Positive airway pressure (PAP) compliance is a hot topic among professionals specializing in the fields of sleep medicine and respiratory care. This issue has proven to be one of the most often studied, written about, and discussed topics featured in the professional journals of these fields. In fact, PAP compliance has such a buzz that almost an entire afternoon of the 2008 Associated Professional Sleep Societies (APSS) conference in Baltimore was dedicated to the subject.1
As medical professionals, it is imperative that we recognize that there are many reasons why compliance to the therapy we provide is of the utmost importance. It is crucial that patients adhere to PAP therapy for their personal health benefit, as the therapy is a useful tool to resolve symptoms of obstructive sleep apnea (OSA). It is estimated that less than 40% of individuals on PAP therapy continue treatment past the first year.2 That is a grave number of failures. Untreated OSA has been linked to hypertension,4 heart failure,5 heart arrhythmia,6 stroke,7 diabetes,8 and excessive daytime somnolence, sexual dysfunction, and depression.9 Additionally, drowsy driving is equilibrated to driving while intoxicated as a cause of motor vehicle accidents.10 Therefore, untreated OSA is a potential menace that not only affects the individual but society as well. Adherence to PAP therapy is also essential because we often need to prove to various entities—such as insurance companies that may be supplementing most of the cost of the therapy—that the prescribed and executed plan of treatment is indeed effective.
Sticking to the Program
Semantics and patient expectations are keys to a successful PAP program. The very term compliance, which is the most commonly used word to describe patient therapy use, is an insensate term defined by the Merriam Webster’s Collegiate Dictionary5 as 1a: the act or process of complying to a desire, demand, proposal, or regimen or to coercion; b: conformity in fulfilling official requirements; 2: a disposition to yield to others. To comply means to follow an order. Human nature does not like to follow demands. Although some may try, often the attempt is disingenuous and failure is imminent. Adherence on the other hand is described in the same dictionary as a term meaning: 1. the act, action, or quality of adhering; 2. steady or faithful attachment: FIDELITY. The key here is faithful attachment to a paradigm shift—a new way of living. An online search of the medical professional literature produces approximately 159,000 articles on PAP compliance and merely 45,000 on PAP adherence, indicating an inappropriate focus on coercion rather than fidelity.
Adherence is the only true method by which to produce an effective long-term lifestyle change. This lifestyle shift of adherence to PAP therapy can be likened to the lifestyle change associated with long-term weight loss. Successful weight loss programs educate and support individuals throughout the entire lifelong process. As many misguided gym-goers would agree, simply joining a health club does not produce considerable weight loss. Those looking to lose weight need more—they need support. For example, some of the most successful weight loss and fitness programs, such as Weight Watchers and Curves for Women, have incorporated education and continued client support by a personal trainer or coach to assist in not only initial weight loss, but maintenance of weight loss as well. With this perspective of understanding, it is incumbent upon us as a medical community to shift away from simply attempting to achieve patient compliance by providing an OSA patient with a PAP device and expecting adherence. If we are truly interested in the well-being of our patient with OSA, we must provide PAP therapy adherence support for the entire length of time the patient is entrusted to our medical care.
Current literature suggests that the major cause of low PAP tolerance is mechanical issues, such as inappropriate mask fit. Although issues such as these are very real and must be appropriately addressed, they are not the sole culprit for PAP failure. PAP adherence is multimodal, with the primary cause of an unsuccessful PAP program being deficient patient education.
Education is the key to any treatment adherence program. In the “ideal world,” patient education would begin with the patient. In this world, the perceptive individual would realize their symptoms and present them to a qualified medical professional to make a diagnosis. They would also know their financial limitations and be satisfied with the very best treatment their money can buy. Also in this ideal world, physicians would exist who could still afford to take the time to listen to the patient, educate them on the suspected diagnosis, and refer them to the most appropriate facility to obtain any further testing that may be needed in order to make the most accurate diagnosis. After the diagnosis, the ideal world physician would educate the patient on their condition, be knowledgeable about treatment options, be updated on all the latest PAP devices and accessories in order to make the most appropriate recommendation, and be aware of the area PAP providers who offer the best equipment, service, and support. Once the diagnosis of OSA is confirmed and the ideal patient education is completed, the patient would be then referred to a premier durable medical equipment (DME) provider, staffed by experienced and qualified respiratory therapists, that has a vast array of PAP devices and appliances available. The RTs would continue the education process, initiate the treatment, and follow through as a coach, a personal trainer of sorts, to assist the patient in achieving and maintaining their therapy goals. While in reality, the ideal world does not exist, the practices of the ideal world are always goals we can strive to achieve. Each of us involved in the care of individuals with OSA should work diligently to compensate for the less than ideal situation in which we may find ourselves.
For DME companies that provide PAP therapy units, the service of a patient educator and coach is often provided as part of the equipment sales service. Currently, RTs at DME companies are the personnel most often assuming this role. Perhaps as the gap between the ideal world and the real world narrows, RTs providing DME service will be reimbursed not only for the equipment they provide, but also for the service they offer their patients. Unfortunately, however, we do live in a less than ideal world and to quote a sports cliché, “it is what it is.” High-quality patient service is still a factor in maintaining a viable DME business.
Following the need for appropriate patient education, mechanical and technical issues have a large impact on a patient’s adherence to their prescribed therapy. The list is basic and often repeated, each component being essential. See the summary of the issues and their most appropriate solutions on page 18.
And the Survey Says
Recently, 20 of the New Orleans metropolitan area physicians with a special interest in treating OSA were surveyed regarding their DME ordering habits (personal communication). The results were as follows: The response rate was 75%. Of the respondents, 90% stated they did not script for a specific mask and allowed the DME company to fit the mask they found most appropriate; 95% did not script for a particular PAP brand. Those who did script for a particular brand did so primarily because of familiarity with the unit. Eighty-five percent used a rotating list of DME providers, and 100% stated they valued the input from the DME provider as to the patient care. In summary, physicians put much trust in the opinion of DME companies. They value the provider’s input for appropriate mask selection and fit, PAP unit choice, and choosing proper humidification. Physicians also rely on DME companies to provide up-to-date reference materials, to have RTs available to care for patient needs, and to aggressively follow up on patients to assess therapeutic progress.
The choice of testing facility and DME provider is essential to long-term patient PAP adherence. It is imperative that the referring entity, whether it is the physician or office staff personnel in charge of making referrals, refer their patients to quality providers who exhibit a record of good customer service and patient education. DME RTs must have equipment knowledge and availability, expert appliance selection technique, and a strong follow-up regimen. OSA patient adherence depends on it. Although this is not the ideal world, here in the real world, PAP therapy providers do not simply provide a commodity. They provide a life-sustaining service and must be mindful that successful adherence to PAP therapy can be a life-changing experience. Shakespeare referred to sleep as the “balm of hurt mind” (Macbeth, Act II, Scene II). We can add that it is also the balm of hurt bodies.
The author would like to thank the sleep professionals in the New Orleans area for their collaboration. She would also like to thank Stephanie Godelfer for her editorial advice. Anna Campo Chiappetta, BSRT, RRT, RCP, is vice president, clinical services, Access Respiratory Homecare, sleep and wellness center, Metairie, La.
- SLEEP 2008. Available at: www.sleepmeeting.org/. Accessed August 4, 2008.
- Ballard RD, Gay PC, Strollo PJ. Interventions to improve compliance in sleep apnea patients previously non-compliant with continuous positive airway pressure. J Clin Sleep Med. 2007;3:706-12.
- Gami AS, Howrd DE, Olson EK, Somers VK. Day-night pattern of sudden death in obstructive sleep apnea. New Engl J Med. 2005:352:1206-14.
- Hla KM, Young TB, Bidwell T, Palta M, Skatrud JB, Dempsey J. Sleep apnea and hypertension. A population-based study. Ann Intern Med. 1994;120:382-388.
- Sajkov D, Cowiee RJ, Thornton AT, Espinoza HA, ÂcEvoy RD. Pulmonary hypertension and hypoxemia in obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 1994;149:416-22.
- Hoffstein V, Mateika S. Cardiac arrhythmias, snoring and sleep Apnea. Chest. 1994;106:466-71.
- Koskenvuo M, Kaprio J, Telakivi T, Partinen M, Heikkilä S, Sarna S. Snoring as a risk factor for ischemic heart disease and stroke in men. Br Med J. 1987;294:16-9.
- Yaggi HK, Araujo AB, Mc Kinlay JB. Sleep duration as a risk factor for the development of type 2 diabetes. Diabetes Care. 2006;29: 657-61.
- Mallon L, Broman JE, Hetta J. High incidence of diabetes in men with sleep complaints or short sleep duration: a 12-year follow-up study of a middle-aged population. Diabetes Care. 2005; 28: 2762-7.
- Nilsson P, Rööst M, Engström G, Hedblad B, Berglund G. Incidence of diabetes in meddle-aged men is related to sleep disturbances. Diabetes Care. 2004; 27: 2464-9.
- Symptoms of Obstructive Sleep Apnea. Available at: www.webmd.com/sleep-disorders/guide/sleep-disorders-symptoms-types. Accessed August 4, 2008.
- Fuchs BD, McMaster J, Smull G, Getsy J, Chang B, Kozar RA.Underappreciation fo sleep disorders as a cause of motor vehicle crashes. Am J Emerg Med. 2001;19: 575-8.
The Essentials of PAP Adherence
Proper diagnosis: Qualified testing facility must use professionally trained registered polysomnographic technologist (RPSGT)/RT to perform diagnostic test. Qualified physician confirms diagnosis.
Proper PAP pressure titration: Qualified testing facility must use professionally trained RPSGT/RT to perform titration. Adherence to AASM guidelines to titrate individual with OSA is necessary. Qualified physician reviews titration and prescribes appropriate PAP settings.
Proper patient information: The patient is informed of diagnosis confirmation and is made aware of treatment options from physician. Appropriate patient education materials are given at this time. Patient is in agreement with treatment of choice and consents to the treatment.
Proper patient expectation: The patient is included in the referral process and is referred to a DME provider with qualified, experienced RTs on staff. DME RTs meet with the patient to reinforce diagnosis education and set the treatment expectations. This includes counseling the patient regarding the difficulty they may experience in the beginning of their new therapy, as it is quite a lifestyle change for most patients. There is a normal learning and tolerance curve. Individuals who begin treatment with proper and realistic expectations are less likely to quit PAP therapy within the first few weeks. Also, patients should be educated on the fact that the symptoms developed from years of sleep deprivation are not commonly resolved overnight.
Proper unit selection: DME RTs follow prescriptions and assess patient’s lifestyle in order to assist and advise on PAP unit choice. For example, patients who suffer from severe sinus problems may benefit from a PAP device with a heated wire mechanism that would deliver the best humidified air technically possible versus the traveling salesman-type patient who may need a small thin PAP unit to carry in his briefcase.
Proper mask fit: DME RTs must be experts in assessing patient’s facial features by proper measurement. This can be facilitated by the use of a template provided by most PAP mask manufacturers. The RT must also ascertain whether patient is an inherent mouth breather for proper full face mask or nasal mask and chin strap use. Additionally, patients who are active and side sleepers may benefit from appliances with headgear glider or swivel applications. Occasionally, physicians may script for a particular mask. If the suggested mask is not tolerated by the patient for long-term use, it is imperative that the DME RT report these findings to the physician and assist in mask selection that will facilitate long-term nightly use of PAP.
Proper humidification: RTs should evaluate the need for PAP humidification if not ordered by physician and consult with physician to suggest order modification if needed. Sinus irritation and congestion are often associated with PAP therapy. RTs should assist patient in device selection and proper humidifier settings to meet their needs. All PAP heated humidifiers are not equal. Some devices use sophisticated technology and tubing circuitry to deliver the most humidification possible while eliminating tubing condensation. Other devices afford the patient easy chamber cleaning and refill ability. Keeping in mind that some payors purchase equipment at the onset, these features are important to assess prior to device delivery.
- Sinus. Even with proper humidification, sinus congestion and irritation may be inevitable. A simple sinus lavage via Netti Pot or other irrigation system may be necessary. Occasionally, prescription nasal steroids may be indicated. An intranasal lubricant can also serve to maintain nasal moisture and integrity.
- Equipment. All PAP devices have an intake filter that must be occasionally washed, discarded, or both.
- Appliances. Masks, tubing, and humidifier chambers are all sources of bacteria growth. If not maintained properly, these devices can transfer bacteria to the patient. Dirty masks may cause skin irritation and breakdown. Contaminated tubing and humidifier chambers may cause sinus and pulmonary infections.
- Patients should be educated as to the proper cleaning procedure and be vigilant with maintaining all of the components of equipment and appliances.
Proper reference materials: Upon initial equipment setup, the patient must be provided with appropriate, easy to read equipment handbooks, cleaning procedures, and other important reference materials.
Proper follow-up: PAP patients should be contacted regularly and communicate openly with their health care providers. This helps the patient keep on track and allows the provider to identify possible