The Challenges in Treating and Identifying Obstructive Sleep Apnea


The director of the Sleep Disorders Research Program at Cleveland Clinic Lerner College of Medicine provided her perspective on the differences in OSA prevalence for men and women and how adherence to CPAP remains a challenge.

Dr Reena Mehra

Reena Mehra, MD, MS, director, Sleep Disorders Research Program, and professor of medicine, Cleveland Clinic Lerner College of Medicine

Reena Mehra, MD, MS

In the treatment of obstructive sleep apnea (OSA), despite having a gold standard of treatment in continuous positive airway pressure (CPAP), patient adherence to the treatment—and interventions for OSA, in general, is a challenge.

Some estimates suggest that even with CPAP mask and machine alterations and accompanying behavioral intervention, adherence remains a severe issue in the management of OSA.1 Reena Mehra, MD, MS, director, Sleep Disorders Research Program, and professor of medicine, Cleveland Clinic Lerner College of Medicine, additionally shared with NeurologyLive that the prevalence of OSA does not differ much between the sexes, making adherence a widespread problem.2

To find out more about what Mehra and her colleagues at Cleveland Clinic are doing to offer patients unique resources, NeurologyLive spoke to her in an interview. She discussed the ways in which adherence issues can be tackled, as well as insight into why it is such a challenge for patients with OSA using CPAP and other medications.

NeurologyLive: Why is keeping patients on their CPAP regimens for OSA a challenge?

Reena Mehra, MD, MS: This is something we struggle with, in terms of adherence with CPAP for the treatment of OSA. General adherence is thought to be around 50% to 70%. Our estimates here at the Cleveland Clinic are a bit higher, at 80%, maybe even 90%. The struggle is, really, to try to identify the root cause of the problem in terms of why the patient is not able to tolerate the device. Sometimes it's pressure and tolerance, sometimes it's a mask interface issue, sometimes it's nasal congestion, and we've pretty much seen everything and we have ways that we can address those issues, including trying different masks, using heated humidification or nasal saline to treat the nasal congestion, if there's a pressure intolerance issue then sometimes there are different modes of positive airway pressure that can be used to make it more comfortable.

We also, here at the Cleveland Clinic, have some unique resources that we offer to help people with adherence such as the CPAP clinic, which is a group-based clinic where patients can come in and get a better sense of what their issues are and how to address them. We help them to utilize a group dynamic for people to lean on one another and discuss the issues they're having, which can be really helpful.

The other resource that we have is the PAP NAP study. This is a daytime study where patients with sleep apnea who are struggling with adherence have a 1-on-1 session with a sleep technologist who really tries to help desensitize and acclimate the patient to positive airway pressure. There are some published data to show that that is an effective strategy in improving adherence. People talk about the poor adherence with positive airway pressure, but when we really think about things it's around the adherence of medications as well, so 50% to 70% is probably a reflection of what real-world adherence is to medications.

Is this a sex-specific issue? Does the prevalence of OSA differ between men and women?

Men are 2 to 5 times more likely to have OSA compared to women. As women get perimenopausal, then our risk for OSA increases and so that is the reason why, particularly around that period of time, if sleep apnea is suspected, we should be looking into that a little bit more closely in women in that perimenopausal period. Our symptoms tend to not be the same—more insomnia, less excessive sleepiness, perhaps more mood changes, compared to the traditional symptoms that we think of, like hyper somnolence and snoring in witnessed apneas.

It's unclear why, again. It may be because we the phenotype that people typically think of in terms of obstructive sleep apnea is the obese male, however, these are patients that meet the criteria for upper airway neurostimulation, so I'm not sure why that would be an explanation. Unless there are some kind of hidden biases there think in terms of thinking that OSA is more of a significant entity and men compared to women.

Transcript edited for clarity.


1. Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg. 2016;45:43.doi: 10.1186/s40463-016-0156-0.

2. Wimms A, Woehrle H, Ketheeswaran S, Ramanan D, Armistead J. Obstructive Sleep Apnea in Women: Specific Issues and Interventions. Biomed Res Int. 2016:1764837. doi: 10.1155/2016/1764837.

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