Airway Flow/Pressure Regimes CPAP/BiLevel

The application of CPAP for the treatment (Rx) of obstructive sleep apnea (OSA) was first described in 1981. Since
then it has become the treatment of choice for obstructed sleep apnea, associated respiratory sleep disturbances and
emergency airway care.

The definition of positive airway pressure is derived from the ability of a sealed or semi closed airflow generator
circuit, being applied to a patient and the subsequent pressure exerted on and through the respiratory system of the
human body.

A Pressure Gradient
Positive airway pressure is applied artificially to the respiratory system and is used to support the pulmonary
structure and function. The lungs, brain and heart work to maintain a homeostatic balance of air exchange.
{ventilation} The lungs draw in air as a response to changing blood gas values and the diaphragm is the key to
ventilation.

Although, the muscles of respiration, chemo-receptors and medulla of the brain have specific roles to play in the
regulation and response to various ventilation patterns.

Ventilation occurs in response to airway pressure differences

Typically, atmospheric pressure is the baseline and is referred to as zero. When the diaphragm contracts a change in
lung volume occurs, a negative intra-thoracic pressure is generated and is less than atmospheric pressure. An in rush
of air occurs. This in rush of gas molecules is referred to as the trans-airway pressure difference or gradient. It is the
pressure difference between the mouth and alveoli.

Each time a breath is taken a driving pressure exists. At the end of inhalation the alveolar pressure equalizes and
then becomes greater than atmospheric. The greater than atmospheric pressure concept and the elastic recoil of the
lung allow exhalation to occur.

A normal airway pressure cycle →

Inspiration (I) time begins when airway pressure falls below atmospheric. Air flows into the lungs and continues
until the airway pressure returns to atmospheric level. {zero}

Expiratory (E) time begins when the airway pressure builds and becomes greater than atmospheric, then air flows
out of the lung.

There is a pause following exhalation when airflow ceases before the next breath. Airflow is not occurring. This is
considered one respiratory pressure cycle. {I, E, & pause}

 Displacement of a gas volume from one point to another is termed flow.

 Air or gas flowing over time is referred to as flow rate.

  When flow encounters resistance a pressure is generated.

Factors to consider if air flow occurs.

 Volume

 Flow

 Pressure

 Time

The application of a Cpap or Bilevel pressure system changes the pressure cycle. Increased airflow is added to the
respiratory structure which generates a higher pressure. Notice how the inspiratory pressure is above the
atmospheric pressure.

With the application of a continuous external supply of air, the generated pressure does not allow the breathing cycle
to return to zero. Otherwise, the breathing cycle remains the same. This increased pressure creates a larger airway
diameter and allows for splinting of the upper respiratory system. The result is unobstructed airflow. The application
of Cpap for use in obstructed sleep apnea is extremely beneficial.

This greater airflow is transmitted through the respiratory system and increases the functional residual capacity of
the lungs. Hence, the application of Cpap in an emergency room or intensive care situation to regulate ventilation
and blood gases.

{Functional Residual Capacity - The amount of air remaining in the lungs following a normal expiration} see -
Wikipedia Definitions

Description of a CPAP system

A typical Cpap sytem includes many of the following components. The individual differences are determined by the
type of system and the patient convenience. http://images.google.com/images?
svnum=10&hl=en&lr=&q=cpap&btnG=Search
An airflow generator unit is powered by a blower device and motor. Typically the blower device is a fan, a
centrifugual disk or piston driven cylinder.

Aerosol tubing approximately one inch in diameter is attached to the output airflow and directed to the mask or nasal
apparatus, which is attached to the patient at the nose and mouth. Oro-nasal masks are numerous and the designs
vary with each manufacturer. Patient fit (sizes), efficiency and comfort are all considerations for the proper oro-
nasal mask.

All facial appliances and equipment have a built in leak port. This applies whether the leak port is at the distal
patient connection or is served by an automatic escape or relief valve at the blower unit. It is important to verify that
the mechanical leak is present before applying the equipment to a patient. The cardinal sign of a problem with the
leak port is that the patient will complain of difficulty inhaling and exhaling. If this should occur, the patient will be
hesitant to use the device and corrections will need to be made.

Patient compliance is a key factor associated with the use of equipment despite proper equipment operation. Always
assure the leak is functioning properly to avoid these issues.

Adaptions and modifications for equipment include swivels, located within the tubing circuitry, usually near the
mask to allow for movement during sleep without pulling and tugging by the patient.

One manufacturer has devised a "T’ or "L" shaped bracket Google which allows the tubing to rest comfortably
above the patients head while movement occurs.

Cloth, cotton, and velcro type straps hold the oro-nasal device firmly in place in order to prevent airflow leakage
directed towards the patient face or eyes.

Frequently a chin strap may be incorporated to keep the mouth in a closed fashion during sleep. Mask safety
releases, and regained muscle strength upon arousal from sleep will overcome a total closure of the mouth, and
protect the patient from untoward effects.

The mask should be seated over the nose to allow for proper fit without the patient feeling that the device is unduely
pressing on the face. The seal is created by the air pressure inflating the soft pliable seal of the mask. Various mask
sizing devices are available by each manufacturer who supply Cpap equipment.

Technologist training is essential for the proper fitting of each patient and instructions on proper fitting are supplied
by Cpap manufacturers.

An alternative to oro-nasal masks are the use of nasal prongs or pillows. These are small "nose only" sized devices
which seat on the opennings of each nares. Proper fitting is essential with the use of these devices. The use of these
allow for comfort in patients who have difficulty with oro-nasal masks. Occasionally a full face mask is used in leiu
of a nasal airflow device. The full face mask covers the nose and mouth.

Caution should be exercised with the use of these masks, aspiration is a concern. Patient education in the proper
removal of the mask in an urgent situation is essential. In addition, patients should refrain from eating 2-3 hours
prior to bedtime.

Newer emergency room versions of Cpap systems incorporate alarms, minimum adjustable respiratory rates, oxygen
mixers and various monitoring displays. These units are excellent to monitor changes in patient status.

Most oro-nasal appliances come complete with fitting accessories. The most common is referred to as a spacer.
These spacers are small foam pieces which may be attached to masks to prevent the hard plastic portions of the
masks from pinching or cutting into the patients nose or forehead. Newer masks have spacers built onto the masks,
and consist of all types of soft pliable materials to help position the mask or nasal prongs.

All Cpap equipment has a method to provide supplemental oxygen. Customarily, this is via the mask ports or may
be connected via the main tubing. Supplemental oxygen is 100% and is tapped into the airflow circuitry to raise the
delivered room air concentration to a greater level by mixing principles.Various devices and adapters are used to
accomplish this task. Remember, oxygen is ordered by a physician and proper indications must be documented,
prior to use.

Airflow and Resistance in a Cpap system

The general principle of operation of Cpap is a pressurized upper airway, and the

subsequent pneumatic splint which is created. Pressurized by definition means a greater than atmospheric pressure
transmitted to and through the respiratory system. This is accomplished by increased airflow, which in turn reflects a
greater pressure exerted in the airways. The pressure, depending on the optimal amount, will assure that the airway
remains open during sleep and recumbancy.

As we fall into different phases of sleep, our air ways tend to relax or collapse and are smaller in diameter than when
awake. A reduction in airway diameter creates increased resistance to breathing. (It is more difficult to breath
through a straw, than a garden hose.) The body and brain can handle a slight reduction during normal sleep.
Due to fatty deposits and reduced airway musculature, problems arise when more than normal amounts of airway
closure occur, or the worst scenario, when total airway collapse occurs. These obstructions to breathing cause the
brain to arouse form sleep in order to trigger the events of normal breathing. Breathing is controlled primarily by the
level of body carbon dioxide(CO2) and is regulated by the brain. Some untreated patients have developed such
obstructed breathing that the body has become insensitive to rising levels of CO2. This process plays havoc with the
cardiovascular and other body systems.

Cpap normally transmits or creates an increase in the capacity or volume of air being exchanged with each breath.
The overall lung volume or ventilation referred to as the functional residual capacity, increases as Cpap pressure is
increased. As a consequence of improved ventilation, CO2 may decrease to such a level as, as to cease its signaling
activity to the brain. In such cases greater amounts of apnea may be present. This situation should be avoided by
careful titration, and observation of pressure increases during patient treatment regimes.

In sleep testing, Cpap is incorporated primarily for the elimination of obstructed breathing. The abbreviated term
Cpap or continuous positive airway pressure refers to the continuous application of the desired pressure throughout
inspiration and expiration. One pressure, greater than atmospheric is applied.

When Bilevel (two pressures) are used, the Cpap pressure, is then referred to as the Epap level.(end or expiratory
airway pressure) The other pressure is the inspiratory airway pressure.(Ipap) With the use of bilevel pressures
airflow and pressure fluctuate throughout the respiratory cycle.

When switching to bilevel pressure from Cpap, make sure that once airway obstruction is eliminated during the
Cpap phase, not to reduce the Epap pressure inadvertently.

Cpap is effective in eliminating....

 Mixed and Obstructive apneas

 Hypopneas

 Desaturations (due to more efficient ventilation, not oxygenation)

 Some Central Apneas

These apparent central apneas or events are usually associated with obstructive type respiratory events and may or
may not be true central apneas. The pure definition of central apnea as we’ll see, is a cessation or reduction in
breathing due to a malfunction of the central brain response.

Increases in pressure treatment may also cause a delay in an inspiration, due to a prolonged inspiration and/or
expiration of the previous breath.

A change in CO2 levels due to the application of pressure devices may reduce the response to CO2 and sebsequently
display waveforms that appear as a cessation of breathing.

Following the Initiation of Cpap

Obstructive type patients will report the effectiveness of Cpap as:

 an increased daytime alertness

 relief of morning headaches

 decreased nocturnal awakenings

  improved temperment

 a rejuvenated sense of well being

This is quite interesting because when the patient arrives at a physicians office, these are the same initial indications
that warrant sleep diagnostic testing.

 daytime sleepiness

 headaches

 arousals during sleep, as reported by self or spouse

 irritability

 depression

The Initiation of Cpap

Even after the first night - patients can relate to the initial signs and symtoms of effectiveness as above.

It takes time to reach peak effectiveness - Compliance is Important.

CPAP can maintain upper airway patency with acceptable levels of SaO2 in the majority. Some patients continue to
have alveolar hypoventilation and decreases in SaO2. This may be attributed to probable, persistent partial airway
obstruction.

Supplemental Oxygen - may be added. Often underlying lung or chest wall abnormalities impair gas exchange.

Side effects of CPAP

Mask related

 skin abrasions

 conjunctivitis (air leak)

Pressure

 chest discomfort - (stretching of chest wall)

 sinus discomfort - nasal congestion, dryness, epistaxis, or rhinorrhea use of nasal sprays or
humidifiers may be needed.

 smothering feeling

 difficulty exhaling

 difficulty initiating and maintaining sleep - (DIMS)

  pneumothorax

 pneumoencephalus

 aerophagia - (swallowing of air)

Other

 cumbersome

 noisey

 spousal intolerance

Shifts to bilevel treatment pressures may be warranted if CPAP is uncomfortable.

Patient Compliance
The most significant difficulty with CPAP is patient compliance. Studies indicate a 50 - 75 % compliancy after 3 -
22 months use of Cpap. It may be important to question whether a patient uses Cpap nightly for a full sleep or just
for so many hours.

How to gauge patient Compliance.

Use objective studies

 Use a questionnaire or interviewer notes to determine compliance

Use timers on devices

 With the use of timers - compliance was 5.1 +/- 2.6 hrs/night.

 40% of patients used the device greater than 6 hours.

Patients have reported an increased excessive daytime sleepiness (EDS) with one night of non-use of CPAP. Others
have reported days or weeks of improvement following some use of CPAP. Symtomatic improvement plays a big
part of compliance with equipment.

Needs:

 Compliance is enhanced by acceptance of equipment.

 Reinforcement of the importance of equipment use is crucial - make telephone calls or check-up
visits

 Support groups enhance the use of equipment - for education and social acceptance.

Important considerations

 Education prior to the initial use of equipment and the attitude of the patient and caregiver during
presentations. Where does education occur? - In the sleep center, doctors office, or at a clinic
  Trial use of Cpap/Bilevel with varying pressures or modes.

 Trial use with various types of equipment.

 Evaluation of equipment use in multiple sleep positions. (back, sides)

Other

CPAP may uncover periodic limb movements of sleep (PLMS) which will continue to cause sleep disturbances.
Prior to using Cpap, many patients roll, jerk and move about the bed. Often PLMS may not be isolated or treated
due to this activity. Cpap may improve the sleep process significantly and in turn allow limb movements to be
evident. These limb movements may disturb the sleep process. This is often seen in the sleep center during Cpap
titration nights.

Variations of CPAP
Pressure ramping

The rise of pressure over a period of time. (The rate of the rising pressure, for example, 2 cm of H20 pressure every
5 minutes) Normally a patient falls asleep in 10-20 minutes. To reach a pressure of 8cm, start at 4cm and at the end
of 10 minutes the max pressure is reached. The rational - it is easier to fall asleep when you're not so conscious of
the air pressure.

Bilevel

Independant adjustment of inspiration and expiration (I to E ratio) with patient inspiratory flow (~ 40ml/second)

Use of IPAP/EPAP

Predetermined delivery of pressure, and the prevention of negative intra-esophageal pressure. Patient maintains
inspiratory flows and respiratory frequency. This can be maintained with system leaks. During Bilevel the EPAP
level may be lower than CPAP alone! (a lower mean pressure results) EPAP = CPAP; essentially they are the same.

Automatic adjustment pressure devices

Treatment (Bilevel)

 Obstructive Hypopneas are eliminated by IPAP.

 Apnea relieved with critical level of EPAP. (CPAP)

 All/most patients found Bilevel more comfortable than CPAP.

Modes of BiLevel Pressure

 Spontaneous

 Patient triggered

 Spontaneous/Timed - patient triggered w/backup rate. (ventilatory assistance)

 Timed - controlled rate ( no spontaneous breathing)

{Example: Timed ventilation is 10 breaths per minute. This equals one breath every 6 seconds. Subsequently IPAP
(inspiration) duration is 2 seconds or ⅓ of the cycle. EPAP (expiration) would be 3 seconds or 50% of the cycle
with a one second pause between breaths.}

Algorithm for adjusting Pressure ( CPAP)

Start at 4 cmH2O

Increase by 2.0 - 2.5 cmH2O increments

Over 20 - 30 minutes - check - apnea events, oxygen desaturations, snoring, arousals

► If eliminated, then therapy is done, if not continue.

Increase by 2.0 - 2.5 cmH2O

Over 20 - 30 minutes - check - apnea events, oxygen desaturations, snoring, arousals

► If eliminated, then therapy is done, if not continue.

If apnea events and hypopneas are eliminated,

But oxygen desaturations, snoring, and arousals persist, continue to increase...

Increase by 2.0 - 2.5 cmH2O

Over 20 - 30 minutes - check - apnea events, oxygen desaturations, snoring, arousals

► If eliminated, then therapy is done, if not continue.

If apnea events, hypopneas and oxygen desaturations are eliminated,

But snore and arousals persist, continue to increase....slowly with the following guidelines.

Increase by 1.0 - 2.5 cmH2O

Over 20 - 30 minutes - check - apnea events, oxygen desaturations, snoring, arousals

► If eliminated, then therapy is done, if not continue.

If apnea events, hypopneas, oxygen desaturations and snoring are eliminated, but arousals are still occurring.
Evaluate if arousals are CPAP induced.

Consider Bilevel therapy if at any point, the patient does not tolerate Cpap or progress in eliminating events is not
occurring. A break point is usually reached during Cpap titration, when the sleep disturbing events will diminish and
the patient will rebound into a long awaited sleep. This will be quite evident with long periods of REM or Delta
sleep.

BiLevel Sequence Algorithm

(Initial order for treatment is Bilevel)

Start IPAP = 5.0 cmH2O EPAP = 2.5 cmH2O

{This is done to acclimate the patient to two pressures}

Raise EPAP to equal IPAP IPAP = 5.0 cmH2O EPAP = 5.0 cmH2O

** If - persistent obstructive apneas occur ►

Then increase EPAP and IPAP equally ( 2.0 - 2.5 cmH2O) each time, according to the Cpap protocol above until the
majority of persistent obstructive apneas disappear. Continue to raise EPAP and IPAP by equal numbers to eliminate
apneas.

At the point when equal pressure raises are not tolerated, then begin the split pressure regime. Raise the IPAP
pressure by 2-3 cmH20. Observe for apneas.

**If - persistent obstructive apneas are mostly eliminated,

but hypopneas, oxygen desaturations, and snoring persist then

► Raise IPAP pressure

Continue to raise IPAP, until hypopneas, oxygen desaturations, and snoring are eliminated. Remember to wait 20 -
30 minutes to allow for acclimation and blood gas balance to the new pressures.

A sufficient waiting period also helps to officially document the effectiveness of the pressure. When this is
accomplished, then adjustments may be made to eliminate arousals.

These initial settings are subject to change and may vary with the sleep center or insurance reimbursement
requirements.

Starting pressures may be 7/4 or 6/3, to fulfill a difference of 3 cmH2O.

BiLevel Sequence
(When treatment is in progress as CPAP)

The treatment in progress sequence usually occurs when Cpap is not performing as expected or the patient is
uncomfortable with the single pressure. Hopefully a pressure greater than the start pressure has been achieved. If this
is not the case then follow the previous bilevel sequence. If greater than start pressures are in progress then:

Raise IPAP to the level of CPAP

This is setting the unit, and preparing for the switch over to occur, although some units already have IPAP and
EPAP set the same. Hopefully the Cpap has reduced or eliminated the persistent obstructive apneas. Then.......

Raise IPAP by 3 cmH2O, leaving the EPAP alone.

If - hypopneas, oxygen desaturations, and snoring persist - Raise IPAP

Increase IPAP by an additional 2 cmH2O.

If long apnea periods start to occur, It is possible that the pressure is too high.

Consider lowering the mean airway pressure!!

 Apneas may be induced by a pressure which is too high. The chest expands to a limit that does not allow
for adequate movement to register on the polysomnography chest sensor units.
  Central brain control of carbon dioxide sensing is diminished due to an increased ventilation and
subsequent lowering of body carbon dioxide tension.

 Both IPAP and EPAP may need to be reduced slightly to observe if the apneas disappear.

If the consideration is made concerning the over pressurization of the chest, then the continuation of pressure
increases may be used to eliminate upper airway resistance syndrome(UARS) or arousals. If apneas subside for that
particular stage of sleep...

then Optimal EPAP has been achieved!

If - Hypopneas, Desaturations, and Snoring persist - Raise IPAP

Continue to raise IPAP, until Hypopneas, Desaturations, Snoring and possibly arousals are eliminated.

Documentation of various levels of treatment will be needed for the physician to provide an adequate prescription.
The physician may also wish to evaluate various stages of sleep and body positions at known levels of treatment
pressures.

The Ultimate Titration Algorithm

Supplemental Oxygen Usage

The addition of supplemental oxygen should be considered in cases of persistant oxygen desaturation despite the
reduction of the apnea/hypopnea index and snoring.

A typical sleep center protocol will include the evaluation of persistant oxygen desaturation PRIOR to beginning a
titration. Supplemental oxygen may be started at the beginning of a study, before Cpap/Bilevel protocols are
initiated, and the patient is allowed to begin sleep. This addition of oxygen supplemental oxygen as a titration
protocol; is used in the sleep center and in the hospital setting for acute and semi-acute care.

Oxygen protocols need to be center/clinic specific regarding the degree of oxygen desaturation. Consideration
should also be made to start oxygen on chronic or noctural oxygen users.

Supplemental oxygen may be added (titrated) in line with positive airway pressure devices. Proximal or distal ports
of pressure devices may be used. Consider the ease of use of the equipment for the patient.

Sterilization and Disinfection of Equipment

A good rule of thumb regarding cleaning your equipment - Always rinse thoroughly. If parts still seem to be oily,
wash them again. The hospital or sleep clinic may use disposable head straps, hoses and mask spacers. Some even
use disposable masks. For home and personal use the following guidelines.

Mask

The mask should last 6-12 months with proper care. Wash the contact areas before applying the mask each night.

 Wash or rinse mask daily after use.

 Wash the mask and frame in warm water using a mild detergent (avoid alcohol-based products).

 Rinse well.
  Soak mask and frame in 1 part white vinegar and 2 parts water for 20 minutes. You can also use Control III
or an equivalent disinfectant for 10 minutes.

 Rinse well and let air dry.

With a soft cloth gently wash all the parts of the mask, the shell or nasal pillows, and the swivels in a solution of
warm water and mild unscented dish detergent. Do not use any cleaners containing fragrance, conditioners or
moisturizers as these will leave a residue. Be sure to thoroughly clean the mask cushion flaps or the nasal pillows.

Headgear

Wash as needed. The straps and headgear may be machine-washed and line dried. These items should be cleaned a
minimum of once each month. To maximize the life of the soft goods hand washing with a standard laundry
detergent is recommended. Never Use Bleach. Before washing, remove the soft goods from the hard goods.

Hose

 Wash weekly in warm water.

 Rinse well.

 Connect tubing to machine to dry inside of tubing.

If desired, you can disinfect the tubing, mask parts, the shell and pillows, swivels in a cold sterilizing solution, such
as Control III, Cidex, or Sonacide, following the manufacturer's directions closely. You can use a white vinegar and
distilled water solution, mixing 1 part white vinegar and three parts distilled water. Allow all items to soak for 20
minutes. Make sure you thoroughly rinse the items after disinfecting them. Any residue left on the parts may shorten
their useful life and/or irritate your skin.

Humidifier

 Empty humidifier daily.

 Rinse.

 Soak humidifier chamber using 1 part vinegar and 2 parts water for 20 minutes. You may also use Control
III for 10 minutes if you prefer.

Always use distilled water in your humidifier. The humidification chamber should be cleaned daily or after each use.
After the heater plate has cooled, disconnect the tubes from the top of the humidification chamber and remove it
from the heater base. Discard any water remaining in the humidification chamber if you are not using distilled water.
Wash the chamber top, base, deflector, and supply tubing in mild dish washing detergent. Rinse thoroughly and air
dry. Disinfect chamber top, base, deflector, and tubing weekly in a solution of Control III. or disinfectant. Follow
the directions carefully. Rinse thoroughly after disinfecting. Inspect the chamber, base, deflector, and tubing to
ensure no residue remains after cleaning and sterilizing.

Flow Generator

 Unplug unit.

 Wipe with warm cloth and dish soap to clean surface as needed.

 Dry unit before plugging in.

Intake Filter

 If disposable, the filter should be changed as directed by the manufacturer.

 If non-disposable, wash as needed in cool water and mild detergent.

 Rinse well.

 Squeeze moisture from the filter in a cloth towel. Allow to air dry before replacing.

Let every thing dry completely before using them again. To make sure all parts of the system are completely dry, put
the system together and run the unit for about 30 minutes before using.

Tips for Home Use

 If you travel a lot for business or pleasure, consider purchasing a device that is light in weight, has
automatic altitude adjustment and runs off either 110 or 220 electrical currents. Also, some devices can
operate using a DC adapter for those who like to camp out or sleep in trucks.

 When you find the mask you like best, it is a good idea to have a second "back up" mask so that if a part
should break, you will still be able to get a good night's sleep. Also, a second mask is good to have if the
first mask has not dried completely from an earlier cleaning.

 Many CPAPs and Auto CPAPs come with extra features that you may or may not need such as memory for
recording sessions, compliance meters.

 You should check the mask or nasal pillows after each cleaning. The silicone mask cushion and the silicone
nasal pillows were designed to last up to 12 months with proper care. Although silicone is not susceptible
to hardening, it can tear. The actual life of the nasal mask or pillows can vary greatly, depending upon use.
Replace the mask when it leaks air excessively, there is a tear in the cushion, or it becomes uncomfortable
to wear.

 Caution: Do not clean any parts of the system with alcohol or cleaning solutions containing alcohol.

 Do not clean the system by steam autoclave or gas sterilization methods. These cleaning processes may
harden or deform the flexible plastic parts of the system and adversely affect their function.

Many patients exhibit nasal congestion during CPAP use.

Recent clinical studies point to mouth leaks or mouth breathing as the main cause. Moist air is exhaled from the
mouth, and the nose loses its supply of moisture normally supplied by the expired air. In a futile attempt to provide
moisture in the nasal cavity, vessels fill with blood trying to create moisture for the next inspiratory breath. The
congestion caused by this blood flow narrows the airway, increasing the resistance. As the nasal resistance increases,
CPAP pressure has to increase as well to make the effective airway splint.

Patients with mouth leaks will increase the nasal resistance the same as nasal problems due to allergies.

 Using heated humidity will alleviate nasal resistance from mouth leaks thereby reducing the need to
increase CPAP pressure to compensate for the nasal congestion.

 Chinstraps can be used to prevent mouth leaks.

  Patients with chronic nasal congestion due to allergies, rhinitis, etc. should talk to their physician about the
possible need of a nasal spray.

When fitting the CPAP mask/headgear to your face:

 Turn the machine on

 Place the headgear on your head, loosely

 Lie down on your back

 Then gently adjust the straps until no leaks are found

Do not overtighten...this makes the mask collapse and may cause leakage as well as discomfort.

If your nose is getting sore from the nasal pillows, try putting Carmex on the outside of the pillows. This will
soften the surface, may help decrease air leaks, and it has a pleasant scent.

More Tips

 Use a steady bedside table, large enough to accommodate your CPAP unit, humidifier, and bedside lamp. It
is not a good idea to keep your CPAP unit on the floor where it will be exposed to household dust and
could become a safety hazard.

 Position the unit so that the air hose can be draped over the head of the bed, with plenty of slack, to allow
you freedom of movement during sleep.

 Keep your air filter free from blankets, curtains, or anything else that could block the free flow of air to the
CPAP unit.

 Keep your bedroom quiet, cool, and dark.

 Don't have a clock visible during the night.

 Wash your face before putting on your mask. Facial oils will impair the seal.

 Don't drink alcohol within two hours of bedtime. Alcohol impairs the quality of sleep.

 Eliminate caffeine products from your diet within a reasonable bedtime.

 Saline nasal spray - use for nasal dryness.

 Lubricating jelly or vitamin E ointment - use for nasal pillow irritation.

 Duoderm or Moleskin - use over a sore area to protect until healed.

 Know when to call your medical equipment supplier.

 Know your replacement schedule for your equipment and supplies.