One of the first issues I hear when a person comes into a sleep lab to be introduced to a CPAP is that they have claustrophobia; that you cannot stand to have anything on your face.  There is always an excuse for not tolerating therapy.  Most of the reason has to do with feeling out of control.  There are so many ways that can create a successful experience.

Let’s start with the mask.  It is probably the most important piece of equipment you will use and the easiest to change.  If you are unable to use the mask during the night of your study tell your tech, however, what usually happens is that they use the mask for 1-3 days at home and find that it is not the best mask for them.  It may move too much causing leaks, it might cause your skin to mark or breakdown, it might make your eyes dry; all these issues can be handles with a change of mask.  It is also common for people who are claustrophobic to be much more successful with a full face mask due to the ability to breathe through both the nose and mouth which will make anyone more comfortable.  Your insurance will pay for replacement mask during the first thirty days of the therapy.   After the first thirty days a new mask must be ordered.  At many centers they will allow you to trial or borrow masks to find one that will work for you.

Knowing how to perform relaxation techniques will allow you to be successful when you are trying to fall asleep the first few days.  It can also help on days where your stress level is high.  The two techniques I have found that help are progressive relaxation.  This is easy to learn and allows you to focus on relaxing as well as helping you to focus your thinking.

1.       Start at your feet and tighten  them as tight as you can, hold for the count of ten and then allow them to relax and go limp

2.       Progressively move up the body focusing on one muscle group at a time. 

3.       To reach the top of your head should be having spent about 10 minutes on deep breathing and your muscles may be relaxed.  This centered concentration helps increase oxygen levels and allows the mind to camp down preparing it for bed.

Diaphragmatic breathing is another exercise that will allow you to relax and breathe deeply with a technique that takes focus.  Lie flat on your back with your hand on your stomach just below your ribs.  As you take a slow deep breath in push your hand out; when you exhale draw in your abdominal muscles so you are pulling your hand in.  I usually like to hold the breath 3-5 second between peak inhalation and exhalation.  Having to concentrate allows the mind to calm and it increases the oxygen level from doing nice slow inhalations.

If relaxation techniques do not work for you medication or working with a councilor that practices Cognitive Behavioral Therapy.  Your physical can help you to find assistance that will work for you.  It is not unusual for someone to need a little extra support, this is long term therapy and sometimes it takes a little time to become compliant with it.

Some accessories can help you with some of the small issues.  Chin Up strips can help a mouth breather minimize the leak.  A Gecko will help with sores on the nose and leaks into the eyes.  A heated hose might help with mouth drying. 

Overall working with a patient technologist or physician is the best way to be successful when using PAP.  The more you communicate about your issues the sooner a solution to help you be successful on your machine, and sleeping a healthy sleep.

I have been working with patients for well over 15 years and during this time therapy has changed greatly.  The problem is that the issues I hear are the same ones I heard when I first worked with patients setting up PAPs in homes in the 1990s.  The facts are that the therapy has changed and the issues are not nearly as serious as they once were.

Many people talk about how unsexy the therapy is.  I think snoring, tossing and turning and being on multiple medications for health issues is much more unattractive.  Many of the new masks on the markets are smaller and less intrusive.  The Fisher Paykel nasal mask and the RESMED pillows and nasal mask are much smaller with less head gears.  These are easier to put on and because less equipment touches the face they are more comfortable to wear. 

Many say the machines are too loud.  This is no longer true.  There are many different machines on the market and the newer ones are much quieter.  In fact many of the people cannot tell if the machine is on.  This is especially true with the correct mask.

There are some who complain that they dry out when they wear their mask.  This was very true when I first set up therapy when I was first doing set ups.  Now not only do they have heated humidification that is almost always ordered with the machine.  The heated wire hoses helps to prevent water buildup in the hose as well.  This new technology helps to make sure those issues, such as nasal congestion, nasal and mouth drying and sinus swelling is kept to a minimum.  If you continue to have such problems there are products that can help or you should consider going to a full face mask. 

I am a mouth breather and cannot find a good mask.  While full face masks can be a little more difficult to get used to there are other options as well.  Chin-up strips to help keep your mouth from opening during the night and the Fit Life mask from Respironics may be a better option because it does not sit on the bridge of your nose but does cover your whole face.  You can also use products like nasal saline spray or Oramoist to help add moisture to your airway.

The biggest complaint is the pressure.  No one expects you to get used to the therapy overnight.  There are people that will help you with desensitization to therapy.  There are also several new ways that can help you.  C-Flex, Sense Awake or ERP are all ways that the machine helps to relieve the pressure.  If that does not work than there are other options for the doctor to take.  But you need to give it a try getting used to the therapy first.  Most people will in 2-4 weeks.

CPAP therapy is one of the best ways to treat sleep apnea.  There are few reasons to not try the therapy.  The most important thing is to keep communicating with the doctor or the home medical equipment company.  They cannot help you if they do not know you are having problems. 

  You have been diagnosed with obstructive sleep apnea or OSA and then they hit you with a bunch of words you have never heard before.  They start talking about machines and mask and humidity.  You are told this is long term therapy.  What they do not explain is what the machine does, what types of therapy are you eligible for and what will be the best type of therapy for you. 

• CPAP stands for continuous positive airway pressure.  It is the most common therapy used for the treatment of OSA.  It is one continuous pressure that supports the airway.  This pressure was determined during the second sleep study, called the titration study.  On some occasions the titration is able to be done on the same night as the diagnostic study.  During the titration the technician will slowly increase the pressure until the breathing issues, snoring and airway resistance is eliminated or reduced to within normal levels.  In order for the insurance company to pay for the machine you must have at least 5 respiratory events an hour with some type of co-morbitity such as hypertension, or excessive daytime sleepiness.  Once the respiratory events increases to 15 events or higher a co-morbidity is no longer needed.
• Bilevel or BIPAP therapy is similar to CPAP however, instead of one continuous pressure there are two pressures.  The lower pressure is the EPAP or expiratory pressure is increased to eliminate obstructions.  The higher pressure called IPAP or inspiratory pressure is adjusted to eliminate snoring, upper airway resistance and partial closing of the airway.  This therapy is also used to help people who can not tolerate CPAP therapy.  Patients who can not tolerate the pressure they need or who need high pressures this can allow the use of a more comfortable lower pressure.  The change in pressure also assists some people to feel more comfortable or natural.  In order for insurance to pay for this therapy the technician or the doctor must document that CPAP was used unsuccessfully and that Bilevel therapy is the best alternative.
• APAP or AutoPAP is a self titrating therapy that is used for people who may need higher pressures part of the night such as when they are in REM, the stage of sleep where they dream or when they sleep on their back.  This allows the pressure to remain low until the higher pressure is needed.  This therapy is also used when the patient does not wish to come back for the second sleep study.  Many insurance companies do not wish to pay for Autopap because it is more expensive and it is not set to specific settings.
• ASV, AutoSV, or BIPAP ST all of these are similar.  They have an inspiratory pressure and an expiratory pressure the difference is they have a rate as well.  This particular therapy was designed for people with central apnea.  Central apnea is when the brain does not tell the body to breathe.  The Bilevel therapy allows the machine to give a breath and the back up rate allows the machine to give the breaths when it does not sense a breath after a certain period of time.  These machines are only ordered when there are more central apneas then obstructive apnea.  Insurances pay differently for this therapy since it needs closer follow up by the doctor and the durable medical equipment company that sets it up. 
• Oxygen can be ordered for some patients.  It can be added to the therapies described above or be given alone.  Oxygen is prescribed when the level of oxygen in the blood is lower then 89% for a minimum of 5 minutes without an associated respiratory event.  This means that there is not an obstructive apnea or hypopnea causing the decrease in oxygen.
  

Therapy for breathing disorders can be complicated.  It is best to talk to your doctor and your technicians.  The more information you have about the therapy and the options available the more likely that you will be successful.  It is also important to understand your insurance policy’s durable medical equipment reimbursement as this can have a high initial cost.  If you work with your team you should have a successful experience and start to feel better rested and healthier in no time.

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