A CPAP acclimation trial increases treatment compliance.

 Nearly every night, sleep disorder centers are on the front line of the CPAP adherence struggle. This is where the CPAP compliance so paramount and sought after by physicians, durable medical equipment carriers, and sleep technicians often begins. Therefore, once a patient has undergone a sleep study with therapeutic intervention, we must go to this figurative front line and examine the role of sleep laboratory processes in CPAP adherence.

The primary objective of a CPAP acclimation trial (CAT) is to familiarize patients with a properly fitted, comfortable mask and with continuous positive pressure prior to testing. This is important because if a patient requires a split-night study and therapeutic intervention must begin halfway through the night, then that patient will be more receptive to a therapy he or she is somewhat familiar with than a completely foreign one.

A patient’s initial introduction to CPAP therapy requires a series of events that needs to occur between that patient and the sleep technician. This symbiotic relationship requires an exchange of education and demonstration, which will benefit both parties when, and if, the implementation of CPAP therapy is needed.

The CAT was developed to allow polysomnographic technicians to invest time in adapting each patient to CPAP therapy prior to testing. By examining the 11 categories that make up the CAT, this article will describe its benefits as well as the techniques that will best serve each patient for a trial and relate those techniques to the settings found in most laboratory environments. These categories are: proper setting and education, time allotted, patient positioning, masks montage, mask fitting approach, application of pressure and heated humidity, patient control, patient adaptation to pressure, troubleshooting, time management, and documentation.

1: Proper Setting and Education
Once a patient has acclimated to the room where the sleep test will take place, completed sleep-related questionnaires, and finished any additional procedures prior to testing, then it is time to begin the CAT. Many sleep centers utilize patient education in different ways, but the end result is that the patient is comfortable with the hookup application process, the testing procedure, and the possible initiation of CPAP therapy should the type of study at hand or the type of protocol the laboratory follows per test ordered require it. Though a sleep clinician or referring physician likely has spoken with the patient about sleep testing during his or her consultation, it is beneficial to cover the basics of the sleep laboratory experience. Some sleep centers may use a video to explain the sleep test experience, the pathology of OSA, and noninvasive therapy. Other centers may choose to not use a video and to educate patients verbally. Either way, this educational process needs to be in place prior to the beginning of a CAT.

2: Time Allotted
Sleep technicians need to spend an adequate amount of time acclimating patients by making sure their masks are fitting comfortably, as well as properly setting individual positive airway pressures. Some patients may easily adhere to the mask and pressure, while others may require more time because of a lack of mask comfort, pressure setting issues, anxiety, claustrophobia, facial hair, or facial deformities. Usually, 15 to 30 minutes is an adequate amount of time for this consultation to be effective, but again, this is dictated by the patient who is under your care.

3: Patient Positioning
The acclimation trials are best performed before the overnight test hookup process for better mobility takes place. At this point patients are not yet restrained by testing equipment or overwhelmed with the procedure.

First, position the patient by having him or her sit at the bedside in a chair. That way the technician can begin showcasing different masks and initiate pressure before the patient is lying down. By having the patient sit in a chair, the technician can slowly graduate that patient to a lying down position. Some patients never sleep supine anyway, so there is no reason to put them at a disadvantage to begin with.

4: Masks Montage
Sleep technicians each have their own favorite repertoire of masks that they like to showcase to patients. This selection is usually narrowed down to three to five masks based on the technician’s experience and the process of elimination for those other 20 masks that either have been outdated or just did not make the grade. Granted, there are plenty of mask types, styles, and manufacturing companies to choose from; however, process and experience usually narrow individual mask selection down to a handful. A sleep technician’s experience is a key factor in mask selection because the technician is the one who must be able to acknowledge the patient’s anatomical features, such as facial hair or a deviated septum, and the feedback from the patient regarding mouth breathing. As mask innovations and concepts keep pace with our growing sleep industry, it is imperative to stay attuned with CPAP technology and apply it effectively in a clinical setting. Most CPAP manufacturing companies will provide a sleep center’s staff with in-service training and sometimes continuing education units that help staff meet sleep laboratory or academic standards.

5: Mask Fitting Approach
Two important exchanges need to take place at this point in the fitting of the mask to the patient. The first is that the technician should recommend which mask out of his or her montage fitted the patient the best. The technician should ask the patient which mask felt the most comfortable; this is the most important component of mask fitting as comfort is key in compliance at home. A patient may have an light-colored machine that looks attractive in a home, no pressure problem complaints, and adequate humidity, but if he or she has an uncomfortable mask, then the door is wide open to poor compliance and possible treatment failure.

6: Application of Air Pressure and Heated Humidity
Always start CPAP during a trial at a minimal level of positive pressure. Most sleep journals and laboratory protocols put this somewhere between 3 and 5 cm H2O. Education is vital at this point. Prior to the patients consuming their first breaths of positive pressure, conduct a good quick review to remind them to keep their mouths closed (unless a full-face mask is used) and make them aware that the air they are about to breathe is filtered regular air with a little pressure applied, not oxygen alone. A good recommendation is to have heated humidification initiated at this point and throughout the entire therapeutic portion of the study as numerous published articles have shown improvements in compliance and lessened complaints of nasal difficulties when heated humidification is used.

7: Patient Control
Once a technician has properly fitted the mask and is ready to initiate CPAP, there are three important steps:

 Allowing the patient to hold the mask gives him a feeling of control and makes the experience less threatening.

Step 1: Give the patient control. When the patient is sitting and about to take that first breath of filtered positive air pressure, give him or her control of the device. Do not attach the mask headgear. Instead—being careful to instruct the patient not to block the air diffuser—put the mask or the point where the hose attaches to the mask in the patient’s hand and tell the patient to slowly put it over the nose (or nasal-oral area if a full-face mask is used) and begin breathing. By giving the patient control, it eliminates forcing the mask toward the patient’s face and allows the patient to begin when he or she is ready and stop and remove the mask when he or she finds it necessary.

Step 2: Practice in intervals. It is a good idea to tell the patient to practice in intervals with each interval growing in mask-wearing time or pressure. Creating this patient control will make the patient more comfortable with the CPAP device which promotes adherence. Once the patient becomes comfortable with the procedure while sitting, ask the patient to try lying down flat on the bed with the device applied and continue breathing. The intent now is to mimic the setting required during a CPAP titration or, once completing the diagnostic portion of a split-night study, when beginning noninvasive therapy.

Step 3: Patient practices alone. A last recommendation is for a technician to step out of the room and let the patient perform this procedure without supervision while sitting or lying on the bed. While this is happening, the technician can assume duties on another patient, check on the patient from the technician control room using audio and video equipment, or make intermittent visits to the patient’s room to see how the patient is coming along.

This is an effective method because the patient becomes responsible and does not feel the pressure of someone watching over him or her. By the patient assuming responsibility and having control over the CPAP device, a successful CAT is in store.

8: Patient Adaptation to Pressure
Once the patient is comfortable and breathing on the minimal positive pressure (3-5 cm H2O), check the CPAP remote control in the technician control room to see if the patient has excessive mask leaks or mouth breathing. Once verified that the pressure flow is stable and the mask has a good seal, consider increasing the pressure to a moderate level. By initializing this increase, the objective is not to find an optimal pressure as that would be clinically insignificant because the patient is awake, but to give the patient a sense of what the feeling would be like on CPAP at a level above the minimal trial pressure. As many technicians have observed, patients that fall asleep on a minimal therapeutic pressure sometimes awaken on an increased pressure level alarmed and startled, resulting in a temporary or elongated awakening. The intent with increasing the pressure at the end of the trial is to familiarize the patient with a comfort zone at a higher level.

9: Troubleshooting
During any acclimation trial or nocturnal titration with CPAP, problems can develop so a sleep technician’s troubleshooting experience comes into play. Patients frequently report difficulties exhaling, struggling to get enough air, being unable to catch their breath, and not managing to breathe only through the nose. All of these problems can result in the escalation of anxiety and discontinuation of CPAP use if not addressed quickly and adequately. If the problem is inadequate air pressure or struggling to breathe, consider adjusting the pressure on the CPAP first. By tweaking the CPAP pressures (increasing pressures in 1-2 cm H2O increments), the primary objective is to find the setting where the patient is comfortable and receptive to a pressure that he or she could relax and fall asleep on.

Other options are available for patients who complain of difficulties exhaling on continuous pressure. For example, the technician can switch the patient to bilevel ventilation to provide reduced exhalatory pressure relief. Newer clinical ventilation systems in sleep laboratories may have other innovative options for flexibility or optimal humidification delivery to benefit certain patients depending on the basis of their complaints.

10: Time Management
Though all of the content mentioned in this article may seem like a lot to do in the little time allotted for a technician with a 2:1 patient-to-technician ratio, a CAT may be time well spent. Depending on the patient’s ability to adapt to CPAP, a CAT can last anywhere from 10 to 45 minutes.

A rarely mentioned primary skill of a sleep technician is patient time management. Taking for granted that most technicians are performing two studies per night and patients are staggered at different times when they are scheduled for their sleep studies, time utilization with each patient is a skill that experience in the field will prove priceless.

Why do a CAT on every patient?
Not every patient will be split or titrated so one may ask, why perform this process on every patient? Some may not even need positive airway pressure anyway. This is a good question, but there are benefits to performing a CAT on every patient. Sleep laboratory protocols vary as some facilities do only nocturnal polysomnograms while other centers will diagnose and treat in the same night provided the split-night protocols met minimal AHI criteria.

For those patients that are not split on their initial study and have physicians that would like them to return for titration, the benefits include that the patients are already familiar with CPAP therapy and that the technicians know what masks fitted the patients well and what levels of pressure the patients experienced during their CAT.

Another benefit is for those patients that report to the sleep laboratory without the Pickwickian physical features commonly seen in sleep apnea patients, such as a thick neck, obesity, or overweight. For these patients, retrognathia or other physical deformities sometimes end up being moderate or severe and meeting the split-night protocol is more difficult. Therefore, it is beneficial to implement the CAT procedure.

11: Documentation
Since a CAT is considered to be therapeutic intervention, it is recommended but not required to document that a trial was performed on a patient. By listing the minimal pressure and increased pressure that the patient was acclimated to, this procedure is documented in the permanent record. In addition, documenting the CAT in the patient record shows that adequate time was committed in this process.

Some laboratories may already have this CAT process as a policy and procedure. Others may want to adopt this method to provide optimal CPAP adherence and patient satisfaction.

The intent of CAT is to avoid slapping an unfamiliar mechanism on a patient in the middle of the night and expecting the best outcome with limited education and no acclimation process in place. For a patient to be successful with CPAP therapy at home, he or she must first be comfortable and receptive to CPAP therapy at the sleep laboratory. The objective is to have a process in place to benefit a patient that will require CPAP therapy. Comfort is the key to a compliant patient. Without comfort, one can try to be compliant but never reap the optimal benefits of CPAP. Therefore, the nightly sleep testing “front line” is where we make a difference.

Jeffrey B. Wathen, RPSGT, is a sleep laboratory supervisor at St. Anthony’s Medical Center, St Louis.