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Identifying Barriers to CPAP Use and Effectiveness
4. Determine whether there are any barriers to CPAP use or effectiveness.
Numerous factors can negatively affect the tolerance and effectiveness of CPAP. Identifying and treating these conditions can result in significant improvements in patient comfort and sleep quality.
Chronic sinus congestion affects approximately 40% of patients with OSA and can have a tremendous impact on the tolerance and effectiveness of CPAP, and all patients should be asked about sinus congestion before initiating therapy. The use of heated humidification can significantly decrease the effect of rhinitis in patients receiving CPAP and has largely eliminated the development of acute, transient sinus congestion commonly seen during the initial treatment period. When present, chronic rhinitis should be treated before CPAP is initiated because it is a common cause for discontinuation.
Concomitant psychological conditions, particularly insomnia, anxiety, and claustrophobia, may interfere with CPAP acceptance and adherence.
Insomnia is common with OSA and is present in 39%-58% of patients. These disorders are frequently considered to be comorbid. Resolution of OSA often leads to resolution of insomnia; however, insomnia often impedes CPAP use, especially in the initial treatment period as patients are transitioning into therapy. Treatment of insomnia during the initial phase of OSA therapy can enhance tolerance, improve effectiveness, and increase patient satisfaction.
Anxiety or claustrophobia can be an important barrier to CPAP therapy and contribute to treatment refusal.However, most patients with claustrophobia can achieve successful treatment with CPAP. Selecting a comfortable mask interface that minimizes feelings of confinement and desensitization to both the mask and the delivered pressure through progressive daytime use and graduated nocturnal use until the patient is comfortable wearing CPAP throughout the night can be effective.
Several other common barriers and complications with CPAP should be appreciated because they often lead to poor adherence with therapy.
Gastric distention from swallowing air is common with CPAP. Flexion of the neck (from using too many pillows) or untreated sinus congestion are common causes. Limiting patients to 1 pillow or slightly hyperextending the neck by placing a rolled-up towel under the lower cervical spine can also minimize air swallowing. If gastric distention persists, consider decreasing the pressure, balancing the risk of incompletely treated OSA with patient comfort.
Pressure ulceration or skin breakdown may occur. Replacing the mask at normal intervals and ensuring that it is regularly cleaned may prevent these problems. Changing the mask type or size may be required. Silicone pads and commercially available skin barriers and creams may also help prevent the development of mask-induced skin breakdown.
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