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Continuous positive airway pressure (CPAP) therapy, although simple in concept has been one of the most dramatic therapies in modern medicine.  Among other things it has shown powerful improvement of sympathetic tone in hypertensive patients as well as marked improvement in daytime performance and improvement in mood.  There is also growing evidence that sudden death, atrial fibrillation, insulin resistance and various psychiatric disorders may have causal relationship with Obstructive Sleep Apnea (OSA).

However, very few of us really understand how CPAP works and how to prescribe this therapy. In fact, this field is rather new, in that there is not yet a standard way to administer CPAP.
CPAP is often prescribed similarly to medications.  Unfortunately, this often results in failure and makes future management even more challenging.  When CPAP is prescribed the physician is attempting to alter a person’s sleep pattern, or more accurately his/her sleep habits.  This is not an easy task and often requires fairly intense and occasionally lengthy intervention.

I believe the following steps are necessary elements of successful CPAP therapy:

Patient education:  The majority of patients (and physicians) have little understanding of nocturnal breathing and sleep apnea.  By understanding how the upper airway relaxes and restricts breathing, thereby interfering with sleep, one can appreciate the importance of an open breathing passage.  Sleep is a vital part of daily life as it is involved in a rejuvenating and restorative process.  In the same way that our bodies need a certain amount of nutrition, we also need adequate sleep for optimal function.  When this health requirement is compromised, fatigue and various physical and psychological dysfunctions result.

Preparing the patient:  Sleep is a very personal experience, and any intervention deviating sleep from its normal pattern will likely lead to a lesser quality sleep.  So, before any sleep study is to take place all components of the sleep study such as the electrodes, belts and airflow meters need to be thoroughly explained to the patient.  Patients are often anxious about not sleeping well and thus having a “bad sleep study”.  It is true that most patients will not have their best night of sleep, but this is perfectly fine as most patients will sleep enough to obtain adequate data.  A fair amount of time also needs to be spent answering questions and touring the actual room/lab.  We do not want any surprises when the patient arrives at the sleep lab.  Any anticipated “unknowns” before the intended sleep study may result in increased anxiety and a poor sleep study, as well as an unpleasant experience.

Role of sleep technicians during the study:  Technicians are not only trained in the technical aspects of a sleep study but must also be able to create an environment of comfort and relaxation.  Part of their job is to be able to induce a sleep promoting situation.  Any conversation that may potentially evoke stress or anxiety must be avoided such as religion, politics, economics or even instructing patients that they need to “Go to sleep now.”  Positive reinforcement and a sense of relaxation often become important elements of a good sleep study.

Understanding the data:  When the study is completed, results should be explained to the patient.  Simply saying, “You have bad sleep apnea.” means little to patients.  Sometimes patients are still not sure what’s occurring with their sleep and why they need to be treated.

CPAP introduction:  During the night of a CPAP study, the patient is asked to sleep with a pressurized airway device (CPAP).  If the patient has never been on CPAP, we often arrange a meeting a few days prior to the scheduled sleep study to allow the patient to briefly wear CPAP.  A prior introduction to the mask helps alleviate anxiety and assists the patient in adjusting to breathing with a pressurized airway.  This also gives us time to try different interface/masks so patients know they have options.  We are planning for the “first date” and should be well prepared for a good experience.

CPAP prescription:  When CPAP is prescribed, it is not uncommon for patients to end up with an ill-fitting mask or inappropriate pressure.  Patients are often unsure how to put on the device (it is not unusual to find a patient wearing his mask upside down).  Also, the CPAP machine itself can be intimidating.  Having a well-trained sleep technician teaching patients all aspects of their CPAP is critical to success.  This is not a “one-stop” meeting, and additional adjustments and training should be expected.  The technician should be easily accessible to the patient.

CPAP follow up:  Treatment does not always go as planned and sleep may not improve. Re-evaluation is needed.  Does the patient have a correct diagnosis? Is he/she really using CPAP? Are there family issues?  Does the patient truly understand the health issues and desire treatment?

Nasal congestion:  This is by far one of the most under-treated conditions in sleep apnea.  If nasal passage is restricted, breathing will be compromised.  This will lead to poor sleep, with or without CPAP.

Are there other issues complicating sleep? Sleep has many variables and proper breathing is just one aspect of sleep.  If the patient is not improving, other variables must be addressed such as:  Sleep related anxiety, restless leg syndrome, smoking and alcohol use, insufficient sleep, and circadian rhythm disorder.

Social support system: Most patients sleep with a spouse and when one partner has a sleep disorder it always affects the other person.  The spouse also needs to understand the condition and needs to be supportive of the evaluation and treatment process.  It is essential that the physician who is referring a patient for sleep study and therapy also has an understanding of the process and show support.

Alternative therapy:  There are many claims of alternative treatment and quick fixes.  All of these have been suboptimal and are not standard therapy.   An oral appliance may work in mild cases. This intervention is not a quick fix and is sometimes more difficult than CPAP.  It requires careful fitting and gradual adjustments by an experienced oral surgeon.  Over-the-counter or internet products have shown no benefit.  Surgery has a very limited role and is only considered in special cases.

In conclusion, prescribing CPAP is not a simple prescription but requires a team approach involving a sleep physician, an experienced sleep technician, and a supportive social structure.  Sleep evaluation and resulting CPAP therapy is a “process” that requires patience and commitment from all involved.  When performed correctly in a structured manner, the success rate is very high and results in tremendous physiological and psychological benefit.  When you witness this positive impact on patients, it is one of the most rewarding aspects in the field of medicine.

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