CPAP compliance is a bit of a thorny topic depending on who you talk to. On one hand, CPAP (Continuous Positive Airway Pressure) is the most common way to treat obstructive sleep apnea. If it’s basically the standard, then surely this treatment approach must work, and patients must be compliant right?
What Is CPAP?
The National Heart, Lung, and Blood Institute defines CPAP as “…a treatment that uses mild air pressure to keep your breathing airways open.”
It involves a CPAP machine that continuously generates and pumps low pressure air into a mask or device. This mask or device fits over the mouth, nose, or both, providing a stream of air that stops the upper airway from becoming restricted or blocked (the “obstruction” in obstructive sleep apnea).
CPAP is definitely an effective therapy. In some cases, it’s life-saving, in severe sleep apnea cases for example. But it only works as long as patients are willing to use it.
CPAP Compliance Isn’t All That High
Unfortunately, overall patient compliance levels aren’t great. Many patients have no trouble at all sleeping with a CPAP device on their face, and many also notice a range of positive effects, both short-term and long-term from using their CPAP machine.
But there are plenty of patients who can’t get comfortable with their CPAP machine. In some cases, they just can’t sleep with it at all, so they simply don’t use it. That’s a pretty drastic choice given the severity of the condition the machine has been prescribed to treat!
Reasons given for non-compliance include:
- Ongoing expenses (disposable masks etc.)
- Discomfort with the mask/device
- Inconvenience of using the machine
- Skin irritation
- Difficulty falling asleep
- Frequent nocturnal awakenings
- Complaints from partner
There are often specific CPAP compliance requirements from health insurers. After all, they won’t keep paying for a treatment if the patient isn’t actually using it enough. For example, in the USA, Medicare states that patients aren’t compliant unless they’re using their machine for at least four hours each night for at least 70% of nights.
Dr. Steven Park is a noted author and surgeon with a focus on sleep medicine. His take on CPAP compliance is:
“Various studies report CPAP compliance rates at 29% to 83%. The problem is that the definition of compliance changes from study to study. More recently, we’ve adopted the new Medicare requirement for CPAP compliance, which requires that the patients use CPAP at least 70% of the time over a 30 day period, for at least 4 hours every night. Otherwise, the machine has to be returned.
If you sleep 7 hours every night, it comes to 210 total number of hours per 30 days that you’re sleeping. Seventy percent of 210 hours is 147 hours. If you sleep only 4 hours every night, then this figure drops to 88 hours, which means that you have to use your CPAP machine only 40% of the total time that you’re sleeping to be considered compliant.”
If 40% compliance is considered adequate compliance, then what happens for the rest of the time? What about patients who simply stop using their machine?
As Dr. Park pointed out above, the figures from various studies on CPAP compliance vary wildly. They show that between 29% and 83% of patients don’t meet even these modest criteria for compliance, which is clearly a problem.
What Can Be Done To Increase CPAP Compliance?
There are a number of factors that can help patients use their CPAP machine more consistently. These include:
1. Changing the fit and/or style of the mask/device.
2. Humidification – certain machines humidify the air going to the patient, which reduces symptoms such as drying of the nose and mouth.
3. Clearing any nasal congestion – if a patient can’t breathe easily through their nose, they’ll have increased discomfort when trying to use a CPAP machine.
4. Using a different type of machine – CPAP is the most common form of Continuous Positive Airway Pressure machine but there are other options:
BiPAP (BiLevel Positive Airway Pressure) machines are able to deliver different levels of air pressure for inhaling and exhaling.
APAP (Automatic Positive Airway Pressure) machines adjust the amount of pressure they deliver, varying it as required with each breath. The idea here is to deliver the least amount of air required to keep the airway unrestricted. These are generally the most advanced and comfortable machines but they’re also the most expansive.
Dr. Park has a written a book specifically to help patients improve compliance with their CPAP machine. It’s available here.
Other Approaches To Treating Sleep Apnea
There are a number of other approaches to treating sleep apnea and sleep disordered breathing.
The American Dental Association recently released a new policy statement called the Role of Dentistry in the Treatment of Sleep-Related Breathing Disorders. The new recommendations are that all American dentists screen their patients for signs and symptoms of sleep disordered breathing.
This is the first step in a major paradigm shift, bringing sleep dentistry into the mainstream alongside sleep medicine. A dentist or orthodontist who is focused on the airway can offer a number of options, both surgical and non-surgical that can help to address and treat the root causes of sleep apnea.
Myofunctional therapy should be a key part in any treatment protocol for sleep apnea. Oral myofunctional exercises have been research proven to reduce the symptoms of obstructive sleep apnea.