***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background and aims Manual laboratory continuous positive airway pressure ( CPAP ) titration for obstructive sleep apnoea ( OSA ) is costly , time intensive and delays access to treatment . Automatic positive airway pressure ( APAP ) titration has the potential to reduce cost and improve access to treatment . The aim of this study was to assess the clinical efficacy and costs of APAP titration compared with manual titration in moderate – severe OSA . Methods Patients with moderate – severe OSA ( apnoea/hypopnoea index > 15 and Epworth Sleepiness Score ≥8 ) who were free of co-morbidities that could impair APAP titration were eligible . 249 participants were r and omised to manual titration , home APAP or laboratory APAP titration to determine a fixed pressure for CPAP . Clinical and direct cost outcomes were assessed after 4 weeks of treatment . Results Average nightly CPAP use , subjective sleepiness , SF36 quality of life , Trails A and B cognitive function and polysomnographic outcomes were similar among the per- protocol groups . Non-hypertensive patients had a lower resting heart rate ( and greater reduction in heart rate ) at 4 weeks after laboratory APAP titration compared with home APAP  titration . Costs per patient were highest in manual ( AU$817.84 ) , followed by laboratory ( AU$647.56 ) and home ( AU$132.09 ) APAP titration . An intention-to-treat analysis confirmed the effectiveness of APAP titration compared with manual titration in the st and ard clinical setting . Conclusions Among patients with moderate – severe OSA without serious co-morbidities , outcomes at 1 month indicate that APAP titration is more cost-effective than manual laboratory titration to determine an appropriate pressure for CPAP for long-term use ; with the largest savings occurring in the home APAP patients . Australian New Zeal and Clinical Trials Registry Number ACTRN12608000054314 BACKGROUND Obstructive sleep apnea syndrome ( OSAS ) has been associated with increased morbidity and mortality , principally from cardiovascular disease , but the impact of nasal continuous positive airway pressure ( CPAP ) therapy is unclear . METHODS We performed a long-term follow-up study of 168 patients with OSAS who had begun receiving CPAP therapy at least 5 years previously , most of whom had been prospect ively followed up , having been the subject of an earlier report on cardiovascular risk factors in OSAS patients . The average follow-up period was 7.5 years . We compared the cardiovascular outcomes of those patients who were intolerant of CPAP ( untreated group , 61 patients ) with those continuing CPAP therapy ( 107 patients ) . RESULTS CPAP-treated patients had a higher median apnea-hypopnea index score than the untreated group ( 48.3 [ interquartile range ( IQR ) , 33.6 to 66.4 ] vs 36.7 [ IQR , 27.4 to 55 ] , respectively ; p = 0.02 ) , but age , body mass index , and time since diagnosis were similar . Deaths from cardiovascular disease were more common in the untreated group than in the CPAP-treated group during follow-up ( 14.8 % vs 1.9 % , respectively ; p = 0.009 [ log rank test ] ) , but no significant differences were found in the development of new cases of hypertension , cardiac disorder , or stroke . Total cardiovascular events ( ie , death and new cardiovascular disease combined ) were more common in the untreated group than in the CPAP-treated group ( 31 % vs 18 % , respectively ; p < 0.05 ) . CONCLUSIONS The data support a protective effect of CPAP therapy against death from cardiovascular disease in patients with OSAS OBJECTIVES To study the effects of augmentation of continuous positive airway pressure ( CPAP ) education and support on compliance and outcome in patients with obstructive sleep apnea ( OSA ) . DESIGN A r and omized , controlled , parallel study of basic vs augmented CPAP education and support . SETTING A university teaching hospital . PATIENTS A total of 108 OSA patients r and omized into  basic-support ( BS ) and augmented-support ( AS ) groups . INTERVENTIONS Patients in the BS group ( n = 54 ) were given educational brochures on OSA and CPAP , CPAP education by nurses , CPAP acclimatization , and were review ed by physicians and nurses at weeks 4 and 12 . Patients in the AS group ( n = 54 ) received more education , including a videotape , telephone support by nurses , and early review at weeks 1 and 2 . MEASUREMENTS Objective CPAP compliance , Calgary sleep apnea quality of life index ( SAQLI ) , and cognitive function after 1 month and 3 months ; and Epworth sleepiness scale ( ESS ) after 3 months of CPAP treatment . RESULTS At 4 weeks , CPAP usage was 5.3 + /- 0.2 h/night ( mean + /- SEM ) vs 5.5 + /- 0.2 h/night in the BS and AS groups , respectively ( p = 0.4 ) . At 12 weeks , CPAP usage was 5.3 + /- 0.3 h/night vs 5.3 + /- 0.2 h/night in the two groups , respectively ( p = 0.98 ) . There was greater improvement of SAQLI at 4 weeks ( p = 0.008 ) and at 12 weeks ( p = 0.047 ) in the AS group . There was no significant difference between BS and AS groups in terms of improvement of ESS and cognitive function . CONCLUSION Augmentation of CPAP education and support does not increase CPAP compliance , but leads to a greater improvement of quality of life during the reinforced period Background Following the World Trade Center disaster , a large number of individuals involved in rescue and recovery activity were exposed to significant amounts of dust , and reported symptoms of chronic nasal and sinus inflammation . An unusually high prevalence of obstructive sleep apnea ( OSA ) has also been observed in this World Trade Center Responder population . This project aims to examine the relationship between nasal pathology and OSA . Our hypothesis is that increased nasal resistance due to nasal inflammation predisposes to OSA in this population . Continuous Positive Airway Pressure ( CPAP ) is the st and ard therapy for OSA but despite its efficacy has poor adherence . Subjects with high nasal resistance may have greater difficulty in tolerating this therapy than those who do not have high nasal resistance . Reduction of excess expiratory positive pressure by the modality known as Cflex ™ during Continuous Positive Airway Pressure therapy ( CPAPFlex ) has been suggested to improve comfort without compromising efficacy . We will compare CPAP to CPAPFlex in subjects with OSA . Study Design Subjects with new onset habitual snoring will be screened for OSA using home sleep studies and rhinomanometry will be used to determine nasal resistance . In 400 subjects with OSA we will perform a r and omized double blind cross-over study comparing CPAP to CPAPflex , and relate nasal resistance to adherence to CPAP therapy . Discussion This is the first multicenter trial design ed to test the hypothesis that adherence to CPAP therapy relates to nasal resistance and CPAPFlex will improve adherence to CPAP in those subjects with high nasal resistance . We anticipate the following results from this trial : 1 . Increased nasal resistance is associated with decreased adherence to CPAP therapy . 2 . Use of CPAPFlex improves adherence with CPAP therapy in subjects with high nasal resistance , but not in those with low nasal resistance . 3 . The benefit of CPAPFlex on adherence is greatest when offered at CPAP therapy initiation rather than as a “ rescue ” therapy in subjects with high nasal resistance . Trial Registration Clinical Trials.gov Identifier : NCT01753999 , Date : 12 December STUDY OBJECTIVES To compare conventional and self-adjusting nasal continuous positive airway pressure ( nCPAP ) therapy in patients with severe obstructive sleep apnea syndrome with respect to suppression of respiratory disturbances , quality of sleep , mean mask pressure , and patient compliance . DESIGN Cohort study of consecutive patients with obstructive sleep apnea syndrome , single-blinded . SETTING Clinical sleep laboratory in Germany . PATIENTS Fifty patients ( 44 men , 6 women who ranged in age from 35 to 71 years ) with polysomnographically confirmed severe obstructive sleep apnea syndrome ( respiratory disturbance index [ RDI ] , > 20/h ) . MEASUREMENTS AND INTERVENTIONS After baseline polysomnography , patients were r and omly treated with nCPAP either in conventional ( group 1 ) or in automatically adjusting ( group 2 ) mode . Three to 6 months after adjustment , all patients underwent polysomnography again . They also were examined with a portable monitoring device and received a question naire on subjective well-being and device evaluation . RESULTS Anthropometric and respiratory data were comparable in both groups ; body mass index had not changed significantly in the follow-up . RDI dropped by 91.5 % ( from 38.3+/- 13.9/h to 3.6+/-4.4/h ) in conventional and by 93.6 % ( from 35.5+/-9.6/h to 2.4+/-1.6/h ) in self-adjusting mode ( statistically not significant [ NS ] ) . Sleep efficiency decreased by 4.0 % in conventional and increased by 2.0 % in self-adjusting mode ( NS ) . In both groups , normal sleep structure was largely restored . Mean mask pressure was 8.1+/-2.5 cm H2O in group 1 and 6.5+/-1.7 cm H2O in group 2 ( p<0.01 ) . Patient compliance in terms of nights per week of mask appliance was better in the self-adjusting mode ( 5.7+/-0.7 to 6.5+/-0.4 ; p<0.01 ) . CONCLUSION Self-adjusting nCPAP demonstrates the same reliability in suppression of respiratory disturbances as fixed-mask pressure therapy .  Sleep quality is slightly superior , patient compliance is highly significantly better The first generation of Auto CPAP devices caused respiratory arousal by apnoes , hypopnoeas , incomplete obstructions and pressurechanges . The new , second generation of CPAP devices which is based on forced oscillation technique will change the pressure with slower velocity and before the respiratory arousal reaction will occur ( 1 , 9 , 10 ) . Fifty patients with severe sleep apnoea ( AHI 66±26 /h ) were treated with both , constant- CPAP ( continous positive airway pressure ) or Auto CPAP under polysomnographic control in a r and omised order . The Auto CPAP based on forced oscillation technique reduced the number of apnoeas and hypopnoeas as did most of the other Auto CPAP systems to AHI 2.5±5.9 /h ( p<0.05 ) . In comparison to Auto CPAP of the first generation it also decreased the number of respiratory arousal reactions caused by apnoeas and hypopnoeas . However there is still a significant difference to number of arousal detected with constant CPAP ( p<0.01 ) . In conclusion although the new generation of Auto CPAP  reduced the number of respiratory arousals compared to first generation , we did not find a therapeutical benefit for patients with severe SAS Daytime CPAP titration studies with full polysomnography have been successfully performed in patients with severe sleep apnea-hypopnea syndrome ( SAHS ) . The implementation of daytime studies in unselected SAHS patients could help to reduce the waiting lists for CPAP titrations . The main purpose of this study was to compare the effectiveness of conventional versus manual or automatic daytime CPAP titration in unselected patients with SAHS . Ninety-three consecutive patients with SAHS in whom CPAP was indicated were assigned to conventional titration or to manual or automatic ( AutoSet ) daytime CPAP titration , after sleep deprivation . The number of valid studies , sleep architecture , final pressure selected and mean pressure in the different sleep stages were compared . Changes in sleepiness ( Epworth sleepiness score ) and hours of CPAP use were assessed after 3 months of treatment . Four patients did not sleep ( 3 AutoSet , 1 conventional daytime groups ) . Sleep latency was shorter during automatic daytime titration whereas REM latency was shorter in daytime studies ; the percentage of sleep stages was similar during all types of titration . CPAP requirements were significantly higher during REM sleep in conventional and manual daytime titrations while mean pressure was unchanged throughout sleep stages during AutoSet titration . CPAP pressure selected with conventional or daytime manual titration ( 7.5(2.2 ) cm H2O and 7.4(1.5 ) cm H2O , ns ) were significantly lower ( P < 0.001 ) than with AutoSet ( 9.4(1.6 ) cm H20 . All groups showed similar decrease of sleepiness and hours of use of CPAP at 3 months of follow-up . Automatic and manual daytime PSG studies after sleep deprivation are useful for CPAP titration in unselected patients with SAHS . Pressure selected with AutoSet is significantly higher than with conventional daytime or nighttime titration , although not significant in terms of treatment compliance and symptom improvement Autoadjusting  nasal continuous positive airway pressure ( CPAP )  greatly reduces the apnoea/hypopnoea index ( AHI ) , and affords a significant reduction in median pressure ( P50 ) compared-with manually titrated conventional nasal CPAP . The aim of the present study was to test whether these benefits were maintained in the medium term at home , in a double-blind crossover study . Ten sequential subjects ( mean AHI 52.9 x h(-1 ) ) were enrolled . After a manual titration , subjects were r and omly allocated to  
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The evidence base for other interventions is smaller , and does not provide sufficient information to determine whether there are important differences between pressure modification strategies and fixed CPAP on machine usage outcomes , symptoms and quality of life .
In adults with moderate to severe sleep apnoea starting positive airway pressure therapy , auto-CPAP probably increases machine usage by about 13 minutes per night .
The effects on daytime sleepiness scores with auto-CPAP are not clinical ly meaningful .
AHI values are slightly lower with fixed CPAP .