Improving Sleep Therapy

Introduction

While some people adjust immediately to sleeping with positive airway pressure, many find the change difficult. Some give up and allow a serious health problem to worsen. Some carry on with treatment—all the while believing that there must be some way to improve their therapy. If you are one of these people, then we have good news: you're right. Therapy can be more comfortable and more effective.

First, consider the goal of therapy. It's simple. You want to stop the effects of your sleep-disordered breathing (SDB): apneas, hypopneas, snoring, and flow limitation. By putting a stop to these things, you allow yourself to get healthy sleep. So, the first two steps will seem obvious.

Make sure that your therapy stops the apneas, hypopneas, snoring, and flow limitation caused by your SDB.

Use your therapy whenever you sleep, day or night. (This is what doctors refer to as treatment compliance.)

These two steps would be easy enough if you knew the quality of your therapy and your therapy were comfortable enough that you felt great using it. And so, knowing your therapy is effective and making it comfortable are the primary ways to improve it. Proper mask selection, AutoSet therapy, humidification, support networks, and education are the most effective ways to improve your therapy.

Mask Selection

When Colin E. Sullivan first used continuous positive airway pressure (CPAP) therapy to treat OSA in 1981, his patients could not choose a mask. They each received the best that medical science had to offer at that time—a mask that had to be glued on each night. Today, there are a number of manufacturers making many mask designs. Because face shapes and preferences differ so much between positive airway pressure (PAP) device users, the number of choices is a good thing. It does, however, present you with a challenge—to find the right mask.

We've listed some of the factors that we consider most important when selecting a mask: comfort, quality of air seal, ease of fit, quietness, convenience, and air venting. These factors are not the only factors to consider, and you may find that only one factor makes any real difference to you. Keep in mind that different people prefer different masks, and while there are some features that appeal to the majority of people, one mask isn't going to meet everyone's needs.

Comfort

The importance of comfort seems obvious, but unfortunately, many patients stop using their PAP device early on because the mask is uncomfortable.

Wearing a mask will be strange at first, just as wearing glasses or contacts is strange at first. However, you should be able to get used to it. If you cannot get used to your mask, try these suggestions.

• Contact your clinician and get another mask. Your quality of life, possibly even your life, depends on it. In some countries, insurance coverage may be an issue. Talk to your clinician or insurance provider to learn about your options.
• Ask your clinician to double-check the mask size and fit. Most masks come in several sizes. The first one you try may not be the best one.
• Ask your clinician if you can try a different style of mask. Most manufacturers produce several mask styles. While one may not work for you, another may be perfect.
• Find out about different mask styles. Find out which one makes you most comfortable.

Quality of Air Seal

A quality air seal is important for therapy because air leaks result in lower treatment pressure. If you don't get the correct treatment pressure, you may continue having apneas, hypopneas, and sleep arousals.

You should try as many masks as possible to see which one provides the best air seal for you. Most masks come in different sizes. A mask should not require tight headgear to maintain a seal.

Ease of Fit

Your clinician will fit your mask initially, but once you take it apart to wash it, you'll have to put it back together and fit it yourself. Make sure you understand how to fit the mask properly.

• Ask your clinician to show you how to fit the mask. Make sure that you can do it.
• Ask if there are any fitting guides you can use. If your clinician doesn't have any, call the mask manufacturer or check their Web site.
• Call the mask manufacturer if you have problems. They may have fitting guides or helpful hints.

Quietness

Some people find the white noise of the PAP device and mask soothing, but others need complete quiet to sleep. If you prefer silence to white noise, make sure you get a mask that won't keep you awake.

Convenience

The mask may fit you perfectly, but if it's so inconvenient that you won't use it, it's not doing you any good. Try to find a mask with the following features.

• It's easy to put back together when you take it apart. Remember, the first few times you put it together may be difficult. Make sure you have a fitting guide.
• Fitting it on a nightly basis doesn't take forever. If you have to refit a mask every time you put it on, you'll be less likely to use it.
• It's easy to take off and put on in the middle of the night.

Air Venting

Check the position of the exhalation port on the mask. Make sure the air flowing from that port won't disturb you or your partner. For example, if the exhalation port is placed right in the middle of the mask and there's no cover to direct airflow, the air can blow straight into your partner's face.

Humidification

Humidifying the air from your positive airway pressure device involves connecting a specially designed humidifier to your therapy system. Humidification is not necessary for all patients; however, adding a humidifier to your system may treat symptoms experienced by some people:

• nasal congestion, dryness, or tenderness
• mouth breathing (commonly referred to as "mouth leak")
• dry mouth or throat.

Treating these symptoms can improve the comfort and quality of your therapy. The following information explains humidification and why it improves therapy for some people.

The body's natural humidification process

The human body has its own humidification process that protects the respiratory system. Every time you take a breath, your nose, pharynx (behind the nasal cavities and mouth), and trachea (in the throat) add moisture to the air so that it does not dry out your lungs.

Your nose is responsible for about two-thirds of this humidification process. As the air passes further into your airway, it becomes warmer and more humid. By the time air reaches your lungs, it is at the ideal temperature and humidity. When you exhale, your nose conserves water by recovering about a third of the moisture present in each exhaled breath. That moisture is then used to humidify your next breath.

Environmental factors

Environmental factors can increase demands on your body's humidification process. If you travel to an extremely dry climate, you may experience a sore throat, nasal congestion, or irritated sinuses. You may also experience these symptoms in extremely cold climates—cold air tends to be less humid. In both cases, the lower humidity puts an extra burden on your body's normal equilibrium. Some people adjust quickly enough that the change in humidity doesn't affect them; some people may experience only temporary discomfort; however, some people may feel as if they can't adjust to the new climate.

Positive airway pressure (PAP) and your body's natural humidification process

Just as some people have difficulty adapting to less humid climates, some people have difficulty adapting to PAP. In essence, PAP therapy creates a new climate for your nose and upper airway because airflow is greater than what your body is used to humidifying—and the greater your treatment pressure the more difficult this task becomes. Your nose may become tender or dry, or it may respond to the new environment by creating more mucus to protect its sensitive tissues. A humidifier can prevent and even reverse these symptoms by treating the air before it even reaches your nose.

Mouth breathing

If you breathe through your mouth, you may develop a dry throat. By breathing through your mouth, you bypass your nose, which is responsible for two-thirds of humidification. So breathing through your mouth triples the amount of work on your upper airway. If you add positive airway pressure on top of that, you may start to experience stronger symptoms. Even if you're only exhaling through your mouth, you are still losing valuable moisture because your nose isn't getting back the moisture you added to the air as you inhaled it.

A vicious cycle

A 1997 study found that nasal symptoms cause mouth breathing and that mouth breathing causes nasal symptoms. Because one symptom causes another, a vicious cycle can develop.

Humidification options

Humidification can resolve and prevent all of the symptoms mentioned above, but not all systems supply the same amount of humidification. There are two types of humidification devices:

• heated humidification
• passive (unheated) humidification.

In heated humidification, the humidifier connected to your system has a hot plate and temperature control. You set the temperature, and the hot plate heats the water, creating water vapor. The pressurized air is now humid, so your nose and upper airway have very little work to do.

A heated humidifier can create a lot of water vapor, soothing extreme nasal dryness and irritation. Studies show that heated humidification is more effective than the alternative, passive humidification and can make therapy more comfortable.

In passive humidification, the air passes through a container half-filled with water. Most passive humidifiers direct the pressurized air over as large a surface area of water as possible, causing the air to "absorb" as much moisture as possible. However, because the water is at room temperature, the pressurized air absorbs relatively little.

Passive humidification is beneficial for minor nasal symptoms or mouth leak. These devices are also handy for travel because they weigh less than heated humidifiers.

Support Networks

Once you've received your positive airway pressure device and started your treatment, you may feel a bit overwhelmed. You might find it helpful to establish a support network. Here are three ways to "join" support networks.

• Join or start a local A.W.A.K.E. (Alert, Well, And Keeping Energetic) group.
• Enlist the help of your spouse, partner, best friend, or parent. Many patients have less trouble with therapy when their spouse, partner, or family member takes an active role in the therapy.
• Start reading and/or posting your questions on Internet newsgroups for sleep apnea patients.  

Education

While some people adjust immediately to sleeping with positive airway pressure (PAP), many find the change difficult. Some give up and allow a serious health problem to worsen. Some carry on with treatment—all the while believing that there must be some way to improve their therapy. If you are one of these people, then we have good news: you're right. Therapy can be more comfortable and more effective.

First, consider the goal of therapy. It's simple. You want to stop the effects of your sleep-disordered breathing: apneas, hypopneas, snoring, and flow limitation. By putting a stop to these things, you allow yourself to get healthy sleep. So, the first two steps will seem obvious.

• Make sure that your therapy stops the apneas, hypopneas, snoring, and flow limitation caused by your SDB.
• Use your therapy whenever you sleep, day or night. (This is what doctors refer to as treatment compliance.)

These two steps would be easy enough if you knew the quality of your therapy and your therapy were comfortable enough that you felt great using it. And so, knowing your therapy is effective and making it comfortable are the primary ways to improve it. Proper mask selection, autotitration therapy, humidification, support networks, and education are the most effective ways to improve your therapy.

Copyright © ResMed 2005, Used with Permission