Adherence to CPAP in OSAS

1. Adherence to CPAP in OSAS BYAHMAD YOUNES PROFESSOR OF THORACIC MEDICINE Mansoura faculty of medicine

2. Establishing a Successful CPAP Adherence Program

3. 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

4. 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 morethansimplysellingaCPAPdeviceandmask: it involves education, support and ongoingcare including the monitoring of treatment adherence. • This is often a shared responsibility between the patient, the sleepphysician, thesleepclinic and organizationwhichprovidesCPAPequipment

5. CPAP adherence • Adherence like compliance refers to the degree that an individual follows a recommended illness-related 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 . • 12to25% of the remaining patients may be expected to have discontinued its use at 3 years

6. CPAP adherence Outcomes • CPAP reduces objective daytimesleepiness , improves some measures of cognitiveperformance ,reduces depression, reduces cardiovascularmortalityandmorbidity , reduces the risk of motorvehiclecrashes and improves perceptions of qualityoflife, • Reduces healthcare utilization • Adherence to CPAP treatment is the largest factor impacting on the effectiveness of treatment

7. The basic requirements are: • Staff who are appropriately trained • A choice of CPAPequipment sufficient to meet individual patient needs • A CPAP initiation service which provides patients with adequate information and education to instill confidence in their treatment. • ACPAPfollow-upservice 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 timelyandefficientcommunicationwithsleepclinicsandreferringdoctors about their patients

8. 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.

9. 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 servo-ventilation. • 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.

10. 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.

11. 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 leaksdepend 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.

12. 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.

13. 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.

14. 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 ACARDREADER INSTEAD • DATACARDS 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.

15. This USB SmartStickMemoryCard 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

16. How to Read a CPAP Adherence Report • Check nightly usage hours • Checkleakdata. 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. • Checkapneaevents. 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 .

17. 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.

18. Barriers to CPAP Adherence

19. Therapy Related Patient Related CPAP Adherence Equipment Related Clinician Related Barriers to CPAP Adherence

20. Equipment Related Barriers • Complexity of therapy/device • Excessive mask leak • Portability/Battery backup • Device noise • Hose length • Improper mask fit

23. Therapy Related Barriers • Adverse reactions that go unaddressed • Nasal dryness or dry eyes • Nasal congestion • Skin irritation • Bloody nose • Expense of therapy • Governmental policies ( funding, licenses of drivers ) • Adherence decreases over time

24. Nasal prongs

25. Nasal pillow

26. Nasal mask

27. Oral CPAP Mask

28. Full face mask

29. Total face mask

30. 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

31. 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 andmay lead to treatment abandonment. • CPAP-related claustrophobia was perceived as one of the largest deterrents to CPAP therapy.

32. 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

34. Therapy Related Patient Related CPAP Adherence Clinician Related Equipment Related Intervention

35. 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

36. Contour CPAP Compliance Pillow

37. The Contour CPAP Pillow works with all major brands of CPAP masks!

38. 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

39. 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

40. 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)

41. 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.”

42. Compliance Program • “Patient education, close follow-upand intervention appear to improve long-term tolerance.” • Education1-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.

43. 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.

44. 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.

45. Psychomotor vigilance testing of professional drivers in the occupational health clinic Psychomotor vigilance testing of professional drivers in the occupational health clinic

48. Initiation of CPAP treatment should also include general advice on lifestyle and medical issues • 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.

49. 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.

50. 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