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Patient Prefer Adherence. 2017 Nov 20;11:1923-1932. doi: 10.2147/PPA.S148099. eCollection 2017.

Positive airway pressure adherence and subthreshold adherence in posttraumatic stress disorder patients with comorbid sleep apnea.

Author information

Sleep & Human Health Institute.
Maimonides Sleep Arts & Sciences, Albuquerque.
Los Alamos Medical Center, Los Alamos, NM, USA.


Study objectives:

Patients with comorbid posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) manifest low adherence to continuous positive airway pressure (CPAP) due to fixed, pressure-induced expiratory pressure intolerance (EPI), a subjective symptom and objective sign aggravated by anxiety sensitivity and somatosensory amplification. As advanced PAP therapy modes (ie, auto-bilevel PAP [ABPAP] or adaptive servo-ventilation [ASV]) may address these side effects, we hypothesized such treatment would be associated with decreased expiratory intolerance and increased adherence in posttraumatic stress patients with co-occurring OSA.


We reviewed charts of 147 consecutive adult patients with moderately severe posttraumatic stress symptoms and objectively diagnosed OSA. All patients failed or rejected CPAP and were manually titrated on auto-adjusting, dual-pressure ABPAP or ASV modes in the sleep laboratory, a technique to eliminate flow limitation breathing events while resolving EPI. Patients were then prescribed either mode of therapy. Follow-up encounters assessed patient use, and objective data downloads (ODDs) measured adherence.


Of 147 charts reviewed, 130 patients were deemed current PAP users, and 102 provided ODDs: 64 used ASV and 38 used ABPAP. ODDs yielded three groups: 59 adherent per insurance conventions, 19 subthreshold compliant partial users, and 24 noncompliant. Compliance based on available downloads was 58%, notably higher than recently reported rates in PTSD patients with OSA. Among the 19 partial users, 17 patients were minutes of PAP use or small percentages of nights removed from meeting insurance compliance criteria for PAP devices.


Research is warranted on advanced PAP modes in managing CPAP failure in PTSD patients with comorbid OSA. Subthreshold adherence constructs may inform clinical care in a patient-centric model distinct from insurance conventions. Speculatively, clinical application of this transitional zone ("subthreshold" number of hours) may increase PAP use and eventual adherence.


CPAP; adaptive servo-ventilation; auto-bilevel; compliance; obstructive sleep apnea; upper airway resistance syndrome

Conflict of interest statement

Disclosure Dr Krakow is involved in six main activities related to his work on sleep medicine: He owns and operates six sites that provide education and offer products and services (,,,,, and He is the medical director of a national DME company Classic Sleep Care in which his sole functions are consultation and QA; he has neither patient encounters nor does he benefit from the sale of any DME equipment. He markets and sells three books for patients with sleep disorders (Insomnia Cures, Turning Nightmares into Dreams, and Sound Sleep, Sound Mind). He owns and operates one commercial sleep center (Maimonides Sleep Arts & Sciences). He conducts CME/CEU educational programs for medical and mental health providers to learn about sleep disorders. Sometimes, programs involve the attendee paying a fee directly to their center. Other times, the workshops at other locations may be paid for by vendors such as Respironics and RESMED or other institutions such as the AMEDDC&S, VAMC, and regional sleep center conferences. He is the president of a nonprofit sleep research center, the Sleep & Human Health Institute (, that occasionally provides consultation services or receives grants for pilot studies, the most recent of which was ResMed (~$400,000, January 2015, funding for randomized control trial of PAP treatment in insomnia patients). Ms Obando, Mr Ulibarri, and Ms McIver report no conflicts of interest in this work.

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