Heated humidification brings new levels of compliance and comfort to CPAP
"Heated humidification is marvelous. It is one of the main
factors in making compliance happen." Shelly Cutting, ME, director
of new market development at Northwest Medical, Portland, Ore., has
no hesitations when it comes to supporting this relatively new technique
for improving compliance in continuous positive airway pressure (CPAP)
patients. "Beyond all other means we have, heated humidification has
certainly become the standard for the least invasive, best method
to constantly control nasal congestion."
Cutting began using the technique approximately five years
ago, but many respiratory therapists have only recently introduced
heated humidification to patients.
Heated humidification helps eliminate the problem
of nasal drying. As a CPAP delivery application, it closely resembles
cool - or passover - humidification. An air hose leading from the
CPAP unit connects to the humidifying device, where is passes over
a chamber of distilled water to pick up moisture. The main hose then
connects to the nasal mask. "It is pretty much a blow-by system,"
says Andrea Pavlak, RRT, of Boardman Medical Supply, Girard, Ohio.
"The heated humidifier basically just adds a heating plate under the
humidifying chamber. That heating plate is adjustable in temperature
so [patients] can adjust it at home to suit their needs."
This simple system has become, in the eyes of many practitioners,
the most effective of several techniques designed to combat the drying
effect of CPAP. "Absolutely, heated humidification has improved compliance
in out patients," says Bob Shellenberger, CRTT, RCP, manager of respiratory
care services at RX Respiratory Care, Monroeville, Pa. "Everyone that
we've used it on so far has had symptoms improved and problems relieved."
Despite its benefits, heated humidification is
often the last resort effort for improving CPAP compliance and patient
comfort. "We know that it works, but because of the cost, doctors
will say, 'Try this nasal spray, try this decongestant,' all the way
down the line to the pass-over humidification, which we know doesn't
work at all," Cutting says. "Finally, we get down to heated humidification."
THE PRICE OF COMPLIANCE
Several factors inhibit standard application of
heated humidification of CPAP users. "Expense is the first issue I'd
be concerned about," Shellenberger says. Each unit can cost as much
as $500. "And second, sometimes there's such a comfort issue with
the heat. It can be a little bit warmer than room temperature." Both
providers note that approximately five percent of their CPAP patients
use heated humidification. "Usually there's a clinical indication
as to why we're going to proceed on to heated humidification," Shellenberger
says. "A lot of them have sinus problems, severe dryness of the sinuses.
Anything like that would be an indication for us to consider heated
humidification."
Recently, RX Respiratory Care has started relying
on heated humidification with more and more CPAP patients. "We're
finding an increasing recommendation for switching patients to heated
humidification for comfort," Shellenberger said. The company now monitors
patients early - within the first 30 days - to catch indications of
future non-compliance and move to heated humidification. "We actually
are more aggressive now in heated humidification as opposed to medication
and other things that [clinicians have used in the past] to relieve
symptoms."
The very nature of CPAP delivery suggests that
heated humidification can and should play a larger role in improving
compliance, according to Cutting. "What we've found is that with a
large percentage of CPAP patients, people do not have any sinus problems
prior to using CPAP, and the CPAP actually creates chronic sinus congestion,"
she says. "The cold air blowing through your nose causes swelling
of the mucus membrane, and of course that is what creates the congestion.
It's directly caused by the CPAP machine, and that's why we have so
many people who need [heated humidification]."
RESEARCH
Several recent studies also offer scientific support for
expanding the role of heated humidification in CPAP use. In a series
of tests performed on six normal subjects, researchers found that
using room air for CPAP delivery resulted in nasal airway resistance
(NAR) of more than 250% of baseline.1 Adding a cool humidifier
did not affect NAR, but use of heated humidification reduced NAR at
two different temperatures settings. (p<.001).
A second study specifically addressed the effects of heated
humidification when a CPAP patient has a mouth leak.2 Eight
subjects using non-humidified CPAP displayed a 65% mean increase in
nasal mucosal blood flux, which in turn increases NAR. Nasal mucosal
blood flux increased by only 8% in the same subjects when heated humidification
was added to their CPAP units. Mouth leaks, which occur when the patient
breathes with an open mouth, cause a unidirectional airflow over nasal
membranes to further exacerbate any drying effect.
Supporters of heated humidification hope these
studies will lead to greater usage of the technique in CPAP delivery.
"This is our first step in helping payors and even some physicians
who aren't as privy become more aware of the advantages of using heated
humidification. It's a good milestone," Cutting says. She believes
scientific support will help sway payors who are hesitant to approve
heated humidifiers in CPAP. "We now have a scientific basis to say,
'Look, payor, this is definitely a measure that works.'"
Currently,
25% of CPAP patients at Northwest Medical successfully use heated
humidification with their units. "We've found that [patients using]
heated humidification definitely have a much higher tolerance and
a much better chance of being long-term users," Cutting says. But
she still has a hard time convincing physicians and payors to try
the technique. "The heated humidifiers are fairly expensive," Cutting
says. "Patients don't want to pay for them, therefore a lot of them
don't go out." Payors who consider heated humidification an accessory
rather than a necessity find it difficult to justify the cost.
"Certainly it should be classified as an accessory, based
on the fact that not every region needs it," Cutting concedes. "However,
the majority of the patients do need it, and probably 85% to 90% of
patients would benefit from it. Even the patients who don't need it
day to day, if they had it, they would be better off than they are."
Kathryn Olson is associate editor of Home Health Care Dealer/Supplier.
REFERENCES
1. Richards G, Cistulli R, Unger R, Berrthon-Jones
M, Sullivan C. “Mouth leak with nasal CPAP increases nasal airway
resistance.” Aust NZJ Med. 1994;24:480
2. Hayes M, McGregor F, Roberts D, Schroter R, Pride
N. “Continuous nasal positive airway pressure with a mouth leak:
effect on nasal mucosal blood flux and nasal geometry.” Thorax.
1995
July/August 1996
Reprinted with permission from Home Health Care Dealer/Supplier
Random
Fact:
Interesting Apnea Statistics
~~ Apnea in the United States ~~
As of March 23, 2007 at 10:54 a.m. (-0500), the U.S. population was 301,442,343. With new estimates
that about seven percent of the population suffers from obstructive sleep apnea, that means
there are potentially 21,100,964 apneics in the U.S.
Apnea around the world ~~
As of March 23, 2007 at 10:54 a.m. (-0500), the world population was 6,584,093,711. With new estimates
that about seven percent of the population suffers from obstructive sleep apnea, that means
there are potentially 460,886,560 apneics in the world.
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Citation: David F. Jackson.
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