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Volume 08 No. 03
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Accepted Papers

Letters to the Editor

The Quest to Improve CPAP Adherence—PAP Potpourri is Still Not the Answer, but More Research is Needed

Stuart F. Quan, M.D., F.A.A.S.M.1,2; Karim M. Awad, M.D.1; Rohit Budhiraja, M.D., F.A.A.S.M.3,4; Sairam Parthasarathy, M.D., F.A.A.S.M.4
1Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; 2Arizona Respiratory Center, University of Arizona College of Medicine, Tucson, AZ; 3Pulmonary and Critical Care Medicine Section, Southern Arizona VA Health Care System, Tucson, AZ; 4Pulmonary, Allergy, Critical Care and Sleep Medicine Section, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ

We have read with interest the Letter to the Editor written by Krakow and colleagues1 in response to our editorial entitled “The Quest to Improve CPAP Adherence—PAP Potpourri is Not the Answer.”2 Although we both agree that addressing psychosocial barriers to positive airway pressure (PAP) adherence is important, we are unmoved by the arguments presented to support their contention that newer PAP modalities can improve PAP usage for all patients. To date, studies attempting to demonstrate improved compliance with new PAP modalities have been, at best inconsistent in their findings (reviewed in Antonescu-Turcu).3 As we stated in our editorial, there will be some patients who will have better adherence with one modality versus another. However, routine use of these modalities as demonstrated in the 2 recent papers published in the Journal,4,5 cannot be recommended.

With respect to their description of manually titrating auto-titrating devices, it is our bias as well that having technicians involved in PAP titration results in more precise titrations and better acceptance of PAP by patients. However, this has not been proven in randomized studies. We would encourage Krakow and colleagues to organize their results and submit them for publication in the Journal or elsewhere. As they have written in their letter, it is a “testable hypothesis.”1 Moreover, it is an important question. As noted in recent perspectives published in the Journal,68 there is a new paradigm sweeping the country for evaluation and treatment of patients with possible obstructive sleep apnea. With increasing insurance mandates for home sleep testing followed by use of autotitrating PAP machines, manual titration of PAP in sleep laboratories may become virtually irrelevant. If, however, manual titration of PAP results in better outcomes, there may still be some role for sleep laboratories in the future.


Dr. Quan is Editor-in-Chief of the Journal of Clinical Sleep Medicine. Dr. Parthasarathy has received research support in the form of a grant to the Biomedical Research and Education Foundation of Southern Arizona from Philips-Respironics. Drs. Awad and Budhiraja has indicated no financial conflicts of interest.


Quan SF; Awad KM; Budhiraja R; Parthasarathy S. The quest to improve CPAP adherence—PAP potpourri is still not the answer, but more research is needed. J Clin Sleep Med 2012;8(3):345.



Krakow B, Ulibarri VA, Sanchez JN, Kikta S, McIver N, Melendez D, authors. Driving on “auto”: hands-on is more effective than hands-free. J Clin Sleep Med. 2012;8:343–4


Quan SF, Awad KM, Budhiraja R, Parthasarathy S, authors. The quest to improve CPAP adherence--PAP potpourri is not the answer. J Clin Sleep Med. 2012;8:49–50. [PubMed]


Antonescu-Turcu A, Parthasarathy S, authors. CPAP and bi-level PAP therapy: new and established roles. Respir Care. 2010;55:1216–29. [PubMed Central][PubMed]


Marcus CL, Beck SE, Traylor J, et al., authors. Randomized, double-blind clinical trial of two different modes of positive airway pressure therapy on adherence and efficacy in children. J Clin Sleep Med. 2012;8:37–42. [PubMed]


Powell ED, Gay PC, Ojile JM, Litinski M, Malhotra A, authors. A pilot study assessing adherence to auto-bilevel following a poor initial encounter with CPAP. J Clin Sleep Med. 2012;8:43–7. [PubMed]


Pack AI, author. Sleep medicine: strategies for change. J Clin Sleep Med. 2011;7:577–9. [PubMed]


Collop N, Fleishman SA, authors. The future of sleep medicine: will you be a part of it? J Clin Sleep Med. 2011;7:581–2. [PubMed]


Kryger M, author. Sleep medicine: The shot heard around the world. J Clin Sleep Med. 2012;8:117–8. [PubMed]