Sleep Breath (2008) 12:85–89 DOI 10.1007/s11325-007-0138-6
ORIGINAL ARTICLE
An orientation session improves objective sleep quality and mask acceptance during positive airway pressure titration Rogerio Santos Silva & Viviane Truksinas & Luciane de Mello-Fujita & Eveli Truksinas & Leiko Kawata Zanin & Maria Christina Ribeiro Pinto & Marta Sevilha de Paula & Robert P. Skomro & Lia Rita A. Bittencourt & Sergio Tufik
Published online: 9 October 2007 # Springer-Verlag 2007
Abstract The aim of this study was to determine whether an orientation session led by a polysomnography (PSG) technician during the night of positive airway pressure (PAP) titration can improve objective sleep quality and acceptance of nasal mask in patients referred to a sleep laboratory. Consecutive patients (n=1,481), referred for PAP titration during PSG, were retrospectively evaluated. Patients were distributed in two groups: the control group, patients referred for PAP titration (n=699) who did not undertake an orientation session led by a PSG technician, and the oriented group, patients referred to PAP titration (n= 782) who followed the orientation session. Demographic data were similar (p>0.05) between groups (control vs oriented) for: male/female proportion (76:24 vs 75:25%), age (mean ± SD; 53 ± 12 vs 52 ± 12 years), Epworth R. S. Silva : V. Truksinas : L. de Mello-Fujita : E. Truksinas : L. K. Zanin : M. C. R. Pinto : M. S. de Paula : L. R. A. Bittencourt : S. Tufik CPAP Clinic, Sleep Institute/AFIP, Discipline of Medicine and Biology of Sleep, Department of Psychobiology, Federal University of Sao Paulo (UNIFESP), Rua Napoleao de Barros 925, Sao Paulo, SP, Brazil 04024-002 V. Truksinas e-mail:
[email protected] L. de Mello-Fujita e-mail:
[email protected] E. Truksinas e-mail:
[email protected] L. K. Zanin e-mail:
[email protected] M. C. R. Pinto e-mail:
[email protected]
Sleepiness Scale score (12±6 vs 12±6), and body mass index (31±6 vs 31±6 kg/m2). PSG data were different (p< 0.05) between the groups for: total sleep time (312±81 vs 326±85 min), sleep efficiency (74±17 vs 77±14%), sleep latency (22±24 vs 18±29 min), S1 (8±8 vs 6±5%), S3 4 (19±11 vs 21±13%), rapid eye movement sleep (17±9 vs 18±9%), and wake after sleep onset (106±68 vs 93± 58 min). After the orientation session, the number of patients who did not accept nasal mask during PSG recording was higher in the control group than the oriented group (80 vs 44; p=0.001). An orientation session led by a PSG technician can improve objective sleep quality and nasal mask acceptance during the night of PAP titration. Such an addition to PAP titration could be an efficient intervention to improve PAP compliance. M. S. de Paula e-mail:
[email protected] L. R. A. Bittencourt e-mail:
[email protected] S. Tufik e-mail:
[email protected] R. P. Skomro Division of Respiratory Medicine, Department of Medicine, Royal University Hospital, University of Saskatchewan, 103 Hospital Drive, Saskatoon, Saskatchewan, Canada S7N OW8 e-mail:
[email protected] Present address: R. S. Silva (*) Av. Bernardino de Campos, 144/21, 04004-040 Sao Paulo, SP, Brazil e-mail:
[email protected]
DO00138; No of Pages
86
Keywords Sleep obstructive apnea . Continuous positive airway pressure . Titration . Polysomnography . Sleep quality
Introduction Continuous positive airway pressure (CPAP) has been shown to be an effective treatment for patients with obstructive sleep apnea syndrome (OSAS) [1–3]. When used properly, CPAP diminishes nocturnal respiratory events and improves daytime sleepiness and cognitive functioning [4–6]. However, poor compliance with CPAP has been demonstrated to be a significant problem in the successful treatment of OSAS [7, 8]. Estimated CPAP compliance in the USA is between 29 and 89% [9]. Improvements in CPAP technology have addressed patient complaints related to the equipment and masks, but the level of compliance with CPAP is still a clinically relevant problem. Only educational orientation and humidification have been shown to be effective for improvement of CPAP therapy [2, 3, 10–15]. When a patient is diagnosed with OSAS, the current standard practice involves performing full attended polysomnography (PSG) during which positive pressure is adjusted to determine optimal pressure for maintaining airway patency [2, 3, 16–18]. Usually, the titration night represents the patients’ initial exposure to nocturnal CPAP treatment. Nearly always, the PSG technician introduces CPAP to the patient. Drake et al. [19] showed that improvement in sleep during the titration night was associated with greater CPAP compliance during a subsequent follow-up period (mean of 48 days). These findings suggest that the patient’s initial experience with CPAP treatment may be an important factor in determining their subsequent adherence to this treatment modality. We hypothesized that one orientation session performed by the technician could improve sleep during the titration night and acceptance of CPAP treatment. The objective of this study was to evaluate whether one orientation session given by a PSG technician at the beginning of the night of positive airway pressure (PAP) equipment titration could improve the objective sleep quality and the acceptance of CPAP equipment during titration by patients referred to the sleep laboratory.
Sleep Breath (2008) 12:85–89
preimplantation of the training program led by technicians for orientation of patients, and the oriented group—782 patients referred to the Institute from March to August of 2004, i.e., after the program implantation. Nasal CPAP apparatus, masks, and straps used in the laboratory were similar during both study periods. Training program for PSG technicians protocol The training program for PSG technicians was implemented in September 2003 and coordinated by a registered technologist (registered polysomnographic technologist) certified by the Board of Registered Polysomnographic Technologists. In the first month of training, the technicians attended a formal class of 90 min approximately, once a week. From the second month on, the classes took place once a month. The content of the classes is described in Table 1. During the PSG night, after the patient had followed an orientation session and questions about the procedures were clarified, the technician chose the most appropriate mask, placed it onto the patient’s face, and left the patient in a seating position for 30 min at a PAP pressure of 4 cm H2O, for a better adaptation to the equipment. Finally, PSG hook-up preparation occurred. The full-night PSG study for PAP titration was recorded and manually scored according to Rechtschaffen and Kales criteria [20]. The respiratory parameters and arousals were analyzed according to the American Academy of Sleep Medicine [16] and American Sleep Disorders Association
Table 1 Content of classes included in the training program for PSG technicians Class Content I
II III
IV V VI
Materials and methods Polysomnographic data of 1,481 patients referred to the Sleep Institute/AFIP for PAP titration were retrospectively evaluated. Patients were divided in two groups: the control group—699 patients referred to our Sleep Institute between March and August 2003, which corresponded to the
VII VIII IX X XI XII
The role of the PAP titration staff; explanation of the PAP titration as per The Policies and Procedures PAP Titration Manual Patient reception and CPAP desensitization Revision of the Manual of the standardized terminology, techniques, and scoring systems for sleep stages of human subjects [20] Revision of EEG arousals in accordance with The American Sleep Disorders Association Atlas Task Force [21] Revision of sleep disordered breathing in accordance with The American Academy of Sleep Medicine Task Force [16] Revision of PAP devices—CPAP, Bi LEVEL PAP, APAP, expiratory pressure relieve PAP Revision of manual CPAP titration Case discussion with CPAP titration Revision of manual PAP with two pressure level (Bi level) titration Case discussion of Bi level PAP titration Materials and disinfectants care Doubts clarification and assessments
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[21] criteria, respectively. Epworth Sleepiness Scale (ESS) [22] was applied before PSG hook-up. PAP titration protocol The PAP titration protocol had already been developed before the implementation of the training program for PSG technicians, and it was identical in both patient groups. All technicians followed a protocol that consisted of beginning the recording with a pressure of 4 cmH2O, applied with the most appropriate mask. The increment of pressure was 1 cmH2O, and titration was performed until the disappearance of respiratory events, O2 desaturation, snoring, and arousals [23, 24]. Mask leak was continuously monitored through rescontrol (Resmed®) and corrected in case it reached values above 25 l/min. Humidifiers were not used during PAP titration. In case of the lack of acceptance of the CPAP equipment, the technician was instructed to try a new model of nasal or oral mask and to reassure the patient, reminding him/her of the importance and value of the exam. Acceptance of the CPAP equipment was considered if a patient used the mask more than 95% of the PAP titration night. The technician/patient ratio for the titrations was 1:1. Data were analyzed using StatSoft [29], STATISTICA (data analysis software system), version 6. All variables exhibited normal distribution. Unpaired Student’s t test was used to compare quantitative variables. The chi-squared test was used for qualitative variables. The significance level for each test was set at p0.05). Comparison of PSG data showed that groups differed (p< 0.05) in regard to total sleep time, sleep efficiency, sleep latency, sleep stage 1, sleep stages 3 4, and REM sleep and wake time after sleep onset. Neither apnea–hypopnea index (AHI) during PAP titration nor optimal pressures were different between groups. After the orientation session, the number of patients that did not accept the mask decreased (80 vs 44, respectively; p=0.001). Thereby, the mask acceptance rate increased; that is, the percentage of patients who tolerated the use of CPAP equipment during the titration night had augmented (Table 3).
Discussion The present study showed that an orientation session given by a PSG technician explaining what OSAS is, what its consequences are, and how to treat it and a PAP mask trial with low level of PAP pressure during 30 min before the PSG hook-up improved the objective sleep quality and mask acceptance in a group of patients consecutively referred to PAP titration at a sleep laboratory. The groups evaluated were similar in male/female ratio, age, BMI, and daytime sleepiness evaluated by ESS. In addition, there were no differences between the groups with regard to SaO2 awake, percentage of SaO2
