CPAP ADHERENCE 1

Jill Stowe12/5/13611 PICO Paper

Will patients suffering from obstructive sleep apnea have a more successful

adherence to CPAP if nurse practitioners provide continuous follow up care opposed to

no psychological therapy and follow up care?

Background and Rationale:

Obstructive sleep apnea (OSA) is a major health issue affecting more than 18

million Americans. It occurs when the muscles in the throat fail to keep the airway open

while they sleep. This causes disturbed sleep and oxygen starvation, which may lead to

hypertension, heart disease and mood and memory problems over time. (Phillips)

“Continuous positive airway pressure (CPAP) therapy is a highly effective treatment for

OSA; however, despite the documented efficacy of CPAP in treating OSA, adherence

rates are poor, with up to 50% of patients abandoning therapy within 1 year,” (Pelletier

20). CPAP is considered the gold standard for OSA therapy, so many studies have been

completed recently to improve adherence to it. Research results show psychological

therapy and follow up care from either a nurse or a respiratory therapist has improved the

compliance with CPAP and OSA coping.

Search Methods:

Databases that were used to complete this research included Ebscohost and

PubMed Health. All of the major research was completed on these, however, some basic

research regarding obstructive sleep apnea and CPAP adherence rates were found using

the search engine, Google. The information taken from this site was minimal and mainly

contributed to background information. Key words that were included in the search

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process included: CPAP adherence, psychological therapy, and effectiveness. When only

one or two key words were used, there were too many results to find useful information

so it was necessary to use multiple key words. The limitations that were placed on the

search process included: English only, having the full article/study available, and being

published within the past 5 years in order to ensure current, up to date information.

Inclusion factors for the articles were if the control and experimental groups were people

living with obstructive sleep apnea and if the experimental group received either

psychological therapy or follow up care that the control group did not. An exclusion

factor was if the authors did not have a health or medical background to verify they had

thorough baseline knowledge of the subject. There were a total of three articles that were

analyzed for this and one other citation that was not a study but it provided baseline

information on the topic.

Critical Appraisal of the Evidence:

The first study that was analyzed was called “Increasing CPAP Adherence Using

Psychological Therapies.” Two doctors of nursing practice and a registered nurse

completed this study. It was published in the American Journal for Nurse Practitioners in

December of 2012. The study was completed at a hospital-owned pulmonary/sleep office

located in southern New Hampshire. Their goal was to determine if an improved

educational and relaxation training program would improve CPAP adherence opposed to

the usual care which consisted of verbal instructions and mask fitting only. The control

and intervention groups consisted of 25 people each who were between 21 and 80 years

old and were referred to receive CPAP therapy for their diagnosed obstructed sleep

apnea. People in the intervention group received the usual care and also received CD’s

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they were to listen to daily for two weeks until their first follow up appointment. The

CD’s were recordings of the consequences of OSA, how CPAP is the most effective

therapy and other relaxation techniques to try while using CPAP. Both groups were using

CPAP machines that contained an internal objective monitor or “smart card” that

recorded how many nights and minutes the machine was in use for 6 weeks. After the 6

weeks was completed, the card was taken out and the information was extracted from it.

The results of the study was that the intervention group used their CPAP machine for an

average of 81.36 hours and the control group used theirs’ for 67.12 hours on average.

While this study showed an improvement with the educational therapy and follow up of

the intervention group, it was not statistically significant (P = .389). Limitations of this

study was the small sample size, the lack of ethnic diversity which makes it difficult to

generalize to everyone with OSA and the study only lasted 6 weeks which does not show

long term is effectiveness. This study was able to provide the world with preliminary

evidence that that educational follow up care and providing the patient with more than

just basic care can help to improve the adherence rate. (Pelletier)

The next study was entitled “Role of a Respiratory Therapist in Improving

Adherence to Positive Airway Pressure Treatment in a Pediatric Sleep Apnea Clinic.”

This study focused specifically on pediatric subjects who are known to be one of the

biggest offenders of poor CPAP adherence. Six doctors and two respiratory therapists

completed this study in March of 2013. They completed this study on 46 children ages 8

to 20, all the kids were diagnosed with obstructive sleep-disordered breathing and are

using Positive Air Pressure therapy. Twelve of the kids (26%) had a 0% adherence to

their CPAP therapy and another 26% had only used their CPAP 1-50% of the time they

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were supposed to. The group of subjects in the experimental group was given respiratory

therapy along with the CPAP machine. The therapist was responsible for evaluating the

mask for the correct fitting, educating the children, parents and families on the

importance to wearing their CPAP machine, follow up care to remind them of the

treatment, explaining the features of the machine, downloading CPAP information for the

patients to take home, etc. The results showed that the children who had a 0% adherence

to the CPAP machine before the follow up care of the respiratory therapist, had a

significant improvement on their adherence of 70% on average. The children who only

used their machine 1-50% each improved by 22% on average and the children who were

already using the machine more than 50% for a baseline did not have any significant

improvement. This study showed that through follow up care by a respiratory therapist,

children who never used their CPAP machine had a 70% improvement, proving that if

health care professionals take the time to make sure the patients are actually using the

machine they gave them, it could really help adherence to it. The limitation to this study

is that the patients were all pediatric patients so it is difficult to generalize to the entire

adult population. Children are very impressionable and their parents tell them what to do

so it may have had a different outcome, had the subjects been older. (Jambhekar)

The third study was completed on 1,100 participants in 17 different trials by

researchers from the Cochrane Collaboration (an international research network) in

September of 2011. All of the participants had obstructive sleep apnea, most of them

severe, and were all using the CPAP machine for the first time. The control group

received their machine and had it explained as well as provided with information about

the CPAP but no additional support was provided afterwards. The experimental group

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received intensive support after the initial education. Along with the basic teaching, these

people were provided with additional programs, which aimed to give them a thorough

introduction to why they should use the CPAP machine, about the features, the dangers of

not adhering to the treatment and providing the participants with follow up programs as

well as people to talk to for support or if they have questions. The study confirmed that

intensive psychological and practical support led to the subjects using their CPAP therapy

for longer each night than the control group. They discovered in one of the trials that 54

out of 100 people who received the therapy used the machine for more than 6 hours each

night whereas in the group that did not receive the therapy, only 15 out of 100 subjects

used it for at least 6 hours a night. This study’s strengths are the much larger sample size

and the multiple trials they completed. A drawbacks of this study was that the results

were vague, only one of the trials had numerical data results and the for the other trials,

the author only stating that there was “improvement.” Since we do not know how much

improvement there was, it is difficult to judge the results.

Evidence Synthesis:

Each of the articles that were reviewed acknowledged right in the beginning that

OSA is a huge problem in America today and while CPAP therapy is the best way to

manage it, adherence is a major issue. People simply do not enjoy sleeping with the

machine and most of the time abandon it soon after it is given to them and hardly ever

make it through the night without taking it off. Since this is the best way out there is

manage OSA, researchers have set out to discover how to get people to use it. Instead of

giving the machine to people, teaching them how to use it and never seeing them again,

like it has been in the past, these three studies had an experimental group of people who

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were given intensive follow up care, psychological support and extensive education about

OSA as well as how important it is to manage their symptoms. Each of the three studies

found that to some degree, providing patients with this follow up care improved their

adherence to the therapy. Some of the studies’ results were more statistically significant

than others but they all involved improvement. None of the studies concluded that follow

up care was useless and provided no improvement. Even if improvement is minimal, in

the long run, it could make a big difference.

The studies all had limitations as well. Some of them were vague with the results

or overly analyzed and complicated them so it is not helpful to the general public. The

studies were also relatively small in size and did not last very long.

Clinical and Research Recommendations:

The results of these studies clearly demonstrate that CPAP therapy is not

something that can be given to a person and then assume they are using it. Health care

professionals, such as doctors, nurses and respiratory therapists, who will be giving

patients this machine, need to acknowledge that CPAP is not a treatment that you can

give once and move on. Follow up care, psychological support and intensive educational

programs must be provided to every person, of every age, who is receiving one as a way

to manage OSA. The follow up care must be a lifelong dedication to ensure that the

person does not eventually give up on it. Obstructive sleep apnea is not a problem that

medical professionals can fix, only the symptoms can be managed. If they are not

managed effectively, it could cause major health problems in the future. Most patients

are not aware of the long term consequences to not using CPAP so in order to guarantee

they do, long term follow up care by nurses is essential.

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Future research in this field is clearly still necessary. Most trials were short-term

and none of them followed patients receiving life-long follow up care. Most of the studies

were relatively small and it is still unclear as to what type of follow up care was the most

effective, i.e. educational programs, relaxation therapy, videos etc. While this field of

research is still developing, it is important for nurses today to be aware of the low

adherence rate to CPAP and prevent assumptions that just because they were given the

machine, they will use it because that is clearly not the case.

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Works Cited

Jambhekar, S. K., Com, G., Tang, X., Pruss, K. K., Jackson, R., Bower, C., & ... Ward,

W. (2013). Role of a Respiratory Therapist in Improving Adherence to Positive

Airway Pressure Treatment in a Pediatric Sleep Apnea Clinic. Respiratory Care,

58(12), 2038-2044.

Pelletier, C. A., Kameg, K. M., & Barret, R. (2012). Increasing CPAP Adherence Using

Psychological Therapies. American Journal For Nurse Practitioners, 16(11/12),

19-24.

Phillips, B. (2013). Sleep Apnea and Sleep. National Sleep Foundation. Retrieved

December 9, 2013, from http://www.sleepfoundation.org/article/sleep-related-

problems/obstructive-sleep-apnea-and-sleep.

Obstructive Sleep Apnea: Can Specific Support Improve the Use of

CPAP Therapy? (2011). In PubMed. Retrieved December 9, 2013, from

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0016276/