Coping with Masks-Associated Aspect Results: A Key to Adhering to CPAP Remedy

Continuous Positive Airway Pressure (CPAP) therapy remains the gold standard for treating obstructive sleep apnea (OSA). It has been shown to be effective in reducing symptoms while improving the quality of life for patients with OSA. However, the success of this approach depends on proper application and compliance by the patient. The results have shown that CPAP non-compliance rates among people with OSA range between 46% and 83%, despite continuous improvements in CPAP device design

An estimated two-thirds of CPAP users experience mask-related side effects (MRSEs) ranging from surface-related effects such as air leakage and rashes, pressure-related effects including nasopharyngeal symptoms and eye complications, to other types of side effects such as infection and voice changes. Cerebrospinal fluid leakage has been observed in rare cases when using nasal CPAP, typically associated with transsphenoidal surgery. 1

Mask-related side effects were cited as the most important factor in adherence to CPAP therapy.1 In one study, researchers found that the number of MRSEs at 1 month independently predicted CPAP adherence at 12 months.2 Recognizing a lack of similar data in For patients on long-term CPAP therapy, the authors of a study recently published in Respiratory Research examined the relationship between MRSEs and CPAP non-compliance (defined in the study as use <4 hours per day) in a sample of 1484 patients (72.2 % Men); Average age 67 years) with an average treatment duration of 4.4 years.

Their analysis found a non-compliance rate of 8.6% and a 16.17% prevalence of excessive residual fatigue (based on an Epstein Sleepiness Scale) [ESS] Score ≥11) .2 Patient-reported leaks were the most common side effect, affecting 75.4% of participants. Other common MRSEs were dry mouth (70.6%), partner-disruptive leaks (69.4%), noisy mask (57.5%), and dry nose (54.4%). The results also showed an independent negative association between MRSEs and CPAP adherence and a positive association between MRSEs and ESS scores. 2

It should be noted that the leaks reported by the patient were not predicted by leaks reported by the device software. “CPAP machines only record leakage currents, while the patient’s perception of a leak is a complex phenomenon that affects not only the strength of the leakage current itself, but also the feeling on their skin / eyes (when the mask is not properly adjusted )) and associated noises, ”explained the authors.2

In addition, device-reported leaks and apnea-hypopnea index were not significantly associated with non-compliance or ESS scores. “Overall, these results suggest that MRSE questionnaires should be included in the data reported by CPAP during patient follow-up and especially in long-term tele-monitoring programs,” concluded the study’s authors.2 Clinicians should closely monitor the CPAP-related side as well address effects at the start of treatment to encourage optimal adherence. 1

To gain further knowledge and clinical recommendations on CPAP side effects and alternative therapies, we asked Dr. Richard J. Castriotta, FCCP, FAASM, pulmonologist, sleep specialist and professor of clinical medicine at the University of Southern Keck School of Medicine interviewed California in Los Angeles.

What are the most common side effects of CPAP therapy and what are the most serious possible side effects?

Most of the side effects of CPAP are caused by a sub-optimal interface – e.g. B. poorly fitting mask or nose pillow – or inappropriate CPAP settings. Advice on how to properly customize the interface is of the utmost importance.

A common side effect is nasal congestion, which, after properly adjusting the interface, can be treated with optimal heated humidification, nasal steroids, antihistamines, nasal salt spray, or, for rhinorrhea, inhaled nasal ipratropium

Other possible side effects include oronasal dryness, skin abrasion or rash at the point of mask contact, aerophagia (treated with simethicone), sinus discomfort, and claustrophobia.1 More serious side effects include epistaxis (usually with cold dry air under high pressure) 1 and – very, very rarely – pneumothorax or pnemoencephaly. 3

What alternative treatment approaches are available for patients who cannot tolerate side effects or who may refuse CPAP therapy?

Alternative treatment options include an oral mandibular advancing device, hypoglossal nerve stimulator, upper airway surgery – such as an adenotonsillectomy or nasal septoplasty -, maxillomandibular advancement (MMA) surgery, tracheotomy, supine sleep apnea positioning devices, and expiratory if necessary Airway pressure strips and alternative positive airway devices such as BPAP (Bilevel Positive Airway Pressure) and automatically titrating positive airway pressure (APAP) 4

What are some additional recommendations for clinicians treating patients with CPAP therapy, and what are the remaining needs in this area?

The only treatment modalities that have been shown to actually eradicate the excessive mortality from OSA are CPAP and tracheotomy at more than 20 apneas per hour.4 Most problems with CPAP can be resolved with appropriate choice of interface and machine along with are counseling, sometimes using cognitive behavioral therapy or other adjunct therapies. 5

All of the above are for using CPAP in OSA. BPAP and APAP should not be used in central sleep apnea and complex sleep apnea as they can exacerbate central apnea. CPAP can also cause or worsen central apnea. If this persists, adaptive servo-ventilation (ASV) can be used when the left ventricular ejection fraction (LVEF) is greater than 45%. Pure central sleep apnea can be treated with phrenic nerve stimulation (Remedē device), oxygen, and ASV if the LVEF is greater than 45% .6-8

There is a great need to educate patients and doctors on this topic. 9


1. Ghadiri M, Grunstein RR. Clinical side effects of continuous positive airway pressure in patients with obstructive sleep apnea. Respirology. 2020; 25 (6): 593- 602

2. Rotty MC, Suehs CM, Mallet JP, et al. Mask side effects in long-term CPAP patients affect adherence and drowsiness: the InterfaceVent real-life study. Respir Res. Published online January 15, 2021. doi: 10.1186 / s12931-021-01618-x

3. Rajdev K., Idiculla PS, Sharma S., Von Essen SG, Murphy PJ, Bista S. Recurrent pneumothorax with CPAP therapy for obstructive sleep apnea. Case Rep Pulmonol. Published online on December 1, 2020. doi: 10.1155 / 2020/8898621

4. Littner MR. Mild obstructive sleep apnea syndrome should not be treated. Con. J Clin Sleep Med. 2007; 3 (3): 263- 264.

5. D’Rozario AL, Galgut Y, Bartlett, DJ. An update on behavioral interventions to improve compliance with sustained positive airway pressure in adults. Curr Sleep Medicine Rep. 2016; 2: 166-179. doi: 10.1007 / s40675-016-0051-2

6. Central Sleep Apnea: Causes and Treatments. Sleep foundation. Accessed February 25, 2021.

7. Asp K. Advantages and disadvantages of adaptive servo ventilation (ASV) in sleep apnea. American Association of Sleep Technologists. Published October 3, 2017. Accessed February 25, 2021.

8. Joseph S., Costanzo MR. A novel therapeutic approach to central sleep apnea: stimulation of the phrenic nerve by the therapeutic system. Int J Cardiol. 2016; 206: Suppl: S28-S34.

9. Hayes SM, Murray S., Castriotta RJ, Landrigan CP, Malhotra A. (Mis) Perceptions and Interactions of Sleep Specialists and Generalists: Obstacles to Referral to Sleep Specialists and Multidisciplinary Team Management of Sleep Disorders. J Clin Sleep Med. 2012; 8 (6): 633- 642.

This article originally appeared on Pulmonology Advisor

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