Adherence to CPAP in OSAS

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

2. 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.

3. 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

4. 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

6. 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

7. 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.

8. 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 mortalityand 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

9. 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 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.

10. 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.

11. 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

12. 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.

13. 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

14. 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.

15. 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.

16. 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.

17. 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.

18. 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

19. 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 .

20. 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.

21. 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

22. 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.

23. 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

24. 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

25. 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.

26. 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

27. 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

28. 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

29. 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.

30. 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

31. 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.

32. 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).

33. 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