What should be included in a subjective note for a patient with sleep apnea who is returning their Positive Airway Pressure (PAP) device to the clinic due to intolerance?

Documentation for PAP Device Return Due to Intolerance

When documenting a patient returning their PAP device due to intolerance, your subjective note should capture the specific reasons for failure, duration of attempted use, side effects experienced, and the patient's understanding of alternative treatment options.

Essential Components to Document

Patient's Reported Reasons for PAP Failure

• Document the specific intolerance issues the patient experienced, which commonly include: pressure intolerance (particularly expiratory pressure discomfort), mask-related problems (discomfort, leak, claustrophobia), nasal symptoms (dryness, congestion), mouth breathing/leak, lack of perceived benefit, or persistent symptoms despite use 1.
• Record any adverse effects such as skin irritation, aerophagia, or sleep disruption from the device itself 2.
• Note if the patient reported the pressure feeling "too high" or uncomfortable, as this is a common reason for discontinuation 3.

Objective Usage Data

• Include downloaded PAP adherence data showing average hours per night and percentage of nights used, as patients typically overestimate their actual adherence 4.
• Document the total duration the patient attempted PAP therapy (e.g., "used for 45 days prior to return") 5.
• Note the prescribed pressure settings (CPAP pressure or IPAP/EPAP if bilevel) that the patient was unable to tolerate 5.

Interventions Already Attempted

• Document what troubleshooting measures were already tried, such as mask refitting, addition of heated humidification, chinstrap for mouth leak, pressure relief features, or changes in mask type 4, 6.
• Note whether the patient received education about OSA pathophysiology, PAP mechanism of action, and potential benefits prior to initiation 4.
• Record if behavioral interventions or close follow-up communication were provided during the initial PAP period 4.

Current Symptom Status

• Document persistent OSA symptoms including daytime sleepiness (consider using Epworth Sleepiness Scale score), sleep quality, morning headaches, witnessed apneas, or nocturia 5.
• Note any cardiovascular comorbidities (hypertension, heart failure, arrhythmias) that remain uncontrolled without PAP therapy 7.

Discussion of Alternative Treatment Options

Surgical Consultation Discussion

• Document that you discussed referral to a sleep surgeon as an alternative treatment option for patients with BMI <40 kg/m² who are intolerant or unaccepting of PAP 3.
• For patients with obesity (BMI ≥35 kg/m²), document discussion of referral to a bariatric surgeon as an alternative treatment option 3.
• Note that this discussion should be "patient-oriented" and include consideration of other viable alternatives such as mandibular advancement devices, positional therapy, and lifestyle modifications 3.

Patient's Understanding and Preferences

• Record the patient's values and preferences regarding alternative treatment options discussed 3.
• Document whether the patient is interested in pursuing surgical consultation, oral appliance therapy, or other alternatives versus declining further treatment 3.

Example Documentation Framework

Subjective: "Patient returns PAP device after [X days/weeks] of attempted use. Downloaded data shows average use of [X hours/night] on [X%] of nights. Patient reports intolerance due to [specific reason: e.g., 'inability to tolerate expiratory pressure of 16 cm H₂O,' 'persistent mask leak despite multiple mask changes,' 'severe nasal dryness unrelieved by heated humidification']. Prior interventions attempted include [list: e.g., mask refitting, heated humidification, chinstrap, pressure relief feature]. Patient continues to experience [persistent symptoms: e.g., 'severe daytime sleepiness with ESS of 18,' 'witnessed apneas nightly per bed partner']. Discussed alternative treatment options including surgical consultation (patient BMI [X]), oral appliance therapy, and lifestyle modifications. Patient [expresses interest in/declines] surgical referral and [states preferences regarding next steps]."

Critical Pitfalls to Avoid

• Do not accept PAP failure without documenting specific technological problems, as 72% of patients can successfully re-initiate PAP with appropriate mask, mode, or pressure changes 1.
• Avoid documenting vague statements like "patient could not tolerate CPAP" without specifying the exact intolerance mechanism 1.
• Do not fail to document the discussion of alternative treatments, as the American Academy of Sleep Medicine strongly recommends discussing surgical referral for PAP-intolerant patients 3.