PAP THERAPY AND COMPLIANCE

To make sure that our patients have the best opportunity for success, when utilizing Positive Airway Pressure (PAP) Therapy, we offer a clinic run by our in-office Registered Respiratory Therapist (RRT).  The RRT serves as a resource for our PAP patients that is easily accessible and available to help answer questions, oversee therapy, and troubleshoot when needed.  The RRT is happy to help over the phone or to make an in-office appointment if warranted.  

We have compiled the following information as general education for patients utilizing PAP Therapy or beginning the diagnostic testing that may show a need for PAP Therapy.

 

 

DIAGNOSTIC TESTS

Home Sleep Apnea Test (HSAT):  This test can be done at home, which many patients prefer.  While the HSAT can diagnose whether or not you have sleep apnea and to what degree, it lacks the ability of the traditional Polysomnography Test to break it down further into obstructive versus central sleep apnea.  This could delay the proper initial diagnosis for patient's with more advanced forms of sleep apneas, often referred to as central or complex sleep apneas.

Polsomnography (PSG):  This test is the more traditional diagnostic study done in the Sleep Lab.  The patient will spend the night in the Sleep Lab being hooked up to a series of leads that measure parameters such as breathing, air flow from nose and mouth, heart rate, oxygen saturation, snore level, and brain waves.  This in-depth testing not only lets us diagnose sleep apnea, but breaks it down into obstructive versus central issues.  This allows for a more accurate initial diagnosis which helps us to choose the most adequate initial therapy and to get patients the help that they need quicker.

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Titration Study:  After being diagnosed with sleep apnea, there are generally two paths forward.  If your insurance company does not want to pay for the Titration Study, they may ask us to set you up with an "AUTO-PAP" machine.  These machines are able to adjust settings to meet your needs, and if you have a simple form of sleep apnea often will provide adequate treatment.  If insurance is willing to pay for a Titration Study, or the "AUTO-PAP" is unable to meet your needs, we will send you for a Titration Study.  During this study, you will be hooked up to the same leads referenced above in the Polysomnography section.  Unlike the Polysomnography test, this test will begin with the patient wearing a CPAP machine.  The benefit to this study is that the patient is monitored while wearing the machine, and the settings are continuously changed to meet the patients needs as the Sleep Technologist tracks their events.  Patients with more advanced forms of sleep apnea benefit from this the most, as they are placed on the most adequate therapy earlier.

 

IMPORTANT TERMS

Apnea Hypopnea Index (AHI):  This refers to the number of respiratory events per hour a patient has.  An AHI less than 5 is normal, 5 to 15 is a mild problem, 16 to 30 is a moderate problem, and greater than 30 is a severe problem.  The goal of treatment is to bring the AHI back down below 5.

Apnea:  The absence of breathing.

Hypopnea:  Very shallow breathing.  These breaths are often so shallow that they do not get down into the lung parenchyma and for all intents and purposes may as well be an apnea.

Obstructive Apnea:  This is the absence of breathing due to obstruction.  These obstructions are caused from muscular tissue in the airways becoming more and more flaccid as the patient falls further asleep.

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Central Apnea:  This is the absence of breathing due to the patient "forgetting" to breath.  There are many conditions that cause this.  Proper diagnosis and treatment is critical.

 

Continuous Positive Airway Pressure (CPAP):  As indicated in the name, this is a steady pressure that the patient breaths against that helps to splint the airways open and reduce obstructive apneas and/or hypopneas.

Bilevel Positive Airway Pressure (BiPAP):  BiPAP utilizes two pressures.  The first is a constant baseline pressure referred to as Expiratory Positive Airway Pressure (EPAP).  The second pressure is an inspiratory boost pressure that is referred to as Inspiratory Positive Airway Pressure (IPAP).  This mode is preferred for more severe obstructive apneas and central apneas.  The addition of a back-up respiratory rate, when central apneas are present, helps to pace the patients breathing and minimize central apneas.

Adaptive Servo Ventilation (ASV):  These machines are very intelligent and are able to accommodate the treatment of the most advanced and complex sleep apneas.  Utilizing a microprocessor, the algorithms programmed into ASV machines are able to track an individual patients breathing and make subtle or large changes to maintain adequate ventilation throughout the night.  Initial settings are for a range of pressures, rather than static pressures.  This allows the machine to utilize any number of pressure combinations to meet the patients needs from minute to minute.

Compliance:  After being placed on a Positive Airway Pressure (PAP) device, your compliance will be monitored wirelessly or through the use of an SD memory card.  Compliance, for the purposes of payment by your insurance company, is considered wearing the machine 4 hours or more a night 70% of the time.  As long as you maintain a compliance at or above that number, your insurance company will continue to pay for your device.

MANAGING LEAKS

Managing mask leaks is one of the most important aspects of ensuring adequacy of therapy.  It is very important for the patient to understand how it is that leaks impact their experience with PAP therapy. 

The PAP machine is set to achieve a certain pressure to stent open the airway and prevent apneas.  The PAP machine achieves this by "blowing" air at the patient until the desired pressure is reached.  If there is a leak present, the PAP machine has to "blow" more air to try and achieve the pressure it is set to.  The larger the leak, the more air the PAP machine has to "blow" at the patient to try and achieve the desired pressure. 

People that are experiencing leaks may complain of dry mouth, increased OSA symptoms, and the sensation that the machine is blowing too much air or that the pressure is too high.  If the leak is within normal limits, the patient should not have any of the above complaints regardless of the PAP machines settings.

Most leaks are the result of the patient using nasal interfaces.  Nasal interfaces may be a little more comfortable than their larger counterparts, but allow for large leaks by way of the mouth.  Below is a picture of the different types of masks:

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Most people that start PAP therapy, especially those not keen on PAP therapy, opt to use a nasal interface as it has the smallest foot print of the PAP mask spectrum.  While these masks may work for people with milder OSA symptoms that have lower pressure requirements, they are not ideal for patients that have moderate to severe OSA and require higher pressures.

 
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