Obstructive sleep apnea syndrome (OSAS) is a major health problem that has gained more and more attention over a relatively short time. In 1981, Lancet published an article describing the use of continuous positive airway pressure (CPAP) to treat sleep apnea.1 Since then, CPAP has become the first line of treatment for OSAS. By applying positive pressure to the upper airway, CPAP increases the cross-sectional area and volume of the oropharynx and laryngopharynx, effectively removing the obstruction of the upper airway by the tongue and pharyngeal tissue, and allows for continuous airflow throughout the breathing cycle. Patients with OSAS who use this treatment have a number of very positive results. First, and often most noticed by the patient, they have improved sleep quality and an increased level of alertness during the day. They also report reduced daytime sleepiness—they are able to function better, they have an improved mood/attitude, and they have fewer automobile accidents. Their blood pressure decreases as well as other cardiovascular abnormalities, including reduced atrial fibrillation and improved ejection fraction for those with OSAS and congestive heart failure (CHF).2 Despite all the positive results, compliance with using CPAP is a problem.
Predicting CPAP Compliance
CPAP compliance is often defined as using the therapy for an average of 4 hours a night for at least 70% of the nights.3 Studies show that somewhere between 29% and 83% of patients do not meet the criteria for compliance due to removing the CPAP early in the night and/or skipping use altogether. When patients first start using CPAP, they usually establish their pattern of compliance early on—within the first week of treatment. Clinicians are able to monitor use of CPAP via built-in smart cards, communication by modem, or a Web-based system to check both the hours the CPAP machine has been run and the amount of time the interface was actually in use. Often there is a discrepancy in run time versus applied time. This occurs when the patient removes the mask but leaves the CPAP unit running.4
Researchers have looked at various factors in trying to predict compliance and have found a few and ruled out many. The patient’s age, sex, and socioeconomic status have been ruled out as having some bearing on compliance. Also, the patient’s feelings of stress, anger, anxiety, or depression did not affect CPAP compliance. However, the severity of their disease as reflected in their apnea-hypopnea index (AHI) showed a relationship with compliance. Those with a higher AHI tend to be more compliant, and if they have both OSAS and CHF and are treated with CPAP, they have less mortality.5 Those patients who have already demonstrated poor medical compliance carry this forward with CPAP therapy. Compliance tends to be less in those who do not understand the health-related problems of apnea, those who refuse CPAP during titration, and those who complain of claustrophobia. Finally, those patients who are self-conscious and reluctant to wear the CPAP interface in the presence of their sleeping partner will be less compliant.6
What Else Contributes to Noncompliance?
Side effects and problems with the patient-CPAP system can cause the CPAP machine to be stuck in the closet, never to be used. The side effects include nasal drying, increased congestion, sneezing, rhinorrhea, sinusitis, conjunctivitis, claustrophobia, pressure sores on the bridge of the nose, difficulty exhaling, allergic reaction to the materials in the mask, air swallowing with gastric distension, machine noise, and skin creases the next morning. Many of these are avoidable if everyone in the health care team does a proper job of education, application, and follow-up with trouble-shooting and making corrections early in the start-up, as needed.7
Improving CPAP Compliance:The Top 10
Getting patients to stay with their CPAP therapy is difficult. Understanding the reasons why CPAP therapy is not succeeding helps the health care team know where to focus their efforts. Here are the top 10 practices that should help improve CPAP compliance. These were gleaned from several recent articles. They are not ranked in order of effectiveness but are based on a review of the literature; they are presented in a logical order that may include a bias for “first things first.” Overriding all of these is the need for communication. Invite the patient to talk, to share their feelings and fears, describe any discomfort while starting the therapy … encourage the patient to be open and talk.
1 EARLY AND ONGOING EDUCATION
Often the first suspicion of a sleep disorder arises from an office visit with a primary care physician (PCP). Education needs to occur with three groups; the PCP, the patient, and the spouse or sleeping partner. Knowledgeable PCPs can help create a good “first impression” of CPAP as the patient becomes aware of their potential problem and hears about the treatment used to correct sleep apnea/hypopnea.8
The patient should be introduced to the idea of CPAP early and often throughout the visit to the sleep disorders center. Beyond the PCP and patient, the third party who needs to be involved in education early and throughout is the spouse. All three parties need to know about the health issues related to OSAS and how CPAP can reverse many of the problems the patient may be experiencing. Topics should also include the CPAP unit (covering issues of its size, any noise it makes), the interface (the supply hose plus nasal mask, nasal pillows, etc), and the headgear or straps.
The patient might be afraid of the medical equipment, might think it is painful, might be afraid of dying in their sleep, or does not want to look strange to their bed partner. Education should cover advantages and disadvantages of treatment, and the positive effects on sleep quality, health, mood, alertness, etc. Open, frank discussion should be encouraged and questions answered, but always maintain a positive approach and focus on the positive outcomes. The physician or other professional explaining OSAS and CPAP should validate that many patients have some trouble getting used to using CPAP and that should problems arise, they should not give up and refuse the therapy. Rather, they need to discuss any problems with the staff and the staff should troubleshoot to correct the problems.
2 INITIATION OF CPAP THERAPY
CPAP is most often started in the sleep disorders center during a split study or the next night after a diagnostic polysomnogram recording has been performed. When the CPAP unit and interface are brought out, the patient should already know what it is, how the titration is to be done, why it is being used, and what to expect during the rest of the night. Poor titrations lead to poor compliance. As devices get more and more sophisticated, the education and skill of the team to match the proper technology with the patient and titrate it properly become more critical in determining compliance. The center should have a variety of masks and headgear, and the technician should work with the patient to get the best choice/fit. Before applying the CPAP, issues related to mouth-breathing, leaks, swallowing, and talking should be discussed. Assure the patient that they will be able to sleep with the CPAP—just be patient and keep in communication with the technician. Troubleshoot any problems and stay positive. If a particular interface is not working well, try another design.
3 IMMEDIATE INDIVIDUAL FOLLOW-UP
Since the first week of therapy tends to set the pattern of use, many sleep disorders centers will call the patient several times during the first 6 to 7 days to discuss the therapy and encourage the patient. The home health care agency involved with the CPAP setup should also be included in follow-up. Some centers establish an agreement with the home health agencies receiving referrals that specify a follow-up visit to the home during the first week of a CPAP setup, or at the minimum insist on a follow-up phone call from the agency to the patient with immediate response to the home if needed to correct any problems. Remember, the first impression sets the stage for months and years to come. Correcting a problem up front is critical.
4 MONITORING COMPLIANCE AND EFFICACY
Compliance should be checked somewhere between 3 and 6 months after the initial CPAP setup. The patient should be seen by a qualified sleep professional to assess usage of the equipment (hours of use and hours of application), check the machine settings, and ensure the interface (mask, pillows, etc) is in good condition. Immediate and long-term follow-up are indeed crucial to compliance, but monitoring efficacy is also critical to compliance and successful therapy. Discuss the results of the hours/usage monitor and reinforce the need to be faithful to the prescribed treatment. Talk about the patient’s sleep habits, quality of sleep, and overall health, and look for anything that might need to be corrected or anything that might affect compliance.
5 LONG-TERM SUPPORT AND TROUBLE-SHOOTING Many of the same activities from #4 also apply here. An annual office visit should be scheduled to check all the equipment and the hours/usage. Masks wear out and break, so an annual replacement should be in the plan. Changes in the patient’s condition may warrant a change in CPAP pressure (ie, weight loss may allow for a lower CPAP setting or vice-versa).
6 MASK FIT AND CHOICE OF INTERFACE
This has been discussed in regard to the first night’s use of the CPAP unit and for ongoing follow-up after initial treatment. Obviously, the nasal mask or the pillows must be the correct size. Several mask types and sizes should be available in order to find a good-fitting interface. Patients with claustrophobia may tolerate nasal pillows or nasal prongs more than the nasal mask. Pillows or prongs are also beneficial to interface with someone who has a mustache or is missing dental support needed for a nasal mask. Head straps should not be too tight and should not cause discomfort. An oronasal mask (combining nasal pillows and an oral mask) may be a better choice for patients with nasal congestion or a persistent mouth leak. A broken or malfunctioning interface/headgear/supply tube must be replaced immediately so that interruption of nightly CPAP use is minimized or eliminated.
7 NASAL CONGESTION, STEROIDS/ANTIHISTAMINES
Not being able to breathe easily through the nose creates a major barrier for compliance and adherence. For someone with congestion or sinusitis, nasal sprays with corticosteroids and antihistamines are a must. Many sleep professionals routinely prescribe these nasal sprays for all patients receiving nasal CPAP in order to avoid any possible complication.
Drying of the mouth and nose is a frequent complaint of CPAP users. Studies have examined heated humidification versus cold humidification and found that heated systems have better results. Evidence-based coverage of this topic was done in a Cochrane review from 2004, and the authors concluded that the evidence needed to make a strong case for humidification is not yet available.9 Regardless, many patients appear to have fewer complaints when using humidification. Bottom line is that more study is needed in this area.
9 CHOOSING THE RIGHT DEVICE
Fixed CPAP was the initial standard for CPAP due to the fact that it was the only means available for providing CPAP in the outpatient setting. Bilevel PAP therapy came along and opened more options (allowing clinicians to set the baseline expiratory pressure and the peak inspiratory pressure). Options opened up for many more delivery systems to adjust pressures, a respiratory rate, triggering thresholds, expiratory thresholds, ramp-up settings, etc. With AutoCPAP (aCPAP), the CPAP unit titrates the pressure up or down as needed to keep the upper airway open at the lowest effective pressure. With pressure-relief PAP, there is a reduction in pressure at the very end of inspiration and beginning of expiration so patients do not have to breathe against the prescribed therapeutic pressure immediately. Before the end of expiration, the pressure is restored to its therapeutic level to keep the airway open at the beginning of the next inspiration. Self-titrating CPAP allows the patient to change their pressure settings on their own. From a study looking at self-titration, there was no significant difference in the hours of CPAP use, the apnea-hypopnea index, or the score on the Epworth Sleepiness Scale, but the subjective measure of quality of life was significantly higher. The authors suspected this may relate to empowering individuals and making them feel better about their control of their health. The Cochrane review of 2004 evaluated these different delivery choices and concluded that aCPAP may be most useful in a select group of patients who require >10 cm H2O in their treatment setting or are poorly compliant with fixed CPAP. The evidence regarding bilevel PAP therapy, pressure-relief CPAP, and self-titration is not clear enough to make a judgement and more study is needed.
10 GROUP SUPPORT
Gathering CPAP patients together for group support is the last area to mention. Support groups have influences in many areas: sharing tips on how to cope with using CPAP; anecdotal discussions regarding the effect of CPAP on health; exploring the effect of CPAP on the relationship with the sleeping partner; reinforcement of the education offered on CPAP; and bearing each other’s burdens. Support groups tend to increase the number of hours for CPAP use and can help lock in the patient who may be wavering or wanting to give up due to side effects or problems.
CPAP for OSAS is getting more and more prevalent, and the problems with compliance are slowly being reduced. However, providing time for education and paying attention to problems during the first few days of CPAP use must be a priority. Incorporating these steps can make CPAP successful and keep the machine from just gathering dust while the patient continues to have poor sleep quality. An honest evaluation of the whole process of patient assessment, treatment, and follow-up (short-term and long-term) may uncover gaps in the plan and allow for effective change. More evidence-based study is needed to sort out the best practices. In the meantime, these top 10 practices should be incorporated into the CPAP plan of action for increasing success.
Bill Pruitt, MBA, RRT, CPFT, AE-C, is a senior instructor in the Department of Cardiorespiratory Sciences, College of Allied Health Science, University of South Alabama in Mobile. He also works as a PRN therapist at Springhill Medical Center and at the Mobile Infirmary Medical Center. For further information, contact [email protected].
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