Dissecting a Case of CPAP Noncompliance

Vol. 10 •Issue 6 • Page 53
Dissecting a Case of CPAP Noncompliance

By Kathleen E. Frost, RRT

A polysomnography test identified a patient who stopped breathing 78 times during the first 78 minutes of his study as having severe obstructive sleep apnea. His primary care physician ordered nasal continuous positive airway pressure to prevent the obstructive events and to allow him to get more restful sleep.

A home care company representative went to the patient’s home and instructed him on the use and care of the equipment. The company provided him with a different mask than the one that he used during the sleep study. A week or so later, the representative called the patient to determine how he was doing with the CPAP. The patient’s wife answered the phone and informed the caller that he might as well take the machine back because her husband wasn’t using it. The caller hung up, and no further communication ever took place.

Ten months later, the frustrated wife called Sleep HealthCenter complaining that her husband could not tolerate the CPAP and his quality of life was declining. He was a baker and started his day at 5 a.m. After working a 12-hour day, he was exhausted and found it difficult to make the 30-minute trip home. He was scared that he would fall asleep driving and hurt another person in an accident. We scheduled an appointment for the patient to come to our CPAP habituation clinic.


When the patient arrived for his visit, I was able to pinpoint several barriers to his CPAP compliance. First, a communication breakdown occurred shortly after the primary care physician prescribed the device. The home care company did not follow written orders. The representative did not seek out why the patient wasn’t compliant or attempt to resolve the issue.

Additionally, the patient was not managed or followed by a sleep specialist. If the patient had been back to see the sleep doctor within four weeks after getting his CPAP, more than likely the sleep doctor could have intervened.

Unfortunately, managed care has left many OSA sufferers to be treated by their primary care physicians. It’s not uncommon for a CPAP user to develop a problem related to equipment use, complain to his PCP, and the PCP doesn’t know what to offer the patient.

What happens to the patient who is using the CPAP and tells his PCP that he still isn’t feeling well rested? Does the PCP know enough to determine if the patient has a second sleep disorder such as periodic limb movement disorder and how to treat it? Does he know enough to look at sleep hygiene issues and what to recommend? Does he know to look at weight gain since he was studied? Being managed by a sleep specialist is important.


As a result of the lack of communication, the baker did not get the chance to explain that his CPAP mask was uncomfortable. Each time he put the mask on, his nose seemed to block up, and he felt claustrophobic. My plan was to try a mask with nasal pillows that would feel less restrictive and add a heated humidifier to reduce the nasal congestion. After habituating the patient to the mask, he was quite impressed with the comfort.

With all the masks available today, there is probably a mask to fit the vast majority of people suffering from OSA. However, there will always be problematic patients such as those with asymmetrical faces or sensitive skin.

Some ambitious patients have come up with creative solutions to improve the fit of their masks. One Web site I found shows pictures of a patient who adjusted his full-face mask by using a chin strap, reduced rainout by knitting a sleeve that insulated his tubing and prevented the tubing from tugging during sleep by creating a pulley. I’m hopeful that the near future will bring airway interface devices that don’t require headgear.


Another barrier to compliance arose when I ordered the new equipment for the patient. The insurance company called me for clarification of the patient’s needs. The representative explained that his policy did not provide for replacement of masks or additional equipment because the CPAP had been converted from a rental to a purchased device. Had the home care company requested the mask and heated humidifier during the CPAP’s first month of use, the insurance company would have covered the needed equipment.

A three-way call between the home care company, the insurance company and myself ensued. The home care company quoted the patient an extravagant price for the mask if the patient wanted to self-pay. We discussed why the price was unfair to the patient. In the end, the patient got the mask at a reduced cost.

All of these issues add to noncompliance to the treatment of a problem with significant long-term health consequences if it is ignored.


Respiratory therapists can help to overcome these barriers. They should educate themselves as to the common problems CPAP users experience. In the CPAP habituation clinic, I listen to what the patient has to say. I want to know what equipment he has tried, what happened when he tried it, and what he has done to address the difficulties.

I tell them that wearing CPAP is not easy in the beginning and reassure them that problems are usually resolved. I strongly encourage the patient to contact me with any questions surrounding the equipment’s use. If I don’t know the answer, most of the CPAP manufacturers have specialists on staff to help with these issues.

The respiratory therapist should be advocating for the patient by calling the physician involved and getting orders for changes in the therapy. Communicating with sleep specialists is often educational, as they explain the reasoning behind their approaches.

The more initiative respiratory therapists take, the more likely their patients will get the treatment they desperately need.

Frost is a senior sleep counselor at Sleep HealthCenter, Newton, Mass.

Evaluating Follow-up Care

By Francie Scott

Susan M. Dignan, RPSGT, and her colleagues knew that CPAP compliance was a problem for many of the patients they diagnosed with obstructive sleep apnea at the Lahey Clinic Medical Center Sleep Disorders Center in Burlington, Mass. To help troubleshoot problems in the weeks after diagnosis, they established a CPAP Clinic for follow-up care several years ago and marketed the service to referring doctors.

“We did it because we felt there was a need for it,” explains Dignan, the supervisor of neurophysiology.

The Lahey team invites patients back to meet with a sleep technologist two or three weeks after their initiation to CPAP. They can discuss any problems they are having with the equipment and share problems relating to comfort levels.

“We meet one-on-one with patients to discuss problems and see why they are not compliant,” Dignan says. “We try and fix the problems.” Most often, problems relate to accessory equipment like masks, she explains.

Although members of the Lahey sleep team felt sure compliance improved in clinic patients, they did not know how effective their strategy was until they compared compliance in clinic and non-clinic patients. During the six-month period they followed compliance in 34 patients, 17 of whom had attended sessions at the CPAP Clinic. They evaluated compliance at one month, three months and six months.

At six months, one member of the clinic group had dropped out of the study, compared with seven members of the control group. Members of the clinic group used their CPAP units an average of 5.0 hours per day compared with 0.7 hours for members of the control group. Clinic patients used their CPAP units 79.2 percent of days while members of the control group used theirs 11.3 percent of days. Overall, members of the clinic group used their CPAP units for more than fours hours per day for 57.9 percent of the days compared to 9.2 percent of days for members of the control group.

“We sort of knew it worked but felt it was important to verify it,” explains Dignan, a coauthor of the study.

David Neumeyer, MD, Paul Gross, MD, and Akmal Sawar, MD, also coauthors, presented the data in abstract form during a poster session at the 2000 meeting of the Associated Professional Sleep Societies.

While members of the Lahey team take pleasure in the positive numbers documented by their study, their most satisfying experiences come from grateful patients like James DelGenio, 35, of Melrose, Mass.

DelGenio tells ADVANCE he had originally worked with a different sleep clinic when his obstructive sleep apnea was first diagnosed. He started CPAP therapy, but his daytime fatigue continued so he sought help at the Lahey Clinic.

Technicians there conducted a second sleep test and discovered the pressures set on his CPAP unit were too low to correct his problem. DelGenio returned home to try the new settings but still believed his apnea deprived him of a good night’s sleep. When he reported his problem to the Lahey team, technicians sent him home for a four-night trial with a computerized CPAP unit that would detect and record apnea levels. At the time of the interview, DelGenio had not heard the results, but he expressed confident enthusiasm for the Lahey service.

While the benefit of the CPAP Clinic is not in doubt, referring physicians have been slow to take advantage of the service. Dignan acknowledged that only one-quarter of patients diagnosed with sleep apnea return for follow-up care.

“It’s up to the referring physician whether they order it or not,” she says.

Francie Scott is senior editor of ADVANCE.