Article | Published:

Positive airway pressure therapy for sleep-disordered breathing confers short-term benefits to patients with spinal cord injury despite widely ranging patterns of use

Spinal Cord (2018) | Download Citation


Study design

Prospective, cohort study.


To evaluate the effectiveness of bi-level positive airway pressure (PAP) therapy and the patterns of use for sleep-disordered breathing (SDB) in individuals with spinal cord injury (SCI).


Academic tertiary care center, USA.


Overall, 91 adults with C1-T6 SCI for ≥3 months were recruited and 74 remained in the study to be evaluated for SDB and follow-up. Individuals with SDB but no nocturnal hypercapnia (NH) were prescribed auto-titrating PAP. Those with NH were prescribed PAP with volume-assured pressure support. Device downloads and overnight transcutaneous capnography were performed at 3, 6, and 12 months to quantify PAP use and effectiveness. Participants kept daily event logs, and quality of life (QOL) questionnaires were performed after 3, 6, and 12 months.


Overall, 45% of 91 participants completed the study. There was great diversity among SCI patients in PAP utilization; after 3 months, 37.8% of participants used PAP for ≥70% nights and ≥240 min per night, whereas 42.2% seldom used PAP and 20% used PAP sporadically or for short periods. PAP therapy was effective in improving OSA in 89% and nocturnal hypercapnia in 77%. Higher PAP pressures predicted higher levels of device use. There were marked reductions in symptoms of autonomic dysreflexia (AD) and orthostatic hypotension as well as some improved indices of QOL.


Despite widely diverse patterns of use, PAP therapy may have short-term benefits with regard to QOL and reducing episodes of dizziness and autonomic dysreflexia.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from $8.99

All prices are NET prices.


  1. 1.

    Bauman KA, Kurili A, Schotland HM, Rodriguez GA, Chiodo AE, Sitrin RG. A simplified approach to diagnosing sleep-disordered breathing and nocturnal hypercapnia in individuals with spinal cord injury. Arch Phys Med Rehabil. 2016;97:363–71.

  2. 2.

    Berlowitz DJ, Brown DJ, Campbell DA, Pierce RJ. A longitudinal evaluation of sleep and breathing in the first year after cervical spinal cord injury. Arch Phys Med Rehabil. 2005;86:1193–9.

  3. 3.

    Burns SP, Little JW, Hussey JD, Lyman P, Lakshminarayanan S. Sleep apnea syndrome in chronic spinal cord injury: associated factors and treatment. Arch Phys Med Rehabil. 2000;81:1334–9.

  4. 4.

    Klefbeck B, Sternhag M, Weinberg J, Levi R, Hultling C, Borg J. Obstructive sleep apneas in relation to severity of cervical spinal cord injury. Spinal Cord. 1998;36:621–8.

  5. 5.

    Leduc BE, Dagher JH, Mayer P, Bellemare F, Lepage Y. Estimated prevalence of obstructive sleep apnea–hypopnea syndrome after cervical cord injury. Arch Phys Med Rehabil. 2007;88:333–7.

  6. 6.

    Short DJ, Stradling JR, Williams SJ. Prevalence of sleep apnoea in patients over 40 years of age with spinal cord lesions. J Neurol Neurosurg Psychiatr. 1992;55:1032–6.

  7. 7.

    Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP, et al. Clinical adults. J Clin Sleep Med. 2009;5:263–76.

  8. 8.

    Jennum P, Riha RL. Epidemiology of sleep apnoea/hypopnoea syndrome and sleep-disordered breathing. Eur Respir J. 2009;33:907–14.

  9. 9.

    Sankari A, Martin JL, Bascom AT, Mitchell MN, Badr MS. Identification and treatment of sleep-disordered breathing in chronic spinal cord injury. Spinal Cord. 2015;53:145–9.

  10. 10.

    Angelico F, del Ben M, Augelletti T, de Vita R, Roma R, Violi F, et al. Obstructive sleep apnoea syndrome and the metabolic syndrome in an internal medicine setting. Eur J Intern Med. 2010;21:191–5.

  11. 11.

    Botros N, Concato J, Mehsenin V, Selim B, Doctor K, Yaggi HK. Obstructive sleep apnea as a risk factor for type 2 diabetes. Am J Med. 2009;122:1122–7.

  12. 12.

    Buchner NJ, Sanner BM, Borgel J, Rump LC. Continuous positive airway pressure treatment of mild to moderate obstructive sleep apnea reduces cardiovascular risk. Am J Respir Crit Care Med. 2007;176:1274–80.

  13. 13.

    Levy P, Bonsignore MR, Eckel J. Sleep, sleep-disordered breathing and metabolic consequences. Eur Respir J. 2009;34:243–60.

  14. 14.

    Papanas N, Steiropoulos R, Nena E, Tzouvelekis A, Maltezos E, Trakada G, et al. HbA1c is associated with severity of obstructive sleep apnea–hypopnea syndrome in nondiabetic men. Vasc Health Risk Manag. 2009;5:751–6.

  15. 15.

    Parish JM, Adam T, Facchiano L. Relationship of metabolic syndrome and obstructive sleep apnea. J Clin Sleep Med. 2007;3:467–72.

  16. 16.

    Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol. 2008;52:686–717.

  17. 17.

    Vgontzas AN, Bixler EO, Chrousos GP. Sleep apnea is a manifestation of the metabolic syndrome. Sleep Med Rev. 2005;9:211–24.

  18. 18.

    Burns SP, Kapur V, Yin KS, Buhrer R. Factors associated with sleep apnea in men with spinal cord injury: a population-based case-control study. Spinal Cord. 2001;39:15–22.

  19. 19.

    Wickwire EM, Lettieri CJ, Cairns AA, Collop NA. Maximizing positive airway pressure adherence in adults: a common-sense approach. Chest. 2013;144:680–93.

  20. 20.

    Kribbs NB, Pack AI, Kline LR, Smith PL, Schwartz AR, Schubert NM, et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis. 1993;147:887–95.

  21. 21.

    Sin DD, Mayers I, Man GC, Pawluk L. Long-term compliance rates to continuous positive airway pressure in obstructive sleep apnea: a population-based study. Chest. 2002;121:430–5.

  22. 22.

    Billings ME, Auckley D, Bence R, Foldvary-Schaefer N, Iber C, Redline S, et al. Race and residential socioeconomics as predictors of CPAP adherence. Sleep. 2011;34:1653–8.

  23. 23.

    Chasens ER, Pack AI, Maislin G, Dinges DF, Weaver TE. Claustrophobia and adherence to CPAP treatment. West J Nurs Res. 2005;27:307–21.

  24. 24.

    El-Solh AA, Ayyar L, Akinnusi M, Relia S, Akinnusi O. Positive airway pressure adherence in veterans with post-traumatic stress disorder. Sleep. 2010;33:1495–1500.

  25. 25.

    Engleman HM, Wild MR. Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS). Sleep Med Rev. 2003;7:81–99.

  26. 26.

    Ballard RD, Gay PC, Strollo PJ. Interventions to improve compliance in sleep apnea patients previously non-compliant with continuous positive airway pressure. J Clin Sleep Med. 2007;3:706–12.

  27. 27.

    Ip S, D’Ambrosio C, Patel K, Obadan N, Kitsios GD, Chung M, et al. Auto-titrating versus fixed continuous positive airway pressure for the treatment of obstructive sleep apnea: a systematic review with meta-analyses. Syst Rev. 2012;1:20.

  28. 28.

    Smith I, Lasserson TJ. Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev. 2009;CD003531,

  29. 29.

    Berlowitz DJ, Spong J, Pierce RJ, Ross J, Barnes M, Brown DJ. The feasibility of using auto-titrating continuous positive airway pressure to treat obstructive sleep apnoea after acute tetraplegia. Spinal Cord. 2009;47:868–73.

  30. 30.

    Bisogni V, Pengo MF, Maiolino G, Rossi GP. The sympathetic nervous system and catecholamines metabolism in obstructive sleep apnoea. J Thorac Dis. 2016;8:243–54.

  31. 31.

    Waring WP 3rd, Biering-Sorensen F, Burns S, Donovan W, Graves D, Jha A, et al. 2009 review and revisions of the international standards for the neurological classification of spinal cord injury. J Spinal Cord Med. 2010;33:346–52.

  32. 32.

    Ellen RL, Marshall SC, Palayew M, Molnar FJ, Wilson KG, Man-Son-Hing M. Systematic review of motor vehicle crash risk in persons with sleep apnea. J Clin Sleep Med. 2006;2:193–200.

  33. 33.

    Friedman O, Logan AG. Sympathoadrenal mechanisms in the pathogenesis of sleep apnea-related hypertension. Curr Hypertens Rep. 2009;11:212–6.

  34. 34.

    Narkiewicz K, Somers VK. Sympathetic nerve activity in obstructive sleep apnoea. Acta Physiol Scand. 2003;177:385–90.

Download references


We wish to thank Kerby Shedden, Ph.D., Director for the University of Michigan Center for Statistical Analysis and Consultation and Research for his advice and expertise. We would also would like to thank Marty Frick and Katie Gootee for administrative support.

Author information


  1. Pulmonary and Critical Care Medicine Division, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, 48109, USA

    • Jeanette P. Brown
    • , Kristy A. Bauman
    • , Armando Kurili
    • , Robert G. Sitrin
    •  & Helena M. Schotland
  2. Department of Physical Medicine and Rehabilitation, University of Michigan Health System, Ann Arbor, MI, 48109, USA

    • Gianna M. Rodriguez
    •  & Anthony E. Chiodo
  3. Department of Neurology, Sleep Disorders Center, University of Michigan Health System, Ann Arbor, MI, 48109, USA

    • Helena M. Schotland


  1. Search for Jeanette P. Brown in:

  2. Search for Kristy A. Bauman in:

  3. Search for Armando Kurili in:

  4. Search for Gianna M. Rodriguez in:

  5. Search for Anthony E. Chiodo in:

  6. Search for Robert G. Sitrin in:

  7. Search for Helena M. Schotland in:

Conflict of interest

The authors declare that they have no conflict of interest.

Corresponding author

Correspondence to Jeanette P. Brown.

Electronic supplementary material

About this article

Publication history