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CPAP for Obstructive Sleep Apnea
Aka: CPAP for Obstructive Sleep Apnea, Continuous Positive Airways Pressure for Obstructive Sleep Apnea
- See Also
- Continuous Positive Airways Pressure (CPAP)
- Non-Invasive Positive Pressure Ventilation
- Sleep Study (Polysomnogram)
- Obstructive Sleep Apnea
- Bilevel Positive Airway Pressure (BIPAP)
- Mechanism
- See Continuous Positive Airways Pressure (CPAP)
- Indications
- See Continuous Positive Airways Pressure (CPAP)
- Obstructive Sleep Apnea
- Loud continuous snoring
- Contraindications
- Central Sleep Apnea
- Precautions
- CPAP will worsen Central Sleep Apnea
- Do not use CPAP empirically without Sleep Study
- Decreases respiratory drive
- Approach: Sleep Apnea Management
- Equipment
- Nasal pillows or full Face Mask
- Small quiet air compressor
- Technique:
- Requires specially-designed, tightly fitting masks
- Mask should have pressure-limiting valves
- Dosing
- Usual dose: 6 to 12 cm H2O (Range: 3 to 20 cm H2O)
- Higher pressure (within range above) indications
- Heavier weight
- Short-thick necks
- More severe Sleep Apnea
- Optimize compliance
- CPAP is discontinued in 50% of Sleep Apnea patients by 1 year
- Encourage use at least 4 hours per night
- Reduce fluid intake in the evening to decrease bathroom breaks (CPAP often not reapplied after middle of night awakenings)
- Recommend CPAP units with embedded tracking to monitor usage
- Treat side effects as below to ensure continued use
- Adverse Effects: Methods to improve compliance in Sleep Apnea
- Optimize mask fit for size and shape of face
- Change to different mask if mask leaks or causes facial irritation
- Utilize mask option patient finds most comfortable
- Full Face Mask
- Appears similar to Simple Oxygen Mask
- Nasal pillows
- Soft adapters fit within both nares
- Consider alternating methods
- Patient should follow-up to make CPAP adjustments
- Treat underlying nasal symptoms (e.g. nasal steroid, Nasal Saline)
- Humidify or cool inspired air
- Consider otolaryngology consult if CPAP not tolerated
- Efficacy: Sleep Apnea
- First line, very effective Therapy
- Reduces coronary ischemia in those predisposed
- Peled (1999) J Am Coll Cardiol 34:1744-9 [PubMed]
- Reduces Blood Pressure in hypertensives
- Becker (2003) Circulation 107:68-73 [PubMed]
- Pepperell (2002) Lancet 359:204-10 [PubMed]
- Management: Follow-up of CPAP monitoring in Sleep Apnea
- Snoring despite CPAP?
- Is CPAP pressure too low?
- Is there a leak at the interface?
- Is the patient sleeping with mouth open?
- Does the patient use excessive Alcohol?
- Weight change since CPAP was started?
- Reassess CPAP if weight gain exceeds 10%
- Consider overnight oximetry
- Calculate desaturation index = (4% desats)/hours
- Desaturation index <5 is normal
- When was CPAP last checked?
- Mask should be changed every 6 months
- Check blower every 12 months
- Is the patient still symptomatic?
- Is patient compliant with CPAP?
- Is the patient allowing enough time for sleep?
- Are there problems with Sleep Hygiene?
- Are other conditions keeping patient awake?
- See Insomnia
- Consider restless legs
- Other conditions making them sleepy (e.g. Narcolepsy)
- Problems with CPAP?
- Intolerant of air pressure
- Activate CPAP ramp up or increase ramp time (machine slowly builds to maximal pressure as the night progresses)
- Add a CPAP humidifier
- Consider a full CPAP Face Mask
- Consider specific devices (Auto-adjust, C-flex)
- Consider lowering CPAP pressure by 1-2 cm H2O
- Sleep center to calibrate device pressure
- Nasal congestion, Vasomotor Rhinitis or nasal dryness
- CPAP heated humidifier
- Consider Nasal Saline at bedtime
- Consider nasal steroid for congestion
- Consider intranasal Ipratropium for Rhinitis
- Mask or pillow leaks (typically noisy and uncomfortable with poor fit)
- Adjust the straps, pads
- Check that the device is not upside down
- Wash face at bedtime and wash device daily
- Sleep center to switch mask types for better fit
- Claustrophobia
- Wear mask when reading or watching television
- Sleep center to resize mask
- Patient pulls off headgear while asleep (very common)
- Add chin strap or adjust for better fit
- Use a disconnect alarm
- Contour pillows can comfortably support the mask with position changes in bed
- Difficulty initiating sleep
- See Sleep Hygiene
- Wear mask when reading or watching television
- Assess for other causes (e.g. restless legs)
- Newer Sedative-Hypnotics such as Ambien or Sonata are considered safe and will not significantly exacerbate Obstructive Sleep Apnea
- Dry Mouth
- Start or increase heated humidification
- Consider a chin strap (e.g. Puresom Ruby)
- Consider full Face Mask (covers nose and mouth)
- Consider artificial Saliva
- Avoid drinking water overnight as solution due to secondary Nocturia
- Difficult to get the CPAP reattached in the middle of the night
- Pressure Sores or skin breakdown from mask
- Consider topical skin protection (e.g. Moleskin, Comfort care pad, Remzzz's, sorespot)
- Consider Topical Ointment at pressure areas (e.g. aquaphor)
- Refer to CPAP vendor for different mask or nasal pillows (especially if mask leak)
- Management: Medicare and Sleep Apnea
- Medicare covers CPAP on a rent-to-own over the first year
- Continued coverage of device requires follow-up and demonstration of compliance
- Face-to-face clinician follow-up is mandatory at 31 to 90 days and
- CPAP use in the first 1-3 months for at least 4 hours/night for 70% of nights over 30 consecutive days
- Device logs document exact periods of use
- References
- Mallemat and Runde in Herbert (2015) EM:Rap 15(2): 7-8
- Marino (1991) ICU Book, Lea & Febiger, p. 379-80
- Olson (2012) Mayo POIM Conference, Rochester
- Bower (2000) Otolaryngol Clin North Am 33(1):49-75 [PubMed]
- Flemons (2002) N Engl J Med 347:498-504 [PubMed]
- Gozal (1998) Pediatrics 102:616-20 [PubMed]
- Owens (1998) Pediatrics 102:1178-84 [PubMed]
- Piccinillo (2000) JAMA 284:1492-4 [PubMed]
- Sliverberg (2002) Am Fam Physician 65(2):229-236 [PubMed]
- Victor (1999) Am Fam Physician 60(8):2279-86 [PubMed]
- Victor (2004) Am Fam Physician 561-74 [PubMed]
- Wickwire (2013) Chest 144:680-93 [PubMed]