Clinical Review

How to Make Your Patient With Sleep Apnea a Super User of Positive Airway Pressure Therapy

Maximizing adherence to positive airway pressure among veterans requires implementing a team approach, setting expectations, and educating patients about the benefits of therapy.

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Adherence to positive airway pressure (PAP) therapy is a difficult patient management issue. Clinicians at the John D. Dingell VA Medical Center in Detroit (VAMC Detroit) developed the O’Brien criteria and extensive patient education materials to increase patient adherence. The importance of PAP therapy and the reasons veterans should sleep with a PAP machine for 7 to 9 hours each night are stressed (many sleep only 4 to 5 hours). Several recent studies have confirmed widely varying PAP therapy adherence rates (30%-84%).1-13 A majority of patients indicated that mask discomfort is the primary reason for nonadherence.1

Adherence is affected by many factors, including heated humidity, patient education, mask type, and type of PAP machine (eg, continuous PAP [CPAP] vs bilevel PAP [BPAP]; auto-PAP vs CPAP). Other factors, such as race and economic status, also affect adherence.14 The Wisconsin Sleep Cohort Study found that patients with moderate-to-severe untreated obstructive sleep apnea (OSA) were 4 to 5 times more likely to die of a cardiovascular event and 3 times more likely to die of any cause.15 The morbidity and mortality associated with severe untreated OSA led the clinicians to intensify treatment efforts.16In this article, the authors summarize the initiative at the VAMC Detroit to enhance PAP therapy adherence in patients with sleep apnea. The goal was to motivate patients to maximize PAP machine use. This article is a guide that federal health care providers and their civilian counterparts in the private sector can use to maximize PAP machine use. Working toward that goal, a set of PAP “super user” criteria was developed and used to create a 5-point method for encouraging patients to maximize adherence to PAP therapy.


Positive airway pressure is the room air pressure, measured in centimeters of H2O, which splints open the airway to prevent snoring, apneas, and hypopneas. An apnea is a 90%-plus airway obstruction that lasts longer than 10 seconds and is seen with sleep study polysomnography. A hypopnea is a 30%-plus airway obstruction that lasts longer than 10 seconds and is accompanied by a 3% drop in pulse oximetry (SpO2).

A CPAP device delivers pressure continuously through a medical air compressor or flow generator called a PAP machine. The BPAP machine has separate inspiratory pressure and expiratory pressure. Auto-PAP machines give minimum pressure and maximum pressure usually between the range of 4 cm H2O to 20 cm H2O. This machine finds the user’s median pressure (90th percentile) and maximum pressure and averages pressure over a specified period of use. The auto-PAP can then be set to CPAP mode and the pressure fixed or set to the 90th percentile.

O’Brien Criteria

The O’Brien criteria for PAP super-user status (Table 1) were developed for maximizing PAP machine use and presented at the 2013 John D. Dingell Sleep and Wake Disorders Center Symposium. There is no other published reference or criteria proposed for maximizing PAP machine adherence. A recent study on sleep time criteria suggested that a higher percentage of patients achieved normal functioning with longer duration nightly CPAP therapy, which is in line with the authors’ recommended PAP machine use duration.17

Positive airway pressure therapy is eligible for insurance reimbursement by Medicare and third-party payers for adult patients who have OSA and achieve 4 hours of nightly use for 70% of nights over 30 days. Coverage for CPAP therapy is initially limited to 12 weeks during which beneficiaries with an OSA diagnosis can be identified and any therapy benefits documented. Subsequent CPAP therapy is covered only for those OSA patients who benefit during the 12-week period.18At VAMC Detroit, the data covering the previous 30 days of use is downloaded. Medicare allows for the best 30-day period out of the 12-week window. The hospital, along with Harper Hospital and the Detroit Medical Centers in conjunction with the Wayne State University sleep program, is an Academic Center of Distinction, which follows the sleep guidelines and practice parameters for Medicare, third-party insurance companies, and the American Academy of Sleep Medicine.

The sleep clinic clinicians follow the clinical guidelines for evaluation, management, and long-term care of adults with OSA.19,20 Follow-up visits are scheduled and made on a consultation basis up to 90 days for the required download or as necessary for PAP therapy. In this initiative, practitioners offer veteran-specific patient care with PAP therapy that exceeds Medicare guidelines. The success of this process yielded a growing cohort of PAP super users at VAMC Detroit. These patients exceed the Medicare criterion of 4 hours of nightly use for 70% of nights over 30 days. Thus, 4 hours of nightly use for 100% of nights over the same period was proposed as another criterion.


Recommended Reading

The Solution for Central Sleep Apnea May Not Be One
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Service Members: It’s OK to Get Some Sleep
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CBT for Insomnia
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Alcohol and Insomnia: Dangerous Synergy
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To Sleep—Perchance to Wake Too Soon
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