Instructions For CPAP Use

1. Instructions For CPAP Use BYAHMAD YOUNESPROFESSOR OF THORACIC MEDICINE Mansoura Faculty Of Medicine

2. Why CPAP? • 2% to 4% of adult population has OSAS • CPAP is the standard treatment of moderate and severe OSAS . • Many patients who use CPAP are non-adherent. • CPAP use may lead to some physical & psychological problems

3. Identify Problems with CPAP Treatment: A- Psychological: • Feelings of anxiety & Claustrophobia B- Social: Spouse distress C- Physical: • Nasal congestion ,rhinorrhea and nasal sores . • Nasal and mouth dryness. • Skin irritation • Pressure leaks • Stomach bloating

5. Other CPAP Side Effects • Rainout . • Getting tangled in hose . • Bad odour.

6. What is CPAP Claustrophobia? • If you are afraid to sleep with your CPAP mask on, or you have feelings of claustrophobia, panic attacks or anxiety with your CPAP, don't get discouraged because 11 to 28% of patients have this problem when they start the CPAP treatment. • Your body's struggle to breathe every night so producing large amounts of stress hormones - adrenaline - that will circulate through your body. • It takes some nights of good sleep on CPAP - without apnea episodes- to clear all the stress hormones out of your body. • After you get used to CPAP, you'll be amazed at how much calmer you are going to feel and the fear will become a thing of the past.

7. Exposure therapy for claustrophobicReactions to CPAP • Claustrophobia is composed of two “core” fears: fear of restriction, and fear of suffocation. • Patient education on sleep apnea and CPAP therapy • Build therapeutic trust • Presentation of treatment rationale • Establish exposure hierarchy • Goal setting/homework

8. Causes and Risk Factors for CPAP Claustrophobia • What kind of fears you have when you try to sleep with the CPAP mask? • Is it the idea of having something on your face? • Are you worried about strangulation from the hose by your neck? • Is it because you can't see far? • Is the weight of the CPAP mask bother you? • Do you have fear of CPAP mask from a previous experience sending you in a panic?

10. Tips to eliminate CPAP claustrophobia • 1. Use CPAP Mask with protection against asphyxiation • The mask should be vented in order to allow the carbon dioxide to escape. • Anti-asphyxia exhaust vents are design to save your life if the power goes off, and your CPAP machine doesn't deliver the vital air.

14. Tips to eliminate CPAP claustrophobia 2. CPAP is offering you the air that you need When you sleep with your CPAP machine and mask, you have to understand that the machine is actually pushing air into you. So, you may feel claustrophobic at first, but the CPAP machine is really giving you air to breathe! 3. It's like brushing your teeth every day. The sooner you'll use the CPAP machine - rather than been afraid of it - the better it works. Let the time passing by without starting the CPAP therapy... and it will be more difficult to overcome your fear. 4. Wear the CPAP mask while awake ,Attach the mask to the CPAP device, and switch the unit "ON". Practice breathing through the mask for one hour while watching TV, reading or performing some other sedentary activity.

15. Tips to eliminate CPAP claustrophobia • Are you looking for CPAP Masks that allows you to read or watch TV in bed? If that has been your habit to help you fall asleep all these years then you should continue to do so. The initial goal here is first be able to use the CPAP. • Do whatever it takes to get accustomed to using and sleeping with the CPAP machine and mask through the night. • Obviously you want a CPAP Mask that does not obstruct your vision eg. Nasal Pillows . • However once you become accustomed to using your CPAP, do not watch TV in bed. The reason is you do not want to be stimulated and stay up late night because there is a good TV show. • The bedroom should be reserved for Sleep and Sexual Intimacy only. Watch TV in another room in your house

16. Tips to eliminate CPAP claustrophobia 5. Positive attitude Maybe you don't realize...but the CPAP machine and mask will be with you for the rest of your life, and it will improve your quality of life tremendously. Once you build this positive mantra into your life, everything will be easier. 6. Have patience with your CPAP therapy Please don't get discouraged if it doesn't work, because it takes some time to getting used to all CPAP new thing. Just expect that it will take a little time to become comfortable with CPAP and then, one day, you will realize that you slept with the mask on, like many others.

17. Tips to eliminate CPAP claustrophobia 7. Mask type is important to help your CPAP claustrophobia • The full face masks are the main causes for CPAP claustrophobia. If this is the cause for you, you may prefer nasal masks or nasal pillows because you know you could always breathe by opening your mouth. • Nasal masks or nasal pillows only works for treating sleep apnea if you can prevent mouth breathing when you sleep. It can be a problem if you breathe through your mouth, because of the dry mouth issues that can appear after you wake up.

18. Patient handout describing exposure steps for home practice. • 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. • 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. • 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. • 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.

19. How to get used having the CPAP mask on your face? • While you are awake, and have the CPAP mask on, you may still have the panic attacks. But you can calm down if you do breathing relaxation technique : 1-take a deep breathe and hold it, and silent count to 4.  2-then breathe out very slowly, while counting to 4.  3-then pause breathing while counting to 4.  4-then breathe in slowly while counting to 4. then repeat the process by holding the air and counting to 4. The concept of square breathing is simple: each inhale and exhale of breath is counted to four, with a four count hold for each inhale and the exhale.  The hold is important to calm the anxiety and to prevent hyperventilation.  After doing this about 12 times, the claustrophobic feeling is usually gone.

21. Do you really benefit from CPAP ramp feature? • Do you have the CPAP ramp feature turned on? If you have CPAP claustrophobia, the ramp function can contribute to the feeling of panic. • The ramp is meant to help you get used to the pressure by starting low, climbing slowly to the set pressure, hopefully when you're already asleep. But, it may work against you because at very low pressures you may feel less air and feel more panicky. • You may need to experiment with turning the ramp feature down, turning the starting pressure of the ramp up, (most of us don't use the ramp after the first week or so because it seems like we're NOT getting enough air at very low pressures).

22. Social Variables • Individuals who live alone are less adherent to CPAP • Individuals whose partners initiate treatment referrals are less adherent than those who initiate themselves. • Approximately 50% of patients report they would discontinue CPAP if it negatively affected the sleep of their bed partner . Thus, inclusion of the bed partner in any treatment program might increase adherence.

24. How do I avoid red marks? • Most red marks on the face are caused by over tightening the CPAP mask. • CPAP masks should only be tightened down enough to create a seal. • To avoid over tightening your mask, you should work clockwise around the mask, making small adjustments to the headgear, until the mask is securely in place but not overly tight. • You should avoid pulling too much on one side of the mask than on the other.

25. How do I avoid red marks? • By cleaning your mask cushion, nasal pillows, and nasal prongs on a daily basis, you ensure a better seal each time you put on your mask. • If you know you have a mask that fits, and are cleaning it daily, and still have red marks, consider using Mask Straps Pads which are soft covering for the headgear straps.

26. Why is my face breaking out around my nose? • Sores, redness and bumps around your nose can be caused by one of three main reasons: facial oils are building up under the mask material; the mask is overly tight; or the mask material is causing an allergic reaction. • You can help minimize this by washing your face before putting on the mask at night and by cleaning the facial oils off the mask every morning. • If you are still experiencing a breakout, you might consider Nasal Pillow Masks. The nasal pillow design has less material in direct contact with the skin.

28. Why is my face breaking out around my nose? • Most masks are made of silicone, which is an inert substance. But silicone is manufactured in chemicals to which some people are allergic. • The chemicals normally degrade and disperse over time, but may cause a reaction when first used. • The solution is to remove surface chemicals before using the mask. Washing the mask will reduce or eliminate the problem. • This process can be accelerated by long soaks in warm soapy water. This method can be used with all types of masks, and should also be applied to mask replacement parts. While soaking the mask will help remove the surface chemicals, it my reduce the life of the silicone.

29. Why is my nose so dried out? • An unheated, Passover Humidifier may not offer enough additional moisture. • Using a Heated Humidifier to add moisture to the CPAP air may reduce or eliminate the irritation. If you are already using a heated humidifier, try turning it up to a higher setting. • If that produces condensation in the hose, you should try an Insulating Cover for the hose. • You can also try using a Nose Lubricant to reduce the dryness.

30. Why is my nose so dried out? • Here are some items we recommend that may help dry nasal passages: Heated HumidifiersMoisture Therapy CreamNasoGELHeated Tubing

31. Why am I getting sores inside my nose? • Sores inside the nose may be caused by nasal pillow or nasal prong devices that are too big or the wrong shape for your nose. • If you use nasal pillows, try the smallest size available that seals around your nares. • Your nose might also be sensitive to the presence of the nasal pillows, and it might take time for your nose to "toughen up" andadjust to the nasal pillows. • Try switching back and forth between the nasal pillow mask and a nasal mask. • You might also try Nose Lubricants to reduce the irritation. • Sores inside the nose may also be caused by the CPAP air drying out the mucous membrane. Adding moisture with a Heated Humidifier may help alleviate the problem.

32. Why do I have a headache when I wake up? • CPAP does not normally cause headaches unless there is a sinus related problem or if the pressure is too high. • When a CPAP is used and part of the sinus cavities are blocked, a situation is created where there is a pressure differential between the sinus cavities affected. These pressure differences can sometimes be felt as sinus headaches or just plain headaches, even though they are caused by sinus blockages. • These can be treated using over the counter medications to open the sinus. • CPAP heated humidifierscan also open and maintain sinus systems. If this does not correct the problem, visit your ENT.

34. Why is my mouth dry in the morning? • Dry mouth is a sign that you are opening your mouth while you sleep. • If you use a nasal mask, breathing through your mouth bypasses any humidification you may be using so increasing the heat will not be effective. • Breathing through your mouth while using a nasal mask reduces the benefit of CPAP therapy. • First, be sure the mask is not leaking. • If the mask is six to nine months old and leaking, try replacing it. • If it is new and leaking, the fit could be incorrect. We can help you find a mask with a great fit. Kuna, et al. Internal Medicine website

35. Why is my mouth dry in the morning? • If your mask is new and NOT leaking, try a Chin strap to keep your jaw up and mouth from dropping open during sleep. • If a chin strap doesn't solve the problem, try masks recommended for Mouth Breathers as full face mask. • If you use a full face mask and have a dry mouth, try adding a Heated Humidifier to add moisture.

36. Why is my mouth dry in the morning? • Here are some items we recommend that may help with dry mouth: Heated Humidifiers Chin straps Full Face Masks Heated Tubing

37. How do I stop mask leaks? • Air leaks can be caused by masks that are too big, too old, or simply the wrong style. • Air leaking into the eyes is usually an indication that the mask is too big (long or wide) as are leaks at the base of the nose. Leaks may also occur under the nose due to facial hair. • As the silicone in the mask cushion ages, it deteriorates and becomes too soft to hold a seal. For many masks, the cushion may be removed and replaced to extend the life of the mask

40. Why do I wake up with dry eyes? • Air leaking from the mask at the bridge of the nose and over the eyes during sleep will cause the eyes to dry out. • The most common reason for air leaking at the nose bridge is that the mask is too big or too long for the nose. • Nasal pillow or nose cushion devices which do not rest on the nose are also an option. • It is not advisable to tighten the headgear to eliminate the air leak. Pressure from a mask that is too tight will cause bruises and even open sores if applied long enough.

42. Why is air leaking from my mouth? • It is common for air to leak from the user's open mouth during CPAP therapy. • Many factors can cause the user's mouth to fall open. For example, a common catalyst for mouth breathers' is nasal irritation from CPAP therapy. • The correlation between a lack of humidification and mouth leaks is a topic that has been heavily researched.

43. The hypothesis is that a significant amount of mouth leakage is caused by the following cycle: • CPAP therapy is used with ineffective or no humidification, • The nasal membranes are unable to adequately condition the increased airflow and after a few minutes the airway and nasal passages become dry. • To remedy the dryness and obtain moisture, the body uses the mouth to breathe. • CPAP air follows the path of least resistance and leaks out of the open mouth. The air leaking through the mouth causes more dryness. • Patient wakes up feeling tired with significant dryness in mouth and dry, swollen nasal passages.

45. Why is air leaking from my mouth? • The answer to this cycle is humidification. If the mouth continues to open during sleep, a Chinstrap may be needed to hold the jaw up so that the mouth can close. If mouth breathing continues, a full face mask, hybrid mask, or oral mask is suggested. • People who have a deviated septum, small nostrils, or who suffer from seasonal allergies or chronic sinus issues, may breathe through the mouth rather than the nose. • Add a Chinstrap if using nasal pillows, nasal prongs or a nasal mask.

46. Why is air leaking from my mouth? • A full face mask or hybrid mask can be used without a chinstrap because the seal covers both the nose and mouth. • A full face mask will allow you to breathe through your mouth or through your nose. • If you suffer from chronic sinus issues, a full face mask or an oral face mask are good options. • Oral masks work best for mouth breathers with blocked nasal passages. • You must use a heated humidifier with the oral mask.

47. Why is air leaking from my mouth? • Here are some suggested items that may help with mouth breathing: Hybrid MasksOral MasksFull Face MasksChin straps

48. Aerophagia • The word "phage" in Greek means "to eat." Aerophagia is literally to eat air. In the modern context, it means swallowing too much air, a common cause of gas in the stomach and belching.This is sometimes a result of CPAP Therapy. • The doctor may suggest decreasing the CPAP pressure in order to decrease the bloating. • your doctor may consider transitioning you to an auto-titrating machine. APAPs reduce the average pressure that the user receives.

49. There are many possible causes: 1. Your CPAP pressure may be higher than you require. The extra air has nowhere else to go – thus, it is directed in to the esophagus and on to the belly. 2. Your pressure may be too low and inadequate to resolve your apnea event. In your effort to get more air into your lungs, you gulp air in quickly and it is forced into the esophagus instead. 3. You may have nasal congestion from a cold, flu or allergies. When your nose is stuffy, you may not be able to receive the CPAP air pressure you need, so you gulp air by mouth and down into the esophagus it goes.

50. There are many possible causes: 4. You may be a mouth breather, who is wearing a traditional nasal mask. As your mouth falls open during sleep, the air that is delivered by CPAP and intended to enter the lungs may instead, escape via your mouth. Your apnea events are not being resolved and in your unconscious panic to breathe, you may suddenly have a choking sensation and gulp air in quickly, forcing it into the esophagus. 5. You may be having difficulty adjusting to exhale over the constant pressure of the air delivered by CPAP. Inhalation of high pressures may be easy, but exhaling may cause anxiety, panic and a feeling of suffocation or choking. When this occurs, the patient may hyperventilate. This can result in a quick sucking in or gulping of air, and that air may be forced into the esophagus rather than the lungs.