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By: Sherri Lindahl on April 1st, 2016

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Dealing with PAP Refusals: Patients Who Don't Want CPAP

Sleep Disorders | Sleep Medicine


How to best deal with patients who are exhibiting PAP refusal (don't want CPAP treatment)

We’ve all been there. Our patient desperately needs CPAP, he’s the perfect candidate, but… after you push that button you hear the dreaded response “No! There’s no way I’m wearing that!” The emotion that exudes from that statement can have a palpable effect on the atmosphere of the room. Suddenly you tense up with a million solutions running through your head.

“Do I try ERP?” “Do I attempt another mask?” “Maybe BPAP?” Though we hate to admit it there is that small part of us hoping that he will just leave, preferably without tearing the wires off himself. But we know we have a job to do and the challenge presented is one that must be conquered. Senior technologists may have developed a thick enough skin to shrug this heated refusal off and move on, but if you are new to the field it may take a few occasions of being in the thick of it to really feel comfortable responding to this statement in a calm, confident manner.

PAP refusals are something we have to deal with on a weekly basis.

I have been in the field for a while working nights and days. I never truly understood what a rewarding challenge PAP refusals can be until I started performing PAP naps. Being able to discuss the risks of untreated sleep apnea and the benefits of PAP therapy with a patient who I didn’t just wake up in the middle of the night was a nice change of pace. There are some tools available during a PAP nap that you won’t have the luxury of using when you are trying to work with a patient in the middle of the night, but I did learn several things while doing PAP naps that can be used during a PAP trial or at 2am.

First of all, always remember that you are the technologist. You are supposed to have the answers. Your patient should be confident in your abilities. When a patient is uncomfortable with CPAP it’s your job to come up with a solution. Asking your patient “What do you want to do?” is like a parent asking their newborn “What do you want to eat today?”

Secondly, you always want to set expectations. If you’ve ever given a patient a mask to try and started the pressure without any explanation, I’m sure you can picture the look of terror in their eyes right now. You would want your physician to give you a heads up for a procedure like a colonoscopy, right? I would hope that all technologists performing sleep studies have actually tried CPAP. If you haven’t then grab a mask and press the button. Having that personal experience will help you immensely when you are explaining what CPAP is going to feel like. Let your patients know it might feel strange but it’s safe, your body can acclimate easily, and its designed to help you while you are sleeping so being awake on PAP is going to feel funny.

I also like to prepare patients for what it might be like when they use CPAP at home. We all have performed beautiful, optimal titrations only to hear the patient complain in the morning about how tired they are and how the CPAP made their sleep worse. This is common and normal. It can take up to a month or so to get used to sleeping with an apparatus on your face. Let your patient know that even if you find that magical number it still might take a while for them to feel the benefits of CPAP, but when they do, they do!

PAP trials can be a life saver. Addressing discomfort when the patient is awake and alert is much more doable than when you’ve woken them up to start PAP after only a few hours of sleep that showed significant OSA. I admit I have a “go to” mask that I use for PAP trials and if the patient is happy and comfortable I call it a day. But if I sense that the patient may be hesitant I will usually bring in some additional interfaces and explain the differences. As technologists, I think we develop a sixth sense that lets us know when patients are going to have trouble adapting to PAP therapy.

Below are some solutions I have used in the past that seem to work for a majority of patients.

  • The pressure is too high! (It’s at 4cm H2O)
    • Try EPR and let the patient know what to expect - “You should feel the pressure decrease when you exhale. This will make breathing feel more natural.”
  • I’m not getting enough air!
    • Increase the pressure - “How does that feel?”
  • I’m claustrophobic!
    • Nasal pillows usually help but the direct flow of pressure might be counterproductive. Explain this to the patient and if they don’t like pillows try something that does not cover the forehead - out of sight out of mind.
  • I can’t breathe!
    • “Just relax, take a few deep breaths.” Again, set the expectation that it may feel strange but the body acclimates. Maybe try BPAP with this patient.

PAP refusals are a common occurrence and a rewarding challenge. Knowing that you played a part in turning those flat airflow lines into uniform consistent waves always produces a good feeling. But taking a firm stance with a positive attitude and assisting patients to increase PAP compliance and their health for years to come feels even better.  That patient you secretly hoped would just go home now has the tools and education to improve his sleep, wake, health, and quality of life.  We've also written about alternatives to CPAP treatment here.

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