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PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
PAP Therapy Compliance
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PAP Therapy Compliance

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  • In 2008 the total population was around 304 million, and 4% of that is 12,162,389 people Cardiovascular disease, increased blood pressure, heart attack, stroke, depression….
  • We wanted to walkthrough the steps leading up to, and through a titration a patient experiences and touch on where proper education and information can help improve compliance in the long run. Brochures, Hand-outs, Website information
  • Here you can gauge important factors that may affect the patients sleep…. Hygiene, bed partners, and so on… Here is break down of this consultation….
  • Again, written materials to give the patient are very important! * Pass around brochure
  • Make sure as a tech you use your time wisely and constructively…
  • Now to go more specifically into pt education…. The more the patients know and understand the more comfortable they will be.
  • This helps familiarize the patient with the equipment and make them more comfortable…
  • Diagrams produced by Respironics…
  • This is a brief form of desensitization, we will touch on this more specifically later on in the presentation…
  • Some orders are asked to be sent immediately to the doctor Be brief
  • Proper disinfectant solutions can be found through research on the internet
  • Encourage patients to work closely with their sleep doctor and CPAP supplier to make sure they have the correct mask, tubing, machine, etc that works best for each individual… Again remember time constraints…
  • Jennifer wanted us to touch on these two specific new approaches directly .
  • This is a new program that is delivered through a series of follow up visits or phone calls after the titration.
  • Communication is very important throughout the MET program…
  • Here are examples of the questions the patient would be asked throughout this therapy…
  • Transcript

    • 1. Enhancing and Improving PAP Therapy Compliance
    • 2. Enhancing and Improving PAP Therapy Compliance
      • Obstructive Sleep Apnea Syndrome (OSAS) is a common condition affecting 2-4% of Americans.
        • (Only 20% of those 2-4% are actually diagnosed)
      • Although OSAS is a known risk factor for a number of diseases, and other health risks, it often goes undiagnosed and dismissed.
      • Positive Airway Pressure (PAP) continues to be the gold standard for treatment of OSAS.
    • 3. Enhancing and Improving PAP Therapy Compliance
      • Ensuring compliance with PAP therapy can be very challenging and rewarding.
      • Many patients find PAP therapy uncomfortable, inconvenient, and bothersome; although the benefits of using PAP therapy are high.
      • The many obstacles and barriers to PAP compliance can be tackled in numerous ways and through different techniques to apply to many different patients.
    • 4. Initial Patient Contact
      • Establishing and maintaining a standard of practice for PAP therapy is essential for enhancing compliance.
      • Consistent and relevant information must be communicated to the patient during their initial contact with a sleep professional, during treatment, and through a follow-up.
    • 5. Initial Consultation
      • Patients must initially meet with either a sleep physician or their primary care physician to be referred for an over night sleep study.
      • Meeting with a sleep or primary care physician for a sleep consultation
        • Most often involves…
          • Physical examination
          • Review of medical history
          • Review of sleep habits and environment
          • Review of OSAS, what it is, and health risks associated
          • Review of over night sleep studies and what they include
    • 6. Initial Consultation cont …
        • Also, written materials and educational videos should be provided to increase knowledge and comfort with…
          • Over-night sleep studies
          • Split night studies
          • Obstructive Sleep Apnea (dangers associated with)
          • Continuous Positive Airway Pressure
          • Alternatives to PAP Therapy
    • 7. Second Contact
      • Second contact for a patient is most often with a sleep technologist during the sleep study.
        • Here, previous education of the patient will prove to be most useful
      • For patients who have not received this information…
        • During the introduction of tech to patient, hook-up, and just before lights off techs are responsible to make the patient comfortable with the process
          • Remember, even a short investment of time before not only a PSG, but also a split night and or titration can make a considerable difference
    • 8. Post Diagnosis
      • Once a diagnosis of sleep disordered breathing has been shown positive through a PSG, the education process must again begin in an effective manner.
      • Different approaches, techniques, and media need to be readily available and provided to the patients to improve the continuing of education.
          • It is crucial for patients to leave the lab and or physicians offices’ with all the information necessary to make informed decisions.
    • 9. Patient Education
      • General Patient education has been proven time and time again to be a very crucial aspect in regards to positive compliance when using the different PAP therapy treatments and equipment.
    • 10. Patient education
      • Patient education is defined as the process that evolves from an exchange between health professionals and patients.
      • Patient education should be viewed as one of the most rewarding and gratifying things a sleep technologist faces every day on the job.
      • Due to a lack of time and tools this can be a frustrating task.
    • 11. Pt education involving the sleep tech
      • The sleep tech for a titration needs to explain different aspects of PAP therapy as well as options for comfort and compliance
        • Explain how CPAP works as far as how the positive air pressure operates from the machine to hose, hose to mask, and mask to airway as a physical stint in the airway
        • Explain the titration will begin at the lowest pressure (unless prescribed with specific directions from a doctor) and increased as needed throughout the study
        • Explain to the patient that normal acts such as talking, swallowing, and exhaling will feel awkward but PAP therapy takes time to adjust to.
    • 12. Pt education involving the sleep tech cont …
      • Also during a titration the sleep tech may find it crucial to explain…
        • Humidification, how it works, and the benefits from using humidification
        • CFLEX / BiFLEX
        • Ramp times
        • CPAP and BiPAP, the differences between the two, and why a patient may be ordered from a doctor to use BiPAP over CPAP and vice versa
    • 13. Pt education involving the sleep tech cont …
      • CPAP / BiPAP
      • CPAP – A CPAP machine delivers positive air pressure through a CPAP mask at a constant rate. CPAP works as a physical stint in your airway.
      • BiPAP – A BiPAP machine delivers two pressures, one which is higher when a person inhales, and a lower pressure upon exhaling. This is more comfortable for patients who have trouble “breathing out against” different CPAP pressures.
    • 14. Pt education involving the sleep tech cont …
      • Humidification
      • Humidification adds moisture to the CPAP / BiPAP air pressure reducing irritation to the nasal passage caused by the increased airflow.
        • Heated Humidifier – Uses heat to produce moisture
        • Passover Humidifier – Is room temperature and delivers moisture
    • 15. Pt education involving the sleep tech cont …
      • CFLEX / BiFLEX
      • CFLEX makes sleep therapy more comfortable for the patient by reducing pressure at the beginning of exhalation and then returns to therapeutic pressure just before inhalation.
      • The level of pressure relief varies based on the patient’s expiratory flow and which of the three CFLEX settings has been selected
    • 16. Pt education involving the sleep tech cont …
      • CFLEX…
    • 17. Pt education involving the sleep tech cont …
      • CFLEX / BiFLEX
      • BiFLEX pressure relief offers pressure relief at inhalation and exhalation to make BiPAP therapy more like natural breathing. By tracking each breath, relief is delivered at three critical points in the breathing cycle…
      • 1.) The transition from exhalation to inhalation
      • 2.) The transition from inhalation to exhalation
      • 3.) During exhalation.
    • 18. Pt education involving the sleep tech cont …
      • BiFLEX…
    • 19. Pt education involving the sleep tech cont …
      • Ramp Time
      • Ramp time allows for a gradual increase of pressure as the patient falls asleep.
      • Ramp time is usually measured in 5 min. intervals, ranging between 5 to 45 mins to ultimately reach the patients prescribed pressure.
    • 20. Pt education involving the sleep tech cont …
      • Mask types and what kind of CPAP mask to start the study on also must be addressed (again, unless specifically prescribed by a doctor.)
        • The three mask types are…
          • Nasal mask – Seals around the nose, is the most commonly used mask, and has many varieties.
          • Full face mask – Covers mouth and nose, most effective for mouth breathers, and due to its size claustrophobia is more prevalent when using this.
          • Nasal Pillows – Two plugs that sit inside the nostril, more effective at lower pressures, the best choice for people who are claustrophobic.
    • 21. Nasal Masks… Flexi-Fit Nasal ComfortGel Mirage Micro
    • 22. Nasal Pillows… ResMed Swift LT Opus Mirage Swift
    • 23. Full Face Masks… Fisher Paykel Flex-Fit Mirage Liberty Comfort Full
    • 24. Pt education involving the sleep tech cont …
      • Fitting for the correct mask size and fit after the patient chooses a mask also is crucial to a successful PAP titration
        • Asses the nose and mouth of the patient and try different sizes to get the best fit
        • Explain the different mask parts and how they work to the patient during this trial period
    • 25. Pt education involving the sleep tech cont …
      • After the patient chooses a mask comfortable to them, allow the patient to hold it on their face and feel the CPAP pressure being delivered to their airway.
        • Tell the patient to relax and take several deep breaths in and out against the pressure
        • Unless using a full face mask let the patient know the mask will be ineffective if they can not keep their mouth closed during this period
        • Ask the patient after trying CPAP if there are any concerns or problems with the pressure and or mask they chose
    • 26. Pt education; involving the morning after the titration…
      • Touch on procedures as far as actually receiving the patients equipment
        • This differs from lab to lab and from patient to patient
          • Time it will take for a patient to actually receive their equipment
          • How equipment will be delivered
          • Explanation of the different equipment and how it operates
    • 27. Pt education; involving the morning after the titration…
      • Briefly address different and crucial cleansing techniques that deal with the patients’ different masks and tubing…
        • Soak tubing in a liquid detergent and warm water
        • Wipe mask, headgear, and or pillows with a damp soft cloth
        • It is recommended to disinfect your mask every third day with either a vinegar and water solution or a suggested disinfectant solution
          • Note: It is suggested that these cleaning techniques are done weekly
    • 28. Pt education; involving the morning after the titration…
      • Also briefly touch on proper care and cleansing of the actual CPAP machine…
        • Keep the unit clean by wiping it down with a clean damp cloth as needed
        • Do not store or use the CPAP on the floor (Dust and other particles can negatively affect the unit)
        • Check the filter regularly and replace or clean the filter as directed when receiving the CPAP machine
        • Remember to also encourage the patient to replace / update needed parts as directed…
    • 29. Different Mask-Related issues that may be questioned…
      • Patients will often have numerous questions or concerns about comfort and or different side effects not only during the titration but also the morning after their titration…
        • Here are a list of some of the most popular complaints that if addressed by sleep professionals immediately can increase the success of CPAP compliance
    • 30. Mask-Related Issues and Solutions
      • Adapting to the CPAP pressure
        • Instruct the patient to exhale while initialing placing the mask on their face
        • Use the flex and or ramp features
        • Add cool or heated humidification
        • Begin relaxation, encouragement, and desensitization techniques
    • 31. Mask-Related Issues and Solutions cont…
      • Noise Complaints
        • Use another source of white noise such as a fan or a device that produces background sounds
        • Recommend earplugs to both the patient and bed partner if needed
    • 32. Mask-Related Issues and Solutions cont…
      • Claustrophobia
        • First have the patient, while sitting up, hold the mask on their face without any pressure
        • Try to fit with many different styles of masks to find the most comfortable for the patient
        • Apply the mask to the patient while sitting up and then ask the patient to lie down
        • Provide distractions early on during the study such as the television or conversation
    • 33. Mask-Related Issues and Solutions cont…
      • Mask Leak
        • Adjust all straps and headgear for the proper fit
        • Apply the mask while pressure is on to ensure proper seal
        • Refit to a different size or style of mask
    • 34. Mask-Related Issues and Solutions cont…
      • Mouth Breathing
        • Try initiating chin strap to the patient
        • Initiate humidification
        • Try using different flex features
        • Switch to a full face mask
    • 35. Mask-Related Issues and Solutions cont…
      • Removing CPAP unknowingly During Sleep
        • Review and re-instate desensitization techniques
        • Check for proper mask fit
        • Activate disconnect alarm if available with equipment
        • Check for nasal congestion, this may cause the patient to remove CPAP, and should be addressed with their physician
    • 36. Mask-Related Issues and Solutions cont…
      • Skin Irritation
        • Check for proper mask fit
        • Check to make sure the patient is not over-tightening the mask
        • Remind the patient to clean the mask dialy
    • 37. Mask-Related Issues and Solutions cont…
      • Eye Discomfort
        • Refit the mask for a different mask or different size
        • Make sure over tightening or loosening is not occurring
    • 38. Mask-Related Issues and Solutions cont…
      • Complaints of still being tired and fatigued
        • Ask if the patient has been snoring
        • Reassess the sleep / wake patterns of the patient
        • Review proper sleep hygiene
        • Make sure mask fit is correct and the patient is wearing CPAP throughout the night
        • Ask about naps
        • Ask about mouth opening during the night and or dry mouth in the morning
    • 39. New approaches…
      • Numerous new approaches have been developed recently to improve CPAP compliance
        • These focus on the psyche of the patient and work constructively with the patient to provide a positive outcome
        • New techniques also help the patient become more comfortable with and help ease their way into treatment…
    • 40. PAP Therapy Desensitization
      • PAP Therapy Desensitization is an effective way to slowly ease the patient into every night use of CPAP.
      • Desensitization is defined as - a behavior modification technique, used esp. in treating phobias, in which panic or other undesirable emotional response to a given stimulus is reduced or extinguished, esp. by repeated exposure to that stimulus.
      • By slowly becoming more comfortable with CPAP the patient will have a higher likelihood of using there treatment every night.
    • 41. PAP Therapy Desensitization Steps…
      • Here is an example of five CPAP desensitization activities for a patient to follow…
        • 1) Wear your mask at home while awake for one hour each day
        • 2)Attach the mask to the CPAP machine and turn it on. Practice breathing through the mask for one hour each day while watching television or reading.
    • 42. PAP Therapy Desensitization Steps…
        • 3) Use CPAP during scheduled one hour naps at home
        • 4) Use CPAP during the initial 3-4 hours of nocturnal sleep
        • 5) Finally, use CPAP through an entire night of sleep
        • All of these methods help desensitize the patient, and length of time spent on each step will vary from patient to patient.
    • 43. A New Approach to Improve Patient Compliance with PAP Therapy
    • 44. Implementation
      • Although timing is not necessarily crucial, there now is data supporting early intervention being the most successful time to tackle compliance with new CPAP users.
        • Timing MET to capitalize on the earliest teachable moment can maximize this source of intervention
          • A study by Weaver showed that skipping CPAP for two or more nights within the first week of treatment signals potential for non-adherence.
          • Also the first week to month of home therapy appears to be the most critical phase for PAP therapy compliance.
    • 45. Motivational Enhancement Therapy Basics
      • Motivational Enhancement Therapy directly targets the issues of readiness, importance, and confidence in each patient.
      • MET is and is successful through Motivational Interviewing.
    • 46. How MET is Effective
      • This therapy uses specific behavioral interventions (and theories) about behavior change
        • Patients are approached in a non-directive manner with knowledge and acceptance, to eliminate doubt about making a serious commitment to the treatment.
        • MET promotes the patient to think about uncertainties involving the treatment and weigh them with the benefits of using the treatment.
        • This therapy increases self-confidence; and is directly related to long-term adherence.
    • 47. Theory behind MET
      • Theory when using MET directly involves three specific constructs…
        • 1) Readiness to change – How motivated is the patient to change his/her behavior?
        • 2) Perceived importance of change – Does the patient believe that the benefits of using PAP therapy out-weigh the costs?
        • 3) Confidence in one’s ability to change – Does the individual believe in themselves to not only change, but continue this even through difficult time?
    • 48. MET’s approach towards patients
      • This patient centered form of counseling focuses on different concerns, any obstacles to be faced, and the benefits of using PAP therapy in a non-confrontational, supportive manner.
      • By supporting the patient, importance of using PAP therapy is more easily addressed and understood.
        • Instead of directly promoting PAP use, the provider asks the patient important questions pertaining to why they are conflicted, pros and cons of using, and allows the patient to realize how dangerous not using CPAP as prescribed can be.
    • 49. Communication in MET
      • By practicing positive communication through the MET process, common obstacles can be addressed and successfully over-come.
        • Strategies to achieve this include…
          • Open-ended questions (improves patient comfort)
          • Reflective listening (provider acts more as a guide rather than expert)
          • Role reversal (ask the patient to argue FOR using CPAP instead of against)
          • Keep the patient in an active role as opposed to a passive role (keep the patient involved in making a decision instead of the patient only being fed and receiving information)
    • 50. Key concepts to make MET successful
      • Support Self Confidence – The patients’ perceived ability to change is very important. By promoting self confidence the patient will be will be more inclined to use PAP therapy on a regular basis.
        • Example response “Most people do take awhile to adjust to CPAP and involve it in their daily lives.”
    • 51. Key concepts to make MET successful
      • Develop Discrepancy – This involves the discrepancy of the patient from not using CPAP to using CPAP. By communicating, in a supportive manner, the discrepancy between the patient’s current risky behavior and the positives of using PAP therapy.
        • Example response “When speaking of losing weight you cant seem to exercise because of fatigue. CPAP can actually help you lose weight by giving you more restful sleep thus giving you more energy.”
    • 52. Key concepts to make MET successful
      • Expressing empathy and avoiding argumentation – This is most effectively carried out through aligning yourself with the patient’s approach to change, and not by confronting the patient on the patient’s poor adherence. Argument for change will only decrease the likelihood of adherence.
        • Example response (If the patient does not feel OSA is very serious) “You are saying OSA hasn’t caused any problems for you recently?”
    • 53. Key concepts to make MET successful
      • Roll with resistance – Resistance is expected, and must be handled in a supportive manner. Change can never be forced but encouraged on the patient.
        • Example response “I recommend that you do use CPAP all night, every night in order to achieve the best health results; however the decision is entirely up to you.”
    • 54. Guiding principles of MET and their application
      • There are six guiding principles to MET therapy that give the patient the option to change or not change, and help you to empathize and assist the patient in making that decision.
        • 1) Feedback – Ensure assessments are thorough and offer personalized feedback about the changes as opposed to OSA between the PSG and titration.
        • 2) Responsibility – Make sure to stress it is the patient’s own personal choice and/or responsibility to decide whether or not they will be using CPAP.
    • 55. Guiding principles continued…
        • 3) Advice – Inform the patients that do to the health risks you advise they do use CPAP regularly; but ultimately it is a decision entirely up to the patients to make.
        • 4) Menu – By having the patients choose from two or more different strategies the patient will directly see benefits. (e.g. recorded improvements in sleepiness and mood daily)
        • 5) Empathy – When the patients states barriers to CPAP compliance empathize with them and reinforce that these are common among many other patients.
        • 6) Self Confidence – Very important regarding to the patients compliance. Highlight different statements and successes thus far the patient has made and feels.
    • 56. Sample questions
      • MET questions when the patient is going home with their CPAP device…
        • Take a moment to review some of these questions…
    • 57. Sample questions continued
      • Areas of discussion at another follow-up within the first week to the first month of use…
        • Take a moment to review some of these questions…
    • 58. Overall goals and Summary of the MET program
      • The overall goal is to approach the different patients at their specific levels of readiness to make the necessary changes using useful and lasting information.
      • Through this approach patients are able to address not only opportunities but barriers to making the behavioral changes needed to use CPAP successfully.
    • 59. Overall goals and Summary of the MET program continued…
      • MET is based on the theory of behavioral health change.
      • Patients will generally appreciate the support and additional attention given to specific circumstances.
      • MET is also brief and can be achieved during the initial dispensing of CPAP devices and equipment.
        • (Also can be executed through follow-up visits or calls making MET very cost effective)
      • Patients will generally appreciate the support and additional attention given to specific circumstances.
    • 60. Overall goals and Summary of the MET program continued…
      • Lastly, a MET program can be provided within a sleep clinic, that will ultimately result in better clinical care.
      • Through MET focusing more on patient centered cares and concerns rather than monotonous instructional and traditional methods, it also proves to be much more successful with the patient base as a whole.
        • More information and training on MET @ www.motivationalinterviewing.org .
    • 61. Questions, Concerns, Feedback Should you have any questions or feedback regarding this presentation please feel free to contact our program director, Jennifer Brickner-York, at [email_address] . Thank You.

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