By Dr. Manvir Bhatia and Ms. Garima Sharma
“Patience and perseverance is the key to success.”
We know how a new foreign object on the face can be intimidating for patients who are already dealing with breathing difficulty day or night time. The right motivation and guidance are a must to begin any therapy. CPAP (continuous positive airway pressure) therapy can work as a life-saving asset for a number of disease conditions. The root of problems can range from respiratory failure to breathing difficulty due to various underlying pathologies of the lungs, heart, kidney, or nervous system.
Chronic obstructive pulmonary disease, Asthma, and Obstructive sleep apnea are some of the major issues that require CPAP to improve oxygenation and keep the airway open while they sleep. CPAP gives the positive airway pressure that is important to keep the airway open and also helps in improving oxygenation by pushing the fluid out of the lungs in diseases like pulmonary edema. It can be an asset to avoid invasive mechanical ventilation that’s difficult to wean off.
There can be many challenges that a patient and clinician might come across while initiating CPAP therapy for the patient. But every problem has a solution.
We will guide you on how to troubleshoot those problems with ease.
PATIENT-RELATED CPAP PROBLEMS:
First and foremost is the comfort of the patient.
The first impression of the therapy to the patient can make a difference.
STARTING TROUBLE: Starting the therapy directly without informing and guiding the patient about how to adjust to the therapy, getting him comfortable with the mask, air pressure, and new change in his regular lifestyle, might scare him off completely can lead him to abandon and deny the life-saving therapy that’s crucial for him.
A patient might be scared to use a mask at first as it gives him the sense that he won’t be able to breathe against a lot of air pressure, or claustrophobia may make him agitated.
INFORM THE PATIENT:
- Informing the patient about how the mask and therapy will help their condition and improve their health is the key.
- We should also show them how the machine works, and make them feel a little pressure on the hand first.
- Make them try different types and sizes of masks.
- Ask them if they are claustrophobic or not. (that can decide which mask will be best suited for them- full face or nasal)
- Make the patient try on the mask in front of the mirror, without air pressure.
- Make them comfortable with lesser P (5cm H20) in the sitting position. If they are comfortable, they can lie down and try relaxing in supine or side ways position.
TIPS FOR THE HEALTH PROFESSIONAL.
- To make the patient comfortable, start the trial with a minimum P – 4 or 5 cm H20.
Set the RAMP time to 5 to 15 minutes according to the need.
- Add sterile water to the humidifier if the patient has mouth dryness issues.
CLAUSTROPHOBIA:
Fear of closed space. A full-face mask might be difficult for a patient having claustrophobia.
How to give CPAP therapy for Claustrophobia patients:
A nasal mask or nasal pillow may be a boon for such patients.
MASK FIT:
If the mask is small or larger than the required size of the patient, it may cause leakage or discomfort for the patient.
HOW to find the right size mask?
The right size of the mask is selected by the size chart that your health professional will use to measure the size between the nasal bridge and upper lip.
Even if the size suggests the best fit, the patient should be allowed to try one size smaller and on size larger mask and choose what’s best for them.
Various sizes of masks are available- small, medium, and large.
For example, some feature full-face masks that cover your mouth and nose, with straps that stretch across your forehead and cheeks. These may make some people feel claustrophobic, but they work well if you prefer to breathe through your mouth during sleep. They also provide a stable fit if you move around a lot in your sleep.
Other masks feature nasal pillows that fit under your nose and straps that cover less of your face. These can feel less cumbersome.
Nasal pillows may work well if you wear glasses or read with the mask on because some don’t block your eyes as much as full-face masks do. However, this mask style may not be an option if you move around a lot in your sleep or sleep on your side.
LEAK AND SOUND COMING FROM THE SIDE OF MASk CUSHION OR THE MASK:
If the size is larger than required, or the head straps are not tightened appropriately, this can cause leakage and the gushing sound of air coming out may cause disturbance in sleep and leads to ineffective therapy.
HOW TO PROPERLY FIT THE MASK?
The straps should be rightly placed in the connectors provided on the mask. The broader part of the strap goes towards the head and narrower towards the neck.
The straps are equally tightened on both sides at a time, facing toward the patient.
DISCOMFORT DUE TO TIGHT MASK:
Pressure sores on the nasal bridge due to a very tight mask can be painful for the patient.
How to ensure the mask isn’t too tight?
There should be a minimum of 2 fingers gap between the face and the straps to make sure the mask isn’t too tight or loose.
A silicon-made cushioned tape can be used on the nasal bridge and the chin to prevent pressure sores.
A mask with a light face cushion and silicon face cover can be more beneficial.
MOUTH DRYNESS:
The patient may complain of mouth dryness and may disconnect the mask repeatedly to drink water which causes disturbance in sleep and disruptions in the therapy. Mask leakage can cause this and also a stuffy nose.
HUMIDIFIER TO THE RESCUE:
A heated Humidifier adds water at a certain temperature to the air before giving it to the patient.
The level of humidification can be adjusted between 1 to 5, where 1 is the minimum to 5 is the maximum humidification.
Nowadays, inbuilt humidifiers come in the form of filters that can be used during travel with certain kinds of traveling, compact CPAP machines.
For a stuffy nose, a nasal saline spray can be used to clear the nasal passage before bedtime.
HIGH PRESSURE:
A patient may complain of discomfort due to high Pressure.
SWITCH THE THERAPY TO BIPAP
The patient should be instructed to breathe along with air pressure and try to relax in the sitting position while holding the mask on the face. If still the pressure feels too much, the therapy can be changed to BIPAP, which gives BI- level Pressure, lower pressure at the expiratory time, and higher pressure at the inspiration phase of the cycle.
INFECTION:
The patient may develop many infections related to the ventilator like ventilator-associated pneumonia or skin infection, due to unsterilized masks and accessories.
CLEAN THE ACCESSORIES REGULARLY:
Proper cleaning instructions are to be followed for cleaning the mas, straps, tube, filter, machine, humidifier, and other parts of the machine regularly.
DIFFICULTY FALLING ASLEEP WITH CPAP:
The patient may sometimes complain that they find it difficult to sleep with the mask on rather than without it.
GETTING USED TO THE THERAPY:
Patients should be advised to practice wearing the mask in the daytime and try taking small naps of 15-20 minutes.
Maintaining sleep hygiene, exercising, and getting proper sunlight that keeps the circadian rhythm (4-hour sleep-wake cycle) in check is important. The patient should be advised to avoid caffeine and alcohol near bedtime.
Do not lie down on the bed until you are tired. If you still do not get the sleep, get out of bed after 20- 30 min and do some reading. Try taking a small walk. And then try again after 30 min or so. Maintain a sleep diary and a constant sleep-wake time.
If required, physicians can diagnose other issues like insomnia if exists.
ADDITIONAL TIPS:
- Get servicing done once a year.
- Keep in touch with your provider for any issues. We are here to help.
- Seek a doctor’s advice before making any changes to the machine.
- Diet, exercise, and making weight changes certainly is an add but you shouldn’t stop the therapy until advised by the doctor.
- Getting used to isn’t like a bad addiction, but a good habit if your doctor has advised you to use it for a longer period of time, as it prevents OSA, other heart-related issues, depression, excessive daytime sleepiness, and hypertension.
- Have hope for a better tomorrow. Initially, this can be frustrating but with the right motivation, guidance, and support, it can be worth it.