What are the recommendations for a patient with obstructive sleep apnea (OSA) undergoing Continuous Positive Airway Pressure (CPAP) therapy who prefers cool air?

Managing OSA Patients on CPAP Who Prefer Cool Air

For patients with OSA on CPAP therapy who prefer cool air, you should still use heated humidification but adjust the temperature settings downward rather than eliminating humidification entirely, as heated humidification significantly reduces treatment-limiting side effects even when thermal comfort is a concern. 1, 2

Primary Recommendation: Adjust Temperature Settings, Not Eliminate Humidification

• The American Academy of Sleep Medicine recommends heated humidification with PAP devices to reduce side effects including dry mouth/throat, nasal discharge, nasal congestion, dry nose, bleeding nose, sinus pain, headache, sore throat, hoarse voice, and reduced smell. 1

• When patients complain of thermal discomfort, adjust the humidifier temperature settings to lower levels rather than completely eliminating humidification, as the benefits of moisture delivery can be maintained while reducing heat output. 2

• Meta-analyses demonstrate clinically significant reduction in multiple PAP-related side effects with heated humidification, though no significant improvement in overall PAP adherence or quality of life was found. 1

Practical Implementation Strategy

Step 1: Initial Temperature Adjustment

• Start by reducing the heated humidifier temperature setting to the lowest comfortable level that still provides adequate moisture. 2

• Modern heated humidification systems allow independent adjustment of temperature and humidity levels, enabling customization for patient comfort. 2

Step 2: Consider Heated Tubing Modifications

• Heated tubing significantly reduces nasal dryness, oral dryness, throat irritation, and nasal congestion during PAP therapy, which are common side effects that can lead to treatment discontinuation. 2

• If the patient finds heated tubing too warm, consider using standard (non-heated) tubing with the heated humidifier, which allows moisture delivery with less heat transfer to the delivered air. 3

• Be aware that non-heated tubing in cool environments may cause condensation ("rain out"), which can be uncomfortable and reduce therapy effectiveness. 1

Step 3: Environmental Considerations

• Patients living in particularly dry climates or using higher PAP pressures (which reduce relative humidity of delivered air) may require heated humidification despite thermal discomfort preferences. 2

• Higher PAP pressures reduce the relative humidity of delivered air, making some level of humidification more critical at therapeutic pressures. 2

Alternative Approaches If Temperature Adjustment Fails

Mask Interface Optimization

• Use nasal or intranasal mask interfaces over oronasal or oral interfaces, as these generally have fewer side effects and may reduce the perception of warm air delivery. 1

• The mask interface that minimizes side effects and optimizes efficacy and adherence should be used, considering individual patient factors. 1

Trial Period Without Humidification

• If the patient remains intolerant of any heated humidification despite temperature adjustments, a trial without humidification is reasonable, but monitor closely for development of nasal symptoms. 4

• Research shows that heated humidification during initial CPAP titration offers no additional benefit in nasal physiology or symptoms during a single night, but longer-term use is effective in alleviating symptoms and improving patient comfort. 4, 5

Critical Pitfalls to Avoid

• Do not assume thermal discomfort means the patient should abandon humidification entirely—these symptoms often indicate correctable issues including inappropriate humidification settings that are too high. 2

• Do not use oily nose drops as an alternative to heated humidification, as they are significantly less effective (only 42% improvement vs. 100% with heated humidification). 6

• Regular cleaning of the humidifier chamber is necessary to prevent mineral buildup that affects performance and may alter temperature delivery. 2

Monitoring and Follow-Up

• Initial CPAP follow-up is recommended during the first few weeks to establish utilization patterns and provide remediation if needed, including addressing thermal comfort issues. 5

• Objective monitoring of CPAP usage should be performed to ensure that temperature adjustments do not negatively impact adherence. 5

• Longer-term follow-up is recommended yearly or as needed to address mask, machine, or usage problems, including reassessment of humidification needs. 5