A Holistic Approach to Improving PAP Compliance

holistic cpap

By Nathan Costiuc, MSN, APRN, FNP-BC

There is a burden that sleep clinicians carry with them in any patient encounter – the burden of knowing that the results of your work with patients suffering from obstructive sleep apnea (OSA) depend heavily on how well those patients adhere to treatment. Unfortunately, because positive airway pressure (PAP) therapy can be uncomfortable, complex, claustrophobic, and expensive1 patients struggle to keep up with treatment, especially in the initial treatment phase when they’re just starting to navigate their PAP device. Examples of issues include access challenges related to insurance or payment, poor health literacy leading to an inaccurate appraisal of the dangers associated with OSA, mental health issues that may require more partner/caretaker/community support, and transportation challenges that dictate a higher level of telehealth follow-up, among other things.

How prevalent are PAP compliance challenges?

According to one 2009 NIH study, approximately 9% of women and 24% of men met a low-threshold criterion for Sleep Disordered Breathing (SDB) consisting of AHI >5.2 Of these, the research on the number of patients struggling to adhere to nightly PAP treatment has never been very positive. One meta-analysis of randomized controlled trials on the subject showed an average rate of 34.1% non-adherence among patients.3

For all the effort and expense devoted to screening for, diagnosing, and treating sleep apnea, it can be disheartening for the clinician that patients will continue to suffer from the disease after being introduced to therapy. This incredible valley between diagnosis and adequate treatment highlights how – despite all our technological advancements in sleep therapy – we still have much farther to come in patient education and collaboration. Consider some of the following clinical techniques in partnership with your patients to help them stick to treatment and improve their outcomes.

1. Identify barriers to compliance early.

Patients can be apprehensive about using CPAP, especially when initial encounters reveal they know little about their diagnosis or therapeutic options. This can tempt sleep technologists, respiratory therapists, pulmonologists, or PCP’s to only broach the subject of airway support at the last possible moment, or only once the patient’s apnea-hypopnea index (AHI) results are positive for OSA.

However, best practice dictates that clinicians should be bringing the subject of therapeutic solutions up sooner rather than later. This gives the patient time to acclimate to the idea, formulate questions, express doubts, and become more educated on the subject. Early discussion of treatment options can also furnish time for the provider to identify health-adjacent issues that could get in the way of adherence.

2. Start low and go slow

Speaking of follow-up, sleep clinicians are all too familiar with the drop-off in usage that occurs during early PAP initiation. To combat this, consider the fact that many patients may be rapidly discouraged with PAP if they are immediately required to keep it on the whole night. After a split study has determined goal settings and patients are implementing therapy at home, have a staff member perform a follow-up screening/coaching session every 1-2 days initially for tolerance issues.

If the patient is struggling, provide an acclimation schedule, starting with one hour per night and increasing use over the course of time, maybe a week or longer as needed. If even this seems too overwhelming or there are anxiety/claustrophobia concerns, try enhancing familiarity by having them use the device during waking hours, or simply holding it to their face without the straps. Reassure them that most patients can become accustomed to the feeling of the device over time.

While a frequent follow-up schedule can seem overwhelming for busy providers, understand that regular follow-ups will decrease as the patient becomes accustomed to a regular PAP routine. As time passes, patients will instinctively realize when something isn’t going right and will be able to reach out as necessary for assistance. As the patient becomes more tolerant of PAP, titration studies every few years may be the only follow-up needed.

3. Navigate mask effectiveness

We live in an age of advanced PAP therapy. With the incredible variety of available options, mask fitting has become complex, to say the least. As such, treat the act of fitting like a sacred ritual in your practice. To this holy custom, you should be bringing a hefty dose of patience and substantial knowledge of how appliance options can achieve the desired fit while balancing patient tolerance and preference. It can be tempting to quickly move past the mask fitting, but generous time here is time well spent for long-term outcomes.

4. Look out for sinus issues

Sinusitis, sinus congestion, and vasomotor rhinorrhea are common contributors to increased nasal resistance which can lead to challenges for PAP patients.4 Congestion can cause mask air leaks and make it difficult or impossible to breathe through the nose. Here are a few tips to help your patients overcome sinus congestion and improve adherence:

  • Suggest an OTC saline spray before bedtime to help clear out the sinuses and reduce congestion.
  • Counsel your patient to drink plenty of fluids during the day to thin out mucus.
  • Consider an ongoing script for nasal decongestants like Flonase or antihistamines for uncomplicated rhinitis/sinusitis.
  • For advanced sinus issues like unfavorable nasal airway anatomy or congestion that is refractory to basic treatment, refer the patient to an ENT for comprehensive care. In the end, sinus improvements will equal sleep improvements.

5. Offer relaxation techniques

Calming techniques are especially useful during the initiation phase when patients tend to be the most wary, claustrophobic, or anxious. Practices like the following can help patients ease into a new routine and sensations:

  • Slow, deep breathing immediately prior to application of the PAP. One popular method and an area of evolving research is called Wim Hof breathing, which involves full inhalation through the belly followed by a slow, unforced exhalation.5 Performing 30-40 of these breaths is theorized to willfully attenuate a global sympathetic response that may help patients feel relaxed prior to trying on the mask.
  • Whole-body stretches near bedtime. Stretches designed to target the thoracic or upper airway muscles (sternocleidomastoid/scalenes group) may be the most helpful.
  • Strict sleep hygiene. The goal behind sleep hygiene is to calm the mind and body down before heading to bed and typically consists of several hours without screen time, adhering to the same daily sleeping schedule, and personalized “winding down” routines that make the patient feel as relaxed and tired as possible.

6. Consider various helpful PAP settings

There are a few on-device options you may consider that could help your patient adhere to the treatment plan. One popular option is using humidified, heated air to further reduce the risk of sinus irritation. Many devices also have ramp features that progressively increase intensity to reduce the abrupt onset of goal pressures. Choosing an AutoCPAP (aCPAP) at the outset can help reduce pressures to the lowest level needed for adequate airway support, theoretically improving comfort. In modern PAP therapy, the sky is the limit – pressure-relief PAP, self-titrating PAP, and trigger thresholds are just a few device-driven changes that could potentially help compliance.

For all the highly technical methods you could implement to get patients on adequate and easily-adhered-to PAP therapy, the best way to determine what works is decidedly less complex: just keep the lines of communication open with your patient and make sure they know you are available to them for questions, concerns, and ongoing adjustments. And hopefully, in due time, the infamous burden of non-adherence will plague clinicians no more.


  1. Mehrtash, M., Bakker, J.P. & Ayas, N. Predictors of Continuous Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea. Lung 197, 115–121 (2019). https://doi.org/10.1007/s00408-018-00193-1
  2. Young T, Palta M, Dempsey J, Peppard PE, Nieto FJ, Hla KM. Burden of sleep apnea: rationale, design, and major findings of the Wisconsin Sleep Cohort study. WMJ. 2009;108(5):246-249.
  3. Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg. 2016;45(1):43. Published 2016 Aug 19. doi:10.1186/s40463-016-0156-0
  4. Hoel H, Kvinnesland K, Berg S. Impact of nasal resistance on the distribution of apneas and hypopneas in obstructive sleep apnea. Sleep Med. 2020;71:83-88. doi:10.1016/j.sleep.2020.03.024
  5. Kox M, van Eijk LT, Zwaag J, et al. Voluntary activation of the sympathetic nervous system and attenuation of the innate immune response in humans. Proc Natl Acad Sci U S A. 2014;111(20):7379-7384. doi:10.1073/pnas.1322174111

nathan costiuc


Nathan Costiuc is a Nurse Practitioner and Freelance Writer based in West Palm Beach, Florida. He sees disabled veterans struggling with sleep disturbances in the context of multiple comorbidities. You can find him at clinicious.com or on his LinkedIn profile.


This article originally appeared in Sleep Lab Magazine Jul/Aug 2022.

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