CPAP ADHERENCE Is it too much pressure

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CPAP ADHERENCEIs it too much pressure?

• Shanon Takaoka,M.D.
• February 7, 2007

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BACKGROUND

• Obstructive sleep apnea (OSA) affects an
  estimated 3 million men and 1.5 million women in
  the U.S. and is INCREASING!
• Untreated OSA is associated with
• Symptoms of sleep deprivation and excessive
  sleepiness
• Diminished quality of life and productivity
• Increased accident risk
• Cardiovascular disease and stroke

Lavie et al. Sleep 1983 6312, Young et al. N
Engl J Med 1993 328 1230
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CONSEQUENCES OF OSA

• Sleep deprivation associated with
• Excessive daytime sleepiness
• Cognitive dysfunction (decreased memory,
  concentration, attention, and ability to process
  new information)
• Sexual dysfunction
• Mood changes

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CONSEQUENCES OF OSA

• OSA is associated with diminished health-related
  quality of life and overall quality of life due
  to
• Daytime sleepiness
• Poor cognitive, social, and physical performance
• Relationship discord and higher divorce rates
• Overall cost of sleep disorders (mainly OSA)
  estimated to be 7.5 BILLION DOLLARS
• Direct health costs, indirect financial costs,
  and non-financial costs of burden of disease

Shah et al. Treat Respir Med 20065235. Moyer
et al. Sleep Med 20012477
Hillman et al. Sleep 200629299
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CONSEQUENCES OF OSA

• Increased accident risk
• OSA patients have a SEVEN-fold higher risk of
  automobile accidents vs. non-OSA patients
• Untreated OSA associated with decreased vigilance
  which has been correlated to increased accident
  risk
• Major disasters have been linked to excessive
  sleepiness/sleep deprivation in workers Exxon
  Valdez, Space Shuttle Challenger, Chernobyl

Findley et al. Am Rev Respir Dis 1988138337
Findley et al. Chest 1995108619
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CONSEQUENCES OF OSA

• Risk of cardiovascular disease, stroke, and
  possibly death
• Sleep Heart Health Study (NHLBI of NIH) showed a
  linear relationship between severity of OSA and
  hypertension
• Untreated OSA also linked to cardiac
  dysrhythmias, coronary artery disease, and
  congestive heart failure
• Increased risk of stroke and death independent of
  other risk factors

Nieto et al. JAMA 20002831829. Yaggi et al.
N Engl J Med 20053532034
Peker et al. Am J Respir Crit Care
Med 2002166159
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EFFECT OF APNEA INDEX ON MORTALITY (UNTREATED OSA)
Graph courtesy of UpToDate based on data from He,
et al. Chest 1988 94 9
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MECHANISMS OF OSA

• OSA is caused by
• an abnormally small airway
• increased relaxation of the throat muscles
• or BOTH
• Leading to partial or complete obstruction of the
  airway that occurs cyclically throughout sleep
• Oxygen desaturations
• Cortical arousals
• Sleep disruption/fragmentation

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CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

• Least invasive AND most successful treatment
  modality for OSA
• Delivery of low levels of continuous pressure via
  a nasal or oronasal interface to splint open
  the airway during sleep

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CPAP BENEFITS

• Minimally invasive and reversible
• Reduction and/or reversal of OSA-related signs
  and symptoms
• Snoring, excessive daytime sleepiness,
  unrefreshing or fragmented sleep, cognitive
  impairment
• Decrease risk of accidents
• Increased productivity
• Decrease long-term complications of OSA
• Hypertension, heart disease, stroke, death

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CPAP ADVERSE EFFECTS
http//www.utdol.com based on data from Strollo
PJ et al. Clin Chest Med 199819 55
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OTHER COMMON PROBLEMS

• Nose bleeds
• Air-swallowing
• Tube condensation
• Claustrophobia/anxiety
• Temporary treatment
• Day-to-day inconvenience
• Difficulty traveling/poor portability
• Relationship discord CPAP is so un-sexy

Can you think of any others?
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STARTING CPAP Three Steps to CPAP SUCCESS!
PATIENT EDUCATION
EQUIPMENT
CPAP TITRATION
PATIENT EDUCATION
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STEP 1 PATIENT EDUCATION

• Increase understanding of
• Causes and mechanisms of OSA
• CPAP therapy (and treatment alternatives)
• Consequences of untreated OSA
• Encourage positive but realistic expectations
• The new person phenomenon is the exception- NOT
  the rule
• Allow time for adjustment and optimization (6-8
  weeks minimum)

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STEP 2 CPAP TITRATION

• CPAP titration
• Full-night, attended, in-lab sleep study
• Determine optimal pressure to maintain airway
  patency
• Eliminate snoring and respiratory-related
  arousals
• Normalize blood oxygen
• Promote sleep continuity
• Observe patient response in all sleep positions
  and stages as OSA tends to be worst in supine REM

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STEP 3 EQUIPMENT

• Choosing the right equipment
• Type of positive pressure (CPAP vs. BiPAP)
• Mask interface fit and comfort
• Nasal masks
• Nasal pillows
• Full-face (oronasal) mask
• Accessories
• Humidifiers
• Pressure ramp
• Altitude compensation

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USING CPAP

• No dosage studies available to suggest how much
  CPAP use is required for beneficial effects
• Improvement in daytime sleepiness
• Achieved even with less than 4 hrs use per night
• Even one night without CPAP associated with
  immediate return of excessive sleepiness and
  decreased vigilance
• CPAP only effective if the equipment is working
  optimally AND there is adherence to therapy

Hers et al. Eur Respir J 1997 10 973
Kribbs et al. Am Rev Respir Dis 1993
1471162
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WHAT IS ADHERENCE?

• Degree to which an individual follows a
  prescribed regimen
• Represents a spectrum
• Dependent upon the balance between perceived
  costs and benefits
• Unrelated to age, gender, educational level,
  socioeconomic status, personality

COSTS
BENEFITS
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CPAP ADHERENCE

• No clear field standard
• Too few studies to define amount of adherence
  needed to treat common sequelae
• Average patient uses CPAP about 5 hours per night
• Most clinicians generally recommend CPAP use for
  more than 4-5 hours per night on 70 of all
  nights
• The more, the better!!

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CPAP ADHERENCE

• Review performed of past 50 years of adherence to
  ALL medical treatments
• Lowest in sleep disorders
• CPAP compliance 65
• Overall average for all medical disorders 75
• Adherent patients tend to gradually increase
  duration of nightly CPAP use
• NOTE timing of use may be as important as
  duration of use

DiMatteo MR. Med Care 2004 2 200.
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CPAP ADHERENCE

• Hypnogram shows increasing REM time in the SECOND
  half of the night
• OSA typically worsens during REM ? CPAP use most
  important during second half of night

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CPAP ADHERENCE

• Early use patterns predict long-term adherence
• Patients appear to establish their patterns of
  use by the FIRST MONTH (as early as 4 days)
• Adherence at 1 month appears to predict adherence
  at 3 months
• Since adherence is established by 3 months,
  alternative forms of therapy should be considered
  in non-adherent patients

Weaver et al. Sleep 1997 20 278
Kribbs et al. Am Rev Respir Dis 1993 147 887
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CPAP ADHERENCE

• Why do we care?
• Consequences of untreated OSA
• Short- and long-term health effects
• Decreased productivity and quality of life
• Risk of accidents
• Allocation of medical resources
• Availability of sleep studies limited
• Expensive diagnosis and treatment (i.e. cost of
  sleep study, CPAP titration, follow-up with
  therapists, equipment)

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FACTORS AFFECTING ADHERENCE
PATIENT-RELATED
CPAP ADHERENCE
CLINICIAN-RELATED
EQUIPMENT-RELATED
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CPAP ADHERENCE PATIENT-RELATED FACTORS

• Lesser severity of symptoms
• Little or no perceived benefit from therapy
• Failure to understand importance of or directions
  for CPAP use
• Use of prescription/non-prescription drugs or
  alcohol
• Lack of social support
• Other medical illnesses or fatigue
• Physical limitations (i.e. vision, hearing, hand
  coordination)

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CPAP ADHERENCE THERAPY-RELATED FACTORS

• Complexity of therapy/device use
• Increased rate of adverse reactions that go
  unaddressed
• Lack of efficacy
• Expense of therapy
• Chronicity of illness
• Compliance decreases over time

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CPAP ADHERENCE CLINICIAN-RELATED FACTORS

• Poor relationship with patient
• Lack of clinician follow-up
• Expression of doubt concerning therapeutic
  potential OR creating falsely elevated
  expectations
• Unwillingness to educate patients
• Lack of knowledge of other medications patients
  may be taking (i.e. alcohol, sedatives)

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MONITORING CPAP ADHERENCE

• Follow-up (at 1 month)
• Clinical assessment of subjective use, response
  to CPAP, adverse effects and other limitations to
  therapy
• Objective assessment of downloaded data
• Mask on time
• Leak values
• Trouble-shooting
• Define specific issues with clear goals
• Specify follow-up (usually 3-6 months)

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CPAP FAILURE

• Use of CPAP for less than 4 hours per night on
  70 of the nights and/or lack of symptomatic
  improvement
• Cause should be identified and addressed, if
  possible (i.e. ear/nose/throat structural
  abnormality)
• Consider alternative diagnoses
• Narcolepsy, periodic leg movements, idiopathic
  hypersomnolence

Kribbs et al. Am Rev Respir Dis 1993 147887
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IMPROVING CPAP ADHERENCE
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TECHNOLOGICAL INTERVENTIONS

• Auto-titrating CPAP
• Pressure delivery is auto-adjusted during
  changing airway conditions overnight
• Bi-level positive pressure (BiPAP)
• Set inhalation pressure with a lower set
  exhalation pressure
• Flexible pressure delivery (C-Flex, EPR)
• Slight reduction in pressure during EARLY
  exhalation

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TECHNOLOGICAL INTERVENTIONS

• Heated humidification
• Decreases nasal/oral dryness for comfort
• Improves nasal resistance
• Pressure ramp feature
• CPAP starts at low pressure (2-4 cmH2O) and
  gradually ramps up to prescribed pressure over
  set time period (5-45 min.)

None of these have been shown to definitively
increase adherence
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BEHAVIORAL INTERVENTIONS

• Patient education
• Systematic desensitization and sensory awareness
  (for claustrophobia)
• Wearing device for progressively longer periods
• Cognitive behavioral therapy/Motivational
  Enhancement Therapy

Findings suggest that maneuvers that increase
knowledge, patient-therapist interaction, and
remove potential barriers to PAP increase use by
0-2.5 hours
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REDUCE SIDE-EFFECTSMask-Related Issues
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REDUCE SIDE-EFFECTSNasal Issues
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REDUCE SIDE-EFFECTSFlow/Pressure Issues
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REDUCE SIDE-EFFECTSOther Common Issues
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IMPROVING CPAP ADHERENCEA General Approach

• Identify and treat source(s) of adverse effects
• Mask
• Nasal
• Flow-related
• Other
• First-line technological interventions
• Assess mask fit and consider alternative
  interfaces
• Heated humidifiers
• Ramp feature
• Auto-CPAP, BiPAP
• Patient education
• Consider alternative behavioral interventions if
  necessary

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STEPS TOWARD BECOMING A CPAP SUPERSTAR

• Knowledge is key
• Realistic expectations
• Correct CPAP prescription
• Appropriate equipment machines, masks,
  humidifiers
• Support and follow-up
• Know when to say when

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OTHER RESOURCES

• Sleep Improvement Program with Positive Airway
  Pressure (PAP) Therapy- Dr. Tracy Kuo
• Six weekly group sessions offered every 6-10
  weeks
• Multidisciplinary program to improve sleep
  quality and optimize use of PAP that integrates
• Sleep medicine
• Mind-body
• Health psychology
• Cognitive-behavioral techniques
• Phone [phone]
• http//www.stanfordhospital.com/