How can I improve my patients' CPAP compliance?

CPAP compliance is a major issue for some of my patients. What are some steps I can take to help them improve their CPAP experience and ultimately their usage? 

CPAP compliance is not a simple matter; it emerges only after a whole lot of inter-related factors are properly addressed in a timely fashion. Although the two most obvious factors that inhibit compliance are mask issues or pressure problems, there are two additional structural problems that are often overlooked or taken for granted.  

The first major barrier is the overemphasis on education as a primary pathway to CPAP compliance.  While education is necessary, the actual experience of using PAP is the most reliable pathway to compliance.  PAP use itself “self-educates” the patient, and then education and experience synergistically produce high levels of compliance as long as the patient receives clear-cut benefits from the device.  Some patients do respond well to an education model, but given the cognitive impairment observed in OSA patients coupled with abysmal compliance rates reported by so many experts in our field, we all need to be wary about over-playing the education card.  Instead, we must drill deeper into our practice models to understand why and how an experiential model proves more consistently effective than an educational model.  

At our sleep center, we provide a very high quality experience for the most problematic patients by scheduling a PAP-NAP as soon as feasible.  In some cases, a patient may need a PAP-NAP before the first titration and again a few months later to overcome resistance. Through this type of experience many patients overcome anxieties and fears about PAP therapy.  We also use a retitration model (we call it REPAP), wherein patients with suboptimal responses return to the lab for therapeutic titrations under the watchful expertise of the sleep technologist.  This experience fine tunes pressure settings and reignites patient motivation.

The second major barrier to CPAP compliance is the government-imposed system that encourages patients to obtain PAP equipment from durable medical equipment (DME) companies unaffiliated with sleep centers, many of which do not possess levels of expertise in managing PAP compliance issues commensurate with sleep physicians and technologists.  Sleep techs average more than a thousand hours per year in direct patient contact in the sleep lab; and, unequivocally, sleep techs possess more influence on patient compliance than any other healthcare provider, including sleep doctors.  

The vast majority of DME companies do not employ sleep techs to manage CPAP compliance programs, which means patients who struggle with CPAP are often steered back to a sleep center for more effective coaching.  By the time the patient’s frustration level has escalated, he or she is just as likely to drop out of care as return to the sleep center.  These patients develop self-defeating animosity directed towards the sleep center that sent them to the DME company, all of which spills over into the patient’s view of PAP therapy.  This classic example of top-down, bureaucratic meddling arguably knocks 25% of all sleep apnea patients out of compliance for no other reason than the hassle factor of dealing with substandard DME companies, which leads to a delay in or cessation of care.  

DMEs that specialize in sleep equipment and DMEs that develop close relationships with sleep centers are viable solutions, which is why I chose to work with Classic SleepCare. CSC specializes in obstructive sleep apnea with a focus on delivering the highest standard of support to patients via the CPAP Circle of Care program delivered via licensed respiratory therapists, many of whom I will have the opportunity to demonstrate some of our Sleep Dynamic Therapy™ coaching techniques.

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

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