How to Make Your Patient With Sleep Apnea a Super User of Positive Airway Pressure Therapy
A full-face mask is used only when the patient cannot breathe out the nose adequately or when PAP becomes too high. A 2013 study found no significant differences among ResMed, Respironics, and Fisher & Paykel CPAP interfaces (Fisher & Paykel Healthcare, Irvine, CA).34 The clinician determines which mask is comfortable for a patient and tries to stay with that mask for that patient.
Adherence Report
A therapy data summary is downloaded and reviewed with the patient.28 A pattern of use report that shows daily use with times over the month is also reviewed.28 The software’s sleep therapy long-term trend report lists important statistics. The adherence data summary and the CPAP summary are also reviewed (Table 2).28 This page is printed and given to patients to reieiw their progress. For some it represents a reward for using the CPAP/BPAP machine as well as a congratulatory note.
In the Example 1 summary download (Table 2), a patient used a PAP machine 4 hours or more on 93.3% of the 30 days the machine was used.28 Residual AHI was low, 2.1, and there was no appreciable leak. The PAP of 11.2 cm H2O was in the 90th percentile. The patient was fixed to 12 cm H2O with expiratory pressure relief (EPR) of 1. The EPR is a comfort feature that reduces pressure from 1 cm H2O to 3 cm H2O to make it easier for the patient to exhale. (A flow generator that produces EPR of > 3 cm H2O is a BPAP machine.)
This patient was not a super user. Overall use was low—5 hours, 28 minutes—which could indicate behaviorally insufficient sleep syndrome. Sleep time is controversial, but the National Sleep Foundation recommends 7 to 9 hours of sleep per night.
A different patient used a PAP machine 4 hours or more on 100% (28/28) of the days when the machine was used (Table 3).29 Residual AHI was low (0.6), median use was 8 hours, 47 minutes, and there was no appreciable leak. The patient was using autoset mode with a minimum pressure of 13 cm H2O and maximum pressure of 18 cm H2O. The 95th percentile pressure was 13.6 cm H2O. The patient’s pressure was changed to 14 cm H2O with EPR of 3. This patient was a super user.
Sleep Hygiene Discussion
Providers must discuss sleep hygiene (good sleep habits) with veterans. If needed, AASM pamphlets on sleep hygiene and other educational materials can be provided. The bedroom should be cool, comfortable, quiet, and dark and should not include a television or computer. Exposure to room light before bedtime suppresses melatonin onset and shortens melatonin duration and tells the brain it is time to wake up.34
Patients are asked about the number of arousals they have per night. At first follow-up, providers must determine what is causing a patient to arouse while on CPAP/BPAP therapy. Some causes are air leak resulting in unresolved OSA, nocturia (may be triggered by unresolved OSA), dry mouth (indicating need for chin strap), nightmares (suggestive of unresolved OSA in REM sleep), posttraumatic stress disorder (PTSD), environmental noise, and claustrophobia. The provider should have thought-out answers to these problems in advance.
Epworth Sleepiness Scale
The Epworth Sleepiness Scale (ESS) is administered as part of the baseline comprehensive examination and at every sleep clinic follow-up after issuing a CPAP/BPAP machine.35 The first evaluation after the machine is issued should show a reduction in ESS. No reduction in ESS indicates that a problem needs to be addressed. The most common reason for insufficient reduction in ESS is suboptimal PAP therapy adherence, usually because of a large leak. Some cases of poor adherence may be attributable to restless legs syndrome, periodic limb movement disorder, chronic musculoskeletal pain, and sleep fragmentation caused by alcohol, smoking, caffeine, or cocaine. Excessive daytime sleepiness may persist from use of pain medications or other sedating medications. One study found a correlation between sleep duration with CPAP therapy and reduction in ESS.36 In addition to administering the ESS, patients are asked how they doing with PAP therapy, and the answer is documented. Treatment changes are made if needed to reduce excessive daytime sleepiness.
Ear-Nose-Throat Examination
A quick look into the nose with a nasal speculum is a crucial component of a thorough examination. The clinician looks for a deviated septum, swollen turbinates, obstruction, polyps, bleeding, infection, septal perforation, and discharge. In addition, the patient is checked for airflow amount, nasal congestion, and obstruction; if necessary a nasal steroid spray or a nasal saline spray is prescribed. In some cases, saline spray can be added to the steroid spray to help reduce or eliminate nasal congestion.37
