1 The Sleep Center at Rocky Mountain Heart and Lung A Department of Kalispell Regional Medical Center 350 Heritage Way, Suite 2100, Kalispell, Montana 59901 (406) 257 8979 Fax (406) 257 8964 WHEN THINGS GO WRONG WITH CPAP (This printed information was taken from the American Sleep Apnea Association (ASAA) website, a non profit organization that does not endorse or recommend any company, products, or health care provider). CPAP is, at the present, the most effective treatment for obstructive sleep apnea. It is, however, only a treatment and has no benefit if it is not used. Current research estimates that the compliance rate for CPAP (how many people use CPAP more than a few months) is approximately 60%. One reason for this may be that CPAP users often experience disagreeable side effects and simply stop using CPAP. Many of these side effects can easily be addressed if a health professional is made aware of the problem or if the CPAP user is educated about ways to manage these problems. Mask discomfort. This problem usually arises because either the patient adjusts the headgear too tight or because the mask does not fit properly. A CPAP mask should fit the face snuggly to avoid air leak but not so tight that is feels uncomfortable or causes pain. If a mask has to be pulled tightly to prevent leaks the mask does not fit properly! You should contact your sleep specialist or home health provider and let them know that your mask may not fit well and you would like to try another size or style mask. There are a number of makers of CPAP masks and not every nose can wear every mask. Do not let anyone tell you that a sore on your nose is to be expected! Nasal congestion, irritation or runny nose that seems to be caused by using CPAP. Your nose is your airway's humidifier. It warms and humidifies the air that you breathe. If the CPAP begins to dry your nose, your body will increase the production of mucus in the nose to add more moisture to the inhaled air. Unfortunately, this may cause nasal congestion and a runny nose. In some cases the dryness will cause irritation, burning and sneezing. These symptoms can be alleviated by the use of a humidifier with your CPAP. Some sleep specialists order a passover (cold water) humidifier with the initial CPAP order. If you do not have one of these speak with your sleep specialist. If you already have a humidifier and still experience these symptoms you may need a heated humidifier. This is a water pan that sits on a heating unit and is attached to CPAP just like the
2 passover humidifier. Heating the air and the water will allow the air to carry more moisture as it travels to your nose (just like the summer air is more humid than winter air). In almost all cases this resolves nasal congestion and irritation if it is caused by CPAP. Difficulty breathing through your nose. If you have allergies, chronic sinus problems or a deviated septum (your nose is crooked on the inside) you may have trouble using CPAP. CPAP is usually applied through the nose. If during the day you often find yourself breathing through your mouth, CPAP may be difficult to use. If the problem is allergies speak with your doctor about treatment. There are a number of good nasal steroid sprays and allergy medications that can treat your nasal congestion. Individuals with a deviated septum or other structural problems in their noses may benefit from seeing an Ear Nose and Throat specialist if CPAP cannot be tolerated. Finally, there are CPAP masks that fit over both the mouth as well as the nose. People have used these with varying success but it may be worthwhile to try a "full face mask" before looking into more invasive or expensive alternatives. Headache or ear pressure. Although treating sleep apnea usually eliminates morning headache, some CPAP users develop headaches on CPAP. Others find that their ears develop pressure or pain in them. Most of this relates to underlying sinus congestion due to allergies or to CPAP itself. It is much like traveling in an airplane when you have a cold. The congestion can block the ear canals and changes in air pressure can cause pain when air gets trapped. It is best to avoid using CPAP when you have a cold or sinus infection to avoid these problems. Sometimes the congestion remains in the ears and sinuses after the acute symptoms of the cold are gone. If you develop headache or ear pain on CPAP, speak with you sleep specialist. In the interim you may try decongestants or antihistamines. Check with your doctor before you take these medications. I take off my mask at night and don't realize it. This can happen for a number of reasons: difficulty breathing through the nose, mask discomfort or sleep disturbance. If your nose is congested when you awaken read the two paragraphs addressing that in this paper. Speak with your home health provider if your mask hurts. If these two problems don't appear to explain why you are pulling off your mask, it may just be that you need some time to adjust to wearing a mask on your face at night. During an arousal, when you are not fully alert you may not remember that you now wear CPAP. It can be a scary thing to awaken with a strange thing on your face! This should improve over time. It may help to take either Benedryl or Tylenol PM an hour before bedtime so that you are drowsy going to bed and so that it is less likely that you will awaken at night. After a few nights you should adapt to wearing the mask without using these. Be sure to talk to your doctor before taking these medications, particularly if you have any medical problems.
3 Air in the stomach. Occasionally, a CPAP user will experience air trapping in the stomach and awaken with stomach pain or gas. Sometimes simply making sure that you sleep with your head aligned with your body can help with this. If you want to elevate your head in bed you should do that with a wedge pillow or with bricks under the headboard. If you sleep with several pillows it may cause your head to tilt forward and block your airway. Lowering the CPAP pressure can help but your sleep specialist may not want to do this if it reduces the effectiveness of your treatment. Switching to bilevel pressure or C-Flex may be very helpful in these cases. The air is too cold. This can be fixed with a heated humidifier. If you cannot get one you may try running the tubing under the covers, next to your body to warm the air. The air is too hot. This is more difficult to fix but it may help to lower your room temperature as low as possible. CPAP is too noisy. It is most likely a lot less noisy than you re snoring, but if noise is a problem you have several options. Most new machines are quiet so this is rarely a problem. Check with your insurance company if you have an old machine. You may qualify for a new CPAP. You can get an extra length of tubing so you can move the CPAP further away from the bed. A fan or other source of "white noise" can also help to disguise the noise. The tubing gets in my way. Draping the tubing behind you and over the headboard helps with that. There is also a new device that attaches to the bed that holds the tubing up and rotates so that it can move with you. I take off my mask at night and can't be bothered to put it back on. When you get up at night, to use the restroom for example, leave your mask on and just disconnect the tubing either at the mask or at the machine. This is easier than having to refit the mask during the night. The following info. Is from a Sleep Apnea/CPAP chat-room on the internet. A patient s struggles with nasal congestion:
4 I use the breeze headgear and RemStar Plus with passover humidifier. I went through a problem with severe allergic rhinitis for a while. Every time I wore the CPAP, I would wake up with uncontrollable sneezing and allergic reactions in the nose. After replacing EVERYTHING but the machine itself - I still had the problem. So I slept without it for several months. Eventually, I got around to getting a new machine with allergy filters and BOY am I glad I did! No allergy problems with the new machine, and I feel much better during the day. A RPSGT's (Sleep Tech.) advice for this patient s problems: My first question is in regard to your humidification. Do you have a warm air humidifier (WAH)? This should help drying out and your sinus problems that occur when using your CPAP. If you do have a WAH have you tried adjusting the temp? To do this hold down the button that turns on the warmer. You should hear two beeps and the display will change to a flashing number (1, 2, 3, 4, or 5). Once you enter this field use the HEAT and/or RAMP buttons to turn up or down the temp.finally either push your START/STOP button or just leave the unit alone for about two minutes and your new settings will be saved. If your warmer is at 1 or 2 then try 3, 4, or 5. The temperature of your room or warmer can affect humidification and sometimes cause "rainout" or basically a flood of water in your mask therefore you don't want to adjust your warmer too fast. For example if it is set to 1, don't jump to 5 right away instead, increase it one number a night and stop once you see moisture in your mask in the morning. If water puddles inside the tubing during the night it will get very loud and disruptive, if this occurs turn down the temp. to the last comfortable setting. If you do not have a WAH then ask your doctor for a prescription for one, Respironics makes a WAH that is made to fit directly in front of your CPAP.(But I would bet you already have one) Also make sure you are turning on the warmer. Either turn on your CPAP or within 15 minutes of going to bed, simply push the HEAT button for 1 second, you will hear a beep and a green indicator light should turn on in the lower right hand corner. For your ear problem try exhaling (through your nose) one deep breath as you place the pressure tubing on to the mask with the CPAP's blower turned on, this sometimes helps to keep the pressure balanced inside your ears, after one deep exhale resume normal breathing. If you have red marks on your face in the morning, that indicates you are over tightening your mask. Start over and loosen your mask completely. Adjust the bottom straps first and then the top straps, you should do this with your CPAP turned on and with you lying down in your normal sleeping position (if you have such a thing). A last resort option would be to boil the gel of the mask for 3 min., cool off for 10 to 15 seconds under cool water, then wear your mask for 5 to 10 minutes. It is not necessary to have your CPAP attached to your mask at this time. This should help customize your mask for your nose. If this doesn't work
5 suggest a different mask, such as nasal pillows which may not leak as much, a very popular mask at the time is the Swift nasal pillows made by Res-Med. You may have some difficulty returning your mask due to reimbursement for a new mask but your doctor should be able to arrange some help with this matter. Medi- care will pay once every 6 months for a mask replacement, once every 2 months for a cushion replacement. Are you aware of the Ramp function? This will turn your pressure down and within a set period of time (5, 10, 15, 20, 25, 30, 35, 40, or 45 minutes) it will increase to your prescribed pressure. As you work out these bugs and start to adjust to sleeping with your CPAP you should find that exhaling does not need to be so labored, this is just your lungs trying to exhale the CPAP air along with your normal respiration, this is a common response and usually will subside as soon as the patient relaxes and forgets about breathing, allowing respirations to occur naturally.