What is positive airway pressure (PAP)
PAP is provided by a device that blows air under pressure into your child's airway. The pressure keeps your child's airway open while they sleep and makes breathing easier.
Overview of breathing
When we breathe in, oxygen enters the lungs. When we breathe out, carbon dioxide exits the lungs. Breathing is a repetitive process and consists of two stages:
- breathing in (inhalation)
- breathing out (exhalation)
When we breathe in, oxygen enters the lungs. When we breathe out, carbon dioxide exits the lungs.
Breathing in
During inhalation, the respiratory muscles contract, causing the diaphragm to move downward. This allows air to move in through our nose and mouth, causing the lungs to fill with air and increase in size. Oxygen and carbon dioxide are then exchanged in the part of the lungs called the alveoli. Oxygen from the inhaled air is transferred to the blood and carried through our bodies. Carbon dioxide from the blood is transferred to air in the lungs.
Breathing out
Exhalation begins when we relax our respiratory muscles. As we breathe out, we blow off carbon dioxide and our lungs decrease in size.
How does PAP work?
There are two types of PAP.
Continuous positive airway pressure (CPAP)
CPAP refers to a device that blows air under a single continuous pressure into your child’s airway through a mask.
Your child may be prescribed CPAP therapy because they have obstructive sleep apnea. Obstructive sleep apnea means that a person's airway becomes partially or completely blocked while they are sleeping. This makes it difficult for them to breathe. Symptoms of obstructive sleep apnea include snoring, gasping or pauses in breathing.
During obstructive sleep apnea, the oxygen levels in your child's blood may change. This can reduce the quality of their sleep. If poor sleep goes untreated, it can affect your child's learning and daytime functioning.
Bi-level continuous positive airway pressure (BPAP)
Bi-level continuous positive airway pressure (BPAP) refers to a device that blows air under two different pressures through a mask. A higher pressure is used to help fill the lungs with air when breathing in and a lower pressure is used when breathing out to prevent the airway from closing. Breathing in and out is controlled by the respiratory muscles. Any condition that weakens the muscles can lead to problems with breathing.
BPAP may be used to:
- improve symptoms of sleep disordered breathing such as shortness of breath, awakenings, morning headaches or daytime sleepiness
- improve the exchange of oxygen and carbon dioxide
- allow respiratory muscles to rest and reduce the work of breathing
- improve respiratory reserve to prevent severe illness when faced with a respiratory illness
Both PAP devices are attached to a mask that is fitted to your child's face with straps. The straps reach around the back of your child's head. Your child will wear the mask while they are sleeping to receive the air from the device. For most children, the air that blows is not oxygen.
What happens if PAP is recommended for my child?
Trying out the mask and headgear
First, your child will be given a mask and headgear to take home so they can practise wearing it at home for short periods during the day. Your child should wear the mask while they are awake and doing a quiet activity they enjoy, such as watching a movie or television show or listening to a story.
Sleep study
Next, your child will have an overnight sleep study to set the pressure(s) on the PAP device. Make sure you bring your child's mask to this study. Your child already had a sleep study before they were diagnosed with sleep apnea. This second sleep study will be similar except a sleep technologist will adjust the pressure(s) from the PAP device while your child is sleeping to achieve the best breathing and sleep for your child.
After the study
If your child has been prescribed CPAP, you will need to buy your child's mask and device from a local home care company. The sleep team will refer you to this company and will give you a prescription with your child's specific CPAP pressure, for example 5 cm H2O. It is a good idea to write the pressure on a piece of paper and tape it to the outside of the CPAP device.
If your child has been prescribed BPAP, the machine will be provided through the Ventilator Equipment Pool of the Ministry of Health. Home care providers from this agency will contact you to set up an appointment in your home.
How long will it take to get the CPAP or BPAP device?
When the home care company or Ventilator Equipment Pool receives the prescription from the hospital, they will contact you to arrange an appointment, usually no more than two months after the sleep study.
How much does the PAP device cost?
If your child needs a CPAP device, you can ask the home care company about the costs. If you receive government assistance or have private insurance, some of the costs may be covered.
If your child needs a BPAP device, you will get it at no cost to you. However, you will need to pay for any replacement masks, filters and hoses.
Using PAP at home with your child
How can I help make sure that PAP is working for my child?
For your child's comfort and for the PAP to work best, the mask must fit properly. If you think the mask is not a good size, contact your home care company to see if there are other masks your child could use.
Do not fasten the mask and headgear too tightly. This could cause skin to break down in the areas around the nose and mouth. Check your child's face for pressure marks and adjust the mask and headgear as needed. Make sure you can place two fingers under the strap.
How can I help my child get comfortable with a PAP device?
Most children take time to become comfortable with a PAP device. You can help with the success of the treatment by making the device part of your child's bedtime routine.
You may also find it helpful to create a reward system for each night your child wears the mask and headgear. For younger children, this may include a sticker chart. Older children may benefit from other rewards. A respiratory therapist (a member of the sleep medicine team) will monitor your child's progress.
If your child continues to have difficulty with the PAP device, contact your home care company or the sleep medicine team.
Will my child have to sleep only on their back while using PAP?
You should encourage your child to sleep on their back or side. If your child is normally a tummy sleeper and is finding it hard to adjust to a new sleep position, you may ask your home care company about a special PAP pillow. It can support your child and may make a change to a new position easier.
Must my child use the PAP device when they sleep away from home?
Yes. PAP is prescribed for every night of sleep and so it should be used even on vacation, sleepovers or camping.
Will my child need to do any other sleep study once they start using PAP?
Yes, your child will be scheduled for another sleep study after they start using PAP. You will need to bring your child's mask, headgear and PAP device to the sleep study so the sleep technologist can make sure everything is working properly. The sleep technologist will monitor your child while they sleep to see if the amount of pressure that has been prescribed needs to change.
How long will my child need to use PAP?
Some children may need to use PAP as a long-term treatment. The sleep medicine team will continue to follow your child and reassess the need for PAP therapy at follow-up sleep studies and clinic visits.
Dealing with problems with the PAP device and tubing
What do I do if my child complains of a dry nose or mouth or if water is pooling in the PAP tubing?
Most often the humidifier warming function simply needs a small adjustment. Increase the setting if your child's nose or mouth is dry or reduce the setting to get rid of condensation in the tubing and circuit.
My child is complaining that the mask is uncomfortable or leaving marks on their face.
First, make sure that the straps on the mask are not too tight. If mask discomfort persists, ask the sleep team for more training to adjust the mask properly or to have your child fitted for another type of mask that may suit them better.
My child does not like the air pressure blowing through the mask.
Make sure the mask fits well without leaks as the PAP machine will blow more air to compensate for leaks which may cause more discomfort. Most PAP devices have settings that can be adjusted to help your child get used to the pressure. Ask a member of the sleep medicine team if this may be helpful for your child.
If changing the settings would help, and your child is using a CPAP device, you may need to bring the device to your home care provider to make the adjustment. If your child is using a BPAP device, the respiratory therapist will make any changes in the clinic.
Maintaining the PAP device, mask and headgear
How do I clean the PAP device, mask and headgear?
The home care company will give you instructions to maintain your child's PAP device.
It is important to clean the mask each morning because the oils from your child's skin can break down the mask. Wash it by hand with warm water and a mild soap and allow it to air dry (do not dry it with a towel or tissue). Wash the headgear by hand with mild soap and water once a week and leave it to air dry.
What do I do if my child's mask, tubing or PAP device is broken?
If there are problems with a CPAP device, contact your home care company. If there are problems with a BPAP device, contact the Ventilator Equipment Pool. You will get instructions on how to fix the problem.
What do I do if I hear an alarm sounding on the machine?
If you notice any alarms sounding when your child is wearing the BPAP machine, you can contact the Ventilator Equipment Pool or a member of the sleep medicine team. If an error message occurs on your CPAP machine, contact your home care company.
Involving your child's health-care provider
The health-care provider who referred your child to the sleep clinic will receive a copy of the sleep study and clinic visit letters. With your permission, the sleep clinic can send the results to your child's other health-care providers. A copy of the sleep study and sleep clinic visit will also be kept in your child's health record at the hospital.
If your child is sick and you are concerned about their breathing, contact your child’s primary health-care provider or have your child seen in your local emergency department. If you have questions about the CPAP device, contact your home care company. If you have questions about your BPAP device, contact the Ventilator Equipment Pool. If you have other questions about your child's sleep, contact a member of the sleep medicine team.