Introduction: Obstructive sleep apnea (OSA) is associated with worse outcome after stroke. Treatment with continuous positive airway pressure (CPAP) may improve recovery after stroke but has been limited by poor adherence.
Methods: In a single-arm ongoing study, adults with stroke underwent an intensive CPAP adherence protocol during inpatient rehabilitation, including motivational interviewing and help with CPAP by nurses and respiratory therapists. A 3-night run-in period of auto-titrating CPAP was used to test for tolerance and to diagnose OSA, based upon the apnea-hypopnea index and flow resistance. Qualifying patients were asked to continue CPAP for 3 months. The outcomes included CPAP adherence, defined as ≥ 4 hours of use on ≥ 70% of nights, and stroke recovery, measured by change in NIH Stroke scale (NIHSS) and Functional Independence Measure (FIM) over 3 months.
Results: During the run-in, 39 of 60 (65%) patients had presumed OSA, 5 (8%) had no evidence of OSA, 4 (7%) had evidence of central sleep apnea, and 12 (20%) were intolerant of CPAP. Among the 34 of 39 patients who chose to continue CPAP after the run-in, the median use per night was 5.3 hours (IQR 4.1, 6.0) with 56% (n=19) adherent during rehabilitation. The median CPAP use per night for the 22 who completed the study was 5.1 hours (IQR 2.5, 6.4) with 54% (n=12) adherent over the 3-month period. Unadjusted for baseline factors, there was a significant change in the NIHSS in adherent patients (n=10) vs. non-adherent patients (n=10) [5 (SD 3) vs. 2 (SD 2), p=0.02]. Comparing adherent (n=7) to non-adherent patients (n=5), the change for total FIM trended towards significant [42 (SD 18) vs. 30 (SD 11), p=0.20] and the change for cognitive component of the FIM was significant [10 (SD 7) vs. 2 (SD 3), p=0.05].
Conclusion: After an intensive adherence intervention, over half of stroke patients with presumed OSA and CPAP tolerance were adherent over 3 months. CPAP adherent patients had greater improvement in NIHSS and the cognitive component of the FIM, although the associations may be confounded by patients’ characteristics influencing both adherence and outcomes. Future studies are needed to evaluate in a randomized trial if the intensive intervention will lead to long-term CPAP adherence and improved stroke recovery.