220 JOURNAL MSMA July 2012

IntroductIon

Obstructive sleep apnea (OSA) is a major sleep disorder affecting about 25% of American adult

population. It is characterized by loud snoring, observed apneas, choking or snorting during sleep, morning headache and feeling tired or sleepy despite spending adequate time in bed. The complications of untreated sleep apnea include poorly controlled hypertension and diabetes, atrial fibrillation, increased risk of stroke and motor vehicle accidents, along with overall increase in mortality. Polysomnography is the gold standard for diagnosis of sleep apnea while continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) are the major treatment modalities available at this time.

CPAP/BiPAP has to be used nightly to achieve the full benefit of treatment of sleep apnea. Because of its cumbersomeness, CPAP compliance among OSA patients are only about 60-70%,1 which can improve to 85% only with consistent follow up and trouble shooting by the providers.2 In this article, we will discuss the key issues faced by the patients while using CPAP, and how to address them.

Key words: Obstructive sleep apnea, CPAP, compliance

1. Motivation: Lack of risk perception is one of the major causes of non-adherence to CPAP therapy.3

Discussing the risks of untreated obstructive sleep apnea with patients help them to be motivated to use the therapy.

2. Finding the right mask: Selecting the appropriate mask is one of the most important steps in being compliant. Patients, who are mouth breathers usually do well on full face mask which covers both nose and mouth, but those with claustrophobia may opt for a nasal mask or nasal pillows that fit under the nose. Addition of a chin strap may minimize the mouth breathing.

About How To Improve CPAP Compliance for the Treatment

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3. Getting used to the mask: Adherence to CPAP use in the first 4 nights can determine the overall CPAP compliance in the future.4 Patients usually have difficulties sleeping well for the first few nights with the new mask on. They need to be encouraged to wear it nightly and be reassured that most people eventually get used to it if used regularly.

4. Nasal dryness: CPAP may cause significant nasal dryness which can be prevented by using a heated humidifier attached to the CPAP unit and can be adjusted as needed. Use of normal saline nasal spray prior to sleep as well as steroid nasal spray may be helpful.

5. Dryness of mouth: People who breathe through the mouth or sleep with the mouth open can suffer from dryness of mouth. A full-face mask or adding a chin strap with the nasal mask can solve the problem.

6. Tolerating the air pressure: “Ramp” button is a unique feature in the CPAP device which helps to start CPAP at a low pressure and increases gradually towards the prescribed setting. The ramp time can be adjusted if the patient needs longer time to fall asleep.

7. Mask leak: A leaky mask fails to deliver the optimal pressure and trying to adjust them inappropriately can cause skin irritation, bruises on the face and irritation of the eyes. This should be fixed by adjusting the pads and straps to get a better fit and by changing the mask if adjustment fails.

8. Involuntary removal of CPAP at night: It is not uncommon for patients to wake up at night and find the CPAP mask displaced. Patients may involuntarily remove the device during sleep, or it may become

July 2012 JOURNAL MSMA 221

displaced during movements in sleep. Nasal dryness and mask leakage can cause irritation, prompting the removal, and should be addresses accordingly.

9. Claustrophobia: A feeling of claustrophobia is one of the most common complaints about wearing a CPAP. Changing a full face mask to a nasal mask or nasal pillows and practicing to use the mask while awake (while watching TV, for example) may desensitize the patients. Short term use of anxiolytics may be helpful.

10. Noise from CPAP unit: Noise produced by the CPAP unit, especially the older models, may interfere with the sleep of the patients or their spouses. Older units should be replaced by newer ones if noise is a problem. If the machine still makes noise, it needs to be checked and air filter may need to be replaced. If the noise is still bothersome, use of ear plugs or a white noise sound machine can be effective.

conclusIon Poor compliance to CPAP therapy is a major obstacle in

the treatment of OSA. Patients are very commonly hesitant to discuss the initial difficulties dealing with the CPAP unit and thus may become non-compliant. Physicians must actively seek and address with compassion the issues faced by the patients. This will lead to better compliance and help improve overall morbidity and mortality resulting from the complications of untreated OSA.

references

1. Waldhorn RE, Herrick TW, Nguyen MC, O’Donnell AE, Sodero J, Potolicchio SJ. Long-term compliance with nasal continuous positive airway pressure therapy of obstructive sleep apnea. Chest. 1990;97(1):33-38.

2. Sin DD, Mayers I, Man GC, Pawluk L. Long-term compliance rates to continuous positive airway pressure in obstructive sleep apnea: a population-based study. Chest. 2002;121(2):430-435.

3. Archbold KH, Parthasarathy S. Adherence to positive airway pressure therapy in adults and children. Curr Opin Pulm Med. 2009;15(6):585-590

4. Weaver TE, Kribbs NB, Pack AI, et al. Night-to-night variability in CPAP use over the first three months of treatment. Sleep. 1997;20(4):278-283.

Author InformAtIon:

Assistant Professor, General Internal Medicine and Sleep Medicine, University of Mississippi Medical Center, Medical Director, Sleep disorders laboratory, G.V (Sonny) Montgomery VA Medical Center, Jackson, MS. E-mail: stamanna@umc.edu; sadeka.tamanna@va.gov (Dr. Tamanna). Assistant Professor, Division of General Internal Medicine, University of Mississippi Medical Center, E-mail: mullah@umc.edu (Dr. Ullah).

Nasal pillow: the headgear is connected to the nasal airway by a soft but thick cannula fitting firmly with the nasal opening

Full face mask

Full face mask fitted on the face along with head gear

Figure 1: Different types of masks and head gears used in CPAP/BiPAP treatment of sleep apnea.

Figure 1. Different types of masks and head gears

used in CPAP/BiPAP treatment of sleep apnea.