The key to successfully treating sleep apnea is based on an open and communicative relationship with patients, home medical equipment service providers, and the diagnostic team.

Compliance with continuous positive airway pressure (CPAP) or bilevel PAP is the primary objective once sleep apnea has been diagnosed and positive pressure therapy is selected for treatment. However, with compliance rates roughly between 50% and 80%, many patients continue to live with the sleep disorder and associated symptoms. Thus, emphasis on the initial setup instruction and follow-up becomes key to successful treatment.

Knowing patients’ specific signs and symptoms points to exactly what should be monitored for successful treatment compliance, thus objectively demonstrating the treatment’s success. Educating patients on these associated symptoms also helps them to monitor their treatment success.

Successful Treatment
In my opinion, initial education should begin at the sleep center. Several times when providing setup instruction, I have encountered patients with minimal knowledge of their condition and why they are receiving positive pressure therapy, although at other times I have found patients to be very knowledgeable about their conditions. These patients are usually from sleep centers where the most is made of the time while preparing them for a sleep study (during electrode placement). While videos are helpful during this time, it is still necessary to explore patients’ specific symptoms and motivation for undergoing a sleep study, for these become focal points for initial setup education and follow-up.

From the perspective of the home medical equipment provider, centers that explain in detail the titration and treatment process are invaluable. This helps patients to understand that pressures less than what was titrated specifically for them may cause symptoms to return. It also proves helpful when more inquisitive patients figure out how to adjust their pressure and believe they know more than their physician does about how much pressure they need.

People suffering from a disease process that includes sleep apnea need assistance in accepting their condition. Like the five stages of dying, these patients need to process their condition until they accept it; therefore, if all parties involved—physician, polysomnographic technician, and home medical equipment provider—assess the patient’s level of acceptance, anticipating problems with compliance is an easier task and more proactive intervention can take place.

We are all aware that a common initial stumbling block is denial. Too often, we hear patients with sleep apnea say, “I’m just getting older and don’t have the energy I used to.” These patients need help accepting their condition. So share objective data that prove their condition exists—for example, blood pressure, oxygen saturation, or a bed partner’s tape recording of the patient’s breathing pattern. Let patients see their sleep tracings and explain the airflow curves and how they have stopped. This information makes it much more difficult for patients to deny their condition and helps them move to the next step. It also helps the home medical equipment provider establish follow-up based on symptom resolution.

Effective Education
One of the most important components of providing effective care is proper instruction. A relaxed and deliberate instruction can put patients and/or caregivers at ease as well as avoid unnecessary after-hours calls. The following information focuses on the instruction of the patients and/or caregivers so they will receive the optimal benefit of the equipment.

Experience has shown that the best instructional technique has patients and/or caregivers (instead of the provider) perform the actual tasks associated with the equipment setup—when possible—for the following reasons:

• When patients/caregivers are actively engaged, distractions are avoided.

• Being involved in setup at the onset puts patients/caregivers at ease knowing that the equipment is not as complicated as it may initially seem.

• Talking patients/caregivers through the equipment setup simultaneously accomplishes the instruction and return demonstration, thus saving time for all involved.

• The end result is giving thorough instruction, decreasing the likelihood of problems, which create anxiety for patients/caregivers and frustration and expense to the sleep center and/or home care provider.

Of course, an additional end result of this type of instruction technique is a satisfied patient.

Initial Setup
Though specifics vary from one home medical equipment provider to another, the first obvious step is preparing the necessary paperwork and supplies. More important, pressure adjustments should be made prior to the home visit. This prevents patients from observing how pressures can be adjusted, thus decreasing the likelihood that they will make adjustments without your knowledge.

Once introductions have been made at the patient’s home, it is important to find a comfortable place to sit and provide the instruction. My personal favorite is the kitchen table because this is a good surface to work from and generally this area has a relaxed atmosphere. This is the place family and friends sit and talk, and what you want is to develop a professional, yet personal relationship with the patient. Establishing this rapport early makes follow-up friendlier and less intrusive.

The next thing I do is called “sink the hook.” I explore why patients sought diagnosis and treatment for their sleep apnea. The answer, which is sometimes uncomfortable for them to discuss, is usually encouragement from a spouse, an automobile accident, or falling asleep on the job. This effectively places the patient on the “dark side” of their condition. Then, I immediately ask them how they felt after their first night of sleep on positive pressure therapy (during titration). The common response is “I felt great,” or “I haven’t had a good night’s sleep like that in a long time.” This technique, while it may be initially uncomfortable for the patient, effectively summarizes the cause and effect relationship of sleep apnea, while at the same time breaks down the barrier of embarrassment when discussing problems during the setup or follow-up.

Once this discussion has taken place, setup can be continued. Verifying proper mask fit is the next logical step. While the sleep technician may have already performed this task, the old adage “measure twice and cut once” applies here. In most cases, it prevents the caregiver from unnecessarily using more than one patient mask and headgear. It also requires the caregiver to carefully inspect the patient’s unique anatomy so potential challenges can be identified.

As alluded to previously, the next technique I employ is having patients perform associated activities such as opening the box, plugging the unit in, and attaching the tubing, mask, and headgear. This has many advantages including engaging patients during the instruction process, thus decreasing the likelihood that their mind will wander during the instruction. It also creates a sense of excitement. Finally, by having the patient put the pieces together, after-hours calls due to forgetfulness are virtually eliminated.

After an effective setup and instruction have taken place, keeping the patient interested and compliant is paramount. A combination of follow-up techniques, which may include electronic compliance data and telephone calls, best accomplishes these objectives. During a follow-up telephone call, I document the individual contacted, including hours used, patient problems, and patient satisfaction; review benefits; and then sink the hook again. If home visits are employed, they should include equipment performance, patient compliance, problems, physical assessment, equipment care assessment, and, again, a review of benefits and sink the hook. The benefit of the physical assessment relates to the issue of symptom resolution discussed at the beginning of this article.

Problems
The final step in effective setup and follow-up is anticipating problems. Maintaining the involvement of significant others is essential to identifying and dealing with these problems. With that said, the three main problems are mask fit, mask fit, and mask fit. Therefore, focusing on potential mask problems such as proper mask and headgear fitting, cleanliness, and mask application pressure is where most time should be spent. Exploring other alternatives to conventional masks is helpful as well. Allowing the patient to participate in the mask selection adds additional ownership of the outcome for the patient. Other problems include nasal dryness, complacency, self-consciousness, and lack of continuing treatment.

Based on the above information, it becomes obvious that successful treatment of sleep apnea is based on an open and communicative relationship with the patient, any significant others, home medical equipment service providers, and the diagnostic team. Maintaining this relationship helps all parties sleep better.

Nicholas J. Macmillan, RRT, consults for various health care providers in Bloomington, Ind.