Zusammenfassung
Der Begriff „Compliance” ist nicht direkt ins Deutsche zu übersetzen; er beschreibt jedoch die Befolgung einer Therapieempfehlung bzw. die Therapieakzeptanz und ist damit ein wesentliches Charakteristikum jeder länger dauernden Therapieform. Continuous Positive Airway Pressure (CPAP) zur Therapie der obstruktiven Schlafapnoe (OSA) hat sich inzwischen etabliert. Wesentliche Ursachen für eine reduzierte CPAP-Compliance (CC) sind die notwendige Langzeitanwendung, der unzureichende Therapieeffekt und die loko-regionalen Nebenwirkungen der CPAP-Therapie. Eine eindeutige Definition für eine ausreichende CC existiert nicht. Die Quantifizierung der CC erfolgte zunächst mittels Fragebögen; später standen Zählwerke zur objektiven Messung von Anwendungs-bzw. Betriebszeit zur Verfügung. Die CC entsprechend der Fragebögen lag im Mittel zwischen 1–1,5 Stunden über der objektiv gemessenen Anwendungsdauer. Um eine falsch ungünstige CC zu vermeiden, muß die absolute CPAP-Anwendungszeit in Relation zur Schlafzeit gesetzt werden, da es bei der Anwendung von CPAP zur Reduktion der Gesamtschlafzeit kommt. Auch wenn die CPAP-Anwendungszeit in Relation zur Schlafzeit deutlich reduziert ist, lassen sich Schläfrigkeit und kognitive Leistung relevant verbessern. Ein Grund hierfür ist ein nachweisbarer „CPAP-Depoteffekt”. Entsprechend der Literatur sind die Schläfrigkeit am Tage, der Schweregrad der OSA und der Multiple Sleep Latency Test (MSLT) vor Beginn der CPAP-Therapie sowie CPAP-bedingte Nebenwirkungen ungeeignet, die CC mit der zu fordernden Genauigkeit vorherzusagen. Demgegenüber kommt dem Ausmaß der Schlaffragmentierung vor Therapiebeginn sowie der Änderung der Schläfrigkeit im Therapieverlauf ein gewisser prädiktiver Wert zu. Die CC ist abhängig vom Modus der Interaktion zwischen Patient und Behandlungsteam sowohl während der prätherapeutischen Diagnostik als auch der Adaptationsphase und im Rahmen der Nachbetreuung der CPAP-Therapie. Zusammenfassend sind die grundlegenden Voraussetzungen für eine langfristig befriedigende CC bei Patienten mit OSA die deutliche Besserung der Symptomatik bei gleichzeitig fehlender bzw. akzeptabler Beeinträchtigung durch die CPAP-Therapie. In zukünftigen Studien müssen u. a. folgende Themenkomplexe unter Berücksichtigung der CC weiter untersucht werden: Bedeutung der Erstversorung mit CPAP und der Nachkontrolle, Outcome, unterschiedliche Technik der CPAP-Geräte, Betreuung von Patienten mit reduzierter CC und Vergleich zwischen CPAP und alternativen Behandlungsformen.
Summary
Nasal continuous positive airway pressure (CPAP) avoids the pharyngeal collapse and therefore leads to normal ventilation during sleep in patients with obstructive sleep apnoea (OSA). CPAP is an established treatment and the preferred option for moderate and severe OSA. However, CPAP compliance may be reduced mainly due to the need of chronic application, reduced efficiency and local side effects of the interface. A generally accepted definition of sufficient CPAP compliance does not exist. Initially CPAP compliance was assessed by questionnaires; furtheron counters were available measuring both running time of the machine and the CPAP working hours at the given pressure level (real time of application). According to the questionnaire data the CPAP working time is over-estimated by 1–1.5 hours/d compared to the corresponding objective measurement. Since CPAP reduces the overall sleep time the measured running time should be related to the associated total sleep time in order not to under-estimate CPAP compliance. The necessary CPAP application time improving sleepiness and cognitive performance may be shorter than the total sleep time. One main underlying mechanism of this phenomenon may be a residual CPAP effect on the degree of OSA during the second part of the night without this treatment after CPAP treatment during the first part of the night. The degree of sleepiness, the severity of OSA and the Multiple Sleep Latency Test (MSLT) before CPAP and local side effects are useless in order to predict the CPAP compliance. However, both sleep fragmentation before CPAP and the degree of reduced sleepiness due to CPAP were positively correlated to compliance. Interaction between the caring staff and the patient is an important issue; therefore the mode of the diagnostic procedures before CPAP, the kind of adaptation and follow-up may influence the compliance. The essential precondition of a sufficient CPAP compliance are both a significant reduction of daytime sleepiness and missing or acceptable side effects by the treatment. Further studies are warranted investigating several topics with respect to compliance: The impact of initiation of CPAP and follow-up, outcome, different techniques of CPAP, interaction between staff and patient, care of patients with reduced compliance, and the comparison with alternative treatments.
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Schönhofer, B. Compliance bei nasaler kontinuierlich-positiver Atemwegsdruck-Therapie. Somnologie 3, 67–72 (1999). https://doi.org/10.1007/s11818-999-0012-9
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DOI: https://doi.org/10.1007/s11818-999-0012-9