By Susan Hoefs
It is common knowledge in the sleep medicine community that adherence to Continuous Positive Airway Pressure (CPAP) is critical to managing Obstructive Sleep Apnea (OSA). It’s also well known that many patients do not comply with CPAP treatment. Fortunately, recent research has found several factors affecting CPAP adherence that are relatively easy to implement and can significantly improve CPAP adherence.
Fitting the CPAP mask correctly on the first try
It’s the most critical component of the recent studies. Bachour et al. studied patients that switched the mask in the initial time period compared to those that didn’t. The conclusion suggests that patients who switched their mask initially were at a seven-fold higher risk of abandoning CPAP therapy during the year following the switch in comparison to those who did not switch.1 The major reason for the observed initial mask switch was poor fit or discomfort and the second major reason was leak related. Both of these reasons can be eliminated by fitting the mask right on the first try and if a patient asks to switch it, be certain the patient is wearing the mask correctly. If the therapist confirms the mask is not leaking or causing issues, the patient should be encouraged to give it more time.
Choose the mask that is best for the patient
This sounds like a no-brainer but a surprising amount of patients complain to the caregivers that they are experiencing claustrophobia and don’t like the unattractive headgear, complex straps, facial imprinting and general discomfort the mask is causing. Weaver & Grunstein (2008)2 cite 78 references validating this. Choose a mask that is comfortable, fits gently and doesn’t need to be over tightened to avoid leaks and looks nice. In recent years, many masks have come on the market that are dramatically more attractive and easier to use than ten years ago. Black headgear is rarely seen in a newer mask and manufacturers do extensive research and field testing to make sure patients find the mask more attractive and comfortable than in years past.
Start with a nasal mask or nasal pillow
Research shows that oronasal masks (full face) have reduced adherence and are linked to depression, low effective pressure and side effects.3 In studies comparing nasal masks, nasal pillows, oral masks and oronasal masks, all parameters were worse in those who used an oronasal mask. Patients on an oronasal mask average three events per hour higher than using a nasal mask or nasal pillow. It doesn’t sound like much, but that can cause as many as twenty arousals during the night. The pressure of the mask on the teeth can push the jaw back, increasing the Apnea-Hypopnea Index (AHI) which then increases the pressure if using auto CPAP.
Clear up nasal congestion
The most common reason a patient ends up with an oronasal mask is not being able to breathe through the nose. Most patients that claim to be “mouth breathers” can learn to breathe in a healthier way through the nose. Those that are congested should clear up that congestion. It’s not a healthy or pleasant day or night. Treatments include the use of nasal saline, nasal irrigation, medication, steroids for nasal polyps, nasal dilator strips, and surgery.
Use of heated humidification
Heated humidification produces an improved CPAP compliance rate when compared with cold passover humidity or no humidity.4 A heated tube with a chamber of water is the best case scenario. Patients that pull off their mask during the night and struggling with nighttime congestion should be asked if water and a heated tube is being used. It’s not uncommon for patients to not bother with using water. Patients may not be aware a heated tube is available.
Education for staff and patients is critical
Staff needs to be aware of the correct way to fit masks and how to determine which mask is right for which patient. Reach out to the manufacturers of masks and ask for training. A twenty-minute session reviewing the fitting and use of a mask can make a world of difference. And don’t forget to educate the patient. Many patients leave the setup appointment overwhelmed with information and anxiety about the coming night. Learners recall about 30% of what they learn through a demonstration such as a CPAP set up.5 Which 70% of the information did the patient not retain? Close monitoring the first week or so is critical and with modems available on the CPAP machines, it should be easy to determine who needs a follow-up call to check in. Utilize texting, apps, and email if the patient prefers.
Have the patient teach the staff member
Learners recall 90% of new information if given the chance to teach it to another. It also clarifies whether the patient understood the information given. And don’t forget to use language that the patient understands. Just because the patient nods and smiles doesn’t mean all that information was understood.
To summarize, utilize the following research-based strategies and practices to increase adherence to CPAP treatment:
- Fit the CPAP mask correctly on the first try
- Choose the mask that is best for the patient
- Start with a nasal mask or nasal pillow
- Clear up nasal congestion
- Use heated humidification including a heated tube
- Educate staff and patients
- Have the patient teach the staff member
Susan Hoefs, CCSH, RPSGT, RST has worked in the field of sleep medicine for over 20 years. Sue has experience as a night tech, day tech, and clinical sleep educator. She has been active in the AAST as a committee chairperson and is one of the founders of the Wisconsin sleep Society.
1 Bachour, A., Vitikainen, P. and Maasilta, P. Rates of initial acceptance of PAP masks and outcomes of mask switching. Sleep Breath, 2016. 20(2): pp. 733-8.
2 Weaver TE et al./ Proc Am Thorac Soc, 2008
3 Borel, J.C., et al. Type of mask may impact on continuous positive airway pressure adherence in apneic patients. PLoS One, 2013. 8(5): p. e64382.
4 Massie CA, Hart RW, Peralez K, Richards GN. Effects of humidification on nasal symptoms and compliance in sleep apnea patients using continuous positive airway pressure. Chest. 1999;116:403-408.
5 The National Training Institute http://www.ntl.org/ accessed December 13, 2017.
what is the common pressure range , you see in pt.’s with Sleep Apnea