For patients with obstructive sleep apnea, continuous positive airway pressure therapy generally is the preferred treatment. When properly implemented and used conscientiously by the patient, CPAP is usually effective in alleviating nocturnal symptoms (frequent awakenings, snoring and gasping) and can improve the patient's daytime sleepiness and quality of life.
And yet, it is well known that as many as 50 percent of patients will stop using CPAP within the first few months after starting treatment.
Why would someone with a debilitating condition like OSA willingly abandon treatment? The answers to this question are complex and have been the subject of a great deal of discussion and research. In individual cases, it is difficult to find a single reason for non-compliance. It is far more likely that multiple factors are at work.
Home medical equipment providers need to be knowledgeable — and sometimes creative — to find solutions that will work for their patients.
WHO'S AT RISK?
There is evidence that certain individuals are more likely to be at risk for discontinuing therapy. Some who are at increased risk of immediate CPAP discontinuance include patients who are younger, thinner, depressed or female. Others have a lower AHI (apnea/hypopnea index), few symptoms or complaints, or lower self-efficacy or self-esteem.
From a psychosocial perspective, such at-risk patients may experience a cognitive disconnect between perceived costs and the benefits of CPAP therapy. By understanding these factors, providers can make a rational decision on how to minimize the potential for non-compliance.
ACCLIMATIZATION TO CPAP
CPAP therapy imposes a substantial life-style change on the patient. Along with the obvious therapeutic benefits of CPAP comes a whole range of side effects. Some arise when the equipment is not properly fitted to the patient, while others are a result of sleeping with the apparatus itself. Either way, CPAP can have a dramatic effect on the way a patient sleeps. Such problems can include:
- Noise, mask discomfort or leakage
- Air blowing on partner
- Nasal obstruction and claustrophobia
- Nasal stuffiness
- Chill or dryness in the upper airway
A wide variety of mask designs is available and, often, the solution is simply a matter of finding the best mask for the individual patient. Attention to comfort, seal of the mask and security of the headgear is vital.
Mask-fitting should be conducted during the initial education session in a relaxed daytime setting. The patient and his or her spouse or family should be instructed on proper positive airway pressure set-up, and the mask should be checked for pressure points and leaks under the prescribed CPAP pressure.
Then the patient might be encouraged to take a brief “practice nap” to test the new devices. This procedure not only ensures that the mask fits properly but also provides a rehearsal for when the patient will have to use the CPAP at night.
Problems with interfaces or devices can be overcome using both high-tech and simple approaches. Upper airway chilling may be solved by providing heated humidification, or simply by placing the tubing under the patient's blanket. Issues of nasal stuffiness or dryness can be overcome by humidification, changing the time on the device and the use of nasal decongestants or normal saline sprays prior to using CPAP.
Upper airway dryness may be a result of sleeping with the mouth open, which can be solved by replacing the nasal mask with a full-face mask or a chin strap. Noise objections can be addressed by using pressure ramping while the patient falls asleep or use of earplugs by the patient or spouse.
A meta-analysis of CPAP compliance research found ample evidence to support that a patient who has a bad experience during the first few weeks of therapy is far more likely to discontinue treatment altogether if there is no intervention. It is critical, therefore, to assess acceptance early so that problems and side effects can be overcome before the patient decides the costs outweigh the benefits of CPAP.
PSYCHOLOGICAL ISSUES
Psychological issues are at least as important in CPAP acceptance as mask discomfort or other physical factors. Self-image can have a great deal to do with how the patient deals with the physical or nuisance problems that may be encountered in the early stages of treatment.
A patient is more likely to develop non-compliance issues if he or she has a poor understanding of the relationship between CPAP adherence and improved quality of life through improved sleep patterns with CPAP therapy. Education and counseling can help.
In a recent study at the University of Kentucky College of Medicine, patients who watched a 15-minute video were significantly more likely to use their CPAP machine and return for a one-month clinic visit than patients who did not see the video. The researchers concluded that the video's discussion of problems and eventual positive outcomes helped patients overlook the initial difficulties and discomforts of positive airway pressure long enough for the benefits to become more obvious.
Education should be aimed at increasing patients' awareness of their illness and the need for treatment in addition to addressing underlying health beliefs. Establishing realistic attitudes about therapy can include acceptance of the significant health consequences of OSA and an understanding that it may take months to become accustomed to the treatment regimen.
Knowing that long-term adherence to treatment can have positive benefits can help, as can knowing that support is available during the process.
Enhancing patient motivation through education can help HME providers achieve the best possible results. Motivational enhancement therapy, described in an article in Behavioral Sleep Medicine, includes the following steps with the initiation of CPAP therapy:
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Help the patient balance risky, noncompliant behavior against self-identified goals and values (develop discrepancy)
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Express empathy
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Avoid argument and accept ambivalence
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Support patient autonomy, and emphasize his/her choice for change (roll with resistance)
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Support patient's perceived ability to change and make optimistic statements to the patient (support self-efficacy)
The psychological/educational component in a program needs to be initiated early and reinforced often. In addition, providers must constantly balance the physical side effects in compliance along with the psychological.
In the end, it appears that both the patient and the caregiver will benefit from an improved understanding of the complex problems associated with long-term CPAP treatment and can enjoy the benefits of positive airway pressure therapy.
Sharon Baer, MBA, RRT, is manager of medical education, Sleep and Home Respiratory Group, for Respironics, Murrysville, Pa. She may be reached via e-mail at sharon.baer@respironics.com.
