Inside Sleep

Moving Beyond the Interface

There are many factors that contribute to successful PAP therapy compliance

• By Kelly Riley
• Apr 01, 2011

When patients begin continuous or bi-level positive airway pressure therapy (PAP), it can be a tough adjustment. Let’s face it, waking up in the middle of the night and feeling like the cat has decided to sleep on your face is downright unsettling! Patients often complain, “I can’t do this; I always pull the mask off.” To this your response should be, “Well of course you do; it takes a while for your brain to recognize and realize there is a change.” In time, the brain will recognize the change, and accommodate as happens with any “life adjusting” event.

To focus on just the interface as the maker or breaker of therapy would be a mistake. There are many other factors that contribute to the overall rate of successful therapy.

The first step would be for those on your PAP set up team (presumably RTs) to have strong knowledge of the proven predisposing factors that affect compliance rates. Factors can be divided into those that are considered negative, as well as those that are classified as positive.

Positive factors would be those that lend to a higher chance of the patient staying/committing to therapy. Negative factors, of course then means the patient is at higher risk for not following through on therapy.

Positive factors include: The severity of OSA; the more severe a patient’s OSA, the higher the probability the patient will accept and utilize therapy. Thus the second metric of higher apnea hypopnea index (AHI), is self explanatory. The third positive indicator of increased daytime sleepiness reveals that any patient who subjectively complains her or she is tired throughout the day and finds this symptom burdensome, will better adapt to therapy. The last positive factor would be “subjective benefit,” which can include the overall feeling of improvement in health; having the bed partner who has moved out of the bedroom return; or simply the return of old energy levels.

Those that warrant some added attention, especially in the early days of therapy, are those that have demonstrated to have what is considered a negative factor for successful therapy.

Negative factors include: The patients who report they don’t feel a lack of daytime sleepiness (they often report they only got studied due to a complaining spouse). Another negative side effect would be those who develop side effects of therapy. This of course can be one or a multitude of issues, including complaints of dryness and/or congestion, pressure intolerance, or condensation issues. Patients who have had previous Uvulopalatopharyngoplasty (UVPP) procedure are also recognized at being at higher risk for therapy discontinuation, as are those who have a history of nasal obstruction (check for history of broken nose). And last, those patients who report a history of claustrophobia.

While all of these factors have solutions, the real key is “early recognition” of the patients who are at risk. This can be done by spending a few minutes reviewing the patient’s history either directly from the patient or by looking at any records. In today’s audit-conscious environment it is hopeful all new patients would arrive with copies of the initial face-to-face evaluation from the treating physician, and some of this could certainly be gleaned from those notes.

To drive higher compliance among your group, as new patients are initiated on therapy, address issues that relate to lifestyle and how those issues can affect sleep and compliance. These include the consumption of alcohol, weight gain or loss, changes in medications, and concerns related to traveling with equipment.

Another issue rarely addressed but identified as a barrier to therapy is the timing of meals. This was proven through a study, done at the Institutes for Sleep/Wake Disorders at the Hackensack University Medical Center in Hackensack N.J. Researchers there suggest that to enhance treatment of sleep apnea with CPAP patients, providers should include education on the timing of the last meal prior to sleep. A significant number of patients reported intolerance and poor compliance to therapy if the last meal was consumed less than one hour prior to usage of CPAP.

To drive higher compliance among your group, as new patients are initiated on therapy, address issues that relate to lifestyle and how those issues can affect sleep and compliance. These include the consumption of alcohol, weight gain or loss, changes in medications, and concerns related to traveling with equipment.

When looking for answers to having higher compliance rates for all patients, you might want to start with the interface as the potential problem, just certainly don’t stop there!

This article originally appeared in the Respiratory & Sleep Management April 2011 issue of HME Business.