Positive airway pressure: Making an impact on sleep apnea

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Adherence to PAP therapy is a problem in terms of both frequency of use and duration of use per night. A review of randomized control trials of CPAP compliance between 2011 and 2015 found adherence varied widely from 35% to 87%.10 The average hours of PAP use per night was found to be 5 hours in APPLES.4 Patients adherent to PAP therapy at 1 month remained adherent at 1 year, suggesting patients using CPAP for 1 month were more likely to continue use at 1 year.10 Impediments to PAP use typically involve the facial interface discomfort, lack of humidity, and pressure intolerance.


Today’s PAP devices have features designed to make them easier to use and more comfortable to improve adherence to therapy. Facial interface options, heated humidifiers, tubing accessories, cleaning devices, reporting of compliance data via telecommunication, and pressure adjustment features of PAP devices may improve patient adherence and comfort, as highlighted in the case scenarios presented below.


Case scenario #1

A 32-year-old woman with moderate sleep apnea complains that her PAP nasal mask is making very loud noises and is disturbing her bed partner. She is a side sleeper and also reports that she wakes with an extremely dry mouth.

Management of the leak could include which of the following?

  1. Chin strap
  2. Avoidance of facial creams before bedtime
  3. CPAP pillow
  4. Clean the mask daily
  5. All of the above

Answer: All of the above.

 Figure 2. Download of positive airway pressure use data for a month (A) and leak data for a night (B).

Figure 2. Download of positive airway pressure use data for a month (A) and leak data for a night (B).

Figure 2 shows an overview of data from the patient’s machine for the past month and 1 night of leak data. Both the month-use data and single-night leak data show mask leakage.

There are many types of PAP interfaces such as nasal masks, nasal pillows, nasal cushions, full-face masks, and less frequently used oral and total face masks. The mask interface is a common impediment to use of PAP therapy often due to poor mask fit or leakage.

Nasal masks cover only the nose and require that the mouth remains closed, which can be achieved with the addition of a chin strap. Nasal masks are available in a variety of materials including cloth. Nasal pillows actually go into the nostrils whereas the nasal mask is positioned under the nose. A nasal cushion mask sits under the nose but does not go into the nostrils.

A study by Lanza and colleagues11 evaluated patient comfort with PAP therapy based on the type of nasal interface mask. Patients using nasal pillows had improvement with respect to swollen eyes, discomfort, skin breakdown, and marks on the face compared with patients using nasal masks; however, nasal pillows can cause nostril pain.

Several types of full-face masks are available, some that fit over the bridge of the nose and some that fit just under the nose. A variety of head straps are available to secure full-face masks. One benefit of full-face masks is that air pressure is delivered to both the nose and the mouth, so the mouth can be open or closed. However, the larger surface area of the full-face mask increases the potential for leaks. A study of adherence in 20 patients using CPAP with nasal masks or full-face masks evaluated hours per use, adherence at 12 months, and comfort.12 Patients using full-face masks had more hours per use, better adherence at 12 months, and more comfort than patients using nasal masks.

Interface skin irritation and leak management. To help combat skin irritation, particularly for patients with rosacea, cloth products are available for use beneath the mask and headgear. Silicone pads for masks that cause pressure on the bridge of the nose can help protect against skin breakdown. Sleeping positions other than the supine position can contribute to mask leak. CPAP pillows are designed to allow patients to sleep in their desired position while maintaining an adequate mask seal. The pillows are shaped or have cutouts that prevent the mask from pushing on the pillow and creating a leak.


Case scenario #2

A 54-year-old man with severe sleep apnea recently initiated CPAP therapy. He quickly discontinued use due to nasal congestion.

Which of the following is NOT recommended?

  1. Assure adequate heated humidification
  2. Assure that the apnea is adequately treated
  3. Use of a full-face mask
  4. Use of short-acting nasal decongestants
  5. Use of a topical nasal steroid

Answer: Use of short-acting nasal decongestants.

Nasal congestion is a common reason for nonadherence to CPAP therapy.13 Pressurized air is very drying and can be very uncomfortable. Residual apneic events can even precipitate further congestion. The use of humidification with CPAP can improve patient comfort and compliance. The vast majority of patients use CPAP devices with heated humidifiers. Heated humidification has been found to increase CPAP use and improve daytime sleepiness and feelings of satisfaction and being refreshed compared with cold humidity or no humidity.14 Cold humidification improved daytime sleepiness and satisfaction, but not to the degree found with heated humidification.

Heated humidifiers are incorporated in the CPAP machine or attach to it. Heated in-line tubing helps with “rain out,” which refers to water condensation inside the tubing and mask associated with CPAP humidification.

Topical decongestants can actually worsen congestion and cause a reflex vasodilation. Topical nasal steroids can be used for nasal congestion and may be beneficial.

Next Article:

Alternative interventions for obstructive sleep apnea

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