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Achieving Adherence to Positive Airway Pressure Therapy: Modifying Pressure and the Holy Grail

Lee K. Brown, MD, FCCP
Author and Funding Information

From the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine; and the Program in Sleep Medicine, University of New Mexico Health Sciences Center.

Correspondence to: Lee K. Brown, MD, FCCP, Department of Internal Medicine, University of New Mexico School of Medicine, 1101 Medical Arts Ave NE, Bldg #2, Albuquerque, NM 87102; e-mail: lkbrown@alum.mit.edu


Financial/nonfinancial disclosures: The author has reported to CHEST the following conflicts of interest: Dr Brown chairs the Polysomnography Practice Advisory Committee of the New Mexico Medical Board and serves on the New Mexico Respiratory Care Advisory Board. He currently receives no grant or commercial funding pertinent to the subject of this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(6):1266-1268. doi:10.1378/chest.11-0185
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Adherence to continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea syndrome (OSAS) continues to be a subject of intense interest to practitioners who treat these patients; indeed, the search for techniques that would ensure compliance could be likened to the search for the Holy Grail, a quest spoken of in medieval mythology. Of the many aspects of CPAP treatment that have been implicated as a cause of reduced adherence, patient complaints about the difficulty of exhaling against pressure are sometimes mentioned, although less often than one might suppose: Only 18% of 204 patients in an often-quoted survey by Engleman et al2 noted it, and it was not even listed as a side effect in several other studies.3-5 More common are symptoms that are almost certainly closely related to the level of pressure, such as mask leaks, aerophagia, and chest discomfort, and those symptoms that are attributable to the magnitude of airflow necessary to maintain a set pressure, such as nasal congestion, sneezing, and rhinorrhea; oral/nasal desiccation; and blower noise.2-5 In addition, problems with mask discomfort and fit often are related to the degree of tightening necessary to prevent leaks, and such complaints are legion among CPAP users (roughly one-half of respondents in most reports2,3,5), although it is likely that advances in mask design have somewhat mitigated this situation. Finally, a complaint of claustrophobia is frequently heard, and some of these patients may actually be reacting to the difficulty they experience in exhaling against pressure.

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