Clinical Review

How to Make Your Patient With Sleep Apnea a Super User of Positive Airway Pressure Therapy

Fed Pract. 2016 March;33(3):14-22

References

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Treatment of congestion requires education, as many patients improperly use these sprays. The steroid spray is not an instant vasoconstrictor; a week of regular use is needed to reduce inflammation and congestion. Saline spray and saline irrigation can be used as a treatment adjunct for symptoms of chronic rhinosinusitis.³⁷If the steroid and saline sprays fail after a 2-month trial, consider an ear-nose-throat (ENT) consultation. A recent study found that adherence rates increased after septoplasty in patients with nasal obstruction.³⁸ The throat is examined for macroglossia or scalloping of the tongue.³⁹ Macroglossic Mallampati IV tongues are platterlike. They are big, long, and wide and often have impressions or scalloping along the outside from a molding of the teeth. The patient is shown a Mallampati diagram and given a Mallampati score.

Creating a Sense of Mission

The sleep physician assistant (PA)at the Detroit VAMC is a retired U.S. Army colonel who ensures that the language the physician uses aligns with the language veterans use. Behavioral techniques are used to create a common culture that helps overcome obstacles—allowing patients to understand the benefits of and need for full CPAP/BPAP therapy adherence. One technique reinforces their sense of mission accomplishment, their military pride, and their interservice rivalry to increase adherence. The mission with each patient is to “work until success is achieved...but the patient can’t quit.” The mantra given to a patient with a difficult case is, “We will not let you fail with CPAP/BPAP therapy,” which echoes a familiar military motto, “We will not leave you behind.” Also, the goal of the physician is: Never give up on the patient.

Behavioral and Psychological Principles

The behavioral and psychological principles for success with PAP super users should be studied to validate better outcomes with longer duration PAP machine use. Patients who are motivated to succeed and to participate in their care can make great strides in changing their behavior to get more and better sleep. Obese patients can get referrals to the MOVE! weight loss program. Some veterans simply follow instructions, pay attention to detail, and do what they are told regarding sleep, PAP education, and good sleep hygiene. Many veterans have poor sleep hygiene and insomnia because they watch television or play games on electronic devices right before bedtime. Many patients develop behaviorally insufficient sleep syndrome. Their behavior prevents them from going to bed at a time that will allow sufficient sleep. Some veterans smoke or drink caffeinated beverages or al cohol immediately before sleep time and then wonder why they have insomnia.

Veterans with insomnia may be referred to the insomnia clinic psychologist for cognitive behavioral therapy for insomnia.⁴⁰ Referral to this psychologist can be very helpful in the treatment of insomnia after the patient’s OSA has been treated. Veterans are encouraged to follow good sleep hygiene principles and permanently discontinue detrimental sleep behaviors.

For veterans with PTSD, imagery rehearsal before sleep has been effective in resolving disturbing nightmares and excluding their violent details.⁴¹ Clinicians recommend that these veterans rehearse a pleasant dream before sleep time. Cartwright and Lamberg performed extensive research on dreams and nightmares, and their book may provide insight into reducing nightmares for veterans with severe PTSD.⁴² Persistent nightmares associated with PTSD also can be reduced with use of prazosin.⁴³

Sleep Clinic Economics

The economic impact of OSA is substantial because of increased risk of cardiovascular disease and risk of motor vehicle accidents and decreased quality of life and productivity. Results of cost-effectiveness analyses support the value of diagnosing and treating OSA. Studies have provided estimates from a payer perspective, ranging from $2,000 to $11,000 per quality-adjusted life year over 5 years for treating moderate-to-severe OSA. The Sleep Heart Health Study showed that OSA was associated with an 18% increase in predicted health care utilization based on medication use.^44,45 Moreover, CPAP therapy was found to be clinically more effective than no treatment: Therapy increased life expectancy in males and females, and effective treatment of OSA was associated with lower health care and disability costs and fewer missed workdays.

The authors’ initiatives to improve PAP therapy adherence required adding a PA and a registered respiratory therapist (RT) to the staff of 2 full-time equivalent (FTE) board-certified sleep physicians. The sleep physicians trained the PA to initiate and complete all the recommendations described, and the PA attended an AASM-sponsored review course for additional training. The PA is responsible for performing comprehensive face-to-face clinical evaluations in 4 half-day clinic sessions each week, as well as providing follow-up care in 4 additional half-day clinic sessions each week.