CPAP: Use It And Live

The majority of patients I encounter in the ICU/CCU who have a diagnosis of sleep apnea do not use their CPAP machines. Those who DO use them seem to have better outcomes.

I work in a cardiac intensive care unit; CCU and SICU together. As an ICU nurse, I’m well acquainted with the correlation between untreated sleep apnea and heart disease, stroke or sudden death. And I wish I had a dollar for every patient with “Obstructive Sleep Apnea” listed as a diagnosis on their chart and no CPAP with them when they’re admitted to the ICU.

Pauline (not her real name) came in for an MI, proceeded to have a CABG and then stroked while still in the ICU. Her history lists “sleep apnea.” When asked if she brought her CPAP, she proudly held up a Respironics bag. At bedtime, we opened it up and found an ancient CPAP machine and full face mask that may have fit her 100 pounds ago (did I mention that she was 5 foot 0 inches and weighed 140 kg.?) The humidifier was missing a part and the hose had toothmarks in it -- canine or feline toothmarks.

“When was the last time you used this,” I asked, thinking that maybe this is her spare and her real machine is at home on her bedside table.

“Oh, I don’t use it,” she said. “I just brought it in because the office nurse told me I ought to.”

Mentally slapping myself on the side of my head, I ask “Why don’t you use it?”

“I don’t like having all that air forced into me,” she says. Like that ventilator you’re going to be stuck with is so much more comfortable? (I’m so proud that I managed to bite my tongue before actually saying this.) Sure enough, she failed her first three extubation attempts, got trached and is now in a long term care facility on a ventilator.

Hermann has a HeartMate II ventricular assist device. He was readmitted not too long ago with a recurrent drive line infection. As part of the admission process, I went over his problem list with him -- and of course obstructive sleep apnea was listed. “Did you bring your CPAP?” I asked.

“I don’t need to use it anymore,” he said. “I have my HeartMate now!” (For all of you nurses who haven’t worked with HeartMates, they’re a left ventricular assist device. They’re used as bridge to transplant, or even destination therapy for heart failure. Blood is routed from the left ventricle through the device and is returned to the aorta.)

Worse, when I read over his clinic notes, there was a note from a nurse practitioner stating something to the effect of “Patient refuses to use CPAP at night. Instructed to use it for 2 or 3 hours during the day when he’s watching TV, so he’ll get at least some benefit from it.” Really? I doubt that the man is have sleep apnea while he’s watching TV. By definition, one needs to be sleeping to have sleep apnea.

Then there was the man who came in for semi-elective valve surgery. Once again, obstructive sleep apnea was noted on his problem list. “Did you bring your CPAP?” I asked. “Oh, no,” exclaimed his wife. “He doesn’t like it, so he never uses it.” It’s been five months and counting -- he’s still in the ICU. The hypertension he developed subsequent to the untreated sleep apnea caused left ventricular hypertrophy and then he arrested post-op . . . .

I was thrilled when last week’s patient swore he used his CPAP faithfully. “I don’t have it with me because I didn’t think I needed it in the hospital and all,” he explained. “But my wife can go home and get it.”

His wife went home and got the CPAP. Interestingly enough, neither the patient or his wife had any idea how to set it up or how the mask fittings worked. What was he using the CPAP for? A paperweight? He’s on his third admission for heart failure and they’re talking transplant now. I wonder if some of his problems could have been avoided had he been actually using the CPAP he got four years ago.

It may be my imagination, but I swear there’s a correlation between showing up with your CPAP and knowing how to use it and eventual outcome . . . those that bring it and use it seem to do well and transfer out of the ICU promptly. Those who don’t bring it, bring only parts of it, can’t set it up or don’t even pretend to use it usually do poorly. Maybe it’s just that those who actually use their CPAP are more compliant patients in general, and compliant patients do better, but I swear that treating sleep apnea enhances patient outcomes.

The woman I admitted today -- with obstructive sleep apnea and heart disease -- claims she “has sleep apnea, but I don’t need to use a CPAP. They told me I only had to use it at night, and I sleep during the day.” I attempted to educate her on the correlation between sleep apnea and heart disease. “Oh,” she said. “I guess I could use it, but it’s just so difficult. You have no idea how difficult it is, strapping that thing on your face and trying to go to sleep.”

I DO know how difficult it is. I strap one on every night when I go to sleep -- and in the afternoon when I take a nap, too. It’s uncomfortable, unsexy, inconvenient and unnatural. It just might save your life, though.

CPAP: Use it and live.