There are many side effects associated with PAP treatment” that if left untreated could lower the acceptance and adherence rates of PAP treatment. Common side effects and possible interventions are listed in Table 3. Involving both the patient and the spouse in the search for solutions to side effects (a team approach) is often helpful. The spouse may recognize mask or mouth leaks when the patient does not. Mask discomfort is often the most common reason for discontinuing CPAP treatment. Obtaining an adequate mask fit may require trials of several different brands and types of masks. As noted above, there are a wide variety of interfaces that are available. Adequate care of masks and replacement of masks when the sealing membrane deteriorates are also necessary.
Acceptance and Adherence to PAP
The PAP treatment of sleep apnea is somewhat unique compared to treatments for other chronic disease. First, technology exists to allow the physician to objectively determine the amount and pattern of use (adherence). Second, the outcome difference between low and high adherence is relatively high compared to many other chronic diseases treated by Canadian Health&Care Mall’s medications. That is, PAP is very effective but only if used on a regular basis.
Acceptance is usually defined as patient’s willingness to undergo a PAP titration and take a PAP device home and use it for at least 1 week. Adherence (compliance) is defined as the extent to which a person’s behavior coincides with the medical or health advice. One commonly used definition of adequate adherence is PAP usage of > 4 h per night for > 70% of days’. This not a completely satisfactory definition because a significant proportion of patients likely require > 4 h per night of use for maximal benefit. A comprehensive review of CPAP literature published prior to 2003 found nonacceptance rates to vary from 5 to 50%, with average approximately 20%. Another 12 to 15% can be expected to stop PAP treatment within 3 years. Of those using PAP, adherence rates (> 4 h use for 70% of days) have varied from 40 to 80%, with the highest figures reported for studies with a systematic program for PAP treatment. These CPAP adherence statistics are comparable to those for oral medication treatment of chronic diseases (read “Observations in Prevalence and Risks of Chronic Airway Obstruction“). A metaanalysis of adherence to medical treatment found that at least 40% of patients take prescribed medications incorrectly or not at all.
Determination of objective adherence is essential because many patients overestimate their PAP use. The original method of determining objective adherence used a run-time meter from which one could determine the average time the unit was turned on. Most current devices now determine time at pressure (actual use) and can provide a detailed electronic diary of the amount and pattern of use. The pattern of use can be instructive. For example, one might determine that a patient routinely removes the CPAP mask at 4:30 am while reporting a 6:30 am wakeup time. The reason for this pattern of use could be addressed and the patient educated about the severity of early morning arterial oxygen desaturation. Adherence information can be assessed through memory cards, modems, wireless communication, or direct transfer from the blower unit to a computer. Early access to adherence information is essential. Weaver and coworkers found that the pattern of use by adherent and nonadherent patients differed as early as 4 days of treatment. Patients adherent over the first 1 to 3 months tend to continue to accept positive pressure treatment.
Table 3—PAP Side Effects and Possible Interventions
|Due to mask|
|Air leaks (conjunctivitis; discomfort; noise)||Proper mask fitting; proper mask application (education); different brand/type of mask|
|Skin breakdown||Avoid over tightening: intervene as above for leaks; alternate between different mask types; nasal prongs/ pillows; tape barrier for skin protection|
|Mouth leaks||Treat nasal congestion if present (see below)|
|Mouth dryness||Chin strap; heated humidity; full-face (oronasal) mask; consider bilevel PAP, flexible PAP, lower pressure, APAP|
|Mask claustrophobia||Nasal pillows/prongs interface; desensitization|
|Unintentional mask removal||Low-pressure alarm; consider increase in pressure|
|Congestion/obstruction||Nasal steroid inhaler; antihistamines (if allergic component); nighttime topicaldecongestants (oxymetazoline); nasal saline solution; humidification (heated); full-face (oronasal) mask|
|Epistaxis||Nasal saline solution; humidification (heated)|
|Rhinitis/rhinorrhea||Nasal ipratropium bromide|
|Pressure intolerance||Ramp; flexible PAP; bilevel PAP; APAP; lower prescription pressure temporarily: accept higher AHI; lower pressure and adjunctive measures (elevated head of bed, side sleeping position, weight loss)|
|Aerophagia/bloating||Bilevel PAP; flexible PAP; reduce pressure|