not discuss, even when a primary sleep disorder exists. The brief SSC checklist, developed in our laboratory, has potential to improve the referral rates of older primary care patients who have sleep disorder.

Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial.

BACKGROUND: Home-based rehabilitation is a promising approach to improve access to pulmonary rehabilitation. OBJECTIVE: To assess whether self-monitored, home-based rehabilitation is as effective as outpatient, hospital-based rehabilitation in patients with chronic obstructive pulmonary disease (COPD). DESIGN: Randomized, multicenter, noninferiority trial. SETTING: 10 academic and community medical centers in Canada. PATIENTS: 252 patients with moderate to severe COPD. INTERVENTION: After a 4-week education program, patients took part in home-based rehabilitation or outpatient, hospital-based rehabilitation for 8 weeks. They were followed for 40 weeks to complete the 1-year study. MEASUREMENTS: The primary outcome was the change in Chronic Respiratory Questionnaire dyspnea subscale score at 1 year. The primary analysis took a modified intention-to-treat approach by using all patients who provided data at the specified follow-up time, regardless of their level of adherence. The analysis used regression modeling that adjusted for the effects of center, sex, and baseline level. All differences were computed as home intervention minus outpatient intervention. RESULTS: Both interventions produced similar improvements in the Chronic Respiratory Questionnaire dyspnea subscale at 1 year: improvement in dyspnea of 0.62 (95% CI, 0.43 to 0.80) units in the home intervention (n = 107) and 0.46 (CI, 0.28 to 0.64) units in the outpatient intervention (n = 109). The difference between the 2 treatments at 1 year was small and clinically unimportant. The 95% CI of the difference did not exceed the prespecified noninferiority margin of 0.5: difference in dyspnea score of 0.16 (CI, -0.08 to 0.40). Most adverse events were related to COPD exacerbations. No serious adverse event was considered to be related to the study intervention. LIMITATION: The contribution of the educational program to the improvement in health status and exercise tolerance cannot be ascertained. CONCLUSION: Home rehabilitation is a useful, equivalent alternative to outpatient rehabilitation in patients with COPD.

An Objective Measure of Drowsy Driving: Are We There Yet?

CITATION: Rizzo D, Baltzan M. An objective measure of drowsy driving: are we there yet? J Clin Sleep Med. 2019;15(9):1191-1192.

A diagnostic symptom profile for sleep disorder in primary care patients.

OBJECTIVE: The aim of the present study was (1) to evaluate the extent and nature of sleep disorder-related symptoms in the older primary care patient population and (2) to differentiate a pattern of self-reported symptoms that identify patients who should be referred to the sleep clinic for further evaluation. METHOD: One hundred ninety-six older adults recruited from family practice centers were administered a brief symptom survey measure. All were invited to participate in an extensive self-report evaluation, consultation with a sleep medicine specialist, and an overnight polysomnographic study. RESULTS: A substantial number of older primary care patients report symptoms related directly or indirectly to physiological sleep disorder. Over 30% of total reported some insomnia, 40% daytime sleepiness, and 10% apnea. Those participants who agreed to pursue further aspects of the study protocol endorsed a higher number and greater severity of primary sleep disorder symptoms than those who declined to continue beyond the first phases. Participants who chose to pursue polysomnography (13% of total) had a very high rate (88.5) of diagnosed sleep disorder. CONCLUSION: This study suggests that an older patient, male or female, who both endorses medically unexplained daytime sleepiness, fatigue, or other sleep disorder related symptoms and agrees to further evaluation, including overnight polysomnography, is at substantial risk for physiologically based sleep disorder. In the future, a brief, validated measure, such as the Sleep Symptom Checklist used in this study, would be an important part of the diagnostic process.

Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea.

BACKGROUND: Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnea (OSA). However, compliance is a significant problem and has been incompletely assessed in long-term studies. OBJECTIVE: To assess the long-term compliance of OSA patients with CPAP therapy. SUBJECTS: Eighty patients who had had a diagnosis of OSA at least four years previously and received a written prescription for CPAP were evaluated. METHODS: Subjects were identified by reviewing sleep laboratory records. Participants were contacted by telephone and were asked to quantitate their CPAP use (hours per night, nights per week) and to evaluate whether there had been improvement in symptoms. Those who commenced but subsequently abandoned therapy and those who never initiated treatment were questioned about their reasons for noncompliance. RESULTS: Patient demographics included mean (+/- SD) age (58+/-11 years), male sex (70 of 80 patients [88%]) and mean apnea-hypopnea index (70+/-44 events/h). At the time of the interview (64.0+/-3.7 months after diagnosis), 43 of 80 patients (54%) were still using CPAP and most reported an improvement in symptoms. Twelve of 80 patients (15%) had abandoned CPAP after using it for 10.1+/-15.5 months, and 25 of 80 patients (31%) had never commenced therapy after initial diagnosis and CPAP titration. Analysis of scores reflecting initial patient sleepiness revealed a significant association of this symptom with subsequent CPAP compliance. CONCLUSION: Although many patients with OSA derive subjective benefit from, and adhere to treatment with CPAP, a significant proportion of those so diagnosed either do not initiate or eventually abandon therapy. Initial experience with CPAP appears to be important, reinforcing the need for early education and support in these patients.