What is the recommended desensitization approach for patients with Continuous Positive Airway Pressure (CPAP)/Bilevel Positive Airway Pressure (BiPAP) intolerance?

Recommended Desensitization Therapy for CPAP/BiPAP Intolerance

The most effective desensitization approach for CPAP/BiPAP intolerance is a structured graded exposure therapy combined with specific device adjustments to address pressure intolerance, mask discomfort, and adaptation difficulties. 1

Assessment of Intolerance Factors

Before implementing desensitization therapy, identify the specific causes of intolerance:

1. Technology-related factors:

   • Mask discomfort/leak (most common)
   • Pressure intolerance (especially expiratory pressure)
   • Claustrophobic reactions
   • Adaptation difficulties

2. Patient-specific factors:

   • Anxiety or claustrophobia
   • Nasal/pharyngeal problems
   • Age (older patients have more difficulty with nasal/pharyngeal side effects) 2

Structured Desensitization Protocol

Step 1: Device Optimization

• Mask Selection and Fitting:

  • Perform mask refit, adjustment, or change mask type whenever significant unintentional leak is observed or patient complains of discomfort 3
  • Consider oronasal mask or chin strap if mouth leak is causing significant symptoms 3
  • Apply thin foam dressing under mask if any non-blanchable or blanchable erythema appears on pressure points 4

• Pressure Adjustments:

  • If patient complains pressure is too high, decrease to a comfortable level that allows return to sleep 3
  • Consider pressure relief during EPAP (flexible PAP) to improve comfort if patient has difficulty exhaling 3
  • Adjust rise time (time duration for pressure change from EPAP to IPAP) for comfort:
    • Shorter rise times (100-400 ms) for obstructive airway disease
    • Longer rise times (300-600 ms) for restrictive disease 3

Step 2: Graded Exposure Therapy

Implement a progressive desensitization approach:

1. Initial Phase (Daytime Practice):

   • Hold mask in hands and examine it
   • Hold mask near face without straps
   • Place mask on face without straps for increasing periods
   • Place mask on face with straps but no pressure for increasing periods

2. Intermediate Phase:

   • Connect mask to CPAP/BiPAP with minimal pressure settings (IPAP 8 cm H₂O, EPAP 4 cm H₂O) 5
   • Practice during daytime while awake, starting with short periods (5-10 minutes)
   • Gradually increase duration of use during daytime

3. Advanced Phase:

   • Use device during daytime naps
   • Begin nighttime use for partial nights
   • Progress to full night use

Step 3: Multiple Re-titrations if Needed

• Consider the REPAP (re-titration of PAP) protocol for patients who fail initial attempts 6
• Multiple re-titrations show significantly higher success rates (80%) compared to single re-titration (61%) 6

Monitoring and Follow-up

• Schedule periodic reassessment as appropriate to stage of disease 3
• Perform regular skin assessments to prevent medical device-related pressure injuries 4
• Monitor for development of daytime hypoventilation, which may necessitate around-the-clock ventilation 3

Common Pitfalls and Solutions

1. Mask-Related Issues:

   • Pitfall: Skin irritation and pressure ulcers
   • Solution: Regular skin assessment, proper mask fitting, use of protective barriers

2. Pressure Intolerance:

   • Pitfall: Starting with pressures too high
   • Solution: Begin with minimum settings and gradually increase; consider BiPAP if CPAP intolerance persists at 15 cm H₂O 3

3. Claustrophobia:

   • Pitfall: Rushing the adaptation process
   • Solution: Gradual exposure therapy, starting with mask handling and progressing to full use 7, 1

4. Nasal/Pharyngeal Problems:

   • Pitfall: Dryness, congestion, irritation
   • Solution: Add heated humidification, consider nasal steroids 3

5. Inadequate Follow-up:

   • Pitfall: Assuming initial settings will remain appropriate
   • Solution: Schedule regular follow-up visits to adjust settings as patient's condition changes 3

By implementing this structured desensitization protocol and addressing the specific causes of CPAP/BiPAP intolerance, most patients can successfully adapt to therapy, leading to improved adherence and better clinical outcomes.