Top 10 Practices to Increase CPAP Compliance
Sleep Review
by Bill Pruitt, MBA, RRT, CPFT, AE-C
Incorporate these practices, and leave little excuse for patient noncompliance.
Obstructive sleep apnea syndrome (OSAS) is a major health problem that has gained
more and more attention over a relatively short time. In 1981, Lancet published an
article describing the use of continuous positive airway pressure (CPAP) to treat
sleep apnea.1 Since then, CPAP has become the first line of treatment for OSAS. By
applying positive pressure to the upper airway, CPAP increases the cross-sectional
area and volume of the oropharynx and laryngopharynx, effectively removing the
obstruction of the upper airway by the tongue and pharyngeal tissue, and allows for
continuous airflow throughout the breathing cycle. Patients with OSAS who use this
treatment have a number of very positive results. First, and often most noticed by
the patient, they have improved sleep quality and an increased level of alertness
during the day. They also report reduced daytime sleepiness—they are able to
function better, they have an improved mood/attitude, and they have fewer
automobile accidents. Their blood pressure decreases as well as other
cardiovascular abnormalities, including reduced atrial fibrillation and improved
ejection fraction for those with OSAS and congestive heart failure (CHF).2 Despite all
the positive results, compliance with using CPAP is a problem.
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PREDICTING CPAP COMPLIANCE
CPAP compliance is often defined as using the therapy for an average of 4 hours a
night for at least 70% of the nights.3 Studies show that somewhere between 29%
and 83% of patients do not meet the criteria for compliance due to removing the
CPAP early in the night and/or skipping use altogether. When patients first start
using CPAP, they usually establish their pattern of compliance early on—within the
first week of treatment. Clinicians are able to monitor use of CPAP via built-in smart
cards, communication by modem, or a Web-based system to check both the hours
the CPAP machine has been run and the amount of time the interface was actually in
use. Often there is a discrepancy in run time versus applied time. This occurs when
the patient removes the mask but leaves the CPAP unit running.4
Researchers have looked at various factors in trying to predict compliance and have
found a few and ruled out many. The patient's age, sex, and socioeconomic status
have been ruled out as having some bearing on compliance. Also, the patient's
feelings of stress, anger, anxiety, or depression did not affect CPAP compliance.
However, the severity of their disease as reflected in their apnea-hypopnea index
(AHI) showed a relationship with compliance. Those with a higher AHI tend to be
more compliant, and if they have both OSAS and CHF and are treated with CPAP,
they have less mortality.5 Those patients who have already demonstrated poor
medical compliance carry this forward with CPAP therapy. Compliance tends to be
less in those who do not understand the health-related problems of apnea, those
who refuse CPAP during titration, and those who complain of claustrophobia.
Finally, those patients who are self-conscious and reluctant to wear the CPAP
interface in the presence of their sleeping partner will be less compliant.6
WHAT ELSE CONTRIBUTES TO NONCOMPLIANCE?
Side effects and problems with the patient-CPAP system can cause the CPAP
machine to be stuck in the closet, never to be used. The side effects include nasal
drying, increased congestion, sneezing, rhinorrhea, sinusitis, conjunctivitis,
claustrophobia, pressure sores on the bridge of the nose, difficulty exhaling, allergic
reaction to the materials in the mask, air swallowing with gastric distension,
machine noise, and skin creases the next morning. Many of these are avoidable if
everyone in the health care team does a proper job of education, application, and
follow-up with trouble-shooting and making corrections early in the start-up, as
needed.7
IMPROVING CPAP COMPLIANCE: THE TOP 10
Getting patients to stay with their CPAP therapy is difficult. Understanding the
reasons why CPAP therapy is not succeeding helps the health care team know where
to focus their efforts. Here are the top 10 practices that should help improve CPAP
compliance. These were gleaned from several recent articles. They are not ranked in
order of effectiveness but are based on a review of the literature, they are presented
in a logical order that may include a bias for "first things first." Overriding all of
these is the need for communication. Invite the patient to talk, to share their feelings
and fears, describe any discomfort while starting the therapy ... encourage the
patient to be open and talk.
1. EARLY AND ONGOING EDUCATION
Often the first suspicion of a sleep disorder arises from an office visit with a primary
care physician (PCP). Education needs to occur with three groups; the PCP, the
patient, and the spouse or sleeping partner. Knowledgeable PCPs can help create a
good "first impression" of CPAP as the patient becomes aware of their potential
problem and hears about the treatment used to correct sleep apnea/hypopnea.8
The patient should be introduced to the idea of CPAP early and often throughout the
visit to the sleep disorders center (SDC). Beyond the PCP and patient, the third party
who needs to be involved in education early and throughout is the spouse. All three
parties need to know about the health issues related to OSAS and how CPAP can
reverse many of the problems the patient may be experiencing. Topics should also
include the CPAP unit (covering issues of its size, any noise it makes), the interface
(the supply hose plus nasal mask, nasal pillows, etc), and the headgear or straps.
The patient might be afraid of the medical equipment, might think it is painful, might
be afraid of dying in their sleep, or does not want to look strange to their bed
partner. Education should cover advantages and disadvantages of treatment, and
the positive effects on sleep quality, health, mood, alertness, etc. Open, frank
discussion should be encouraged and questions answered, but always maintain a
positive approach and focus on the positive outcomes. The physician or other
professional explaining OSAS and CPAP should validate that many patients have
some trouble getting used to using CPAP and that should problems arise, they
should not give up and refuse the therapy. Rather, they need to discuss any
problems with the staff and the staff should troubleshoot to correct the problems.
2. INITIATION OF CPAP THERAPY
CPAP is most often started in the SDC during a split study or the next night after a
diagnostic polysomnogram recording has been performed. When the CPAP unit and
interface are brought out, the patient should already know what it is, how the
titration is to be done, why it is being used, and what to expect during the rest of the
night. Poor titrations lead to poor compliance. As devices get more and more
sophisticated, the education and skill of the team to match the proper technology
with the patient and titrate it properly become more critical in determining
compliance. The center should have a variety of masks and headgear, and the
technician should work with the patient to get the best choice/fit. Before applying
the CPAP, issues related to mouth-breathing, leaks, swallowing, and talking should
be discussed. Assure the patient that they will be able to sleep with the CPAP—just
be patient and keep in communication with the technician. Troubleshoot any
problems and stay positive. If a particular interface is not working well, try another
design.
3. IMMEDIATE INDIVIDUAL FOLLOW-UP
Since the first week of therapy tends to set the pattern of use, many sleep disorders
centers will call the patient several times during the first 6 to 7 days to discuss the
therapy and encourage the patient. The home health care agency involved with the
CPAP setup should also be included in follow-up. Some SDCs establish an agreement
with the home health agencies receiving referrals that specify a follow-up visit to the
home during the first week of a CPAP setup, or at the minimum insist on a follow-up
phone call from the agency to the patient with immediate response to the home if
needed to correct any problems. Remember, the first impression sets the stage for
months and years to come. Correcting a problem up front is critical.
4. MONITORING COMPLIANCE AND EFFICACY
Compliance should be checked somewhere between 3 and 6 months after the initial
CPAP setup. The patient should be seen by a qualified sleep professional to assess
usage of the equipment (hours of use and hours of application), check the machine
settings, and ensure the interface (mask, pillows, etc) is in good condition.
Immediate and long-term follow-up are indeed crucial to compliance, but
monitoring efficacy is also critical to compliance and successful therapy. Discuss the
results of the hours/usage monitor and reinforce the need to be faithful to the
prescribed treatment. Talk about the patient's sleep habits, quality of sleep, and
overall health, and look for anything that might need to be corrected or anything
that might affect compliance.
5. LONG-TERM SUPPORT AND TROUBLE-SHOOTING
Many of the same activities from #4 also apply here. An annual office visit should be
scheduled to check all the equipment and the hours/usage. Masks wear out and
break, so an annual replacement should be in the plan. Changes in the patient's
condition may warrant a change in CPAP pressure (ie, weight loss may allow for a
lower CPAP setting or vice-versa).
6. MASK FIT AND CHOICE OF INTERFACE
This has been discussed in regard to the first night's use of the CPAP unit and for
ongoing follow-up after initial treatment. Obviously, the nasal mask or the pillows
must be the correct size. Several mask types and sizes should be available in order
to find a good-fitting interface. Patients with claustrophobia may tolerate nasal
pillows or nasal prongs more than the nasal mask. Pillows or prongs are also
beneficial to interface with someone who has a mustache or is missing dental
support needed for a nasal mask. Head straps should not be too tight and should not
cause discomfort. An oronasal mask (combining nasal pillows and an oral mask)
may be a better choice for patients with nasal congestion or a persistent mouth leak.
A broken or malfunctioning interface/headgear/supply tube must be replaced
immediately so that interruption of nightly CPAP use is minimized or eliminated.
7. NASAL CONGESTION, STEROIDS/ANTIHISTAMINES
Not being able to breathe easily through the nose creates a major barrier for
compliance and adherence. For someone with congestion or sinusitis, nasal sprays
with corticosteroids and antihistamines are a must. Many sleep professionals
routinely prescribe these nasal sprays for all patients receiving nasal CPAP in order
to avoid any possible complication.
8. HUMIDIFICATION
Drying of the mouth and nose is a frequent complaint of CPAP users. Studies have
examined heated humidification versus cold humidification and found that heated
systems have better results. Evidence-based coverage of this topic was done in a
Cochrane review from 2004, and the authors concluded that the evidence needed to
make a strong case for humidification is not yet available.9 Regardless, many
patients appear to have fewer complaints when using humidification. Bottom line is
that more study is needed in this area.
9. CHOOSING THE RIGHT DEVICE
Fixed CPAP was the initial standard for CPAP due to the fact that it was the only
means available for providing CPAP in the outpatient setting. Bilevel PAP therapy
came along and opened more options (allowing clinicians to set the baseline
expiratory pressure and the peak inspiratory pressure). Options opened up for
many more delivery systems to adjust pressures, a respiratory rate, triggering
thresholds, expiratory thresholds, ramp-up settings, etc. With AutoCPAP (aCPAP),
the CPAP unit titrates the pressure up or down as needed to keep the upper airway
open at the lowest effective pressure. With pressure-relief PAP, there is a reduction
in pressure at the very end of inspiration and beginning of expiration so patients do
not have to breathe against the prescribed therapeutic pressure immediately.
Before the end of expiration, the pressure is restored to its therapeutic level to keep
the airway open at the beginning of the next inspiration. Self-titrating CPAP allows
the patient to change their pressure settings on their own. From a study looking at
self-titration, there was no significant difference in the hours of CPAP use, the
apnea-hypopnea index, or the score on the Epworth Sleepiness Scale, but the
subjective measure of quality of life was significantly higher. The authors suspected
this may relate to empowering individuals and making them feel better about their
control of their health. The Cochrane review of 2004 evaluated these different
delivery choices and concluded that a CPAP may be most useful in a select group of
patients who require >10 cm H2O in their treatment setting or are poorly compliant
with fixed CPAP. The evidence regarding bilevel PAP therapy, pressure-relief CPAP,
and self-titration is not clear enough to make a judgement and more study is
needed.
10. GROUP SUPPORT
Gathering CPAP patients together for group support is the last area to mention.
Support groups have influences in many areas: sharing tips on how to cope with
using CPAP; anecdotal discussions regarding the effect of CPAP on health; exploring
the effect of CPAP on the relationship with the sleeping partner; reinforcement of
the education offered on CPAP; and bearing each other's burdens. Support groups
tend to increase the number of hours for CPAP use and can help lock in the patient
who may be wavering or wanting to give up due to side effects or problems.
CONCLUSION
CPAP for OSAS is getting more and more prevalent, and the problems with
compliance are slowly being reduced. However, providing time for education and
paying attention to problems during the first few days of CPAP use must be a
priority. Incorporating these steps can make CPAP successful and keep the machine
from just gathering dust while the patient continues to have poor sleep quality. An
honest evaluation of the whole process of patient assessment, treatment, and
follow-up (short-term and long-term) may uncover gaps in the plan and allow for
effective change. More evidence-based study is needed to sort out the best practices.
In the meantime, these top 10 practices should be incorporated into the CPAP plan
of action for increasing success.
Bill Pruitt, MBA, RRT, CPFT, AE-C, is a senior instructor in the Department of
Cardiorespiratory Sciences, College of Allied Health Science, University of South
Alabama in Mobile. He also works as a PRN therapist at Springhill Medical Center
and at the Mobile Infirmary Medical Center. He can be reached at
sleepeditor@ascendmedia.com.
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