Once patients agree to a trial of CPAP, the next challenge is to get them to actually use it. Dr. Friedman likes to “ease them into it,” trying it for 5 minutes every night for the first week, 10 minutes every night for the second week, and 15 minutes every night for the third week. “Many patients fall asleep with it and get used to it during the first week,” he said. “Some patients say it’s the first time they have slept through the night in years.”
Explore this issue:November 2006
About 25% of all patients with obstructive sleep apnea will be compliant; among those with severe sleep apnea, compliance is about 40%, Dr. Friedman said. Among patients who improve considerably on CPAP, 80% will be compliant.
Patients in Dr. Friedman’s practice who are not compliant are told that they have three choices: doing nothing, using CPAP, or resorting to surgery. He tells patients that doing nothing is dangerous, and that CPAP can correct the problem. “Surgical options are better than nothing, but are not as risk-free as CPAP.”
Problems Accepting CPAP
Patients who try CPAP in short increments but still don’t want to use it may have problems with the classical face mask, which can make people feel that they are suffocating. Dr. Friedman suggests trying other interfaces, such as a face mask that covers only the nose (not the mouth) and/or nasal pillows. Also, adjusting the pressure using BIPAP (higher pressure at inhalation and lower pressure at exhalation) or other types of adjustable pressure machines can make CPAP more tolerable.
A recurring reason for noncompliance with CPAP is that the pressure is too high, Dr. Woodson said. “In the effort to cure every case of sleep apnea, the technician may titrate the pressure too high. This makes it harder for patients to tolerate CPAP and harder to fit a mask. Sometimes adjusting the pressure downward will improve tolerance,” he noted. If that doesn’t work, Dr. Woodson suggested repeating the sleep study or using an auto-adjusting CPAP machine for several weeks at home to determine the optimal pressure for an individual patient. Tolerable pressure can be variable for patients, and 20% to 30% will prefer an auto-adjusted machine to a fixed pressure.
Co-Existing Sleep Disorder and Sleep Apnea
Certain personality types have greater difficulty accepting CPAP, such as people with anxiety disorder or insomnia. These co-existing disorders may require treatment before addressing CPAP compliance. Behavioral therapy and education are the best approaches, but sometimes medications (such as non-benzodiazepine sedative hypnotics) are necessary to alleviate anxiety and insomnia. Dr. Woodson cautioned that medications can worsen sleep apnea and should be used cautiously and not in severe obstructive sleep apnea patients, except in an observed setting.