For people without breathing problems such as sleep apnea, it’s difficult to understand the compliance issues that come between wearing a continuous positive airway pressure (CPAP) device to help experience restorative sleep, and a restless night that zaps you of your energy and overall health.
But when providers think of CPAP devices as complicated breathing machines, they can more easily begin to realize the compliance challenges that they, along with other medical professionals and caregivers face when dealing with patients using these devices. Tracy R. Nasca, founder and senior vice president of Talk About Sleep — and a CPAP user — puts it into perspective:
“CPAP is challenging for most patients,” she says. “Let’s face it, who wants to sleep with a mask strapped to the face with hurricane winds blowing up their nose?”
With that said, the National Institutes of Health call CPAP treatment “the most effective treatment for obstructive sleep apnea.” And the benefits of CPAP therapy are many. The device can help:
- Keep the airway open during sleep.
- Correct snoring so others in a household can sleep.
- Improve sleep quality.
- Relieve daytime sleepiness.
- Decrease or prevent high blood pressure.
For patients, the detrimental effects of untreated sleep apnea are far reaching, including varying degrees of memory loss, high blood pressure and depression. For providers, CPAP treatment can be a significant part of their business. Therefore, it’s imperative for providers to understand CPAP treatment, why patients become noncompliant at alarming rates and what you can do to help patients achieve the best possible quality of life.
CPAP noncompliance rates
To get a perspective on the problem, each of the experts interviewed for this article were asked about noncompliance rates regarding CPAP-using patients. Although there wasn’t a main industry study cited, each shared company data that pointed to concerning news.
“With any treatment regimen, medical professionals recognize that patient compliance is directly infl uenced by a perceived, typically immediate, benefit,” says Maura Toole Weis, director, sleep marketing for Philips Home Healthcare Solutions. “When patients are breathing and sleeping comfortably with a CPAP device, essentially a breathing machine that keeps the airway open during sleep, they are not conscious of the positive experience. This makes CPAP a challenging therapy when it comes to patient compliance.”
Weis says that Philips data indicate that 20 percent will not use it, 20 percent will readily adopt therapy and 60 percent will have trouble and require care and attention in varying degrees to achieve compliance.
Mike Marcinek, vice president of sales and marketing of sleep solutions for DeVilbiss Healthcare, says research puts CPAP noncompliance levels as high as 60 percent. However, regarding patients that DeVilbiss contacts for re-supply under its Keystone Services Replenish program, 14 percent report they are noncompliant. These are patients beyond 90-days from the start of therapy. This stresses the importance of obtaining objective usage data and not relaying solely on patient-reported data. Based on the data compiled from Keystone Services, he estimates that about 20 percent of noncompliant patients can return to therapy with minor intervention and troubleshooting (replace mask, coaching, etc.).
“We are not in the business of caring directly for patients, but we know through conducting our own research that remaining compliant with a CPAP therapy program is a compelling problem,” says Susan Sarko, marketing director for Contour Products. “Some statistics say that 60 percent of CPAP patients abandon CPAP therapy within one year. One of the biggest problems is the mask. Over 90 percent of patients struggle with mask discomfort.”
“The good news is that many patients do, or can learn to perceive the positive effects of restorative sleep,” Weis says. “This is what motivates them to comply — not the feeling of breathing better, like many daytime respiratory devices, but rather the feeling of having more energy and a better quality of life during the day. It is this positive experience that results from use of therapy that patients and their healthcare providers need to focus on to help make CPAP therapy a positive part of their living and sleeping routine.”
Why Patients Don’t Comply
Providers must understand that the road to patient CPAP compliance can be long and arduous. And the journey starts by knowing what it is that causes patients to reject CPAP devices in the first place. Unfortunately, those reasons are numerous, compounded by the simple fact that all patients are different regarding shape, tolerance level, peer pressure and commitment to successful therapy.
“It’s one thing for a patient to be continually awakened during sleep by apnea events; it’s quite another to be awakened by the pain and discomfort of an ill-fitted mask or painful nasal dryness from the lack of or inadequate humidification,” says Talk About Sleep’s Nasca. “The proper equipment should promote and deliver restorative sleep, not cause further disruption. It’s amazing to me how many patients think pain and discomfort is the ‘norm’ and the price they must learn to pay by using CPAP. I believe this is one of the biggest reasons why so many give up.” (For more about patient noncompliance, see the sidebar.)
According to Weis, various studies point to comfort as the catch-all complaint for issues that may be associated with mask design, mask fit, pressure delivery and the ability to fall asleep in a customary fashion.
Sarko says that Contour’s research shows that the top five reasons for noncompliance are mask discomfort issues; mask leaks that lead to dry eyes, nasal passages and skin; noise due to mask leaks such as air hissing out the side of the mask; heat build-up from using humidified air; and self-consciousness.
David Groll, CEO, Circadiance, says that if you measure compliance as the fraction of patients who are prescribed a CPAP system who are still using it one year later, his data suggests the number is less than 50 percent. And the single biggest cause of noncompliance, he says, is intolerance of hard plastic masks.
“The fundamental problem with the [plastic] masks is that you’re putting pressure on the throat of the patient to splint it open while they sleep,” Groll says. “In order to get the mask to seal, you have to exert more pressure against the face of the patient than there is inside of the mask. Because you’re exerting mechanical force against the patient’s face, the force of the mask pushing on their face exceeds the perfusion pressure in the capillary vent in the tissue. Just by the nature of the technology, it’s going to cause pressure sores and irritate their skin.”
“An uncomfortable mask probably tops the list for noncompliance,” says Marcinek, “However, there’s also the psychological factor of CPAP being viewed as unattractive. It’s a lifestyle change that can be embarrassing. Therefore, it’s critical that providers educate the user on OSA and CPAP, stressing the health risks and concerns associated with untreated OSA. There are also many users who abandon their therapy due to incorrect pressures, dry mouth, dry nose, and an overall discomfort.”
Based on what Contour has learned, Sarko names lack of comfort as the primary reason for noncompliance.
“Have you ever tried wearing a CPAP mask?” she says. “When they shift and leak, people often overtighten the mask straps to try to compensate for the shifting. That makes matters worse and can result in painful pressure from the mask sitting tightly against a person’s face. Bruising and even pressure sores around the bridge of the nose and where the mask seal meets the skin are not uncommon.”
Keys to Comfort and Compliance
Compliance starts with patient and caretaker education about the problem and the treatment plan. Especially where noncompliance is high, education is critical to map out expectations. Without it, unexpected roadblocks are magnified and chip away at the goal of reaching full compliance.
“Early intervention and education can make the difference in catching the minor issues and providing solutions to your patients before they get discouraged,” Marcinek says.
Marcinek understands that giving patients high-quality time with a live person can put a strain on providers’ staff. But that’s where his Keystone Services helps. This approach helps the provider keep a high level of contact during the early part of therapy and identifies patients who need live intervention.
“We believe that controlling the mask variables are key to remaining compliant with CPAP therapy,” says Sarko, whose company makes a line of CPAP accessory items, such as a pillow. “Equally important is the follow-up care program. Staying in touch with your patient, especially in those first 90 days, is crucial.
Working with them to find the best mask fit, CPAP machine and pressure level is key. Once all of that is in place, then it becomes important for RTs and other medical providers to address comfort issues and to have products available that will help the patient more readily accept and embrace their CPAP therapy program.”
Nasca points out that “when it comes to interfaces, one size does not fit all. Since there is no industry-sizing standard, patients must personally try on a variety of masks to find the one that best suits their facial features. Mask frames, which vary greatly in length and width, is first consideration and key to finding best fit. The soft inner cushion is vital to sealing the mask to the patients face and provides the comfort consideration. Nasal pillow masks, in my opinion, are underutilized and resolve many common challenges experienced by female patients and those who are claustrophobic.”
Groll’s company created a mask made of cloth to try to solve the discomfit issues he says occur when using plastic masks. He says the benefits of soft cloth masks include reduced air leakage, reduced headgear pressure, more sleep positions, no skin irritation and less noise.
For specific problems that cause noncompliance, Weis offers the following advice: Dryness is best alleviated with humidification. Since the introduction of humidification and with reimbursement coverage, most CPAP prescriptions include humidification. Studies show a direct link between the use of humidification and increased compliance (AASM Guidelines, SLEEP 2006:29(3):375-380).
Recent advancements also address the issue of rainout. Rainout happens when the water vapor moves through the tube away from the heated device and into a cooler environment of the room. With the Philips Respironics System One Humidity Control, rainout is eliminated, under most conditions. The device monitors room temperature and humidity and adjusts the heater plate to account for the environment, resulting in a patient-selected humidification level without rainout.
Comfort may refl ect mask or pressure issues. A patient and care provider must work through mask issues regarding fitting and use. Patients may try different types of masks. Many patients have success when going home with two masks to use interchangeably. Pressure relief technology has helped to improve comfort issues associated with pressure concerns. Flex pressure relief gently reduces pressure during exhalation, when patients are most uncomfortable trying to breath out against the air pressure, and then gently returns to therapeutic pressure to ensure the airway remains open throughout the breathing cycle.
Finally, don’t overlook the caretaker’s role in supporting CPAP compliance.
“Caregivers are crucial to patient compliance,” Sarko says. “It is imperative that the caregiver be in tune with what type of lifestyle the patient leads, what his or her individual hesitations and issues are, and work with that patient to overcome those obstacles. Furthermore, caregivers should have an arsenal of tools available to help the patient remain compliant. Some of these tools include cash items like pillows, hose covers, moisturizers, convenience cleaning wipes and sprays, facial strap cushions, and chin straps. All of these things can make the difference between compliance and falling off the program altogether.”