Management Of Continuous Positive Airway Pressure Failure

What constitutes CPAP failure? This is a subjective issue and, in the absence of hard data addressing the diverse health consequences of varying "exposures" of CPAP for sleep apnea, practice varies from center to center. CPAP failure certainly includes those cases with continuing significant sleepiness or other sequelae of sleep apnea. An objective measure of CPAP failure (as measured by usage of the CPAP therapy) has been defined (a priori) as the "use of CPAP for less than four hours per night on 70% of the nights and/or lack of symptomatic improvement" (86). This figure equates to a minimum acceptable average usage of only 2.7 hours per night. This figure was essentially an arbitrary threshold, based on the authors' expert clinical opinion (86). Some have adopted a policy of reclaiming loaned CPAP machines if use is less than two hours per night (92). Sometimes patients will use CPAP effectively but only for part of their total sleep time. This may represent CPAP failure depending on the endpoint of therapy (103,104).

Clearly, it is important to identify the cause of CPAP failure. Some of the commonest side effects and potential solutions have been mentioned. Ear, nose, and throat assessment may be appropriate in looking for any structural reasons to explain CPAP failure. It is important also to consider if there has been a misdiagnosis or if there is coexistent sleepiness from other causes (104). Residual sleepiness in CPAP-treated subjects should be subjected to rigorous review including, if necessary, the use of esophageal pressure balloons to detect subtle episodes of upper airway obstruction. A proportion of such patients will be shown to have been under-treated rather than having truly failed treatment.

Some attempts to overcome true CPAP treatment failures have involved the use of PAP devices other than CPAP, such as bilevel PAP, but supporting evidence is limited (84).

Sleep Apnea

Sleep Apnea

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