CPAP: Tips for Nurses

Ruby Vee, BSN

So your patient comes into the hospital, assisted living or long term care facility with a diagnosis of sleep apnea and one of those dreaded CPAP machines in tow. Congratulations! Your patient is more compliant than the average patient! From my (admittedly limited) experience, the majority of patients with sleep apnea have never gotten themselves a CPAP machine, have it but don't know how to use it, know how to use it but won't or use it only inconsistently. The "reasons" for their noncompliance range widely from vanity reasons ("my husband will never want to make love to me again once he sees me in this!") to comfort ("I can't sleep with that thing on my face!" or "I don't like having that air forced into me!") to lack of capacity to make an intelligent decision ("they said I only needed to use it at night, but I sleep during the day time.") Machines and supplies are expensive and someone who lacks good insurance (or has other priorities such as rent, groceries or the latest designer handbag) may put off getting started with their therapy. If your patient has a machine, knows how to use it, uses it and actually brings it to the hospital, you're the lucky nurse of a patient who is involved in his own therapy and motivated to do what he needs to in order to be healthy. We all know how rare that can be.

CPAP machines ("blowers")are expensive little guys, most of them the size of a shoebox or smaller. They're not at all like the enormous, bulky machines the respiratory therapist brings up for a patient who may or may not need CPAP but the doctor wants to give it a try to improve their oxygenation issues. They operate by blowing air into the nose (or nose and mouth) of a patient to hold open their airways when sleep would otherwise relax those structures, obstructing the airway. The machine itself is a blower and may or may not have a humidifier attached. the humidifier warms and moistens the air the patient gets, thus making the therapy more comfortable to many patients. The "interface" -- mask for those of us who dislike reading scholarly articles -- sits on the patient's face and is held in place by a system of elastic or neopryne straps called "headgear." And the hose, obviously, carries the pressurized air from the blower to the the mask. The machine is pre-set to the patients prescribed pressure.

When your patient comes in with a CPAP machine, make sure the machine, the carry case and the parts are marked with his name and/or medical record number. They're expensive -- from a few hundred to a few thousand dollars -- and while the hospital doesn't want to pay to replace it, patients can be very attached to their machines and don't want to lose them. A machine from a different manufacturer, even when set to the patients prescribed settings, may have a different algorithm for inhalation, exhalation relief, etc. and may be difficult for the patient to adapt to. separating a patient from his CPAP creates a good deal of anxiety -- both because of the expense involved, and because the patient knows he cannot sleep or cannot sleep safely without it.

Have the CPAP machine checked and certified by biomed if required in your hospital as early as possible -- your patient should not -- and many absolutely cannot -- nap without it. Make sure all of the necessary parts are in your patient's possession, and make sure that you know how to set it up and put it on the patient in the event that they're unable to do it for themselves. Alternatively, you may allow a family member who knows how to use the machine stay the night with the patient. many patients can sleep at home without using a humidifier, but require one in the drier atmosphere of the hospital, so ensure that you have the humidifier if possible.

Establish a safe place for the CPAP in close enough proximity that the hose will reach the patient and the patient can reach the controls. again, blowers are expensive -- don't set it up where it can easily be knocked over. The humidifier should be filled with distilled water only, although many patients use tap water at home. (how clean is your hospital's water supply? I'd use distilled water or sterile water.) watch the water level when you're filling the humidifer -- most of them have fill lines. be careful not to overfill. Once the humidifier is filled with water and attached to the machine, it should not be moved. If a machine is tilted the wrong way with a filled humidifier attached, the water could flow into the machine, ruining it's electronics. This is more likely if the humidifier is overfilled. (see above cautions about the expense of and dependence on a cpap machine).

Masks are very personal and your patient no doubt has his preferred mask. fitting the mask to the patient can be very difficult and time consuming, and no doubt your patient has already made the adjustments to his mask to achieve a good seal between the mask and his face yet still be comfortable enough to sleep with. Do not attempt to adjust the patient's headgear. If you must remove the patient's mask without his help, unclip it or unsnap it using the fasteners between the straps and the mask. do not mess with the velcro! The patient has no doubt already adjusted the length of the straps for best fit, and if you unfasten his mask by unfastening the velcro, you've ruined all of that hard work.

If a patient has a full face mask, covering his nose and mouth, make sure you know how to remove it swiftly in the event that he needs to vomit. A face mask full of emesis is nasty as well as unsafe.

Ihe patient's machine settings have in all liklihood been determined in a sleep lab with a sleep titration study. Don't even attempt to mess with the settings, and don't let your residents (or even attendings) order new settings without consultation with a sleep doctor, preferably the patient's sleep doctor. In the event the the patient requires oxygen, there is a simple fitting that can allow oxygen to be bled into the hose. You may titrate the oxygen as needed, but you probably won't be able to adjust the pressure settings without the operator's manual anyway. (most patients have the patient manual which does not contain information about how to adjust the settings, rather than the clinician manual.)

Humidifier settings, unlike pressure settings, are under patient control. Some patients like their humidifiers as high as possible, others turn the humidifier completely off and just let the pressurized air blow over the water in the humidifier. If the setting is turned too high, your patient may experience "rain-out". The water condenses in his hose, and when he turns over in bed or readjusts his hose, he can get a faceful of water and wake up feeling as though he's drowning. If that happens, dialing down the humidifier a notch or two may help.

Don't ever let anesthesia (or anyone else) tell you that your patient won't need to use his cpap while he's in the hospital. Unless he's on a ventilator, he cannot sleep without it.

A patient who is compliant with his therapy and goes to the trouble of bringing his machine and equipment with him when he comes to the hospital is likely to be very involved with his care. remember -- he's been dealing with this disease and this therapy far longer than you, and he's going to have to continue to deal with it even after he leaves your care. Allow him as much leeway as possible in controlling his own therapy and encourage independence. Be willing to learn from your patient -- it's the rare patient who cannot teach us something and maybe your patients will give you more useful tips that you can bring to this forum.

CPAP: Tips for Nurses

About Ruby Vee, BSN

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