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CPAP COMPLIANCE

Obstructive Sleep Apnea & CPAP ComplianceMichelle CaoStanford University Sleep Disorders Clinic3/05/2008

A.W.A.K.E.

Alert, Well, And Keeping Energetic for sleep apnea patientsWhat is obstructive sleep apnea?Repetitive upper airway partial or complete obstruction during sleep associated with a drop in oxygen level and arousal from sleepDiagnostically proven on an overnight sleep studyAssociated with daytime symptoms and frequent night awakeningsConsequences of untreated sleep apnea:Excessive daytime sleepinessDaytime fatigueCognitive dysfunction (decreased memory, concentration, attention, and mental sharpness)Sexual dysfunctionMood changesPoor social interaction and physical performanceIncreased automobile accidentsIncreased cardiovascular complications (high blood pressure, heart attacks, strokes, heart rhythm disturbances)

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Downloaded from: Principles and Practice of Sleep Medicine (on 25 February 2008 07:35 AM) 2007 Elsevier

AWAKESLEEPCPAP ON7Why CPAP?CPAP reverses repetitive upper airway obstruction and associated daytime symptoms, reduce automobile accidents, and reduce cardiovascular events

Patients using CPAP commonly describe treatment as.emerging from a daytime fog and being able to live a productive and healthy life.Benefits from CPAPHighly effective if used correctly and regularlyNoninvasive (nonsurgical)Sleep pattern normalizesGreater alertness and less daytime sleepinessBetter moodImprovement in work productivityReduce incidence of high blood pressure and heart related diseaseSide effects of CPAPIndefinite useDevice provokes anxiety (especially mask) and therefore more fragmented sleepMask and headgear trigger claustrophobiaMechanical irritation of the bridge of the noseIrritation of nose and throat nasal congestion, dry mouthDifficulty in breathing out especially if pressure is highEye irritation if there is mask leakADVERSE EFFECTS OF CPAPMask marks on face48%Nasal bridge discomfort or breakdown33%Nasal congestion26%Dry nose/dry or red eyes21-22%Machine noise17%Ear pain8%Prolific rhinitis7%Facial acne under mask6%Difficulty exhaling6%http://www.utdol.com based on data from Strollo PJ et al. Clin Chest Med 1998;19: 5511Knowing and recognizing the common adverse effects related to CPAP is important as patients who complain of side effects tend to use CPAP less than patients without side effects (Engleman et al. Chest 1996; 109: 1470) Most of the side effects are related to pressure or airflow or mask-nose interface

Other CPAP use problems:Nose bleedsAir swallowingTube condensationTemporary treatmentDay-to-day inconvenienceDifficulty with travelingUnattractive for relationshipsCPAP CompliancePattern of adherence to CPAP is established early on.within 1st week of usePredicts long term useThose who skip nights of CPAP also use it for shorter duration during the nighton average 3 hours/nightFailure to use CPAP nightly causes reemergence of daytime symptoms, even with one skipped nightHow many hours of CPAP use is considered effective?Studies have shown that certain hours of CPAP use improves symptoms:Subjective sleepiness> 4 hours of useObjective sleepiness> 6 hours of useMemory> 6 hours of useDaily functioning> 7.5 hours of useAny use is better than no use, but greater gains may be obtained with longer consistent nightly useWhat contributes to compliance or noncompliance of CPAP use?Disease severity: Patients who experience more severe daytime sleepiness have better compliance with long-term use of CPAP, while those with minimal or mild daytime sleepiness are less compliant with CPAP

Nasal congestion or small nasal passage (due to allergies, colds, flu, previous trauma, or anatomical obstruction)Compliance to CPAP was significantly increased with nasal surgeryCPAP and Nasal CongestionNasal congestion is experienced by at least 10% who complain of persistent stuffiness to some degree after 6 months of therapyCPAP can increase nasal congestion by:Provoke nasal pressure-sensitive mucosal receptors resulting in vasodilatation and mucus productionUnmask allergic rhinitis by restoring nasal breathingFixed obstruction (nasal polyps or deviated nasal septum) Oral leak which increases nasal resistance by exposing the nasal mucosa to higher flow rates and reduced relative humidity

How patients were initially exposed to CPAP determines how comfortable patients will be with CPAP (having someone available for questions, education, reinforce important benefits of CPAP, trouble shoot problems)

Claustrophobia Intrusive nature of CPAP into the sanctity of the bedroom

Aversion to unattractive headgear in bed

Patients who experience greater improvements in daily functioning have higher CPAP compliance

Patients who aggressively tackle obstacles associated with CPAP use by a problem-solving approach were more successful usersSocial support, partner interaction, partner sleep quality all determine compliance

If the idea to seek treatment originated with the partner, then this may decrease compliance

However, if the partners post-treatment sleep quality and overall quality of life were improved, compliance is improved as well

Interventions to improve CPAP compliance:Nasal stuffiness/congestion treatment:

Allergy treatment (medications)Nasal surgery (radiofrequency ablation of turbinates, septoplasty, nasal valve reconstruction)Heated humidification of the airway (no cold water systems)

Machine design and choice (size of machine, pressure ramp settings):

Various types of positive pressure modalities:

Bilevel machines (designed with a lower expiratory pressure to reduce expiratory work of breathing and increase patient comfort)Auto-CPAP (developed to vary and optimize the level of CPAP through the night, reducing mean pressure and minimizing local side effects)Pressure relief or flexible CPAP (C-Flex: alternates airway pressure between exhalation and inhalation on a breath-by-breath basis to improve patient comfort)It is important to remember that these new modalities were designed with the belief that higher CPAP pressures contributes to decreased compliance

The reality is that there is little evidence that the level of fixed pressure influences compliance at all

These new modalities have much higher cost, there is little rational for routine use except in a rescue role after poor adherence to standard CPAPBehavioral interventions:Patient education and support:

Availability of nurse or technician contact by phone during first few weeks of useEarly enrollment in group cognitive behavioral therapy program for CPAP useAWAKE classMask Related IssuesPROBLEMSOLUTIONSkin breakdown/irritation Refit mask Try nasal pillowsEye irritation Refit mask Saline eye drops Eye maskMouth leaks Chinstrap Switch masks (full face mask)Mask leaks/discomfort Refit or switch masks24Nasal issuesPROBLEMSOLUTIONNasal congestion Heated humidification Nasal saline sprays Nasal steroids decongestants antihistamines Correct any anatomic obstructionEpistaxis Heated humidifiers and salineRhinorrhea Heated humidifier, nasal saline antihistamines25Nasal congestion is experienced by at least 10% who complain of persistent stuffiness to some degree after 6 months of therapy (Pepin JL, Leger P, Veale D, et al. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome: Study of 193 patients in two French sleep centers. Chest 1995;107:375-381)CPAP may provoke nasal pressure-sensitive mucosal receptors, resulting in vasodilatation and mucus production OR may unmask allergic rhinitis in certain patients by restoring nasal breathing OR may be due to a fixed obstruction (nasal polyps or deviated nasal septum) OR may be due to an oral leak which increases nasal resistance by exposing the nasal mucosa to higher flow rates and reduced relative humidity (P&P)

Pressure IssuesPROBLEMSOLUTIONAerophagia (air swallowing) Reduce CPAP pressure Consider APAP, BilevelClaustrophobia Switch to nasal pillows DesensitizationDifficulty exhaling Ramp feature Consider switch to APAP, Bilevel, C-flex Consider re-titrationOther CPAP issuesPROBLEMSOLUTIONNoise Move unit away (under bed, in closet)- may need extra hose Change machinesTube condensation Insulated sleeve for hosePartner intolerance Move machine away Education/bring to follow-up visitsPortability Smaller units Letters of necessityA general approach to improving CPAP complianceIdentify and treat source(s) of problem:MaskNasalPressure-relatedOtherFirst-line technological interventionsAssess mask fit and consider alternative interfacesHeated humidifiersRamp featureC-flex, Auto-CPAP, BilevelPatient education Consider alternative behavioral interventions if necessaryKnowledge is keyRealistic expectationsCorrect CPAP prescriptionAppropriate equipment: machines, masks, humidifiersSupport and follow-up