Rationale: Twenty-eight percent of people with mild to moderate obstructive sleep apnea experience daytime sleepiness, which interferes with daily functioning. It remains unclear whether treatment with continuous positive airway pressure improves daytime function in these patients. Objectives: To evaluate the efficacy of continuous positive airway pressure treatment to improve functional status in sleepy patients with mild and moderate obstructive sleep apnea. Methods: Patients with self-reported daytime sleepiness (Epworth Sleepiness Scale score >10) and an apnea-hypopnea index with 3% desaturation and from 5 to 30 events per hour were randomized to 8 weeks of active or sham continuous positive airway pressure treatment. After the 8-week intervention, participants in the sham arm received 8 weeks of active continuous positive airway pressure treatment. Measurements and Main Results: The Total score on the Functional Outcomes of Sleep Questionnaire was the primary outcome measure. The adjusted mean change in the Total score after the first 8-week intervention was 0.89 for the active group (n = 113) and −0.06 for the placebo group (n = 110) (P = 0.006). The group difference in mean change corresponded to an effect size of 0.41 (95% confidence interval, 0.14–0.67). The mean (SD) improvement in Functional Outcomes of Sleep Questionnaire Total score from the beginning to the end of the crossover phase (n = 91) was 1.73 ± 2.50 (t[90] = 6.59; P < 0.00001) with an effect size of 0.69. Conclusions: Continuous positive airway pressure treatment improves the functional outcome of sleepy patients with mild and moderate obstructive sleep apnea. Clinical trial registered with www.clinicaltrials.gov (NCT 00127348).

Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnea. However, the success of this treatment is hampered by nonadherence in half of the treated patients. Moreover, in clinical trials, poor adherence reduces adequate exposure required to determine its true effect. There is growing evidence that behavioral interventions, in addition to education, are a promising approach to improving adherence. Behavioral interventions include the use of cognitive behavioral therapy and motivational enhancement therapy designed to elevate a patient’s self-efficacy. The abundance of data obtained by CPAP tracking systems enables daily surveillance of use, and this telemonitoring along with telehealth allows the provider to quickly intervene when nightly CPAP use falls below thresholds or mask leaks are present. Telehealth reaches a large number of patients who may not be able to regularly attend a clinic, providing support and reinforcement. Peer support may also be useful in improving adherence. Not all obstructive sleep apnea patients present with the same phenotype, and can, therefore, be clustered into several groupings. Which intervention is most successful with a given phenotype or cluster remains unexplored. Comprehensive adherence management requires a team approach with the unique contribution of different professionals.

Summary: This study aimed to identify pre‐treatment and immediate early treatment factors predicting continuous positive airway pressure (CPAP) use during the first week of therapy, when the pattern of non‐adherence is established. Four domains of potential predictors were examined: pre‐treatment demographic and clinical factors, patients’ perceived self‐efficacy, treatment delivery (mask leak and bothering side effects) and immediate disease reduction (residual respiratory events and flow limitation). The Autoset™ Clinical System objectively documented daily CPAP use, mask leak, residual respiratory events and flow limitation. Ninety‐one CPAP‐naive patients with newly diagnosed obstructive sleep apnea were followed for 1 week after treatment initiation. Mean CPAP daily use during the first week was 3.4 ± 2.7 h, with significantly lower use observed in black than non‐black participants (2.7 versus 4.4 h, respectively, P = 0.002). Less intimacy with partners caused by CPAP was the only treatment side effect correlated with CPAP use (r = −0.300, P = 0.025). Reduced CPAP use during the first week was associated simultaneously with being black, higher residual apnea–hypopnea index and the treatment side effect of less intimacy with partners. The three factors together accounted for 25.4% of the variance in the CPAP use (R² = 0.254, P < 0.01). These data suggest the need to assess the impact of CPAP on intimacy and troubleshooting aspects of the treatment that interfere with sexual relationships. Assessing the presence of residual respiratory events may be important in promoting CPAP adherence. The association of race and CPAP use needs to be explored further by including more socioeconomic information.

Significant interindividual variability in sleepiness is observed in clinical populations with obstructive sleep apnea (OSA). This phenomenon is only partially explained by the apnea–hypopnea index (AHI). Understanding factors that lead to sleepiness is critical to effective management of patients with OSA. We examined demographic and other factors associated with sleepiness in OSA. Prospective study of 283 patients with newly diagnosed OSA by polysomnography (AHI ≥ 5 per hour). Subjective sleepiness (Epworth Sleep Scale [ESS] ≥ 11) and objective sleepiness (psychomotor vigilance task [PVT] mean lapse ≥ 2) were assessed. Participants were classified into four groups (1: sleepy by ESS and PVT, 2: sleepy by PVT only, 3: sleepy by ESS only, and 4: nonsleepy reference group) and compared by generalized logit model. Shorter daily sleep duration by actigraphy and less morningness were associated with higher risk of sleepiness (Odds ratio [OR] = 0.52, 95% confidence interval [CI] 0.33–0.82 and OR = 0.89, CI 0.80–0.98, respectively). African-American race was associated with sleepiness (group 1, OR = 8.8, CI 2.8–27.3; group 2, OR = 16.6, CI 3.3–83.6; and group 3, OR = 3.3, CI 1.0–10.1). IL-6 level was higher in groups 1 and 3 (OR = 1.9, CI 1.0–3.4 and OR 2.0, CI 1.1–3.7, respectively). African-American race, short sleep duration, chronotype, and increased proinflammatory cytokine IL-6 level were associated with sleepiness in OSA. These findings will inform future investigations determining mechanisms of sleepiness in OSA.