Telemonitoring With CPAP in Severe Obstructive Sleep Apnea in Primary Health Care

Obstructive sleep apnea (OSA) is a chronic sleep-related breathing disorder characterized by recurrent episodes of upper airway obstruction during sleep, leading to intermittent hypoxia and sleep fragmentation. OSA is associated with increased risk of cardiovascular disease, metabolic disorders, neurocognitive impairment, mood disturbances, and reduced quality of life.

Continuous Positive Airway Pressure (CPAP) therapy is the most effective treatment for moderate to severe OSA. Despite its proven clinical benefits, adherence to CPAP therapy remains suboptimal in many patients. Barriers to adherence include discomfort with the device, technical difficulties, lack of support, and limited follow-up after treatment initiation.

Recent advances in digital health technologies have enabled remote monitoring of CPAP usage and performance. Telemonitoring systems allow healthcare professionals to track adherence, identify technical issues, and provide timely interventions to support patients during treatment. However, evidence regarding the effectiveness of telemonitoring in real-world primary care settings within public health systems remains limited.

This study aims to evaluate the impact of CPAP telemonitoring integrated into primary health care on treatment adherence and clinical outcomes among patients with severe OSA.

The study will be conducted within the Primary Health Care network of the Southeast Regional Health Coordination of São Paulo, Brazil. A total of 200 adult participants aged 18 to 75 years with a confirmed diagnosis of severe obstructive sleep apnea (apnea-hypopnea index ≥30 events per hour) and who have initiated CPAP therapy within the previous 30 days will be recruited from participating primary health care units.

Participants will be randomly assigned in a 1:1 ratio to one of two groups:

Intervention group (Telemonitoring): Participants will receive remote monitoring through the AirView® platform (ResMed) and the myAir® mobile application. Healthcare professionals will monitor CPAP usage data, including nightly usage time, residual AHI, leak levels, and therapy pressure. When adherence problems or technical issues are detected, the primary health care team will provide support through phone calls, educational reinforcement, or home visits.

Control group (Standard care): Participants will receive routine follow-up provided by primary health care services without access to telemonitoring tools or mobile applications.

Participants will be followed for 12 months, with data collection at baseline, 3 months, 6 months, and 12 months.

Primary outcomes include:

• CPAP adherence (average nightly use and percentage of nights with ≥4 hours of use)
• Residual apnea-hypopnea index (AHI)

Secondary outcomes include:

• Daytime sleepiness assessed using the Epworth Sleepiness Scale
• Sleep quality assessed using the Pittsburgh Sleep Quality Index
• Anxiety and depressive symptoms assessed using the Hospital Anxiety and Depression Scale
• Cognitive complaints assessed using the Cognitive Failures Questionnaire
• Patient and health professional perceptions regarding telemonitoring and care processes

Quantitative analyses will be conducted using mixed statistical models to evaluate longitudinal outcomes. Qualitative data obtained from semi-structured interviews will be analyzed using thematic content analysis.

This study seeks to generate evidence regarding the feasibility and effectiveness of telemonitoring strategies for CPAP therapy within public primary health care systems. The findings may support the implementation of digital monitoring strategies to improve adherence, optimize resource utilization, and enhance the management of obstructive sleep apnea in large-scale health systems.

Inclusion criteria

• Age between 18 and 75 years.
• Diagnosis of severe obstructive sleep apnea (OSA) confirmed by polysomnography with apnea-hypopnea index (AHI) ≥30 events/hour.
• New CPAP users (≤30 days since initiation of CPAP therapy).
• Resident within the coverage area of the Southeast Regional Health Coordination (CRS Sudeste), São Paulo, Brazil.
• Ability to understand and sign the informed consent form.

Exclusion criteria

• Previous CPAP use for more than 30 days prior to enrollment.
• Indication for bilevel ventilation (BiPAP) or non-invasive ventilation due to conditions such as hypoventilation syndromes, chronic hypercapnic COPD, or neuromuscular diseases.
• Predominant central sleep apnea (≥50% central events) or Cheyne-Stokes respiration.
• Recent unstable or severe comorbidity (e.g., decompensated heart failure, acute coronary syndrome within 30 days, stroke within 3 months).
• Severe cognitive impairment or psychiatric disorder that prevents understanding of study procedures or adherence.
• Conditions preventing safe use of CPAP mask (e.g., major craniofacial deformities, facial trauma, extensive facial skin lesions).
• Inability to maintain follow-up in primary care services of CRS Sudeste.
• Participation in another interventional clinical trial that may interfere with study outcomes.