Issue Navigator

Volume 14 No. 10
Earn CME
Accepted Papers

Letters to the Editor

PAP Treatment for Patients Who Have Had a Stroke

Anupama Gupta, MBBS, PhD; Garima Shukla, MD, DM
Department of Neurology, All India Institute of Medical Sciences, New Delhi

The letter by Ganguly is pointed, explicit and much appreciated.1 Reiterating the important points raised in our original paper,2 as well as in this letter, sleep apnea has been long established as an independent risk factor for stroke. A recent meta-analysis of randomized controlled trials showed that despite the heterogenicity of positive airway pressure (PAP) therapy among patients who have had a stroke, PAP treatment may have a significant role in neurological recovery.3 Another meta-analysis concluded that more than 4 hours of continuous positive airway pressure use in > 70% of the nights within the study period significantly reduced the risk of stroke.4

While seeking evidence favoring sleep apnea screening and PAP treatment among patients who have had a stroke, it is extremely important that we consider challenges in gathering this evidence. It has been observed that only approximately 2.3% of potential participants of trials can actually be treated for sleep apnea adequately, as there are various challenges in recruitment and initiation of PAP therapy.5 We came across similar challenges in our study. Despite obtaining consent from almost twice the number of patients required to reach our desired sample size, we found conducting overnight in-laboratory sleep studies, PAP initiation, and PAP adherence, to be difficult because of various factors listed in the paper, such as patient acceptance, mask fitting problems due to facial weakness, inability to independently handle the PAP device, and many psychosocial factors. These factors dominated despite 100% follow-up through telephone reviews, regular hospital visits as well as home visits by trial staff.2

In addition to better neurological recovery as well as some indication towards lower incidence of secondary vascular events among those who receive PAP treatment, we should also keep in view the undisputable facts that sleep apnea also causes recurrent hypoxia, sleep fragmentation, and exessive day time sleepiness, all of which have deleterious effects on patients who have had a stroke and could certainly be reduced with PAP treatment.6


Work for this study was performed at All India Institute of Medical Sciences, New Delhi. All authors have seen and approved the manuscript. The authors report no conflicts of interest.


Gupta A, Shukla G. PAP treatment for patients who have had a stroke. J Clin Sleep Med. 2018;14(10):1825.



Ganguly G. Let's get it right this time: controversies and now redacted 2018 AHA stroke guidelines. J Clin Sleep Med. 2018;14(10):1823


Gupta A, Shukla G, Afsar M, et al. Role of positive airway pressure therapy for obstructive sleep apnea in patients with stroke: a randomized controlled trial. J Clin Sleep Med. 2018;14(4):511–521. [PubMed Central][PubMed]


Brill AK, Horvath T, Seiler A, et al. CPAP as treatment of sleep apnea after stroke: a meta-analysis of randomized trials. Neurology. 2018;90(14):e1222–e1230. [PubMed]


Faheem N, Stevens S. Systematic review and meta-analysis of randomized control trials examining efficacy of CPAP for prevention of stroke in patients with moderate to severe obstructive sleep apnea (S54.003) [abstract]. Neurology. 2018;90 15 Suppl:S54.003


Tomfohr LM, Hemmen T, Natarajan L, et al. Continuous positive airway pressure for treatment of obstructive sleep apnea in stroke survivors: what do we really know? Stroke. 2012;43(11):3118–3123. [PubMed Central][PubMed]


Hermann DM, Bassetti CL. Role of sleep-disordered breathing and sleep-wake disturbances for stroke and stroke recovery. Neurology. 2016;87(13):1407–1416. [PubMed Central][PubMed]