A randomized, placebo-controlled trial using a novel PAP delivery platform to treat patients with OSA and comorbid PTSD

  • Aaron Holley
  • David Shaha
  • Camille Costan-Toth
  • Jennifer Slowik
  • Brian D. Robertson
  • Scott G. Williams
  • Seth Terry
  • Dana Golden
  • Teotimo Andrada
  • Sonja Skeete
  • Karen Sheikh
  • George Butler
  • Jacob F. CollenEmail author
Sleep Breathing Physiology and Disorders • Original Article



Positive airway pressure (PAP) adherence is poor in comorbid OSA/PTSD. SensAwake™ (SA) is a wake-sensing PAP algorithm that lowers pressure when wake is detected. We compared auto-PAP (aPAP) with and without SA for comorbid OSA/PTSD.


Prospective, randomized crossover study comparing aPAP to aPAP + SA. We enrolled patients with OSA/PTSD who were PAP naïve. Four weeks after randomization, the patients were crossed over to the alternate treatment group, with final follow-up at eight weeks. Sleep questionnaires (ESS, ISI, FSS, and FOSQ-10) were assessed at baseline and follow-up.


We enrolled 85 patients with OSA/PTSD. aPAP reduced AHI to < 5/h in both groups. Our primary endpoint, average hours of aPAP adherence (total) after 4 weeks, was significantly increased in the SA group in our intention-to-treat (ITT) analysis (ß = 1.13 (95% CI 0.16–2.1); p = 0.02), after adjustment for ESS differences at baseline. After adjustment for ESS, SA (ITT analysis) also showed significant improvement in percentage of nights used for ≥ 4 h (ß = 14.9 (95% CI 1.02–28.9); p = 0.04). There were trends toward an increase in percentage nights used total (ß = 17.4 (95% CI − 0.1 to 34.9); p = 0.05), average hours of aPAP adherence (nights used) (ß = 1.04 (95% CI − 0.07 to 2.1); p = 0.07), and regular use (OR = 7.5 (95% CI 0.9–64.7); p = 0.07) after adjustment for ESS at baseline. After adjustment for ESS and days to cross over, SA by actual assignment did not show any effect on adherence variables. The ESS, ISI, FSS, and FOSQ-10 all showed significant improvements with PAP, but there were no differences in the magnitude of improvement in any score between groups.


Adherence to aPAP may be improved with the addition of SA and deserves further study. SA is as effective as standard aPAP for normalizing the AHI and improving sleep-related symptoms.

Clinical trial registration NCT02549508

“Comparison Study Using APAP With and Without SensAwake in Patients With OSA and PTSD”.


Obstructive sleep apnea Post-traumatic stress disorder PTSD Continuous positive airway pressure CPAP CPAP adherence CPAP compliance 



American Academy of Sleep Medicine


apnea–hypopnea index


continuous positive airway pressure


auto-PAP (auto-adjustable continuous positive airway pressure)


Epworth Sleepiness Scale


Functional Outcomes of Sleep Questionnaire


Fatigue Severity Scale


Insomnia Severity Index


intention-to-treat analysis


obstructive sleep apnea


positive airway pressure


PTSD checklist




pressure transducer airflow


post-traumatic stress disorder


SensAwake™ (SA; Fisher and Paykel Healthcare, Auckland, New Zealand)


Walter Reed National Military Medical Center, Bethesda, MD



All of the study authors contributed to the study and have reviewed the final manuscript. Dr. Holley conceived the research idea and performed statistical analysis and manuscript editing. Dr. Shaha contributed to data collection and analysis and assisted in the first draft of the manuscript. Mr. Terry contributed to patient recruitment, data collection, and data analysis. Dr. Costan-Toth contributed to data collection and data analysis. Dr. Slowik contributed to data collection and analysis. Dr. Robertson contributed to patient recruitment and data analysis. Dr. Williams contributed to patient recruitment and data collection. Ms. Golden contributed to patient recruitment, data collection, and analysis. Mr. Andrada contributed to data collection. Ms. Skeete contributed to patient recruitment and data collection. Ms. Sheikh contributed to patient recruitment and data collection. Mr. Butler contributed to data collection. Dr. Collen is the guarantor of the final article and is responsible for the integrity of the data and contents of this manuscript from study inception to publication of the final product.

Funding information

This study was funded by Fisher-Paykel Healthcare (Grant #WR-GVA-FPH-10-32). This investigator-initiated project was conducted by using an unrestricted research grant and PAP machines provided by Fisher & Paykel Healthcare to the Geneva Foundation for the Advancement of Military Medicine. Fisher & Paykel Healthcare was involved with the study design, but not with patient enrollment, data collection and interpretation, manuscript preparation, or the decision to submit the manuscript for publication.

Compliance with ethical standards

Conflict of interest

None of the study authors have any relevant conflicts of interest to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Statement and declarations

All authors have seen and approve the manuscript. This investigator-initiated project was conducted by using an unrestricted research grant and PAP machines provided by Fisher & Paykel Healthcare to the Geneva Foundation for the Advancement of Military Medicine. Fisher & Paykel Healthcare was involved with the study design, but not with patient enrollment, data collection and interpretation, manuscript preparation, or the decision to submit the manuscript for publication. The study authors have no other relevant disclosures.

Supplementary material

11325_2019_1936_MOESM1_ESM.docx (16 kb)
ESM 1 E-Table 1: Baseline description of study population (demographic and clinical characteristics) based on treatment received. E-Table 2: PAP adherence for aPAP with SA-ON and SA-OFF based on treatment received. Residual (Treated) “AHI” (PAP estimated residual respiratory disturbance index), measures of PAP leak, and minimum and maximum PAP pressures. 1. Overall percentage of nights PAP was used during the study (“Nights used (%)”). 2. Percent of nights with use greater than or equal to 4 h (“Nights ≥ 4 h (%)”). 3. Average hours of use per night, over total nights (“Hours/nights, total”). 4. Average hours of use per night, averaged only over the nights PAP was actually used (worn) (“Hours/nights, used”). 5. Regular use = ≥ 4 h for ≥ 70% of nights [57] (DOCX 16 kb)
11325_2019_1936_MOESM2_ESM.docx (17 kb)
ESM 2 E-Table 3: by treatment received. PAP adherence by treatment received, with adjustment for differences at baseline. 1. Average hours of use per night, averaged only over the nights PAP was actually used (worn) (“Hours/nights, used”). 2. Average hours of use per night, over total nights (“Hours/nights, total”). 3. Overall percentage of nights PAP was used during the study (“Nights used (%)”). 4. Percent of nights with use greater than or equal to 4 h (“Nights ≥ 4 h (%)”). 5. Regular use = ≥ 4 h for ≥ 70% of nights [57]. E-Table 4: Differences in sleep-related symptoms at 4 weeks by intention-to-treat and by treatment received. E-Table 5: Intra-patient comparisons for PAP adherence by treatment received. 1. Overall percentage of nights PAP was used during the study (“Nights used (%)”). 2. Percent of nights with use greater than or equal to 4 h (“Nights ≥ 4 h (%)”). 3. Average hours of use per night, over total nights (“Hours/nights, total”). 4. Average hours of use per night, averaged only over the nights PAP was actually used (worn) (“Hours/nights, used”) (DOCX 16 kb)


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Copyright information

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2019

Authors and Affiliations

  • Aaron Holley
    • 1
  • David Shaha
    • 2
  • Camille Costan-Toth
    • 3
  • Jennifer Slowik
    • 4
  • Brian D. Robertson
    • 1
  • Scott G. Williams
    • 3
  • Seth Terry
    • 1
  • Dana Golden
    • 1
  • Teotimo Andrada
    • 1
  • Sonja Skeete
    • 1
  • Karen Sheikh
    • 1
  • George Butler
    • 1
  • Jacob F. Collen
    • 5
    Email author
  1. 1.Walter Reed National Military Medical CenterBethesdaUSA
  2. 2.Womack Army Medical CenterFort BraggUSA
  3. 3.Fort Belvoir Community HospitalFort BelvoirUSA
  4. 4.Madigan Army Medical CenterTacomaUSA
  5. 5.Uniformed Services University of the Health SciencesBethesdaUSA

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