• Ian Smith, Vidya Nadig, and Toby J Lasserson.
• Respiratory Support and Sleep Centre, Papworth Hospital, Papworth Everard, Cambridge, UK, CB3 8RE. ian.smith@papworth.nhs.uk
• Cochrane Db Syst Rev. 2009 Apr 15 (2): CD007736.

BackgroundAlthough effective in the treatment of obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) does not meet with universal acceptance by users. Educational, supportive and behavioural interventions may help people with obstructive sleep apnoea recognise the need for regular and continued use of continuous positive airway pressure.ObjectivesTo critically assess strategies that are educational, or supportive, or behavioural in encouraging people who have been prescribed or offered CPAP to use their machines.Search StrategySearches were conducted on the Cochrane Airways Group Sleep Apnoea trials register. Searches are current to September 2008.Selection CriteriaRandomised parallel group studies which assessed an intervention aimed to inform participants about CPAP or OSA, or to support them in using CPAP or to modify their behaviour in increasing their use of CPAP machines. Studies of any duration were considered.Data Collection And AnalysisTwo authors assessed studies to determine their suitability for inclusion in the review. Data were extracted independently and entered in to Review Manager software.Main ResultsSeventeen studies met the review entry criteria (1070 participants). Support/encouragement offered on an ongoing basis led to increased average machine usage (0.59 hours/night (95% CI 0.26 to 0.92), although there was a significant degree of variation between the results of the studies. The effects of these interventions on the likelihood of study withdrawal, symptoms and quality of life were not statistically significant.Short-course educational intervention was not more successful in improving average machine usage than usual care.Cognitive behavioural therapy led to a significant improvement in average machine usage in two studies (2.92 hours/night (95% CI 1.93 to 3.92)), and a number needed to treat of 3 (95% CI 2 to 6) for one additional patient to achieve machine usage of six or more hours per night. Overall, In the control groups 85 people out of 100 had failed to comply with CPAP over 4 to 12 weeks, compared to 46 (95% CI 68 to 25) out of 100 for the cognitive behaviour groups.Authors' ConclusionsThere is some evidence that a supportive intervention which encourages people to continue to use their CPAP machines leads to greater levels of CPAP machine usage than control, although the variation across the studies introduces some uncertainty over how consistent this effect is. We could not find evidence that a short-term educational intervention led to improvements in usage. Cognitive behavioural therapy led to the largest increases in average machine usage, partly because more participants were prepared to try out the treatment. Studies generally recruited CPAP naive patients whose sleep apnoea was severe. Trials in patients who have struggled to persist with treatment are required, as there is currently little evidence in this population. This could make a valuable contribution to our understanding of the complex relationship between initial motivation, ongoing perception of benefit and long-term health benefits.

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