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

The super-user criteria, which provide motivation to reach the top, stimulate many patients to achieve the Medicare criteria. All 5 criteria must be satisfied to attain super-user status, and becoming a super user is not easy. In fact, the expectation is that, if an adherence data study is conducted, it will show that only a small percentage of all users meet the criteria. Maximum adherence is expected to be the tail (3%-4%) of a bell-shaped curve.

PAP Super-User Status

At the initial evaluation, practitioners create a self-fulfilling prophecy that, as first described by Merton, sets expectations.²¹ A self-fulfilling prophecy is a prediction that directly or indirectly causes the prediction to become true as a result of the positive feedback between belief and behavior.²¹ The personnel at VAMC Detroit sleep clinic set a tone that enables patients to meet and exceed the Medicare sleep guidelines and their expectations. Patients are encouraged to make it their personal mission to achieve the goal of becoming a PAP super user. The patients receive the O’Brien criteria for PAP super-user status—guidelines thought to contribute to higher quality of life.

The Medicare criterion emphasized is the minimum required for full adherence. The goal is to reduce sleepiness and increase well-being. The literature shows that increasing duration of sleep results in lower daytime sleepiness.²² Inadequate sleep has many detrimental effects. According to a recent study, insufficient sleep contributes to weight gain.²² Desired patient outcomes are increased sleep time without arousals, increased slow-wave sleep (SWS), consolidation of memories and rapid eye movement (REM), and improvement in emotional and procedural skill memories.²³ Patients are informed that using a PAP machine for 7 to 9 hours can reduce excessive daytime sleepiness and allow for more SWS and REM sleep, which help improve memory, judgment, and concentration. Many other studies have shown how 7 to 9 hours of sleep benefit adults. Thus, 7 to 9 hours became the criterion for maximizing PAP sleep time.

Initial Evaluation and Sleep Study

A primary care provider can enroll a patient into the clinic for a sleep study by requesting an evaluation. The consultation is then triaged using the STOP-BANG (Snoring, Tiredness, Observed apnea, high blood Pressure–Body mass index > 35, Age > 50, Neck circumference > 40 cm, Gender male) questionnaire. The STOP-BANG has a high sensitivity for predicting moderate-to-severe (87.0%) and severe (70.4%) sleep-disordered breathing.²⁴ More than 3 affirmative answers indicate a high risk for sleep-disordered breathing and is cause for ordering a sleep study.

CPAP Group Class

Patients with a diagnosis of sleep apnea subsequently receive their CPAP machines when they attend a 2-hour group class taught by a respiratory therapist. Group education sessions increase the chance of issuing more machines and providing better education.²⁵ One study found that “attendance in a group clinic designed to encourage compliance with CPAP therapy provided a simple and effective means of improving treatment of OSA.”²⁵

In class, the respiratory therapist briefly assesses each patient’s CPAP prescription, describes the patient’s type of sleep apnea and final diagnosis, and reviews the CPAP machine’s features. Veterans are then instructed to take their CPAP machines home to use all night, every night for 4 weeks. All night is defined as a period of 7.5 to 8 hours, as population-based study results have shown that sleep of this duration is associated with lowest cardiovascular morbidity and mortality. After the initial 4-plus weeks of machine use, patients with all their CPAP equipment are seen in the sleep clinic.

First Sleep Clinic Follow-Up Visit

At first follow-up, patients are asked for a subjective evaluation of their sleep. Most state they are “better” with PAP therapy. Each patient’s mask is checked and refitted with the patient’s prescribed pressure.

Patients are informed of their PAP settings and requirements from the sleep study and told their particular “magic pressure.” Patients understand that a person’s magic pressure, determined in the laboratory, is the pressure of room air blown into the nose, mouth, or both that eliminates not only snoring, but also partial and complete airway obstructions (hypopneas, apneas). Patients are asked to remember their particular magic pressure and their AHI and told their OSA status (mild, moderate, or severe) as assessed by the laboratory study.²⁶ Extensive education on sleep apnea and treatment are also addressed. Education and training are among the most important tenets of PAP therapy, and these are incorporated into all encounters.^25,26

PAP Data Report and Leak

The CPAP data are downloaded and printed. If adherence is suboptimal, clinician and patient discuss increasing adherence and possibly becoming a super user. The patient receives a copy of the report, which can be compared with the patient’s adherence statistics and with the adherence statistics of similar patients who are super users. A few blacked-out names are posted on the board in front of the provider’s computer station. Patients can thus easily see that attaining super-user status is very difficult but possible. Some patients maximize their therapy and are designated PAP super users. These patients are proud to receive this designation, and they strive to keep it.