The PAP-NAP one decade later: patient risk factors, indications, and clinically relevant emotional and motivational...

Positive airway pressure (PAP) noncompliance remains a major barrier in obstructive sleep apnea (OSA) treatment. The PAP-NAP, a daytime PAP "test-drive," has been associated with increased PAP use, but risk factors and indications for the procedure remain unspecified.

A retrospective chart review was conducted on 139 patients who (1) were diagnosed with OSA (n = 116) or upper airway resistance syndrome (UARS) (n = 23); (2) adamantly refused to proceed with either a full-night attended titration or in-home trial of PAP; and (3) elected to proceed with a PAP-NAP instead. Risk factors for PAP rejection (identified on intake) and indications for the PAP-NAP (identified post-diagnostic polysomnography) were confirmed through multiple encounters with sleep center personnel. All patients completed the PAP-NAP, which utilizes an elaborate desensitization program to provide a less challenging introduction and facilitate a gentler adaptation to pressurized air as well as to test advanced PAP modes when subjective or objective expiratory pressure intolerance emerges. Both emotional aversion toward and lack of motivation for PAP therapy were assessed pre- and post-PAP-NAP. PAP use was determined several months post-procedure.

At intake, most common risk factors for PAP rejection were depression, insomnia, and claustrophobia; most common indications for PAP-NAP were general reluctance, anxiety, and claustrophobia. Procedure averaged 3+ hours [tech coaching, 83 (± 30) min; napping, 107 (± 57) min]. Ninety-nine percent required advanced PAP. Compared to baseline, emotional aversion (p = 0.0001) and motivation (p = 0.0001) significantly improved for the entire sample of which 86% completed full-night titrations and 78% filled PAP prescriptions. At final follow-up, 71% (n = 98) were users and 29% (n = 41) were non-users. Compared to non-users, users showed significantly greater decreases in emotional aversion (p <  0.001; Z = - 6.11) and greater increases in motivation (p <  0.001; Z = - 8.57).

PAP-NAP was associated with a sizeable proportion of highly reluctant patients proceeding to titrations they initially had rejected, and the majority achieved PAP user status. Improvements in emotional aversion and motivation were associated with increased PAP use. Randomized control trials must assess the experiential component at the core of the PAP-NAP procedure and its efficacy in reversing early PAP rejecters.