What are the common reasons for noncompliance with nasal CPAP (n-CPAP) for the treatment of sleep-disordered breathing (SDB)?

Updated: Feb 13, 2020
  • Author: Vittorio Rinaldi, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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One problem with n-CPAP is that although this modality provides good improvement in symptoms and physiologic parameters, compliance with treatment is not good, with regular use sometimes estimated as low as 30% (46% in one study defining use as at least 4 hours/day, 5 days/week). Noncompliance has been classified by Zoula et al into the following categories [88] :

  • Tolerance problems
  • Psychological problems
  • Lack of instruction, support, or follow-up

Tolerance problems may be due to side effects (ie, dry mouth, conjunctivitis, rhinorrhea, skin irritation, pressure sores, nasal congestion, epistaxis), mask leaks, difficulty exhaling, aerophagia, chest discomfort, and bed-partner intolerance. [82]  Psychological problems include lack of motivation, claustrophobia, and anxiety. The suggestions below for dealing with some of these problems may assist the physician in improving treatment compliance.

Many patients report claustrophobia. They find that the sensation of covering the nose with a mask makes them so uncomfortable that they cannot tolerate wearing the n-CPAP device. Sometimes this can be helped with a smaller or more transparent mask design. Use of nasal pillows (inserted into the nostrils) instead of a formal nasal mask may allow such patients to tolerate n-CPAP.

Some patients have trouble tolerating the initial pressure. Especially when higher pressures (>12-13 cm H2O) are required for elimination of apneas and hypopneas, this level of pressure may be uncomfortable. Many n-CPAP machines have a built-in ramp or gradual increase in pressure. With this feature, the mask can be placed and pressure begun at a very low and easily tolerated level. Over 30 minutes, the pressure gradually builds to the full amount necessary. Often, the patient can fall asleep during this time. Full pressure is not used until the patient is actually asleep.

Patients may experience nasal obstruction. Evaluation by an otolaryngologist reveals whether this is predominantly a fixed skeletal obstruction or a soft-tissue obstruction potentially modifiable without surgery. Marked septal deviation or turbinate hypertrophy usually requires surgery for resolution. Alar collapse may be adequately treated by internal or external dilators (eg, Breathe Right strip, Nozovent). Surgery is sometimes required for repair of marked alar collapse.

Mucosal edema may be due to allergic rhinosinusitis or to vasomotor or irritative rhinitis. Allergy testing and treatment and pharmacotherapy trials (eg, topical steroids or antihistamines, oral antihistamines, or decongestants) may be beneficial.

One way of determining whether sufficient potentially reversible mucosal edema exists to warrant pursuing that avenue of treatment is to perform the topical decongestant test. The patient uses a nasal topical decongestant (eg, oxymetazoline) at bedtime for several days, with the patient and bed partner observing for any improvements in snoring or apneas. A marked improvement suggests potentially reversible mucosal edema as a main contributor to the nasal obstruction. Failure to improve suggests a fixed skeletal obstruction that requires surgical correction.

Sometimes the dryness of the air or its temperature may be irritating to the patient. Use of inline humidification and warming of the inspired air may alleviate patient discomfort. [89, 90]

A number of patients report facial or nasal pain. Sometimes this pain can be related to a poorly fitting mask. With the many different types of masks available now, different styles and sizes can be tried to select the optimal fit for each individual anatomy. Because the mask is pulled tight against the face, an edentulous anterior maxilla may not provide the resistance necessary for a good fit. Leaving dentures in at night can help with this.

If the facial or nasal pain persists despite mask refitting, evaluation for nasal obstruction or chronic sinusitis may be helpful. The CPAP Pro delivery method anchors the tubing to a platform based on an upper retainer, obviating the need for a forehead strap.

Patients may experience dry eye or other eye discomfort. If the mask does not seal well, egress of pressurized air from the upper end of the mask toward the eye may occur, causing dry eye or even exposure keratitis. Mask refitting usually eliminates this problem.

Patients may sleep with the mouth falling open, awakening with dry mouth. Sometimes a chin strap is required to prevent the mouth from opening at night. A commercially available disposable adhesive bandage may used to pull the chin up toward the lower cheeks. [91]

Patients may experience epistaxis. This may be related to the high-flow dry air and may be helped by humidification and warming of the inspired air.

Some patients experience nasal drying. Forced dry air can be irritating to the nose, encouraging mucosal inflammation and crusting. Use of humidified air for n-CPAP usually eliminates this problem.

Other problems may also occur. Pneumopericardium has been reported with n-CPAP. [92]  Pneumocephalus has occurred when n-CPAP was used in a patient with cerebrospinal fluid rhinorrhea. Eustachian tube dysfunction, serous otitis media, bulging of the eardrums, and eardrum perforation have also been reported.

Rigorous patient education and early reinforcing follow-up may improve long-term use of n-CPAP.

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