Frequency of Upper Airway Symptoms before and during Continuous Positive Airway Pressure Treatment in Patients with Obstructive Sleep Apnea Syndrome

Background: Upper airway side effects are common during nasal continuous positive airway pressure (nCPAP) treatment and may affect the use of nCPAP. Objectives: It was our aim to evaluate the prevalence of upper airway symptoms in obstructive sleep apnea syndrome (OSAS) patients before and during nCPAP treatment and to assess the possible association between the symptoms and long-term adherence to the treatment. Methods: We examined 385 consecutive OSAS patients (79% men, mean age 8 SD 52 8 10 years and apnea-hypopnea index 33 8 23) by means of a prospective questionnaire-based survey. The patients filled in questionnaires about upper airway symptoms before starting nCPAP and after 2 months of treatment. Results: Upper airway symptoms were common before starting nCPAP: 61% of the patients reported dryness of mouth, 54% dryness of throat, 52% nasal stuffiness, 51% dryness of nose, 30% sneezing, 24% mucus in throat, 17% rhinorrhea, and 6% nose bleeds daily or almost daily. In CPAP users there was a significant decline in the number of patients with frequent mouth Received: March 25, 2010 Accepted after revision: July 12, 2010 Published online: September 28, 2010 Hanna-Riikka Kreivi, MD Division of Pulmonary Diseases Department of Medicine, Helsinki University Central Hospital Haartmaninkatu 4, PO Box 340, FI–00290 Helsinki (Finland) Tel. +358 9 4711, Fax +358 9 4717 4481, E-Mail hanna-riikka.kreivi @ fimnet.fi © 2010 S. Karger AG, Basel 0025–7931/10/0806–0488$26.00/0 Accessible online at: www.karger.com/res D ow nl oa de d by : 54 .7 0. 40 .1 1 11 /1 /2 01 7 12 :2 5: 48 A M Upper Airway Symptoms and CPAP Treatment Respiration 2010;80:488–494 489 Upper airway side effects, which are often reported during nCPAP treatment, may cause substantial discomfort to the patients and even lead to treatment cessation despite improvements in OSAS symptoms [4–7] . These side effects have mostly been related to local irritation caused by the nasal masks and by mouth leaks that produce high unidirectional airflow over the nasal and oral mucosa. Nasal and pharyngeal side effects can be managed by mask optimization, by intranasal corticosteroid therapy [8–10] , by adding a humidifier to the treatment [9–11] or by corrective surgery for obstructive lesions (e.g., deviated septum) [12, 13] . Most of the reports about side effects are retrospective analyses and often lack baseline data [14] . Previous smallscale studies revealed that OSAS patients had suffered from nasal and pharyngeal problems even before treatment [4, 5] and that some of the symptoms became worse during treatment [4] . The present prospective study was carried out as part of the clinical follow-up of our sleep clinic patients in order to (1) evaluate upper airway symptoms in a large group of OSAS patients both before and during nCPAP treatment, and (2) analyze the relationship between nasal and pharyngeal symptoms and longterm adherence to the treatment. Patients and Methods All consecutive OSAS patients (n = 385) who were admitted to the sleep unit of Hyvinkää Hospital for nCPAP pressure titration from January 2003 to December 2004 were included in this study ( table 1 ). The patients had earlier undergone a diagnostic limited sleep study (Embletta , Flaga, Reykjavik, Iceland). All the sleep recordings were analyzed manually [15] and the apnea/hypopnea index/hour and a reduction in oxygen saturation 6 4%/h were recorded. Apneas were defined as a complete cessation of airflow for 6 10 s, and hypopneas as a decrease of 6 50% in the amplitude of breathing for 6 10 s that was associated with an oxygen desaturation of 6 3% [16] . nCPAP treatment was started during 1 night in the sleep clinic using an autotitrating CPAP device (Autoset , Resmed, Sydney, NSW, Australia); the fixed treatment pressure chosen was the pressure eliminating 95% of obstructive apneas and hypopneas, snoring and flow limitation. The nasal masks were individually adjusted to minimize discomfort related to their use. Full face masks were used if nasal masks were not tolerated. All patients were given detailed instructions on nCPAP treatment and its possible side effects. The patients were advised how to treat nasal and pharyngeal symptoms with topical medications (oily or saline nasal drops, as well as temporary use of nasal decongestants during viral infections), and all were given a prescription of intranasal steroids with the advice to purchase the medication from a pharmacy and to start the treatment if nasal symptoms became problematic during nCPAP treatment. Humidifiers were added to the treatment only if local treatment was not sufficiently effective (not before the first follow-up visit after 2 months of treatment). All the patients filled in 2 questionnaires on nasal and pharyngeal history and current symptoms. The symptoms were scored (1) in the evening before nCPAP pressure titration, and (2) at the 1st follow-up visit after 2 months of treatment. All the patients were examined by a physician (specialist in pulmonary medicine), and careful ear, nose and throat (ENT) status was routinely included in the physical examination. If there were major anatomical problems, the patients were referred to an ENT specialist before starting nCPAP. Their Epworth sleepiness scale score [17] was assessed, and weight and body mass index were measured at baseline and at follow-up visits. At the follow-up visits, hours of nCPAP use were recorded from the timers incorporated into the devices. The time of the year was registered both at CPAP initiation and at follow-up visits. The study was approved by the local ethics committee. Questionnaires The questionnaire comprised 2 sections: (1) history of nasal and pharyngeal disorders, operations, allergic rhinitis and medications, and (2) current upper airway symptoms (nasal stuffiness, dryness of throat, mouth and nose, sensation of mucus in throat, sneezing, rhinorrhea and nose bleeds). At follow-up visits, the patients filled in another questionnaire asking the same questions about upper airway symptoms occurring during nCPAP treatment. The frequency of symptoms was evaluated by asking how often the symptom was experienced using a scale of 1–4 (1 = never; 2 = occasionally; 3 = often, i.e. almost every day; 4 = all the time, i.e. every day). Scores 3 and 4 were combined and represented frequent symptoms in the final analysis. At the follow-up visits, the patients were asked if they experienced a benefit from the treatment. They were also asked whether nasal symptoms were the reason for stopping the treatment. Statistical Analysis An independent samples t test,  2 test and Mann-Whitney U statistics were used to compare differences between separate patient groups. The difference in the number of symptomatic patients before and during nCPAP treatment was tested with McNemar’s test. All statistical analyses used SPSS 15.0 for Microsoft Windows (SPSS Inc. Chicago, Ill., USA). p values ! 0.05 were considered significant. Table 1. C haracteristics of participants (n = 385) Men 304 (79%) Age, years 52819 BMI 3387 ESS 984 AHI 33823 ODI4 32824 CPAP pressure, cm H2O 982 D ata are presented as the mean 8 SD, unless otherwise indicated. BMI = Body mass index; ESS = Epworth sleepiness scale (0–24); AHI = apnea/hypopnea index; ODI4 = oxygen desaturation index. D ow nl oa de d by : 54 .7 0. 40 .1 1 11 /1 /2 01 7 12 :2 5: 48 A M Kreivi /Virkkula /Lehto /Brander Respiration 2010;80:488–494 490 Results Adherence to nCPAP Treatment After pressure titration, 370 patients (96%) initiated nCPAP treatment. The treatment was abandoned by 82 (22%) patients before or at the first follow-up visit, and by another 51 (14%) patients during the first year. Thus, 237 patients (64%) were continuing with the treatment after the first year ( fig. 1 ). At the first follow-up visit, mean ( 8 SD) hours of use were 3.2 8 2.6 h/day, and 52% of the patients were using nCPAP for 1 4 h/day. At 1-year follow-up, the mean use was 3.9 8 2.4 h/day, with 58% of the patients using nCPAP 1 4 h/day. Both at 2-month and 1-year follow-up, the patients who chose to continue nCPAP (‘users’) showed a significantly higher rate of use than those who terminated the treatment after that follow-up (‘non-users’) ( table 2 ). The users were more obese at baseline than the non-users, and their sleep apnea was more severe ( table 2 ). Further, the users more often gained benefit from the treatment than non-users (after 2 months, 84 vs. 9%, p ! 0.001; after 1 year, 96 vs. 5%, p ! 0.001). Frequency of Upper Airway Symptoms before and during nCPAP Treatment Upper airway history and treatments before nCPAP start are shown in table 3 . The prevalence of frequent nasal and pharyngeal symptoms before nCPAP treatment and at the 1st follow-up visit is depicted in figure 2 . The symptoms were common already before starting nCPAP treatment and exhibited no increase during therapy in the overall patient group. On the contrary, the patients reported less dryness of mouth, throat and nose after 2 months of treatment. Only 36 patients did not have any of the upper airway symptoms before nCPAP treatment. Altogether, 142 patients (37%) had no throat dryness before the treatment, and of those, 38 patients (22%) had throat dryness at the 2-month follow-up; 119 patients (31%) had no mouth dryness before the treatment, and of 15 patients