Transcript Subject Characteristics

Adherence to CPAP in OSAS
BY
AHMAD YOUNES
PROFESSOR OF THORACIC MEDICINE
Mansoura faculty of medicine
Establishing a
Successful CPAP
Adherence Program
Studies show that patients having OSA
typically go undiagnosed for up to 10
years with steadily increased use of
healthcare resources
• Co-morbidities associated with OSAS:
• Diabetes
• Hypertension
• Heart Disease
• Stroke
CPAP TREATMENT FOR OSAS
• OSAS occurs in an estimated 5% of the adult population.
• CPAP is a first line treatment for moderate to severe OSA.
• CPAP is almost 100% effective when used regularly but
adherence with treatment poses problems for many
patients.
• The provision of CPAP involves more than simply selling a
CPAP device and mask: it involves education, support and
ongoing care including the monitoring of treatment
adherence.
• This is often a shared responsibility between the patient,
the sleep physician, the sleep clinic and organization
which provides CPAP equipment
CPAP adherence
• Adherence like compliance refers to the degree
that an individual follows a recommended illnessrelated recommendations, but while compliance
suggests a passive role, adherence emphasizes an
active role.
• Adherence failure : use of CPAP for less than
4 h / night on 70% of nights and or lack of
symptomatic improvement.
• Internationally 5-50% of OSA reject CPAP treatment
option or discontinue use within the first week .
• 12 to 25% of the remaining patients may be expected
to have discontinued its use at 3 years
CPAP adherence Outcomes
• CPAP reduces objective daytime sleepiness ,
improves some measures of cognitive
performance ,reduces depression, reduces
cardiovascular mortality and morbidity ,
reduces the risk of motor vehicle crashes and
improves perceptions of quality of life,
• Reduces healthcare utilization
• Adherence to CPAP treatment is the largest
factor impacting on the effectiveness of
treatment
The basic requirements are:
• Staff who are appropriately trained
• A choice of CPAP equipment sufficient to meet
individual patient needs
• A CPAP initiation service which provides patients
with adequate information and education to instill
confidence in their treatment.
• A CPAP follow-up service which comprises an
appropriate number of follow-up contacts and the
opportunity for patients to access the service on
an as-needed basis.
• An infrastructure that enables timely and efficient
communication with sleep clinics and referring
doctors about their patients
Assessment of CPAP adherence
• To assess CPAP adherence and treatment efficacy, CPAP
manufacturers have implemented tracking systems that
monitor CPAP efficacy (residual sleep-disordered
breathing, hours of CPAP use, and mask leak ).
• Despite the fact that CPAP adherence tracking systems
have not yet been rigorously tested to show measurably
improved outcomes, their use seems clinically sound.
• In fact, CPAP adherence tracking now is a requirement for
Medicare and other payers to continue reimbursement for
CPAP beyond the first three months of treatment.
Moreover, we can track CPAP use better than almost any
other therapy for a chronic disease and we have the ability
to specifically link patterns of use to OSA outcomes.
Why do we care about CPAP adherence and hours of use?
• Because studies have shown that increasing hours of CPAP
use results in better outcomes.
• Patients routinely overestimate their CPAP usage with self
report .Thus, objective monitoring of CPAP use has become
the standard of care for managing patients with sleep apnea.
• The tracking systems are not limited to conventional CPAP
alone, but also can be utilized in patients being treated with
auto-CPAP, bi-level, auto-bi-level, or adaptive servoventilation.
• Adherence tracking systems can collect data that measures
the date ranges of CPAP usage, the total number of nights the
CPAP was utilized (and not utilized); sort the data to the
percent of nights CPAP was utilized, percent of nights CPAP
was used > 4 hours/night,
• In general, the CPAP adherence-tracking systems are accurate
in objectively determining CPAP use.
Unfortunately, sleep-disordered breathing event detection
and leak data are more problematic to interpret than hours
of use.
• CPAP tracking systems provide averaged data (over many
nights, so these data may not reflect the last week or
month) for the residual AHI while using CPAP.
• Currently CPAP devices use a reduction in airflow
(measured with a pneumotachograph) to estimate the
residual AHI . In contrast, during polysomnography, apnea
or hypopnea determination is based on more robust data,
including respiratory flow patterns (nasal pressure and a
thermistor), EEG arousal, thoraco-abdominal effort, and
oxyhemoglobin desaturations.
• Thus, residual AHI measured from a CPAP download is
not a true surrogate of the AHI measured during a sleep
study. Caution therefore must be used in interpreting OSA
resolution or persistence from CPAP adherence data
reports.
Event detection data should be used in the management of
OSA patients if the data are at either end of the spectrum
[normal AHI(< 5 events/hour) or very high AHI (> 30
events/hour).
• Intermediate residual AHI data can be difficult to interpret
and should be examined within the clinical context of the
patient.
• Reduction in CPAP mask leak can improve adherence and
improved adherence can improve OSA outcomes,
• Mask leaks depend on both the mask (nasal pillows, or
full face) and the pressure being delivered.
• What is a clinically significant mask leak? There are no
data to answer this question but there may be no leak
threshold that is "clinically acceptable," as even a small
leak directed into a patient's eyes can be a problem.
Mask leak data are averaged measurements and may not
reflect recent changes in the CPAP interface.
• Mask leak may be secondary to leaking through the mouth or around
the mask.
• If the CPAP unit is running when a patient goes to the bathroom, this
may appear as large leak in the download even though there is not a
true mask leak.
• Leak data, like event detection data, must be examined within the
clinical context of a patient; extreme measurements on the spectrum
are more likely to be valid than middle of the road numbers.
• If the patient's mask leak is significantly greater than the leak
threshold specified by the specific CPAP manufacturer, the interface
could be changed.
• The new CPAP adherence tracking devices measure many other
respiratory signals data , including periodic breathing (Cheyne-Stokes
pattern), vibratory snoring, flow limitation, clear airway apnea (central
sleep apnea). Unfortunately there are essentially no examining the
validity, reliability, reproducibility, or utility of these signals.
There are several different methods to transmit CPAP
adherence tracking data
• Most systems use cards (smart
card-SD cards), memory sticks,
download cable or wireless
transmission.
• CPAP adherence profiles are
not standardized between the
different proprietary tracking
systems and the reports are not
yet easily exportable to
electronic medical records.
• DOWNLOAD CABLES CONNECT YOUR
MACHINE TO YOUR COMPUTER SO
THAT YOU MAY DOWNLOAD YOUR
SLEEP METRICS TO YOUR COMPUTER
FOR VIEWING. SOFTWARE IS NEEDED
TO RETRIEVE THIS DATA.
• IF YOU DON'T WANT TO DEAL WITH
MOVING YOUR MACHINE CLOSE TO
YOUR COMPUTER, CHECK TO SEE IF
YOUR MACHINE HAS A CARD READER
INSTEAD
• DATA CARDS FIT INTO YOUR MACHINE
TO COLLECT YOUR SLEEP DATA.
THESE CARDS CAN BE TAKEN OUT
AND READ BY A CARD READER THAT
HOOKS UP TO YOUR COMPUTER.
SOFTWARE IS STILL NECESSARY FOR
DATA TO BE DOWNLOADED.
• This USB Smart Stick Memory Card is
designed for use with all Fisher & Paykel
Sleep Style 242 (HC242), Sleep Style 244
(HC244) and Sleep Style 254 (HC254) CPAP
Machines.
• The Smart Stick works as a miniature USB
drive capable of transferring therapy data
from a Smart Stick enabled Sleep Style
CPAP to a computer without the need for a
separate card reader.
• To review data on the card software, like
Fisher & Paykel's ,Performance Maximizer
Software, is required. Fisher & Paykel 900HC611
How to Read a CPAP Adherence Report
• Check nightly usage hours
• Check leak data. This is usually shown as L/sec.
Values significantly greater than 0.4 L/sec are an
indication that the patient is using an
inappropriate or poorly-fitting CPAP mask.
• Check apnea events. This indicates the number
of times the patient has stopped breathing and
is shown as events per hour (or e/hr.) These
values should be at or near zero if the patient is
receiving sufficient airway pressure; multiple
apnea events per hour are an indication that the
patient's CPAP pressure needs to be adjusted .
In conclusion
1-CPAP adherence must be followed consistently
over time.
2-CPAP adherence, in terms of hours of use / night,
has been shown to improve clinical outcomes.
3-CPAP usage can be reliably obtained from CPAP
tracking systems and these data are robust.
4-The residual events (apnea / hypopnea) and leak
data from CPAP tracking systems are not as easy
to interpret and standards need to be developed
to optimally utilize these data.
Barriers to CPAP
Adherence
Barriers to CPAP Adherence
Therapy Related
Patient Related
CPAP Adherence
Clinician
Related
Equipment
Related
Equipment Related Barriers
• Complexity of therapy/device
• Excessive mask leak
• Portability/Battery backup
• Device noise
• Hose length
• Improper mask fit
Therapy Related Barriers
• Adverse reactions that go unaddressed
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Nasal dryness or dry eyes
Nasal congestion
Skin irritation
Bloody nose
• Expense of therapy
• Governmental policies ( funding, licenses of
drivers )
• Adherence decreases over time
Nasal prongs
Nasal pillow
Nasal mask
Oral CPAP Mask
Full face mask
Total face mask
Patient Related Barriers
• Health literacy
• Ambivalence
• Lack of family or other social support.
• Patient economics
• Lack of reimbursement
•
Psychological variables - claustrophobia
• Physical limitations
• Less severe factors/Little or no perceived benefit from
therapy
• Use of prescription/non-prescriptions drugs or alcohol
Claustrophobia
• Claustrophobia is a form of specific phobia that
entails extreme anxiety and panic elicited by
situations such as tunnels, elevators, or other
settings in which the individual experiences a
sense of being closed in or entrapped.
• Almost one-third of sleep apnea patients
endorse CPAP-related claustrophobia and may
lead to treatment abandonment.
• CPAP-related claustrophobia was perceived as
one of the largest deterrents to CPAP therapy.
Clinician Related Barriers
• Poor patient relationship
• Lack of clinician follow-up
• Expression of doubt concerning
therapeutic potential or creating falsely
elevated expectations
• Unwillingness to educate patient
• Lack of knowledge on patient’s medical history,
and other medication the patient may be taking
Intervention
Therapy Related
Patient Related
CPAP Adherence
Clinician
Related
Equipment Related
Equipment/Therapy Interventions
• Heated humidification to relieve nasal dryness, running
nose, nose bleeds
• Nasal spray
• CPAP modalities: auto-titrating or bilevel PAP
• Refit interface
• Change mask type
• Comfort features
– Ramp
– Quieter blower
– Battery backup
– Expiratory pressure relief
Contour CPAP Compliance Pillow
The Contour CPAP Pillow works with
all major brands of CPAP masks!
The Contour CPAP Pillow Improves:
• CPAP Ease of use
• Sleep Comfort for all CPAP users
• CPAP Compliance • Neck support and spine alignment
• Airway alignment
The Contour CPAP Pillow Reduces:
• Mask leaks
• Pressure on mask and face
• Mask discomfort
Patient/Clinician Intervention
• Family/social support
• Bed partner’s acceptance
• Suitable education and training on equipment
• Cognitive behavioral therapy, motivational
enhancement therapy
• Rapid response to difficulties
Compliance Program Options
• Physician/Sleep Lab follow-up programs
• Support meetings (CPAP clinics)
• Home care therapist-driven programs
• Internet programs
• Follow up cards
• Telephone (Hotline)
Compliance Program
• Why this Protocol…Critical 1st Days
• “Failure to adhere with treatment has been
reported to be as high as 50%, with patients
typically abandoning therapy during the first 2 to
4 weeks of treatment.”
• “Those patients who manifested good
adherence during the first week of treatment
continued using CPAP for the entire first year.
• Hours of use the first week was correlated to
hours of use the first year.”
Compliance Program
• “Patient education, close follow-up and intervention
appear to improve long-term tolerance.”
• Education
1-Disease state
– What is their diagnosis
– How severe is their OSA
– How will it impact their lives
– What are the potential co-morbidities
– What should they expect
2-Equipment
– How it works
– How to inspect and replace when required
– What support is available to ensure the patients success in
therapy.
Vigilance Testing
Reaction time
• The lapse of time between stimulation and the beginning
of response.
• Click the large button on the right to begin.
• Wait for the stoplight (red) to turn green.
• When the stoplight turns green, click the large button
quickly!
• Click the large button again to continue.
• The stoplight may take up to seven seconds to change.
The amount of time is random.
• You may press any key, instead of clicking the mouse
button, if you prefer.
• You will be tested five times, and your average reaction
time will be calculated.
Conner’s Continuous Performance Test
• Test vigilance in all subjects before CPAP use and again
12 weeks after use had been initiated.
• Letters are flashed on a computer screen in rapid
succession. Subjects are asked to press a response key
when they see the letter X, but only when it is preceded
by the letter A.
• This AX condition is thought to maximize the cognitive
load of vigilance over and above that of simple reaction
time.
• The test lasts about 12 minutes, and provides measures
of accuracy and speed of target detection.
• Dependent measures include the total number of hits,
average reaction time to targets, d´ (a measure of signal
sensitivity), and the total number of target omissions.
Psychomotor vigilance testing of professional drivers in
the occupational health clinic
Initiation of CPAP treatment should also include
general advice on lifestyle and medical issues
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Patients who smoke should be advised to stop.
Alcohol should be avoided.
Avoided nocturnal sedatives or sleeping tablets.
Advice regarding body weight and its interaction
with OSA should be provided if appropriate.
• Patients should be informed about the impact of
sleeping position on sleep apnea severity.
• Relief of nasal obstruction should be viewed as an
adjunct to CPAP therapy, potentially improving
adherence.
Initiation of treatment:
• Education and reassurance are critical components
of the initiation of therapy. This process must be
interactive with the patient having opportunity to
have their questions answered and concerns
addressed. The involvement of the patient’s partner
in this process is important to encourage acceptance
and subsequent adherence.
• The interface fit shall be assessed while the patient
lying down in supine and lateral postures.
• The patient shall be given the opportunity to try a
variety of CPAP interfaces to ensure optimal fit and
comfort and minimal leak.
SESSION 1
• Review subject’s sleep data
• Review symptoms noticeable to the subject ( fatigue,
excessive daytime sleepiness)
• Review symptoms not apparent (hypertension, cardiac
problems)
• Review results of performance on cognitive tests .
• Rate the importance of treatment .
• Review PSG with CPAP and specify how this might
address the above problems.
• Discuss the advantages and disadvantages of treatment
• Develop goals for therapy
Ongoing Management of CPAP Usage:
• It is suggested that approximately 7, 30, 60 days and
approximately 12 months after treatment initiation are
appropriate times.
• At this time the provider shall
1- Determine the patient’s usage from the meter of the
CPAP device and calculate the average daily hours of
CPAP usage.
2- Check the device and humidifier for satisfactory
operation.
3- Check filters, mask and head-gear for satisfactory
condition and advise the patient of any faults and
suggested remedial actions.
SESSION 2
• Examine compliance data for the first week
• Discuss noticeable changes with treatment .
• Discuss changes not apparent (hypertension
,cardiac problems) .
• Troubleshoot discomfort .
• Discuss realistic expectations of treatment .
• Review treatment goals .
Exposure therapy for claustrophobic
reactions to CPAP
• claustrophobia is composed of two “core”
fears: fear of restriction, and fear of suffocation.
• Exposure therapy is indicated for individuals
with sleep apnea who are unable to tolerate
CPAP devices due to anxiety reactions.
• CONTRAINDICATIONS :unstable psychiatric
symptoms (substance use, post-traumatic
stress disorder, suicidal/homicidal ideation,
psychosis), inability to maintain a therapeutic
relationship, or economic/domiciliary instability
RATIONALE FOR INTERVENTION
• Because CPAP requires the patient to breathe
pressurized air through a nasal or full-face mask strapped
to the head, it is not difficult to understand how this
treatment can tap into fears of suffocation and restriction.
• In some patients, this therapy may elicit memories of the
original Unconditioned stimulus or set of circumstances
that elicited the claustrophobic response to CPAP.
• some patients appear to develop claustrophobic
reactions de novo, specifically in response to an
unpleasant experience while using CPAP.
• The treatment of choice for specific phobias, including
claustrophobia, is exposure therapy
RATIONALE FOR INTERVENTION
• The phobic individual confronts the feared object or
situation either imaginally or in real life (in vivo).
• Typically, a hierarchy of fearful situations ranging from
least to most anxiety-provoking is generated by the
individual.
• The individual is supported in experiencing these feared
situations in a gradual manner, and over time the
anxiety decreases.
• The effectiveness of exposure therapy stems from
learning to tolerate and manage anxiety without the
need to escape or avoid the phobic stimulus,
• Exposure therapy increases the individual’s perception
of control over fear
RATIONALE FOR INTERVENTION
• Exposure therapy for CPAP emerged as a means of
breaking the link between anxiety (triggered by CPAP as
the CS) and the avoidance response
• A deconditioning process based on those used for
specific phobias is employed so that CPAP loses it value
as a Condition stimulus for anxiety and avoidance.
• This goal is achieved through the gradual re-exposure
of the patient to CPAP in a structured manner so as to
extinguish the link between CPAP as the Condition
stimulus , and the Uncondition stimulus that led to the
initial problematic response.
• This link is often a symbolic one in that CPAP was never
associated with the original Uncondition stimulus but
merely mimics it and elicits memories of it.
STEP BY STEP DESCRIPTION OF PROCEDURES
• Exposure therapy for CPAP-related claustrophobia can
be delivered effectively in one to six sessions over 1–3
months.
Initial Session (Session 1)
• Assessment and history
Claustrophobia (tolerating air pressure, having the
mask on the face, having the mask strapped over the
head) claustrophobia in other situations and the
presence of other anxiety disorders
• Patient education on sleep apnea and CPAP therapy
• Build therapeutic trust
• Implementation of exposure therapy
Presentation of treatment rationale
Establish exposure hierarchy
Goal setting / homework
Patient handout describing exposure
steps for home practice.
• Do not try wearing CPAP during sleep until you are comfortable with it
during the daytime.
• If your machine has a RAMP button, you may use this function to keep
the pressure at a low level during practices.
1-Turn the CPAP airflow ON. Hold mask over your nose, and practice
breathing with machine on while awake. While you are doing this, keep
your mouth closed and breathe regularly through your nose. Start with
short periods of time (1–5 min) and gradually build up to longer periods
of time.
2. Turn the CPAP airflow ON and wear the mask over your nose with the
straps on your head. Practice breathing with CPAP on while awake.
Wear CPAP for longer periods of time until you can have it on for 15–20
min comfortably.
3. Take a nap during the day with CPAP machine and mask on. It is not
important whether you fall asleep or not – the goal is to rest
comfortably in your bed with the CPAP on.
4. Wear CPAP at night when you go to sleep. If you experience
claustrophobia or uncomfortable feelings, go to previous step until
comfortable. Then proceed to next step.
Follow up Sessions (Sessions 2–6)
• Assess adherence to homework (Monitor progress )
Patient self-report
Objective CPAP data (CPAP card is read during the session)
• Problem-solve obstacles
• Conduct in-session exposure trial (If the patient continues
to report claustrophobic reactions while using CPAP at
home) asking patients to apply their CPAP as they do at
home. This reveales that, for some patients,
“claustrophobia” is caused by an incorrectly applied or
fitted mask. claustrophobia can sometimes be ameliorated
by trying an alternative mask style,
• Provide feedback and support regarding CPAP use( once
patients complete the exposure protocol and are using
CPAP at home successfully, follow-up visits may be spaced
at increasing intervals (e.g., 3 months, 6 months, 12
months), or as needed).
CPAP adherence
• A team effort is needed to enhance CPAP adherence.
The team may consist of the patient , family/bed partner,
medical-equipment provider, respiratory therapist, sleep
center staff, sleep center physician, primary care
physician, and a home nursing service if applicable.
• Adherence is dependent on layers of information
providing the patient with ongoing education, written
instructions, demonstration of equipment, and the
timely addressing and troubleshooting of the patient’s
concerns and problems.
• Adherence of patients are clear indicators of the quality
of the service.