Obstructive Sleep Apnea & CPAP Compliance

Michelle CaoStanford University Sleep Disorders Clinic

3/05/2008

A.W.A.K.E.

Alert, Well, And Keeping Energetic for sleep apnea patients

What is obstructive sleep apnea?

• Repetitive upper airway partial or complete obstruction during sleep associated with a drop in oxygen level and arousal from sleep

• Diagnostically proven on an overnight sleep study• Associated with daytime symptoms and frequent night

awakenings

Consequences of untreated sleep apnea:

– Excessive daytime sleepiness– Daytime fatigue– Cognitive dysfunction (decreased memory, concentration,

attention, and mental sharpness)– Sexual dysfunction– Mood changes– Poor social interaction and physical performance– Increased automobile accidents– Increased cardiovascular complications (high blood

pressure, heart attacks, strokes, heart rhythm disturbances)

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

AWAKE SLEEP CPAP ON

Why 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 CPAP

• Highly effective if used correctly and regularly• Noninvasive (nonsurgical)• Sleep pattern normalizes• Greater alertness and less daytime sleepiness• Better mood• Improvement in work productivity• Reduce incidence of high blood pressure and heart related

disease

Side effects of CPAP

• Indefinite use• Device provokes anxiety (especially mask) and therefore more

fragmented sleep• Mask and headgear trigger claustrophobia• Mechanical irritation of the bridge of the nose• Irritation of nose and throat – nasal congestion, dry mouth• Difficulty in breathing out especially if pressure is high• Eye irritation if there is mask leak

ADVERSE EFFECTS OF CPAP

Mask marks on face 48%

Nasal bridge discomfort or breakdown 33%

Nasal congestion 26%

Dry nose/dry or red eyes 21-22%

Machine noise 17%

Ear pain 8%

Prolific rhinitis 7%

Facial acne under mask 6%

Difficulty exhaling 6%

http://www.utdol.com based on data from Strollo PJ et al. Clin Chest Med 1998;19: 55

Other CPAP use problems:

• Nose bleeds• Air swallowing• Tube condensation• “Temporary” treatment• Day-to-day inconvenience• Difficulty with traveling• Unattractive for relationships

CPAP Compliance

• Pattern of adherence to CPAP is established early on….within 1st week of use

• Predicts long term use• Those who skip nights of CPAP also use it for shorter duration

during the night…on average 3 hours/night• Failure to use CPAP nightly causes reemergence of daytime

symptoms, even with one skipped night

How many hours of CPAP use is considered effective?• Studies have shown that certain hours of CPAP use improves

symptoms:• Subjective sleepiness > 4 hours of use• Objective sleepiness > 6 hours of use• Memory > 6 hours of use• Daily functioning > 7.5 hours of use Any use is better than no use, but greater gains may be

obtained with longer consistent nightly use

What 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 surgery

CPAP and Nasal Congestion

Nasal congestion is experienced by at least 10% who complain of persistent stuffiness to some degree after 6 months of therapy

CPAP can increase nasal congestion by:• Provoke nasal pressure-sensitive mucosal receptors resulting

in vasodilatation and mucus production• Unmask allergic rhinitis by restoring nasal breathing• Fixed 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 users

Social 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 partner’s 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 CPAP

Behavioral interventions:

Patient education and support:

• Availability of nurse or technician contact by phone during first few weeks of use

• Early enrollment in group cognitive behavioral therapy program for CPAP use

• AWAKE class

Mask Related Issues

PROBLEM SOLUTION

Skin breakdown/irritation • Refit mask• Try nasal pillows

Eye irritation • Refit mask• Saline eye drops• Eye mask

Mouth leaks • Chinstrap• Switch masks (full face mask)

Mask leaks/discomfort • Refit or switch masks

Nasal issues

PROBLEM SOLUTION

Nasal congestion

• Heated humidification• Nasal saline sprays• Nasal steroids ± decongestants ± antihistamines• Correct any anatomic obstruction

Epistaxis • Heated humidifiers and saline

Rhinorrhea • Heated humidifier, nasal saline ± antihistamines

Pressure Issues

PROBLEM SOLUTION

Aerophagia (air swallowing)

• Reduce CPAP pressure• Consider APAP, Bilevel

Claustrophobia • Switch to nasal pillows• Desensitization

Difficulty exhaling • Ramp feature• Consider switch to APAP, Bilevel, C-flex• Consider re-titration

Other CPAP issues

PROBLEM SOLUTION

Noise • Move unit away (under bed, in closet)- may need extra hose• Change machines

Tube condensation • Insulated sleeve for hose

Partner intolerance • Move machine away• Education/bring to follow-up visits

Portability • Smaller units• Letters of necessity

A general approach to improving CPAP compliance• Identify and treat source(s) of problem:

– Mask– Nasal– Pressure-related– Other

• First-line technological interventions– Assess mask fit and consider alternative interfaces– Heated humidifiers– Ramp feature– C-flex, Auto-CPAP, Bilevel

• Patient education – Consider alternative behavioral interventions if necessary

• Knowledge is key• Realistic expectations• Correct CPAP prescription• Appropriate equipment: machines, masks, humidifiers• Support and follow-up