Positive Airway Pressure Device Care and Cleaning Practices in the Pediatric Home

Abstract

BACKGROUND:

Regular care and cleaning of positive airway pressure (PAP) devices are important for maintaining equipment in the home. Illness and hospitalization have occurred from inadequate cleaning and use of tap water in the humidifier. In recent years, ozone and ultraviolent-light disinfection devices have been advertised for cleaning home PAP equipment. Our clinic provides instructions; however, cleaning practices performed in the home are unknown.

METHODS:

A survey of home cleaning practices for PAP equipment was conducted in a pediatric sleep clinic during 2019–2020. Survey domains were method, cleaning and replacement frequency for each component, type of water used, instruction preferences, and demographics. The primary aim was to identify home PAP cleaning practices and compare with provided instructions. The secondary aim was to determine if respiratory-related symptoms (eg, congestion, runny nose, sneezing, coughing) occurred or increased with PAP use or inadequate cleaning.

RESULTS:

The survey was completed by 96 respondents. Most reported weekly cleaning of mask (36, 38%), tubing (41, 43%), and humidifier (31, 33%) with soap and water as the primary method for each. The majority used distilled water in the humidifier (74, 77%) and reported respiratory symptoms did not occur with PAP use (64, 67%). Very few indicated a device was used to clean equipment. No associations were found between length of time for PAP use and cleaning practices. There was a moderately low correlation between age and cleaning. Increased age was associated with decreased cleaning frequency (r = 0.20, P = .048).

CONCLUSIONS:

Care and cleaning practices of home PAP equipment varied from instructions provided in clinic. Most reported at least weekly cleaning of items for which daily cleaning is recommended. Few reported using a device for cleaning or having respiratory symptoms from PAP treatment.

Introduction

Positive airway pressure (PAP) devices including CPAP and bi-level PAP (BPAP) are frequently prescribed for treatment of obstructive sleep apnea (OSA). Regular care and cleaning of mask interface, tubing, and the humidification chamber are an important consideration for maintaining home PAP equipment. Acute illness, infection, and hospitalization have been associated with inadequate care and cleaning of home respiratory equipment.^1-3

All medical equipment, including home respiratory devices, is classified as either critical, semi-critical, or non-critical based on the risk of infection from potential contamination.^4-6 Critical items, such as tracheostomy tubes, pose the highest risk of infection if contaminated since utilized in sterile tissue.⁵ Semi-critical items have contact with either mucus membranes or non-intact skin, whereas non-critical items have contact with skin but not mucus membranes.^4-6 PAP devices are considered non-critical, whereas the mask and tubing are semi-critical.⁵

Care and cleaning instructions for home PAP equipment vary by device manufacturer and model. Although instructions are provided to patients and families in our pediatric sleep disorders center, practices performed in the home are unknown. It is also not known if illness or infection related to inadequate cleaning regimens has occurred. The aims of the study were to identify care and cleaning practices for PAP equipment performed in the home and to determine if respiratory-related symptoms were associated with PAP use or deficient cleaning practices.

QUICK LOOK.

Current Knowledge

Regular care and cleaning of positive airway pressure (PAP) devices are important for maintaining equipment in the home. Illness and hospitalization have occurred from inadequate cleaning and use of tap water in the humidifier. Actual cleaning practices performed in the home are unknown.

What This Paper Contributes to Our Knowledge

A survey of care and cleaning practices for home PAP equipment revealed a discrepancy between reported practices and instructions provided in a pediatric sleep clinic. Few respondents indicated that respiratory symptoms had occurred or increased from PAP treatment.

Methods

A survey was developed to identify care and cleaning practices for home PAP equipment to compare with instructions provided in clinic. The clinic respiratory therapist (RT) is the primary individual responsible for providing instructions at our pediatric sleep disorders center. The same instructions are provided to all patients and/or caregivers. Instructions are based on manufacturer recommendations and include daily cleaning of the mask and humidifier chamber and weekly cleaning for tubing. Distilled water is recommended for the humidifier and is emptied and replaced daily. Device filter cleaning and replacement vary upon device model and filter type, as some are washable and others disposable.

Survey domains were cleaning frequency and method for each component (mask, water chamber, tubing, and filter), replacement frequency for disposable items, respiratory-related symptoms (eg, congestion, runny nose, sneezing, coughing) that occurred or increased with initiation of PAP treatment, length of time for PAP use, preference for instructions, and demographic information. The questionnaire was piloted with 5 adults prior to the study for accuracy of wording and understanding of survey items. These individuals were not followed in the clinic, and some used PAP at home. Final survey items are included as a supplementary file (see related supplementary materials at http://www.rcjournal.com).

Inclusion criteria were caregivers of children 0–17 y and young adults age 18–21 y followed in our pediatric sleep clinic and prescribed PAP for treatment of OSA. Caregivers of young adults with cognitive impairment were approached for participation when the individual was unable to provide consent. Exclusion criteria were residents of long-term care facilities. The primary aim was to identify care and cleaning practices for home PAP equipment and compare with instructions provided in clinic. The secondary aim was to determine if respiratory-related symptoms occurred or increased with initiation of PAP treatment and if there was an association with reported cleaning practices. The study was approved by the institutional review board at the University of Arkansas for Medical Sciences.

The survey was conducted in the sleep disorders center at Arkansas Children’s Hospital from April 2019–March 2020. Young adults and caregivers of children prescribed PAP were invited to anonymously complete the survey while attending a follow-up clinic visit. Subjects were asked to complete the survey while waiting in the clinic exam room. Responses were collected electronically in Research Electronic Data Capture (REDCap) application.

Survey items related to cleaning PAP equipment and demographic information were evaluated by computing the frequencies and percentages for each response option. Summary statistics for continuous data were expressed as either mean ± SD or median and interquartile range (IQR), depending on the distribution. Prevalence was calculated for respondents who adhered to cleaning recommendations. To determine if cleaning practices varied with age, rank-order correlation analysis was computed. Chi-square tests or Fisher exact tests (ie, when cell numbers were < 5) were computed to determine the association between cleaning practices, length of time PAP was used, and sex of individual who used PAP. A logistic regression model was utilized to assess the relationship between frequency and method of cleaning and potential demographic characteristics on reported respiratory symptoms (ie, yes/no). All analyses were performed in SAS software version 9.4 (SAS Institute, Cary, North Carolina).

Results

Ninety-six respondents completed the survey, and the majority (87, 91%) were the parent or guardian of the child who used PAP at home. The median age (IQR) of the individual prescribed PAP treatment was 13.0 (8.8–16.0) y. Most were male (66, 69%), Black (47, 49%), or non-Hispanic (83, 87%). Medicaid was main type of health insurance (44, 46%). Median length of time PAP had been used at home was 1.5 (0.5–3.0) y, whereas most had used for 1–4 y (42, 44%). Parents or guardians were primarily responsible for cleaning the device (64, 67%) (Table 1).

Table 1.

Subject Characteristics

Once a week was most common frequency reported for cleaning the mask (36, 38%), tubing (41, 43%), and humidifier chamber (31, 33%), whereas soap and water were the cleaning methods predominately used for each (Table 2). Mask and tubing were most often replaced every 3–6 months (Table 3). The majority of respondents (74, 77%) reported using distilled water in humidifier chamber. Few reported using tap (7, 7%), bottled (6, 6%), or sterile (3, 3%) water. One indicated that well water was used, and some (5, 5%) noted water is not used in the chamber. Only one reported not using a humidifier. Water was emptied from the humidifier chamber daily by most respondents (56, 58%), whereas several (22, 23%) noted that new water is added as needed. Others reported emptying at least weekly (10, 10%) or > once a week (3, 3%).

Table 2.

Cleaning Frequency and Methods

Table 3.

Mask and Tubing Replacement Frequency

Most reported the device has either a washable (40, 41%) or disposable (39, 41%) filter, whereas 17 respondents (18%) were not sure of the filter type. Washable filters were most commonly washed weekly (26, 65%) or monthly (12, 30%), whereas very few (2, 3%) reported filter was washed either daily or never. Both types of filters were most often replaced every 6 months (Table 4). The majority (64, 67%) reported that respiratory symptoms did not occur or increase with PAP use, whereas some (18, 19%) were unsure. Congestion (11, 12%), runny nose (8, 8%), sneezing (7, 7%), coughing (9, 9%), and sinus problems (10, 10%) were identified as symptoms associated with PAP use.

Table 4.

Filter Replacement Frequency

The sleep clinic RT (43, 45%) was most often noted as individual who provided cleaning instructions, followed by durable medical equipment (41, 43%), clinic nurse practitioner (27, 28%), or physician (18, 19%). Many respondents indicated they preferred to receive cleaning information only if requested (35, 37%) or at every visit (33, 34%), whereas some would rather have only at time of initial set-up (16, 17%) or 1–2 times a year (12, 13%). Written (55, 57%) or verbal (49, 51%) cleaning instructions were favored over video (15, 16%).

There was a moderately low correlation between age and cleaning. Increased age was associated with decreased cleaning frequency (r = 0.20, P = .048). There was no association between length of time for PAP use and frequency of cleaning the mask (P = .90), tubing (P = .33), water chamber (P = .19), frequency of emptying the chamber (P = .79), washing the filter (P = .27), or changing the filter (P = .38). Additionally, no association was found between length of time PAP was used or respiratory-related symptoms (P = .36).

Discussion

There was a discrepancy between reported care and cleaning practices of home PAP equipment compared to instructions provided in our clinic. Daily mask cleaning is recommended to remove facial oils, which may affect the ability to obtain an adequate seal. However, most participants reported weekly mask cleaning. Humidifier chambers should also be cleaned daily per device manufacturers, but the majority of respondents performed weekly cleaning. The most common type of water used in the chamber was distilled, which is consistent with recommendations. Nevertheless, 7% admitted using tap water, and some participants indicated certain items were never cleaned.

Although rare, several reports of illness and hospitalization associated with improper care and cleaning practices of PAP equipment, namely the humidifier, have been described in adults with OSA.^1-3 Hospitalization was required in one case due to legionella pneumonia.¹ Investigation by the local health department concluded the source of infection was CPAP equipment that had not been regularly cleaned, although it was not specifically tested for legionella.¹ Use of tap water in the humidifier on a single night resulted in prolonged respiratory illness in another case who had previously used CPAP for 6 years without difficulty.² Analysis of tap water from the home revealed higher-than-acceptable concentrations of endotoxin.² Mycobacterium gordonae was recovered from a home CPAP water chamber during hospitalization in a case admitted for worsening shortness of breath and increased lung infiltrates following routine use of tap water for humidification.³

Even when cleaning recommendations are followed, children with underlying conditions may be colonized with bacteria that can contaminate PAP equipment.⁷ A child with spinal muscular atrophy type 1 and central sleep apnea who utilized BPAP was hospitalized for recurrent respiratory infections and found to be colonized with Pseudomonas aeruginosa.⁷ Despite eradication efforts, addition of a filter, and very stringent daily cleaning regimen, the same Pseudomonas genotype was isolated from both the child’s nasopharyngeal aspirate and face mask.⁷ An in vitro evaluation of CPAP water chambers contaminated with bacteria concluded addition of a filter placed at the outlet of the humidifier reduced risk of bacterial transmission in tubing.⁸ Whereas bacteria filters are commonly used with invasive home mechanical ventilation, that is not standard practice with home PAP in our experience.

A study of adults with OSA found that CPAP was not associated with prevalence of rhinosinusitis, respiratory tract infections, or identification of microorganisims.⁹ Most of our respondents reported that respiratory-related symptoms had not occurred or increased with initiation of PAP treatment. We were unable to make any associations with cleaning practices due to the small number of subjects indicating respiratory symptoms. We are not aware of any illnesses from our center specifically attributed to PAP devices or water chambers. However, children with conditions other than OSA who require PAP or noninvasive ventilation may be at higher risk of infection.⁷

No associations were found between length of time for PAP use and cleaning practices. However, there was a moderately low correlation with age, as older age was associated with decreased frequency of cleaning. In our study, approximately 26% of those who used PAP were responsible for cleaning. We speculate that teens and young adults may not clean equipment as frequently compared to their parents.

Very few respondents reported using a device to clean PAP equipment. In recent years, ozone cleaners and ultraviolent (UV)-light sanitizing devices have advertised fast and convenient cleaning of PAP equipment. Ozone disinfection has proven effective against bacteria such as P. aeruginosa and Staphylococcus aureus in home nebulizers.¹⁰ Although convenient and potentially time saving, health insurance plans generally do not provide reimbursement for these devices, and the United States Food and Drug Administration cautions they are not approved for this use (https://www.fda.gov/consumers/consumer-updates/cpap-machine-cleaning-ozone-uv-light-products-are-not-fda-approved. Accessed March 22, 2022). Most survey respondents reported Medicaid for health insurance, which does not provide coverage for these devices in our state.

There are also health concerns with using ozone disinfectant and UV-light devices for cleaning home respiratory equipment.^11,12 Multiple reports of cough, difficulty breathing, headache, and asthma exacerbation have been attributed to use of ozone disinfection for home CPAP equipment.¹² Asthma is a common comorbidity in children with OSA and sleep-disordered breathing.^13,14 A bidirectional relationship exists between asthma and OSA, as asthma is a risk factor for more severe OSA in children and OSA has been associated with more severe asthma.^13,14 Adverse events from UV-light devices have not been reported, but there is a risk of burns, eye damage, and increased risk of skin cancer.¹² Clinicians should be aware of potential hazards of using these devices to clean PAP equipment and educate patients and families accordingly.

There were several limitations to the study. Results were from a single pediatric sleep disorders center and may not be generalizable to other pediatric centers or adult populations. The survey did not specifically inquire about ozone or UV-light disinfection. The term automatic sterilizer was used to represent any type of cleaning device, including a baby bottle steamer, which is frequently utilized to disinfect home nebulizers.¹⁵ However, there was an option for all survey item responses to further describe anything not included in the selection choices. Additionally, the survey did not explicitly ask if illness occurred related to PAP use, but no comments were received in this regard.

Conclusions

Reported care and cleaning practices for home PAP equipment varied from instructions provided in a pediatric sleep clinic. Most indicated at least weekly cleaning was performed for items in which daily cleaning is recommended. Few respondents indicated that respiratory-related symptoms had occurred or increased with PAP treatment. Further study is needed to establish evidence-based best practices for cleaning home equipment.