Dose-response relationship between positive airway pressure therapy and excessive daytime sleepiness: the HomePAP study

Maeve Pascoe, James Bena, Noah D. Andrews, Dennis Auckley, Ruth Benca, Martha E. Billings, Vishesh K. Kapur, Conrad Iber, Phyllis C. Zee, Susan Redline, Carol L. Rosen, Nancy Foldvary-Schaefer*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Study Objectives: The clinical benefits of positive airway pressure (PAP) therapy for obstructive sleep apnea are assumed to require adherent PAP usage, defined by the Centers for Medicare & Medicaid Services as ≥ 4 hours of use ≥ 70% of nights. However, this definition is based on early data and does not necessarily capture improvements at subthreshold adherence. We explored dose-response relationships between PAP adherence measures and excessive daytime sleepiness from the HomePAP randomized controlled trial. Methods: Participants aged ≥ 18 years with an apnea-hypopnea index ≥ 15 events/h and baseline sleepiness (Epworth Sleepiness Scale [ESS] ≥ 12) received PAP therapy. Data were collected at baseline, 1-month follow-up, and 3-months follow-up. Regression models and receiver operating characteristic curves evaluated PAP measures as predictors of ESS change and normalization (ESS < 10). Results: In 119 participants (aged 49.4 ± 12.6 years, 66.4% male, 72.3% White), > 50% were PAP nonadherent per Centers for Medicare & Medicaid Services criteria at 3 months. The percentage of nights with PAP use ≥ 4 hours predicted ESS change (P = .023), but not when controlling for the apnea-hypopnea index. The percentage of nights with ≥ 4 hours and average PAP use provided the best discrimination for predicting ESS normalization; each 10% increase in PAP use ≥ 4 hours increased the odds of ESS normalization by 22% (P = .007); those using PAP ≥ 4 hours had a nearly 3-fold greater odds of ESS normalization (P = .025). PAP use for at least 4 hours and on 70% of nights provided the best balance between specificity (0.50) and sensitivity (0.73). Conclusions: Although subadherent PAP usage may still confer some benefit for patients with obstructive sleep apnea, adherence to current criteria confers the highest likelihood for ESS change and normalization.

Original languageEnglish (US)
Pages (from-to)1027-1034
Number of pages8
JournalJournal of Clinical Sleep Medicine
Issue number4
StatePublished - Apr 1 2022


  • Epworth Sleepiness Scale
  • HomePAP trial
  • PAP therapy
  • adherence
  • excessive daytime sleepiness

ASJC Scopus subject areas

  • Clinical Neurology
  • Neurology
  • Pulmonary and Respiratory Medicine


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