Bell, whistles, and leak profiles.

Positive airway pressure (PAP) therapy is almost universally effective in treating obstructive sleep apnea. The biggest obstacle in treating obstructive sleep apnea is getting patients to use the PAP device. The term " adherence " is gaining favor over the term " compliance. " The definition of PAP adherence varies, but the generally accepted (and somewhat arbitrarily chosen) definition is Ն 4 hours per night. PAP adherence rates vary widely. A large study in the United Kingdom found a 10-year adherence rate of 70%. 1 Another study that followed a non-insured population in the United States found an adherence rate of 48%, but the rate dropped to 30% if the patients who did not follow up in clinic were considered non-adherent. 2 Regardless of the population studied, inadequate adherence is a big problem. Research on adherence can be divided into 2 broad categories: interventions that increase adherence (eg, mask changes, auto-titrating devices vs fixed pressure devices), and predictors of non-adherence (eg, age, severity of obstructive sleep apnea). Research on predictors of non-adherence will help clinicians identify individuals who may not adhere to PAP therapy, but that knowledge will be useful only if we can improve adherence. Unfortunately, little progress has been made on this front. As long-term adherence patterns are established within the first 7 days of PAP therapy, early intervention is important. 3 Behavioral and non-behavioral interventions have been studied. The most effective interventions are behavioral, 4,5 but these interventions are time and labor intensive for both the patient and the practitioner. Non-behavioral interventions include changing masks or improving mask fit, heated humidification, using a bi-level (BiPAP) device or a flexible bi-level device (eg, C-flex, Respironics, Pittsburgh, Pennsylvania), or using an auto -titrating device. Some of these interventions have shown early promise in selected groups, but others have shown no advantage. 6 Advances in device technology are not limited to pressure modification. Most current PAP devices record several variables in addition to hours used per night and number of nights used. Adherence data over the last 8 months from a patient in our clinic yielded a 15-page report that included values such as " average vibratory snore index, " " average maximum leak, " " average 90% leak, " and " average max leak. " A full hour-by-hour report of each night was also available, in a hypogram-like graph. Intuition and anecdotal evidence indicate that a high level of …