Positive airway pressure telehealth models and long-term therapy termination: a healthcare database analysis.

Background: Telemonitoring-guided interventions can improve short-term positive airway pressure (PAP) therapy adherence, but long-term effects are unknown. This study investigated long-term PAP therapy termination in patients with sleep apnoea managed with standard care, telemonitoring-guided proactive care or telemonitoring-guided proactive care + patient engagement tool. Methods: German healthcare provider data were analysed retrospectively. Individuals aged 18-100 years who started PAP from 2014 to 2019 and had device type/interface data were included. Time-to-termination periods were analysed using Kaplan-Meier plots and Cox proportional hazards regression, adjusted for age, sex, insurance type, and device and mask type. Results: The per-protocol population (valid telemonitoring data) included 104 612 individuals (71% male; 95% aged >40 years). Mean follow-up was 3.3±2.0 years. The overall therapy termination rate was significantly lower in the telemonitoring-guided proactive care group versus standard care (20% versus 27%; p<0.001), and even lower in the telemonitoring-guided care + patient engagement tool group (11%; p<0.001 versus other treatment groups). Adjusted risk of therapy termination was lower versus standard care (hazard ratio 0.76, 95% confidence interval 0.74-0.78; and 0.41 (0.38-0.44) for telemonitoring-guided proactive care alone + patient engagement). Age <50 or >59 years and use of a nasal pillows or full-face mask were significant predictors of therapy termination; male sex, use of telemonitoring-guided proactive care (± patient engagement) and private insurance were significantly associated with lower therapy termination rates. Conclusions: Use of telemonitoring-guided proactive care and a patient engagement tool was associated with lower rates of PAP therapy termination.

Effect of switching from continuous to bilevel positive airway pressure on sleep quality in patients with obstructive sleep apnea: the prospective POP IN VAuto study.

Background: Issues with tolerability and side effects can decrease continuous positive airway pressure (CPAP) device usage and the benefits of therapy. Different positive airway pressure (PAP) therapy modes providing expiratory pressure relief or using a different pressure during inspiration vs. expiration (bilevel PAP) may alleviate some of these issues. This multicenter, prospective study evaluated the effects of switching from CPAP to bilevel PAP (VAuto mode) on respiratory parameters, device usage, side effects and patient-reported outcomes in patients with obstructive sleep apnea (OSA). Methods: Eligible OSA patients had started CPAP ≥3 months previously, had good compliance (mean 6.1±2.0 h/night) and well-controlled OSA [residual apnea-hypopnea index (AHI) 4.9±3.1/h] but had pressure tolerance issues or persistent side effects/discomfort. All were switched from CPAP to bilevel PAP (AirCurve 10 VAuto; ResMed). Effectiveness (residual AHI), sleep quality, daytime sleepiness, fatigue, therapy-related side effects, and patient satisfaction/preference were assessed after 3 months and 1 year. Results: Forty patients were analyzed (68% male, age 64±11 years, body mass index 30.7±5.8 kg/m2). At 3 months and 1 year after switching to bilevel PAP, median [interquartile range] residual AHI was 4/h [2-5.3] and 3.7/h [1.8-5], respectively, and device usage was 7.0 [4.9-7.5] and 6.4 [4.4-7.3] h/night, respectively. Device switch was associated with significant reductions from baseline in expiratory PAP {from 12 [11-13] to 8 [7-9] cmH2O at 3 months (P<0.001) and 9 [8-12] cmH2O at 1 year (P=0.005)}, 95th percentile pressure {from 14 [12-14] to 10 [9-11] and 10 [8-11] cmH2O; P<0.001 and P=0.001, respectively} and leak {from 1 [0-6] to 0 [0-1] and 0 [0-2] L/min; P=0.049 and P=0.033, respectively}. The Pittsburgh Sleep Quality Index score decreased significantly from baseline to 3 and 6 months [7.2±4.0 to 5.0±3.2 (P=0.005) and 4.5±2.7 (P<0.001), respectively]. CPAP-related mouth dryness, choking sensation and aerophagia were significantly improved one year after switching to bilevel PAP. Bilevel PAP was preferred over CPAP by 90% of patients. Conclusions: Switching to bilevel PAP had several benefits in patients struggling with CPAP, facilitating therapy acceptance and ongoing device usage.

Early identification of heart failure deterioration through respiratory monitoring with adaptive servo-ventilation.

Cardiac decompensation is associated with worse prognosis in patients with heart failure. Reliable methods to predict cardiac decompensation events are not yet available. Sleep-disordered breathing (SDB) is a frequent comorbidity in heart failure, and it has been shown to correlate with heart failure severity. This prospective observational trial investigated SDB characteristics in patients with heart failure with the aim to identify patterns that may predict early cardiac decompensation. Patients with heart failure with diagnosed SDB and hospitalised for cardiac decompensation were prospectively enrolled and treated with adaptive servo-ventilation (ASV). SDB characteristics, daily body weight and clinical cardiac decompensation events were collected over a 1-year follow-up. Clinical events were categorised by an independent clinical event committee. A total of 43 patients were enrolled (81% male, mean [SD] age 71 [11] years, body mass index 30 kg/m2 , 95% New York Heart Association function class III or IV, mean [SD] left ventricular ejection fraction 37% [11%], median apnea-hypopnoea index [AHI] of 37 events/h). A total of 48 cardiac decompensation events were recorded during the 1-year study period. Respiratory rate was found to be significantly lower in patients with cardiac decompensation. The AHI and applied inspiratory pressure ASV-device support were significantly increased 10 days before a clinical cardiac decompensation event. Device usage was also found to be significantly decreased 2 nights before cardiac decompensation. Device-derived respiratory data in ASV therapy devices for SDB may therefore serve as a monitoring tool to predict early clinical cardiac decompensation events. Prediction and avoidance of cardiac decompensation, in turn, may attenuate serious health consequences in patients with heart failure.

Prevalence and predictors of sleep-disordered breathing in chronic heart failure: the SchlaHF-XT registry.

AIMS: Heart failure with preserved ejection fraction (HFpEF) is a condition with increasing prevalence. Sleep-disordered breathing (SDB) is an important co-morbidity in HFpEF. The SchlaHF-XT registry evaluated the sex-specific prevalence and predictors of SDB, including obstructive (OSA) and central sleep apnoea, in patients with HFpEF compared with heart failure with mildly reduced (HFmrEF) or reduced (HFrEF) ejection fraction. METHODS AND RESULTS: Consecutive adults with chronic heart failure treated according to current guidelines were enrolled. The presence of moderate-to-severe SDB (apnoea-hypopnoea index ≥15/h) was determined using Type 3 polygraphic devices. Of 3289 patients included, 2032 had HFpEF, 559 had HFmrEF, and 698 had HFrEF, of whom 34, 21, 23, and 42%, respectively, were female. Prevalence of SDB in HFpEF was high, but significantly lower than in HFmrEF or HFrEF (36% vs. 41 and 48%, respectively). Rates of SDB in males and females were 41 and 28% in HFpEF, 44 and 30% in HFmrEF, and 50 and 40% in HFrEF. The proportion of males and females with SDB who had OSA was significantly greater in those with HFpEF vs. HFrEF. Male sex, older age, higher body mass index, and New York Heart Association functional Class III/IV were significant predictors of moderate-to-severe SDB in HFpEF patients. CONCLUSIONS: Prevalence of SDB in HFpEF was high, but lower than in patients with HFmrEF or HFrEF. Moderate-to-severe SDB occurred more frequently in males than in females across the whole spectrum of heart failure. In both sexes, the proportion of OSA in SDB patients with HFpEF was higher than in those with HFrEF.

Prevalence Of Chronic Hypercapnia In Severe Chronic Obstructive Pulmonary Disease: Data From The HOmeVent Registry.

Background: Non-invasive ventilation (NIV) has been shown to improve survival and quality of life in COPD patients with chronic hypercapnic respiratory failure. However, the proportion of COPD patients with chronic hypercapnia is not yet known and clinical data enabling better identification of patients are scarce. The HOmeVent registry was initiated to determine the prevalence of chronic hypercapnia in COPD in an outpatient setting and to evaluate the predictors of hypercapnia. Methods: HOmeVent is a multicenter, prospective, observational, non-interventional patient registry that includes COPD patients in GOLD stage 3 or 4. Eligible patients were identified and enrolled in an outpatient setting during routine clinic visits. Assessments included blood gas analyses, pulmonary function testing and quality of life assessment. Results: Ten outpatient clinics in Germany enrolled 231 COPD patients in the registry (135 in GOLD stage 3 (58%) and 96 in GOLD stage 4 (42%)). Arterial carbon dioxide pressure (PaCO2) was ≥45 mmHg in 58 patients (25%); of these, 20 (9%) had PaCO2 ≥50 mmHg. The prevalence of hypercapnia at both cut-off values was numerically higher for patients in GOLD stage 4 versus 3. An increased body mass index, a decreased forced vital capacity and an increased bicarbonate level were significant independent predictors of hypercapnia. The proportion of patients who received NIV was 6% overall and 22% of those with hypercapnia. Conclusion: A relevant proportion of COPD patients in GOLD stage 3 and 4 exhibits chronic hypercapnia and might, therefore, be candidates for long-term domiciliary NIV treatment.

Predictors of positive airway pressure therapy termination in the first year: analysis of big data from a German homecare provider.

BACKGROUND: There is a lack of robust data about factors predicting continuation (or termination) of positive airway pressure therapy (PAP) for sleep apnea. This analysis of big data from a German homecare provider describes patients treated with PAP, analyzes the therapy termination rate over the first year, and investigates predictive factors for therapy termination. METHODS: Data from a German homecare service provider were analyzed retrospectively. Patients who had started their first PAP therapy between September 2009 and April 2014 were eligible. Patient demographics, therapy start date, and the date of and reason for therapy termination were obtained. At 1 year, patients were classified as having compliance-related therapy termination or remaining on therapy. These groups were compared, and significant predictors of therapy termination determined. RESULTS: Of 98,329 patients included in the analysis, 11,702 (12%) terminated PAP therapy within the first year (after mean 171 ± 91 days). There was a U-shaped relationship between therapy termination and age; therapy termination was higher in the youngest (< 30 years, 15.5%) and oldest (≥ 80 years, 19.8%) patients, and lower in those aged 50-59 years (9.9%). Therapy termination was significantly more likely in females versus males (hazard ratio 1.48, 95% confidence interval 1.42-1.54), in those with public versus private insurance (1.75, 1.64-1.86) and in patients whose first device was automatically adjusting or fixed-level continuous positive airway pressure versus bilevel or adaptive servo-ventilation (1.28, 1.2-1.38). CONCLUSIONS: This analysis of the largest dataset investigating PAP therapy termination identified a number of predictive factors. These can help health care providers chose the most appropriate PAP modality, identify specific patient phenotypes at higher risk of stopping PAP and target interventions to support ongoing therapy to these groups, as well as allow them to develop a risk stratification tool.

Mask humidity during CPAP: influence of ambient temperature, heated humidification and heated tubing.

PURPOSE: Mucosal drying during continuous positive airway pressure (CPAP) therapy is problematic for many patients. This study assessed the influence of ambient relative humidity (rH) and air temperature (T) in winter and summer on mask humidity during CPAP, with and without mask leak, and with or without heated humidification ± heated tubing. METHODS: CPAP (8 and 12 cmH2O) without humidification (no humidity [nH]), with heated humidification controlled by ambient temperature and humidity (heated humidity [HH]) and HH plus heated tubing climate line (CL), with and without leakage, were compared in 18 subjects with OSA during summer and winter. RESULTS: The absolute humidity (aH) and the T inside the mask during CPAP were significantly lower in winter versus summer under all applied conditions. Overall, absolute humidity differences between summer and winter were statistically significant in both HH and CL vs. nH (p < 0.05) in the presence and absence of mouth leak. There were no significant differences in aH between HH and CL. However, in-mask temperature during CL was higher (p < 0.05) and rH lower than during HH. In winter, CPAP with CL was more likely to keep rH constant at 80% than CPAP without humidification or with standard HH. CONCLUSION: Clinically-relevant reductions in aH were documented during CPAP given under winter conditions. The addition of heated humidification, using a heated tube to avoid condensation is recommended to increase aH, which could be useful in CPAP users complaining of nose and throat symptoms.

Effect of a patient engagement tool on positive airway pressure adherence: analysis of a German healthcare provider database.

OBJECTIVE/BACKGROUND: This study investigated the addition of a real-time feedback patient engagement tool on positive airway pressure (PAP) adherence when added to a proactive telemedicine strategy. PATIENTS/METHODS: Data from a German healthcare provider (ResMed Healthcare Germany) were retrospectively analyzed. Patients who first started PAP therapy between 1 September 2009 and 30 April 2014, and were managed using telemedicine (AirView™; proactive care) or telemedicine + patient engagement tool (AirView™ + myAir™; patient engagement) were eligible. Patient demographics, therapy start date, sleep-disordered breathing indices, device usage hours, and therapy termination rate were obtained and compared between the two groups. RESULTS: The first 500 patients managed by telemedicine-guided care and a patient engagement tool were matched with 500 patients managed by telemedicine-guided care only. The proportion of nights with device usage ≥4 h was 77 ± 25% in the patient engagement group versus 63 ± 32% in the proactive care group (p < 0.001). Therapy termination occurred less often in the patient engagement group (p < 0.001). The apnea-hypopnea index was similar in the two groups, but leak was significantly lower in the patient engagement versus proactive care group (2.7 ± 4.0 vs 4.1 ± 5.3 L/min; p < 0.001). CONCLUSIONS: Addition of a patient engagement tool to telemonitoring-guided proactive care was associated with higher device usage and lower leak. This suggests that addition of an engagement tool may help improve PAP therapy adherence and reduce mask leak.

Phenotyping of Sleep-Disordered Breathing in Patients With Chronic Heart Failure With Reduced Ejection Fraction-the SchlaHF Registry.

BACKGROUND: Different sleep-disordered breathing (SDB) phenotypes, including coexisting obstructive and central sleep apnea (OSA-CSA), have not yet been characterized in a large sample of patients with heart failure and reduced ejection fraction (HFrEF) receiving guideline-based therapies. Therefore, the aim of the present study was to determine the proportion of OSA, CSA, and OSA-CSA, as well as periodic breathing, in HFrEF patients with SDB. METHODS AND RESULTS: The German SchlaHF registry enrolled patients with HFrEF receiving guideline-based therapies, who underwent portable SDB monitoring. Polysomnography (n=2365) was performed in patients with suspected SDB. Type of SDB (OSA, CSA, or OSA-CSA), the occurrence of periodic breathing (proportion of Cheyne-Stokes respiration ≥20%), and blood gases were determined in 1557 HFrEF patients with confirmed SDB. OSA, OSA-CSA, and CSA were found in 29%, 40%, and 31% of patients, respectively; 41% showed periodic breathing. Characteristics differed significantly among SDB groups and in those with versus without periodic breathing. There was a relationship between greater proportions of CSA and the presence of periodic breathing. Risk factors for having CSA rather than OSA were male sex, older age, presence of atrial fibrillation, lower ejection fraction, and lower awake carbon dioxide pressure (pco2). Periodic breathing was more likely in men, patients with atrial fibrillation, older patients, and as left ventricular ejection fraction and awake pco2 decreased, and less likely as body mass index increased and minimum oxygen saturation decreased. CONCLUSIONS: SchlaHF data show that there is wide interindividual variability in the SDB phenotype of HFrEF patients, suggesting that individualized management is appropriate. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01500759.

Telemedicine-based proactive patient management during positive airway pressure therapy: Impact on therapy termination rate.

BACKGROUND: Adherence to positive airway pressure (PAP) therapy is essential for the benefits of therapy to be realised. Telemedicine-based strategies provide a new option for enhanced monitoring and intervention to promote adherence during PAP. This study investigated the impact of telemedicine-based proactive patient management on PAP therapy termination rates versus standard care. METHODS: Observational data were obtained from ResMed Germany Healthcare, a German homecare provider. Patients were undergoing routine homecare using either a standard or proactive management strategy. The proactive strategy used data from AirView™, a cloud-based remote monitoring system, to prompt patient contact and information sharing/education. Patients receiving their first PAP therapy were included and analysed in matched pairs. RESULTS: In all, 3401 patients were included in each group. In the first year of PAP therapy, overall therapy termination rate was significantly lower (5.4% vs 11.0%; p < 0.001) and time to therapy termination was significantly longer (348 ± 58 vs 337 ± 76 days; p < 0.05) in the proactive versus standard care group. Cox proportional hazard analysis revealed a significantly reduced risk of PAP termination in the proactive versus the standard care group (hazard ratio 0.48, 95% confidence interval 0.4-0.57). Findings were consistent in subanalyses according to gender, type of device and insurance status, and in patients aged ≥40 years. However, in the subgroup of patients aged younger than 40 years, the risk of PAP termination was similar in the proactive and standard groups. CONCLUSION: A telemedicine-based proactive management strategy compared with standard care of PAP patients was associated with a lower long-term therapy termination rate.

Prevalence of Sleep-Disordered Breathing and Patient Characteristics in a Coronary Artery Disease Cohort Undergoing Cardiovascular Rehabilitation.

PURPOSE: Coronary artery disease (CAD) is a leading cause of death and identification of risk factors for CAD is crucial. One such potential risk factor is sleep-disordered breathing (SDB). This prospective cohort study investigated the prevalence of SDB and determined risk factors for the presence of SDB in a large CAD cohort undergoing cardiac rehabilitation. METHODS: A total of 1425 patients with confirmed CAD starting rehabilitation were screened for SDB using cardiorespiratory polygraphy (n = 921) or polygraphy plus pulse oximetry (n = 484). RESULTS: A total of 1408 patients were included; 69.5% were male, 78% had acute coronary syndrome, and 22% had stable CAD. The prevalence of SDB (apnea-hypopnea index [AHI] ≥5/h) was 83%. Moderate to severe SDB (AHI ≥15/h) was present in 53%. Up to 70% of coronary artery bypass graft (CABG) recipients had an AHI ≥15/h versus 33% of those who had not undergone CABG. SDB severity did not vary significantly in patients with stable CAD or on the basis of left ventricular ejection fraction. SDB was more severe and the frequency of oxygen desaturation was higher in men than in women. Multivariate logistic regression identified age, sex, body mass index, and CABG as independent risk factors for severe SDB. CONCLUSION: SDB is a highly prevalent comorbidity in patients with CAD, particularly those who have undergone CABG. These results strengthen existing associations and emphasize the importance of diagnosing and monitoring SDB in patients with CAD entering a cardiac rehabilitation program. Early diagnosis and intervention has the potential to have a beneficial effect on CAD prognosis.

Prevalence and Predictors of Sleep-Disordered Breathing in Patients With Stable Chronic Heart Failure: The SchlaHF Registry.

OBJECTIVES: This prospective study investigated the prevalence of sleep-disordered breathing (SDB) and its predictors in patients with stable chronic heart failure (HF). BACKGROUND: SDB is increasingly recognized as being important in patients with HF. METHODS: The multicenter SchlaHF (Sleep-Disordered Breathing in Heart Failure) registry provides demographic and clinical data on chronic, stable, symptomatic patients with HF (New York Heart Association functional class ≥II; left ventricular rejection fraction ≤45%). Moderate-to-severe SDB (apnea-hypopnea index ≥15/h) was determined by a 2-channel screening device (ApneaLink, ResMed, Sydney, Australia). RESULTS: Data from 6,876 patients were analyzed. The prevalence of moderate-to-severe SDB was 46%, with a significant sex difference: 36% in women (n = 1,448) versus 49% in men (n = 5,428). Prevalence of SDB rose with increasing age (31%, 39%, 45%, 52%, and 59% in those age ≤50, >50 to 60, >60 to 70, >70 to 80, and >80 years, respectively). Risk factors for SDB were body mass index (per 5 units; odds ratio [OR]: 1.29; 95% confidence interval [CI]: 1.22 to 1.36), left ventricular rejection fraction (per 5% decrement from 45%; OR: 1.10; 95% CI: 1.06 to 1.14), age (per 10-year difference to 60 years; OR: 1.41; 95% CI: 1.34 to 1.49), atrial fibrillation (OR: 1.19; 95% CI: 1.06 to 1.34), and male sex (OR: 1.90; 95% CI: 1.67 to 2.17). CONCLUSIONS: SchlaHF registry data demonstrate a high prevalence of SDB in a representative population of stable patients with chronic HF receiving contemporary medical management. Male sex, age, body mass index, and the severity of both symptoms and left ventricular dysfunction were clinical predictors for prevalent SDB. (Prevalence, Clinical Characteristics and Type of Sleep-disordered Breathing in Patients With Chronic, Symptomatic, Systolic Heart Failure; NCT01500759).

Risk factors for, and prevalence of, sleep apnoea in cardiac rehabilitation facilities in Germany: The Reha-Sleep registry.

AIM: To determine the prevalence of, and the risk factors for, sleep apnoea in cardiac rehabilitation (CR) facilities in Germany. METHODS: 1152 patients presenting for CR were screened for sleep-disordered breathing with 2-channel polygraphy (ApneaLink™; ResMed). Parameters recorded included the apnoea-hypopnoea index (AHI), number of desaturations per hour of recording (ODI), mean and minimum nocturnal oxygen saturation and number of snoring episodes. Patients rated subjective sleep quality on a scale from 1 (poor) to 10 (best) and completed the Epworth Sleepiness Scale (ESS). RESULTS: Clinically significant sleep apnoea (AHI ≥15/h) was documented in 33% of patients. Mean AHI was 14 ± 16/h (range 0-106/h). Sleep apnoea was defined as being of moderate severity in 18% of patients (AHI ≥15-29/h) and severe in 15% (AHI ≥30/h). There were small, but statistically significant, differences in ESS score and subjective sleep quality between patients with and without sleep apnoea. Logistic regression model analysis identified the following as risk factors for sleep apnoea in CR patients: age (per 10 years) (odds ratio (OR) 1.51; p<0.001), body mass index (per 5 units) (OR 1.31; p=0.001), male gender (OR 2.19; p<0.001), type 2 diabetes mellitus (OR 1.45; p=0.040), haemoglobin level (OR 0.91; p=0.012) and witnessed apnoeas (OR 1.99; p<0.001). CONCLUSIONS: The findings of this study indicate that more than one-third of patients undergoing cardiac rehabilitation in Germany have sleep apnoea, with one-third having moderate-to-severe SDB that requires further evaluation or intervention. Inclusion of sleep apnoea screening as part of cardiac rehabilitation appears to be appropriate.

Determining the prevalence and predictors of sleep disordered breathing in patients with chronic heart failure: rationale and design of the SCHLA-HF registry.

BACKGROUND: The objective of the SCHLA-HF registry is to investigate the prevalence of sleep-disordered breathing (SDB) in patients with chronic heart failure with reduced left ventricular systolic function (HF-REF) and to determine predictors of SDB in such patients. METHODS: Cardiologists in private practices and in hospitals in Germany are asked to document patients with HF-REF into the prospective SCHLA-HF registry if they meet predefined inclusion and exclusion criteria. Screening was started in October 2007 and enrolment was completed at the end of May 2013. After enrolment in the registry, patients are screened for SDB. SDB screening is mainly undertaken using the validated 2-channel ApneaLink™ device (nasal flow and pulse oximetry; ResMed Ltd., Sydney, Australia). Patients with a significant number of apneas and hypopneas per hour recording time (AHI ≥15/h) and/or clinical symptoms suspicious of SDB will be referred to a cooperating sleep clinic for an attended in-lab polysomnography with certified scoring where the definite diagnosis and, if applicable, the differentiation between obstructive and central sleep apnea will be made. Suggested treatment will be documented. DISCUSSION: Registries play an important role in facilitating advances in the understanding and management of cardiovascular disease. The SCHLA-HF registry will provide consistent data on a large group of patients with HF-REF that will help to answer questions on the prevalence, risk factors, gender differences and stability of SDB in these patients by cross-sectional analyses. Further insight into the development of SDB will be gained by extension of the registry to include longitudinal data.

Age- and gender-dependent adherence with continuous positive airway pressure therapy.

BACKGROUND: Several studies have analysed adherence to continuous positive airway pressure (CPAP) therapy but little is known on the effects of age and gender. METHODS: Data from 4281 patients with obstructive sleep apnea (OSA) treated with CPAP (S8, ResMed, Sydney, Australia) were analysed, including apnea-hypopnea index (AHI), mask pressure, leakage, period of use (hours of use/night), and efficiency (days of use/total days). Patterns of use and treatment efficacy were compared between different age groups and genders. RESULTS: Average numbers of days used per week (range of the subgroups 5.8±1.6 to 6.3±1.2 days/week) and period of use (range 363±88 to 395±120 min) increased with age. Residual AHI(CPAP) (range 4.8±3.4 to 11.1±9.0/h), leakage (range 0.09±0.11 to 0.27±0.32l/s) increased significantly with age. Males had statistically significantly higher average hours of use (377±94 vs. 370±96 min), AHI(CPAP) (6.4±4.9 vs. 5.4±4.5/h), mask pressure (8.8±2.0 vs. 8.4±1.9 cm H(2)O), and leakage (0.13±0.16 vs. 0.11±0.15l/s) than females. CONCLUSION: Adherence to therapy is high and therapeutic efficacy is excellent in long-term CPAP users. Adherence is both age- and gender-dependent, but the differences are small and not clinically relevant.