A CPAP acclimation trial increases treatment compliance.

Nearly every night, sleep disorder centers are on the front line of the CPAP adherence struggle. This is where the CPAP compliance so paramount and sought after by physicians, DME providers, and sleep technicians often begins. Therefore, once a patient has undergone a sleep study with therapeutic intervention, we must examine the role of sleep laboratory processes in CPAP adherence.

The primary objective of a CPAP acclimation trial (CAT) is to familiarize patients with a properly fitted, comfortable mask and with continuous positive pressure prior to testing. This is important because if a patient requires a split-night study and therapeutic intervention must begin halfway through the night, then that patient will be more receptive to a therapy he or she is somewhat familiar with than a completely foreign one.

A patient’s introduction to CPAP therapy requires a series of events that needs to occur between that patient and the sleep technician. This symbiotic relationship requires an exchange of education and demonstration, which will benefit both parties when, and if, the implementation of CPAP therapy is needed.

The CAT was developed to allow polysomnographic technicians to invest time in adapting each patient to CPAP therapy prior to testing. By examining the 11 categories that make up the CAT, this article will describe its benefits as well as the techniques that will best serve each patient for a trial and relate those techniques to the settings found in most laboratory environments. These categories are: proper setting and education, time allotted, patient positioning, masks montage, mask fitting approach, application of pressure and heated humidity, patient control, patient adaptation to pressure, troubleshooting, time management, and documentation.

1: Proper Setting and Education
Once a patient has acclimated to the room where the sleep test will take place, completed sleep-related questionnaires, and finished any additional procedures prior to testing, then it is time to begin the CAT. Though a sleep clinician or referring physician likely has spoken with the patient about sleep testing during his or her consultation, it is beneficial to cover the basics of the sleep laboratory experience. Some sleep centers may use a video to explain the sleep test experience, the pathology of OSA, and noninvasive therapy. Other centers may choose to not use a video and to educate patients verbally. Either way, this educational process needs to be in place prior to the beginning of a CAT.

2: Time Allotted
Sleep technicians need to spend adequate time acclimating making sure masks are fitting comfortably, as well as properly setting individual positive airway pressures. Some patients may easily adhere to the mask and pressure, while others may require more time because of a lack of mask comfort, pressure setting issues, anxiety, claustrophobia, facial hair, or facial deformities.

3: Patient Positioning
The acclimation trials are best performed before the overnight test hookup process for better mobility takes place. At this point patients are not yet restrained by testing equipment or overwhelmed with the procedure.

4: Mask Montage
Sleep technicians each have their own favorite repertoire of masks that they like to showcase to patients. This selection is usually narrowed down to three to five masks based on the technician’s experience and the process of elimination for those other 20 masks that either have been outdated or just did not make the grade. As mask innovations and concepts keep pace with our growing sleep industry, it is imperative to stay attuned with CPAP technology and apply it effectively.

5: Mask Fitting Approach
Two important exchanges need to take place at this point. The first is that the technician should recommend which mask fitted the patient the best. The technician should ask the patient which mask felt the most comfortable; this is the most important component of mask fitting as comfort is key in compliance at home. A patient may have an light-colored machine that looks attractive in a home, no pressure problem complaints, and adequate humidity, but if he or she has an uncomfortable mask, then the door is wide open to poor compliance.

6: Application of Air Pressure and Heated Humidity
Always start CPAP during a trial at a minimal level of positive pressure. Most sleep journals and laboratory protocols put this somewhere between 3 and 5 cm H2O. Education is vital at this point. Prior to the patients consuming their first breaths of positive pressure, conduct a good quick review to remind them to keep their mouths closed (unless a full-face mask is used) and make them aware that the air they are about to breathe is filtered regular air with a little pressure applied, not oxygen alone. A good recommendation is to have heated humidification initiated at this point and throughout the entire therapeutic portion of the study.

7: Patient Control
After the mask is fitted and you are ready to initiate CPAP, there are three important steps.
Step 1: Give the patient control. When the patient is sitting and about to take that first breath of filtered positive air pressure, give him or her control of the device. Do not attach the mask headgear. Instead—being careful to instruct the patient not to block the air diffuser—put the mask or the point where the hose attaches to the mask, in the patient’s hand and tell the patient to slowly put it over the nose (or nasal-oral area if a full-face mask is used) and begin breathing. By giving the patient control, it eliminates forcing the mask toward the patient’s face and allows the patient to begin when he or she is ready and stop and remove the mask when he or she finds it necessary.

Step 2: Practice in intervals. It is a good idea to tell the patient to practice in intervals with each interval growing in mask-wearing time or pressure. Creating this patient control will make the patient more comfortable with the CPAP device, which promotes adherence. Once the patient becomes comfortable with the procedure while sitting, ask the patient to try lying down flat on the bed with the device applied and continue breathing. The intent now is to mimic the setting required during a CPAP titration or.

Step 3: Patient practices alone. A last recommendation is for a technician to step out of the room and let the patient perform this procedure without supervision while sitting or lying on the bed. This is an effective method because the patient becomes responsible and does not feel the pressure of someone watching over him or her. By the patient assuming responsibility and having control over the CPAP device, a successful CAT is in store.

8: patient AdaptAtion to Pressure
Once the patient is comfortable and breathing on the minimal positive pressure (3-5 cm H2O), check the CPAP remote control to see if the patient has excessive mask leaks or mouth breathing. Once verified that the pressure flow is stable and the mask has a good seal, consider increasing the pressure to a moderate level. By initializing this increase, the objective is not to find an optimal pressure, as that would be clinically insignificant because the patient is awake, but to give the patient a sense of what the feeling would be like on CPAP at a level above the minimal trial pressure. Patients that fall asleep on a minimal therapeutic pressure sometimes awaken on an increased pressure level alarmed and startled, resulting in a temporary or elongated awakening. The intent with increasing the pressure at the end of the trial is to familiarize the patient with a comfort zone at a higher level.

9: Troubleshooting
During any acclimation trial or nocturnal titration with CPAP, problems can develop. Patients frequently report difficulties exhaling, struggling to get enough air, being unable to catch their breath, and not managing to breathe only through the nose. All of these problems can result in the escalation of anxiety and discontinuation of CPAP use if not addressed quickly and adequately. If the problem is inadequate air pressure or struggling to breathe, consider adjusting the pressure on the CPAP first. By tweaking the CPAP pressures (increasing pressures in 1 to 2 cm H2O increments), the primary objective is to find the setting where the patient is comfortable and receptive to a pressure that he or she could relax and fall asleep on.

10: Documentation
Since a CAT is considered to be therapeutic intervention, it is recommended but not required to document that a trial was performed on a patient. By listing the minimal pressure and increased pressure that the patient was acclimated to, this procedure is documented in the permanent record. In addition, documenting the CAT in the patient record shows that adequate time was committed in this process.

The intent of CAT is to avoid slapping an unfamiliar mechanism on a patient in the middle of the night and expecting the best outcome with limited education and no acclimation process in place. For a patient to be successful with CPAP therapy at home, he or she must first be comfortable and receptive to CPAP therapy at the sleep laboratory. The objective is to have a process in place to benefit a patient that will require CPAP therapy. Comfort is the key to a compliant patient. DP

Jeffrey B. Wathen, RPSGT, is a sleep laboratory supervisor at St. Anthony’s Medical Center, St Louis.