Continuous positive airway pressure (CPAP) is the standard first-line approach for moderate to severe obstructive sleep apnea. Although CPAP can alleviate sleep apnea in the majority of patients and may represent a cure for some patients, compliance is often difficult to achieve. Many patients are resistant to wearing an oral or oral/nasal mask at night, and CPAP can interfere with sleep, making patients irritable and tired during the day. ENToday spoke with several experts on how to improve compliance with CPAP.
Explore This IssueNovember 2006
First, the clinician should confirm the diagnosis. Patients are often misdiagnosed with sleep apnea, said B. Tucker Woodson, MD, who is Professor and Chief of the Department of Otolaryngology and Communication Sciences at the Medical College of Wisconsin in Milwaukee, Wis. Dr. Woodson said that the diagnosis should be based on a complete history and not entirely on the polysomnogram. “A correct diagnosis is critical,” he stated.
“CPAP is the least invasive approach to obstructive sleep apnea, and complications are rare. The most serious problem I’ve seen with CPAP is patients dropping the appliances on their feet. The basic challenge is to gain patient acceptance of therapy,” Dr. Woodson commented.
“The first hurdle is to get patients to try CPAP. Ninety percent of patients come in with preconceived ideas and won’t accept it,” said Michael Friedman, MD, Professor of Otolaryngology and Chairmen of the Section of Head and Neck Surgery at Rush University Medical Center and Chairman of Otolaryngology at Advocate Illinois Masonic Medical Center in Chicago, IL.
Early education by the physician about CPAP can help gain patient acceptance. Dr. Woodson offers education at the first office visit, showing patients the different types of masks and prescribing a mask and machine before patients visit the sleep lab. For problem patients, he introduces CPAP as a gradual process, having the patient try several different types of masks with or without either heated humidification or cool humidification.
“The goal is to keep it [education] simple and not overload patients. There is a variation in CPAP masks and chin straps, and this needs to be explained,” he said. “Work with the patient to iron out the kinks, and don’t give up on CPAP too quickly and resort to surgery,” he added.
In his practice, Dr. Friedman recommends a two-week trial of CPAP on a temporary basis, explaining to patients that they have other options if CPAP doesn’t work. He lists the reasons to try CPAP, emphasizing that this treatment should allow them to sleep and that this approach to sleep apnea is risk-free.
“You should assume that patients may not choose CPAP, but before they choose another option, they should be encouraged to try CPAP as a temporary measure,” he said. “The Center for Medicare and Medicaid Services [CMS] guidelines state that surgery should not be attempted unless patients have failed CPAP; surgery is not reimbursed unless patients have tried CPAP first. I never perform surgery without a trial of CPAP first,” Dr. Friedman said.
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.”
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.
Patients with heart failure, underlying heart disease, or claustrophobia symptoms may feel short of breath on CPAP. Many of these patients have difficulty tolerating more than 10 cm water pressure, which worsens symptoms and may cause central apneas. Use of a full face mask to allow oral breathing while falling asleep and a repeat sleep study may be beneficial.
“For hard-core patients who will not or cannot tolerate CPAP, minimally invasive surgical procedures can be helpful. If snoring is the major complaint, surgeries of the tongue base, palate, and/or nose may be beneficial,” Dr. Friedman said. If a nasal abnormality is present, sometimes just treating the nose can resolve the apnea and improve compliance.
There is growing evidence that nasal blockage is associated with poor CPAP compliance, stated Edward M. Weaver, MD, MPH, Associate Professor of Otolaryngology and Surgical Program Director of the Sleep Disorders Center at the University of Washington School of Medicine in Seattle, WA.
“Emerging research and experience suggest that surgery correcting nasal obstruction will improve CPAP compliance,” Dr. Weaver stated.
According to Dr. Friedman, the Pillar procedure, which stiffens the palate via three injections, can eliminate palatal snoring in 80% of patients with mild disease, and reduce apneas and hypopneas. If the Pillar procedure is effective, patients do not need CPAP. Patients who fail to be cured by the Pillar procedure may be better able to tolerate CPAP, Dr. Friedman said.
“Doing nothing is not an option, unless the patient has mild sleep apnea. The biggest disservice sleep physicians can do is to tell patients their choices are to use CPAP or go untreated. I’ve seen patients who were never told there were other options,” Dr. Friedman stated.
©2006 The Triological Society