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Worth the effort? Weighing up the benefit and burden of continuous positive airway pressure therapy for the treatment of obstructive sleep apnoea in chronic tetraplegia


Study design

Mixed methods


Continuous positive airway pressure (CPAP) therapy is the recommended treatment for obstructive sleep apnoea (OSA). The aim of this study was to estimate CPAP adherence in people with tetraplegia and OSA, and to explore the barriers and facilitators to CPAP use.


Hospital outpatient department in Melbourne, Australia


People with chronic tetraplegia and OSA were commenced with auto-titrating CPAP and supported for 1 month. Semi-structured interviews were conducted with participants at one month and analysed thematically. CPAP usage was measured at 1, 6 and 12 months, with “adherent” defined as achieving more than 4 h average per night.


Sixteen participants completed the study (80% male; mean age 56 (SD = 15)). Mean nightly CPAP use at one month was 3.1 h (SD = 2.5; 38% adherent), and at 6 months and 12 months were 2.6 h (SD = 2.8; 25% adherent) and 2.1 h (SD = 3.2; 25% adherent). The perceived benefit/burden balance strongly influenced ongoing use. Burden attributed to CPAP use was common, and included mask discomfort, and physical and emotional problems. Adherent participants were motivated by the immediate daytime benefits to mood, alertness and sleepiness. There was a tendency to not recognise symptoms of OSA until after they were treated.


CPAP use is challenging for people with tetraplegia, who experience substantial burden from using the device. When tolerated, the proximate benefits are substantial. People with tetraplegia need more intensive support for longer to help them overcome the burdens of CPAP and benefit from the treatment.

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  1. 1.

    Giannoccaro MP, Moghadam KK, Pizza F, Boriani S, Maraldi NM, Avoni P, et al. Sleep disorders in patients with spinal cord injury. Sleep Med Rev. 2013;17:399–409.

  2. 2.

    Graco M, Schembri R, Cross S, Thiyagarajan C, Shafazand S, Ayas NT, et al. Diagnostic accuracy of a two-stage model for detecting obstructive sleep apnoea in chronic tetraplegia. Thorax. 2018:thoraxjnl-2017-211131:1–8.

  3. 3.

    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.

  4. 4.

    Berlowitz DJ, Spong J, Gordon I, Howard ME, Brown DJ. Relationships between objective sleep indices and symptoms in a community sample of people with tetraplegia. Arch Phys Med Rehabil. 2012;93:1246–52.

  5. 5.

    Schembri R, Spong J, Graco M, Berlowitz D. Neuropsychological function in patients with acute tetraplegia and sleep disordered breathing. Sleep. 2017;40:1–6.

  6. 6.

    Sankari A, Martin JL, Badr MS. Sleep-disordered breathing and spinal cord injury: challenges and opportunities. Curr Sleep Med Rep. 2017;3:272–8.

  7. 7.

    Respiratory management following spinal cord injury: a clinical practice guideline for health-care professionals. Consortium for Spinal Cord Medicine; Paralyzed Veterans of America; 2005.

  8. 8.

    Qaseem A, Holty J-EC, Owens DK, Dallas P, Starkey M, Shekelle P. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013;159:471–83.

  9. 9.

    Giles TL, Lasserson TJ, Smith B, White J, Wright JJ, Cates CJ. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database of Systematic Reviews. 2006 .

  10. 10.

    McMillan A, Bratton DJ, Faria R, Laskawiec-Szkonter M, Griffin S, Davies RJ, et al. Continuous positive airway pressure in older people with obstructive sleep apnoea syndrome (PREDICT): a 12-month, multicentre, randomised trial. Lancet Respir Med. 2014;2:804–12.

  11. 11.

    Ryan CM, Bayley M, Green R, Murray BJ, Bradley TD. Influence of continuous positive airway pressure on outcomes of rehabilitation in stroke patients with obstructive sleep apnea. Stroke. 2011;42:1062–7.

  12. 12.

    Weaver TE, Sawyer AM. Adherence to continuous positive airway pressure treatment for obstructive sleep apnea: implications for future interventions. Indian J Med Res. 2010;131:245.

  13. 13.

    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.

  14. 14.

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

  15. 15.

    Ward K, Hoare KJ, Gott M. What is known about the experiences of using CPAP for OSA from the users’ perspective? A systematic integrative literature review. Sleep Med Rev. 2014;18:357–66.

  16. 16.

    Sawyer AM, Deatrick JA, Kuna ST, Weaver TE. Differences in perceptions of the diagnosis and treatment of obstructive sleep apnea and continuous positive airway pressure therapy among adherers and nonadherers. Qual Health Res. 2010;20:873–92.

  17. 17.

    Fogelberg DJ, Leland, Blanchard NEJ, Rich TJ, Clark FA. Qualitative experience of sleep in individuals with spinal cord injury. OTJR: Occup, Particip Health. 2017;37:89–97.

  18. 18.

    Chai-Coetzer CL, Luo Y-M, Antic NA, Zhang X-L, Chen B-Y, He Q-Y, et al. Predictors of long-term adherence to continuous positive airway pressure therapy in patients with obstructive sleep apnea and cardiovascular disease in the SAVE study. Sleep. 2013;36:1929.

  19. 19.

    Braun V, Clarke V, Terry G. Thematic analysis. APA Handb Res Methods Psychol. 2012;2:57–71.

  20. 20.

    Weaver TE, Kribbs NB, Pack AI, Kline LR, Chugh TK, Maislin G, et al. ‘Night—to-night variability in CPAP use over the first three months of treatment. Sleep. 1997;20:278–83.

  21. 21.

    Adriaansen JJ, Post MW, de Groot S, van Asbeck FW, Stolwijk-Swüste JM, Tepper M, et al. Secondary health conditions in persons with spinal cord injury: a longitudinal study from one to five years post-discharge. J Rehabil Med. 2013;45:1016–22.

  22. 22.

    Rosbach M, Andersen JS. Patient-experienced burden of treatment in patients with multimorbidity–a systematic review of qualitative data. PLoS ONE. 2017;12:e0179916.

  23. 23.

    Brown JP, Bauman KA, Kurili A, Rodriguez GM, Chiodo AE, Sitrin RG, et al. 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;56:777–89.

  24. 24.

    Eton DT, Yost KJ, Lai J-s, Ridgeway JL, Egginton JS, Rosedahl JK, et al. Development and validation of the Patient Experience with Treatment and Self-management (PETS): a patient-reported measure of treatment burden. Qual Life Res. 2017;26:489–503.

  25. 25.

    Luyster FS, Dunbar-Jacob J, Aloia MS, Martire LM, Buysse DJ, Strollo PJ. Patient and partner experiences with obstructive sleep apnea and CPAP treatment: a qualitative analysis. Behav Sleep Med. 2016;14:67–84.

  26. 26.

    Broström A, Nilsen P, Johansson P, Ulander M, Strömberg A, Svanborg E, et al. Putative facilitators and barriers for adherence to CPAP treatment in patients with obstructive sleep apnea syndrome: a qualitative content analysis. Sleep Med. 2010;11:126–30.

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The authors wish to thank ResMed for the donation of the AirSense 10 Autoset devices, and the people with spinal cord injury who generously offered their time to participate in this research.

Author contributions

Study design: MG, SEG, JT, MB, DJB. Participant recruitment and data acquisition: MG, JT, BS, SH, CN, MB. Data analysis and interpretation: MG, SEG, AR, DJB. Manuscript preparation and approval of final version: all authors.


MG was supported by an Australian Government National Health and Medical Research Council post-graduate scholarship (grant number 1114181) and an Australasian Spinal Cord Injury Network PhD scholarship.

Online supplement

The online supplement contains the following information: additional methods (including participant recruitment and data collection; qualitative analysis and coding framework) and additional results (including individual participant CPAP data; univariate analysis of risk factors for CPAP use; barriers and enablers to CPAP use).

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Conflict of interest

The authors declare that they have no conflict of interest.

Correspondence to Marnie Graco.

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