Personalized Treatment Strategies to Improve Continuous Positive Airway Pressure (CPAP) Adherence in Patients with Obstructive Sleep Apnea

Abstract

Continuous positive airway pressure (CPAP) is the standard treatment for moderate to severe obstructive sleep apnea (OSA), which affects almost one billion persons worldwide. Its therapeutic benefit is critically dependent on the extent of nightly use, yet adherence has improved little over two decades of device refinement, with long-term use frequently below 50%. The disparity between the efficacy of CPAP under controlled trial conditions and its effectiveness in routine clinical practice is attributable predominantly to non-adherence. This narrative review examines CPAP therapy personalization to promote adherence. It critically appraises conflicting findings, examines methodological limitations, and delineates evidence gaps rather than merely cataloguing the literature. Four converging personalization levels are investigated. Behavioral tailoring using motivational interviewing, cognitive behavioral therapy, motivational enhancement therapy, and individualized feedback; technology-enabled personalization through telemonitoring, mobile health, and cloud-connected devices; device-level and algorithmic personalization, which matches interface, pressure mode, and flow-generator response profile to the individual; and phenotype- and endotype-driven care. Machine-learning models can now predict non-adherence from the first 30 nights of device telemetry with clinically useful discrimination. Behavioural interventions increase nightly use by approximately one hour and telemonitoring by approximately forty minutes, although these effects attenuate over time and are seldom stratified by baseline readiness to change. Evidence on major cardiovascular endpoints remains contested, largely because trial cohorts achieved sub-therapeutic exposure. Personalization appears most effective when behavioural, technological, and physiological approaches are combined. Effectiveness is the product of efficacy and sustained use. A stepped, patient-centred approach that characterises the patient before initiation, intervenes intensively during the first month, re-optimises the device before discontinuing CPAP, and applies phenotyping to guide selection of alternatives offers the most coherent strategy. Standardized adherence indicators, treatment-fidelity reporting, prospective endotype-guided allocation validation, explainable AI, and targeted equity are priorities.