Abstract Background Bilevel positive airway pressure (BPAP) is currently not recommended for obstructive sleep apnea (OSA), but this stems from meta-analyses comprising a limited number of trials. Expiratory pressure relief algorithms (EPRAs)—which deliver pressure support similarly to BPAP—are widely used without a clear risk:benefit assessment. A framework assessing the broader effect of pressure support on adherence is missing. Methods MEDLINE, EMBASE, CENTRAL, Clinicaltrials.gov and major abstract repositories were searched for randomized controlled and observational trials assessing the effect of pressure support on adherence (primary outcome) vs. continuous PAP (CPAP) in OSA adults and in those with CPAP intolerance (exploratory). Subgroup analyses and meta-regressions assessed potential causes of heterogeneity. Epworth Sleepiness Scale (ESS) changes from baseline, residual apnea-hypopnea index (AHI) and leak (secondary outcomes) were also analyzed when available. GRADE was used for certainty of evidence (CoE) rating. Results In twenty-one studies (N = 1462 participants), pressure support did not affect adherence vs. CPAP (mean difference 95%CI: 0.21 -0.01, 0.44 h/night, P = 0.06; heterogeneity=45%; CoE: very-low-to-moderate; Figure 1). BPAP had a larger effect in PAP intolerants (0.68 0.14, 1.23 h/night, P = 0.01), but CoE was very-low. Longer follow-up was associated with decreasing pressure support adherence (-0.18 -0.36, -0.03 h/night per additional trimester beyond 3 months, P = 0.03). There was no difference in ESS and AHI between interventions, but leak was reduced on pressure support (CoE: low-to-moderate). Conclusions Pressure support is equivalent to CPAP for adherence and efficacy. EPRAs have similar cost to CPAP, however BPAP is more expensive, thus its use in OSA cannot be recommended. This abstract is funded by: None
Messineo et al. (Fri,) studied this question.