CPAP ADHERENCE Is it too much “pressure”?

1. CPAP ADHERENCEIs it too much “pressure”? Shanon Takaoka,M.D. February 7, 2007

2. BACKGROUND • Obstructive sleep apnea (OSA) affects an estimated 3 million men and 1.5 million women in the U.S.… and is INCREASING! • Untreated OSA is associated with: • Symptoms of sleep deprivation and excessive sleepiness • Diminished quality of life and productivity • Increased accident risk • Cardiovascular disease and stroke Lavie et al. Sleep 1983; 6:312, Young et al. N Engl J Med 1993; 328: 1230

3. CONSEQUENCES OF OSA • Sleep deprivation associated with: • Excessive daytime sleepiness • Cognitive dysfunction (decreased memory, concentration, attention, and ability to process new information) • Sexual dysfunction • Mood changes

4. CONSEQUENCES OF OSA • OSA is associated with diminished health-related quality of life and overall quality of life due to: • Daytime sleepiness • Poor cognitive, social, and physical performance • Relationship discord and higher divorce rates • Overall cost of sleep disorders (mainly OSA) estimated to be 7.5 BILLION DOLLARS • Direct health costs, indirect financial costs, and non-financial costs of burden of disease Shah et al. Treat Respir Med 2006;5:235. Moyer et al. Sleep Med 2001;2:477 Hillman et al. Sleep 2006;29:299

5. CONSEQUENCES OF OSA • Increased accident risk • OSA patients have a SEVEN-fold higher risk of automobile accidents vs. non-OSA patients • Untreated OSA associated with decreased vigilance which has been correlated to increased accident risk • Major disasters have been linked to excessive sleepiness/sleep deprivation in workers: Exxon Valdez, Space Shuttle Challenger, Chernobyl Findley et al. Am Rev Respir Dis 1988;138:337 Findley et al. Chest 1995;108:619

6. CONSEQUENCES OF OSA • Risk of cardiovascular disease, stroke, and possibly death • Sleep Heart Health Study (NHLBI of NIH) showed a linear relationship between severity of OSA and hypertension • Untreated OSA also linked to cardiac dysrhythmias, coronary artery disease, and congestive heart failure • Increased risk of stroke and death independent of other risk factors Nieto et al. JAMA 2000;283:1829. Yaggi et al. N Engl J Med 2005;353:2034 Peker et al. Am J Respir Crit Care Med 2002;166:159

7. EFFECT OF APNEA INDEX ON MORTALITY (UNTREATED OSA) Graph courtesy of UpToDate based on data from He, et al. Chest 1988; 94: 9

8. MECHANISMS OF OSA • OSA is caused by: • an abnormally small airway • increased relaxation of the throat muscles • or BOTH… • Leading to partial or complete obstruction of the airway that occurs cyclically throughout sleep • Oxygen desaturations • Cortical arousals • Sleep disruption/fragmentation

10. CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) • Least invasive AND most successful treatment modality for OSA • Delivery of low levels of continuous pressure via a nasal or oronasal interface to “splint” open the airway during sleep

11. CPAP: BENEFITS • Minimally invasive and reversible • Reduction and/or reversal of OSA-related signs and symptoms • Snoring, excessive daytime sleepiness, unrefreshing or fragmented sleep, cognitive impairment • Decrease risk of accidents • Increased productivity • Decrease long-term complications of OSA • Hypertension, heart disease, stroke, death

12. CPAP: ADVERSE EFFECTS http://www.utdol.com based on data from Strollo PJ et al. Clin Chest Med 1998;19: 55

13. OTHER COMMON PROBLEMS • Nose bleeds • Air-swallowing • Tube condensation • Claustrophobia/anxiety • “Temporary” treatment • Day-to-day inconvenience • Difficulty traveling/poor portability • Relationship discord… “CPAP is so un-sexy” Can you think of any others?

14. STARTING CPAP: Three Steps to CPAP SUCCESS! PATIENT EDUCATION EQUIPMENT CPAP TITRATION PATIENT EDUCATION

15. STEP 1: PATIENT EDUCATION • Increase understanding of: • Causes and mechanisms of OSA • CPAP therapy (and treatment alternatives) • Consequences of untreated OSA • Encourage positive but realistic expectations • The “new person” phenomenon is the exception- NOT the rule • Allow time for adjustment and optimization (6-8 weeks minimum)

16. STEP 2: CPAP TITRATION • CPAP titration • Full-night, attended, in-lab sleep study • Determine optimal pressure to maintain airway patency • Eliminate snoring and respiratory-related arousals • Normalize blood oxygen • Promote sleep continuity • Observe patient response in all sleep positions and stages as OSA tends to be worst in supine REM

17. STEP 3: EQUIPMENT • Choosing the right equipment • Type of positive pressure (CPAP vs. BiPAP) • Mask interface: fit and comfort • Nasal masks • Nasal pillows • Full-face (oronasal) mask • Accessories • Humidifiers • Pressure ramp • Altitude compensation

18. USING CPAP • No dosage studies available to suggest how much CPAP use is required for beneficial effects • Improvement in daytime sleepiness • Achieved even with less than 4 hrs use per night • Even one night without CPAP associated with immediate return of excessive sleepiness and decreased vigilance • CPAP only effective if the equipment is working optimally AND there is adherence to therapy Hers et al. Eur Respir J 1997; 10: 973 Kribbs et al. Am Rev Respir Dis 1993; 147:1162

19. WHAT IS “ADHERENCE”? • Degree to which an individual follows a prescribed regimen • Represents a spectrum • Dependent upon the balance between perceived costs and benefits • Unrelated to age, gender, educational level, socioeconomic status, personality COSTS BENEFITS

20. CPAP ADHERENCE • No clear field standard • Too few studies to define amount of adherence needed to treat common sequelae • Average patient uses CPAP about 5 hours per night • Most clinicians generally recommend CPAP use for more than 4-5 hours per night on ≥ 70% of all nights • The more, the better!!

21. CPAP ADHERENCE • Review performed of past 50 years of adherence to ALL medical treatments • Lowest in sleep disorders • CPAP compliance: 65% • Overall average for all medical disorders: 75% • Adherent patients tend to gradually increase duration of nightly CPAP use • NOTE: timing of use may be as important as duration of use… DiMatteo MR. Med Care 2004; 2: 200.

22. CPAP ADHERENCE • Hypnogram shows increasing REM time in the SECOND half of the night • OSA typically worsens during REM  CPAP use most important during second half of night

23. CPAP ADHERENCE • Early use patterns predict long-term adherence • Patients appear to establish their patterns of use by the FIRST MONTH (as early as 4 days) • Adherence at 1 month appears to predict adherence at 3 months • Since adherence is established by 3 months, alternative forms of therapy should be considered in non-adherent patients Weaver et al. Sleep 1997; 20: 278 Kribbs et al. Am Rev Respir Dis 1993; 147: 887

24. CPAP ADHERENCE • Why do we care? • Consequences of untreated OSA • Short- and long-term health effects • Decreased productivity and quality of life • Risk of accidents • Allocation of medical resources • Availability of sleep studies limited • Expensive diagnosis and treatment (i.e. cost of sleep study, CPAP titration, follow-up with therapists, equipment)

25. FACTORS AFFECTING ADHERENCE PATIENT-RELATED CPAP ADHERENCE EQUIPMENT-RELATED CLINICIAN-RELATED

26. CPAP ADHERENCE: PATIENT-RELATED FACTORS • Lesser severity of symptoms • Little or no perceived benefit from therapy • Failure to understand importance of or directions for CPAP use • Use of prescription/non-prescription drugs or alcohol • Lack of social support • Other medical illnesses or fatigue • Physical limitations (i.e. vision, hearing, hand coordination)

27. CPAP ADHERENCE: THERAPY-RELATED FACTORS • Complexity of therapy/device use • Increased rate of adverse reactions that go unaddressed • Lack of efficacy • Expense of therapy • Chronicity of illness • Compliance decreases over time

28. CPAP ADHERENCE: CLINICIAN-RELATED FACTORS • Poor relationship with patient • Lack of clinician follow-up • Expression of doubt concerning therapeutic potential OR creating falsely elevated expectations • Unwillingness to educate patients • Lack of knowledge of other medications patients may be taking (i.e. alcohol, sedatives)

29. MONITORING CPAP ADHERENCE • Follow-up (at 1 month) • Clinical assessment of subjective use, response to CPAP, adverse effects and other limitations to therapy • Objective assessment of downloaded data • “Mask on” time • Leak values • Trouble-shooting • Define specific issues with clear goals • Specify follow-up (usually 3-6 months)

30. CPAP “FAILURE” • “Use of CPAP for less than 4 hours per night on 70% of the nights and/or lack of symptomatic improvement” • Cause should be identified and addressed, if possible (i.e. ear/nose/throat structural abnormality) • Consider alternative diagnoses • Narcolepsy, periodic leg movements, idiopathic hypersomnolence Kribbs et al. Am Rev Respir Dis 1993; 147:887

31. IMPROVING CPAP ADHERENCE

32. TECHNOLOGICAL INTERVENTIONS • Auto-titrating CPAP • Pressure delivery is auto-adjusted during changing airway conditions overnight • Bi-level positive pressure (BiPAP) • Set inhalation pressure with a lower set exhalation pressure • Flexible pressure delivery (C-Flex, EPR) • Slight reduction in pressure during EARLY exhalation

33. TECHNOLOGICAL INTERVENTIONS • Heated humidification • Decreases nasal/oral dryness for comfort • Improves nasal resistance • Pressure ramp feature • CPAP starts at low pressure (2-4 cmH2O) and gradually ramps up to prescribed pressure over set time period (5-45 min.) None of these have been shown to definitively increase adherence

34. BEHAVIORAL INTERVENTIONS • Patient education • Systematic desensitization and sensory awareness (for claustrophobia) • Wearing device for progressively longer periods • Cognitive behavioral therapy/Motivational Enhancement Therapy Findings suggest that maneuvers that increase knowledge, patient-therapist interaction, and remove potential barriers to PAP increase use by 0-2.5 hours

35. REDUCE SIDE-EFFECTSMask-Related Issues

36. REDUCE SIDE-EFFECTSNasal Issues

37. REDUCE SIDE-EFFECTSFlow/Pressure Issues

38. REDUCE SIDE-EFFECTSOther Common Issues

39. IMPROVING CPAP ADHERENCEA General Approach • Identify and treat source(s) of adverse effects: • Mask • Nasal • Flow-related • Other • First-line technological interventions • Assess mask fit and consider alternative interfaces • Heated humidifiers • Ramp feature • Auto-CPAP, BiPAP • Patient education • Consider alternative behavioral interventions if necessary

40. STEPS TOWARD BECOMING A CPAP SUPERSTAR • Knowledge is key • Realistic expectations • Correct CPAP “prescription” • Appropriate equipment: machines, masks, humidifiers • Support and follow-up • Know when to say “when”

41. OTHER RESOURCES • Sleep Improvement Program with Positive Airway Pressure (PAP) Therapy- Dr. Tracy Kuo • Six weekly group sessions offered every 6-10 weeks • Multidisciplinary program to improve sleep quality and optimize use of PAP that integrates: • Sleep medicine • Mind-body • Health psychology • Cognitive-behavioral techniques • Phone: (650) 723-6601 • http://www.stanfordhospital.com/