Transcript The CPAP provider

Adherence to CPAP in OSAS
BY
AHMAD YOUNES
PROFESSOR OF THORACIC MEDICINE
Mansoura faculty of medicine
Adherence
• Adherence refers to the degree that an individual
follows a recommended illness-related recommendations
Adherence failure : use of CPAP for less than 4 h/night on 70% of
nights and or lack of symptomatic improvement.
• 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.
• Claustrophobia is a commonly reported side effect of CPAP therapy,
and may lead to treatment abandonment.
• Almost one-third of sleep apnea patients endorse CPAP-related
claustrophobia
• CPAP-related claustrophobia was perceived as one of the largest
deterrents to CPAP therapy.
Complications of CPAP
Facial and nasal pressure injury and sores
Result of tight mask seals used to attain adequate
inspiratory volumes
Minimize pressure by intermittent application of
noninvasive ventilation
Schedule breaks (30-90 min) to minimize effects of mask
pressure
Balance strap tension to minimize mask leaks without
excessive mask pressures
Cover vulnerable areas (erythematous points of contact)
with protective dressings
Complications of noninvasive ventilation
Gastric distension
Avoid by limiting peak inspiratory pressures to less than 25 cm water
Nasogastric tubes can be placed but can worsen leaks from the mask
Nasogastric tube also bypasses the lower esophageal sphincter and
permits reflux
Dry mucous membranes and thick secretions
Seen in patients with extended use of noninvasive ventilation
Provide humidification for noninvasive ventilation devices
Provide daily oral care
Aspiration of gastric contents
Especially if emesis during noninvasive ventilation
Avoid noninvasive ventilation in patient with ongoing emesis
or hematemesis
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 organisation which
provides CPAP equipment
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.
CPAP is a cost effective intervention in symptomatic patients
with moderate to severe OSAS
• CPAP reduces objective daytime sleepiness ,
improves some measures of cognitive performance
,reduces depression, energy, reduces cardiovascular
mortality and morbidity , reduces the risk of motor
vehicle crasheS and improves perceptions of quality
of life,
• Adherence to CPAP treatment is the largest factor
impacting on the effectiveness of treatment
Reaction time :
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The lapse of time between stimulation and the beginning of
response.
Click the large button on the right to begin.
Wait for the stoplight 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.
Vigilance Testing
• 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.
Best practice principles.
• The diagnosis and treatment of (OSAS),and the monitoring
of the response, should be carried out by a specialist service
with appropriately trained medical and support staff.
• Treatment with CPAP must be based on a prior diagnosis of
OSA established using an acceptable method.
• Close follow-up for CPAP usage and problems in patients
with OSAS by appropriately trained health care providers is
indicated to establish effective utilization patterns and
remediate problems, if needed. This is especially important
during the first few weeks of CPAP use.
• CPAP usage should be objectively monitored
Evidence available on the effectiveness of
various interventions
• Patient education about the nature, complications
and treatment of OSA with CPAP is an important
component of all treatment strategies.
• A formal cognitive behavioural therapy intervention
of two hours duration has also been shown to
improve attitudes to CPAP and uptake of treatment.
• Behaviour of patients in the first two weeks of CPAP
treatment predicts whether they will use it in the
long term. Late intervention may not be as effective
as efforts made to maximise usage at the initiation
of therapy.
Evidence available on the effectiveness of
various interventions
• Weekly phone calls during the first month and
written information have been shown to be effective
in improving adherence .
• Long-term follow-up for CPAP-treated patients by
appropriately trained health care providers is
indicated yearly and as needed to troubleshoot
mask,machine, or usage problems.
• The patient’s partner should be involved in the
CPAP treatment process as their acceptance and
support of treatment is important in encouraging
uptake and continued adherence with treatment
Evidence available on the effectiveness of
various interventions
• The addition of heated humidification is indicated to improve
CPAP utilization .
• There is a paucity of evidence that auto-CPAP is more
effective in improving adherence than conventional CPAP.
• Pressure-relief CPAP devices are as effective as
conventional fixed pressure CPAP and although may be
preferred by the patient but have not shown to improve
adherence to treatment as a result of improved comfort.
• BPAP is an optional therapy in some cases where high
pressure is needed and the patient experiences difficulty
exhaling against a fixed pressure .
• There is no evidence to support the use of one type of nasal,
full face mask or other interface over another. Patient
preference and individual fit and seal are the best guides to
interface selection.
Initiation of CPAP treatment should also include
general advice on lifestyle and medical issues
• Patients who smoke should be advised to stop.
• Excess alcohol should be avoided.
• Nocturnal sedatives or sleeping tablets should be
avoided.
• 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 apnoea severity.
• Relief of nasal obstruction should be viewed as an
adjunct to CPAP therapy,potentially improving
adherence.
RECOMMENDATIONS
• The success of CPAP therapy is critically dependent on the
role of sleep clinic and CPAP provider.
• Provision of CPAP does not end with the sale of a CPAP
device. The organisation providing CPAP must undertake to
provide ongoing service of the equipment, and ongoing
advice and support to the patient.
• An appropriate facility to undertake CPAP fitting is also
required. This should be a private area and have a bed
where patients can trial masks in all sleep positions.
• CPAP adherence, are clear indicators of the quality of the
service.
Conflicts of Interest:
• The relationship between clinician and patient
should not be compromised by commercial or other
interests that could subvert the principle that the
interests of the patient should be primary.
• It is not desirable for an individual clinician engaged
in diagnosis of OSA to derive income from the
business of CPAP provision. Nor is it desirable for
an organisation engaged in CPAP provision to
provide diagnostic services with a view to profit from
subsequently selling CPAP to a patient.
Organisational Considerations:
• schedule of technical services to patients such as
CPAP pressure checks or machine downloads shall be
agreed between the referring doctor or sleep clinic and
CPAP provider.
• The CPAP provider shall maintain a range of CPAP
machine types (eg, auto and fixed pressure)
• The CPAP provider shall maintain a broad range of
CPAP interface types and sizes (eg, nasal masks, full
face masks)
• The CPAP provider shall maintain sufficient supplies of
spare parts to ensure that they can remedy common
patient problems with a same day service
Training of CPAP Providers/Practitioners:
• CPAP practitioners shall undertake a training
course in CPAP fitting and troubleshooting and be
fully conversant with equipment offered before
undertaking patient contact.
• The supply of CPAP equipment must be undertaken
with a full understanding of the patient’s medical
condition including co-morbidities.
• The facility shall include an appropriate clean-up
area where CPAP equipment can be cleaned and
disinfected to manufacturer’s recommendations.
• The CPAP provider shall check the pressure
delivered to the interface, by use of a manometer .
Initiation of treatment:
• Initiation of CPAP treatment and the patient’s initial
experience with treatment is the most critical factor in
determining the success of subsequent 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 (e.g.,
anergia, EDS)
• Review symptoms not apparent (e.g., 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.
Ongoing Management of CPAP Usage:
4- The CPAP provider shall provide a “CPAP
download” service for the patient, at which time the
patient’s usage shall be determined and reported to
the referring doctor .
5- The CPAP provider shall have available loan
equipment so that if it is necessary for a patient to
return their equipment to the manufacturer for
repair, a loan machine can be provided.
6- Provide further information and education to the patient
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
Quality Assurance
• Simple measures of CPAP success to be collected
and recorded for each patient. This may include
patient visits, CPAP equipment type, CPAP treatment
usage and symptom scores.
• The CPAP provider shall review the quality of their
service and the outcome of their treatment on a
regular basis.
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 UCS 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 CS 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 CS, and the
UCS that led to the initial problematic response.
• This link is often a symbolic one in that CPAP was never
associated with the original UCS but merely mimics it
and elicits memories of it.
• Graded exposure to CPAP under therapeutic guidance
helps eliminate this link and foster CPAP tolerance.
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).
POSSIBLE MODIFICATIONS/VARIANTS
• The CPAP exposure protocol also can be modified and
implemented prophylactically to prevent anticipated
claustrophobia.
• Exposure treatment can be employed successfully with
other types of positive airway pressure delivery systems
(e.g., auto-CPAP, BiPAP, etc.)
• The implementation of relaxation training may be
indicated for patients who are unable to reduce their
level of anxiety sufficiently during the exposure
protocol.
• cognitive-behavioral therapy techniques can be useful
both in challenging patient beliefs or thoughts that may
be interfering with the exposure therapy and in helping
the patient develop positive coping statements