When talking with groups of sleep technologists about ways to achieve superior PAP therapy titration studies, I always ask, “What are the two most important factors in performing outstanding titrations?”

Let’s be clear, this is a trick question and rarely is it answered correctly, except by unusually savvy sleep technologists.

Many vote for the perfect mask and mask fitting; others are persuaded to find the right pressure delivery system; still others exclaim that titrations are more art than science, leading them to extol the virtues of careful observation and diligence as the real keys to success.

All these factors are highly relevant, but they are not the two most important factors. The next round of contributors move closer to the secrets of success but don’t quite get there: patients must be effectively desensitized to the mask as well as the pressurized airflow prior to starting the titration; patients must be thoroughly educated about their sleep breathing symptoms and how PAP therapy will correct the problem; and patient motivation must be thoroughly assessed, and, if lacking, then a healthy dose of support and encouragement must be provided to raise the motivational level.

All well and good and necessary, but still no bull’s-eye, so we continue and finally move just to the very edge of the answer. Patients must feel very comfortable with every conceivable factor in the lab environment, including temperature, bed, bedroom, and bathroom, along with removal of any possible noise or distracting elements; patients must feel safe and secure in this environment; and patients must be in a frame of mind that permits them to sleep.

These factors are all critical to but not the keys to success, because they are necessary yet not sufficient for a superior titration.

If you are an experienced sleep technologist, lab manager, or sleep medicine specialist and have not arrived at the answers yet, take a deep breath—with or without CPAP—and picture for just a moment the initial point of view that your patients may hold when they first enter the sleep lab environment. I believe many patients are worried, nervous, or outright fearful of what lies ahead, which is why they need:

Trust and Time.

Without the patient trusting the sleep technologist, it would be almost impossible to accomplish all the tasks and goals described above, because without trust it is impossible to attain the essential level of rapport between patient and tech. And, without rapport, all progress slows to a crawl, while with the highest level of rapport, success follows and sometimes yields a near perfect titration on the very first attempt. Yet, even with excellent rapport, some patients need more time to fully embrace and adapt to PAP therapy. One could argue, then, that time is the ultimate factor, but building trust between sleep tech and patient can dramatically decrease the time span needed to gain comfort with the titration procedure. While time is beyond our control, we have the potential to influence how much trust we engender with our patients and how much rapport results from building that trust.

Unfortunately, neither trust nor rapport falls into the category of readily teachable interpersonal skills. Sure, you can follow tips about introducing yourself clearly, making solid eye contact, listening well, and yes, even smiling and good grooming matter, but patients are very adept at picking up on sincerity or its absence. Patients trust you faster when they see or feel two things early in the night: first, they perceive you are competent and confident in what you do; and second, they feel (not necessarily think) that you are sincerely trying to help them. To create an appropriate and sincere therapeutic bond between tech and patient, then, is often more “art” than anything else, which explains why this essential capacity is largely a matter of your upbringing, life experiences, and ultimately your personality.

For a lab manager or physician, it is best to evaluate this capacity (or its absence) in the individual during the hiring interview for the sleep tech position. For the sleep tech, the most valuable lesson is to look back over any titration that didn’t succeed and focus on how well you engaged the patient. In addition to any of the technical issues you rehash, reflect on how well you and the patient communicated, how comfortable you or the patient felt that night, and how much satisfaction or frustration you felt about your efforts.

These dimensions reveal a great deal about your capacity to engage the patient. Therefore, every night you spend in the lab is your single best opportunity to assess your capacity to build trust and establish rapport, because you can always look back and relive the experiences in your mind to identify strengths and weakness regarding your capacity. From there, you can bring new ideas, attitudes, and techniques to the next titration from which trust will emerge and rapport will follow. Just give it time.

Barry Krakow, MD,, is author of Sound Sleep, Sound Mind, principal investigator at Sleep & Human Health Institute, and medical director at Maimonides Sleep Arts & Sciences Ltd (www.sleeptreatment.com), and blogs at www.sleepdynamictherapy.com. He can be reached at [email protected].