Effectiveness of positive airway pressure therapy in reducing recurrent vascular events and improving the health outcomes of patients with post-stroke sleep-disordered breathing: A systematic review and meta-analysis

Abstract

Background: Sleep-disordered breathing (SDB) is an under-recognised independent risk factor and a potential consequence of stroke. Positive airway pressure (PAP) therapy is typically the first treatment for SDB. However, current reviews summarising PAP therapy's effect lacked evidence-based conclusion to justify its use in post-stroke SDB patients. Aim: To synthesise the best available evidence to evaluate the effectiveness of PAP therapy in reducing recurrent vascular events and improving other health outcomes in post-stroke patients with SDB as compared to no treatment, usual care, or placebo. Design: A systematic review and meta-analysis. Methods: A comprehensive three-step search strategy was used to search for relevant published and unpublished studies from nine bibliographic databases of CENTRAL, Embase, PubMed, CINAHL, PsycINFO, Scopus, ProQuest, Web of Science, and CNKI. Randomised controlled trials examining adult stroke patients with established SDB treated with PAP therapy and published in English or Chinese with no year limitation were included. Two independent reviewers performed databases search, data extraction, and risk of bias assessment. Meta-analyses were performed for the primary outcome of recurrent vascular events and secondary outcomes of neurological deficit, cognition, functional independence, daytime sleepiness, and depression, using RevMan 5.4 software. Results: Twenty-four studies were included. PAP therapy results in a large reduction in recurrent vascular events risk (RR = 0.57, p < 0.0001), and may result in a reduction in neurological deficit (SMD = -0.78, p < 0.0001), slight increase in functional independence (SMD = 0.45, p = 0.02), and large reduction in daytime sleepiness (SMD = -0.97, p = 0.0002). Effects on cognition and depression remains uncertain. Substantial heterogeneity was observed for all secondary outcomes. No publication bias was detected. Conclusions and Implications: Post-stroke patients with SDB benefited from PAP therapy. Prospective RCTs are needed to determine the ideal initiation period and the minimum effective therapeutic dose.