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Original Investigation
April 11, 2019

Association of Positive Airway Pressure Prescription With Mortality in Patients With Obesity and Severe Obstructive Sleep Apnea: The Sleep Heart Health Study

Author Affiliations
  • 1Paris Descartes University, Faculty of Medicine, Paris, France
  • 2INSERM, UMR-S970, Paris Cardiovascular Research Center, Department of Epidemiology, Paris, France
  • 3Department of Head and Neck Surgery, Georges Pompidou European Hospital, Paris, France
  • 4CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
  • 5Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, Netherlands
  • 6Department of medicine, Service of internal medicine, Lausanne University Hospital, Lausanne, Switzerland
  • 7Center for Investigation and Research in Sleep, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
JAMA Otolaryngol Head Neck Surg. 2019;145(6):509-515. doi:10.1001/jamaoto.2019.0281
Key Points

Question  Is the prescription of positive airway pressure (PAP) associated with lower all-cause mortality?

Findings  In this cohort study of 392 patients with obesity and severe obstructive sleep apnea with 11 years of follow-up, we found that prescription of PAP therapy was associated with a 62% lower risk of all-cause mortality compared with nonprescription of PAP, independent of major confounders.

Meaning  Positive airway pressure therapy prescription is associated with lower all-cause mortality, beginning several years after PAP prescription.


Importance  The association of positive airway pressure (PAP) with reduced mortality in patients with obstructive sleep apnea (OSA) remains uncertain.

Objective  To investigate the association between PAP prescription and mortality.

Design, Setting, and Participants  This multicenter, population-based cohort study evaluated data from the Sleep Heart Health Study (SHHS), a long-term observational cohort study that included participants between 1995 and 1998, with a mean follow-up of 11.1 years. Analyses were performed in September 2018. Within the SHHS, we compared patients with obesity and severe OSA with (n = 81) and without (n = 311) prescription of PAP therapy, after matching patients from each group by age, sex, and apnea-hypopnea index.

Exposures  Self-reported use of PAP.

Main Outcomes and Measures  All-cause mortality.

Results  Of 392 study participants, 316 (80.6%) were men, and mean (SD) age was 63.1 (11.0) years. Ninety-six deaths occurred; 12 among the prescribed-PAP group and 84 among the nonprescribed-PAP group, yielding crude incidence rates of 12.8 vs 24.7 deaths per 1000 person-years. In Cox multivariate analysis, the hazard ratio (HR) of all-cause mortality for prescribed PAP therapy was 0.38 (95% CI, 0.18-0.81). After propensity matching, the HR of all-cause mortality for prescribed PAP therapy was 0.58 (95% CI, 0.35-0.96). According to survival curves, the difference in mortality appears 6 to 7 years after initiation of PAP therapy.

Conclusions and Relevance  Positive airway pressure prescription is associated with reduced all-cause mortality, and this association appears several years after PAP initiation. If replicated, these findings may have strong clinical implications.