February 10, 2011
As a resident during otolaryngology training, I rotated in the medical center’s craniofacial clinic, seeing various disorders that lead to underdeveloped or malformed facial or skull structures. These syndromic children clearly had severely asymmetric faces or underformed jaws. In many cases they had breathing problems requiring surgery.
One of the more common conditions you’ll see in such a clinic is Pierre Robin sequence, where due to improper maturation of the lower jaw, the lower chin is recessed severely. You’ll see milder variations of this all the time, but if severe enough, these people can’t breathe, especially at night.
Treating Only The Extremes
One of the problems with modern medicine is that we name and treat only the extreme end of a continuum, or only when significant problems result. Having a slightly recessed chin may be thought of a the person’s normal facial feature, and his or her ability to breathe is never even considered.
The entire basis for my sleep-breathing paradigm is that all modern humans have constricted facial structures, not due to a congenital or genetic problem, but due to our eating and lifestyle habits. Genetically, we’re all programmed to have relatively wide jaws, with room for all your wisdom teeth. Now, that rarely ever happens. This is why obstructive sleep apnea can be described as a mild craniofacial condition that can significantly affect your upper breathing passageways.
Small Jaws, Small Airway
It seems that almost everyone these days will need braces to fix crooked teeth or narrow dental arches. Dental crowding by definition means that your upper and lower jaws are underdeveloped. This creates less total volume inside your mouth, leading to overcrowding of your tongue. Your tongue can then fall back easier when on your back, and when in deep sleep, due to muscle relaxation, you’ll stop breathing more often at night.
Even your nose can be affected by this problem. Since your nasal sidewalls follow your upper molars, the side to side distance in your nose will be more narrow, and as the roof of your mouth (nasal floor) gets pushed up, it’ll also cause your septum to buckle.
If you add additional inflammation and swelling in your nose (due to colds, allergies or nonallergic rhinitis), your nose will become stuffier faster, and even worse, your nostrils will cave in easier.
Having underdeveloped upper jaws prevents proper cheekbone fullness, giving your mid-face a sinked-in look. This type of facial appearance is so common these days that it’s almost accepted as normal. I remember reading in the New York Times a few years back where they reported that women’s preferences for male actors has changed from the classic square-faced, angular facial features, to softer, more feminine, rounded faces.
Despite having some good first line options such as CPAP or oral appliances, these approaches don’t really address the root cause. If your child’s jaw was severely underdeveloped and your choice was either lifetime CPAP or jaw enlargement, which would you choose? What if, rather than cutting the jaws and pulling it forward, you can apply distraction plates that can be pulled slowly, little by little, to normalize the jaws and improve the airway significantly? What about advanced dental appliances that can expand your upper and lower jaws in three dimensions, making more room for your tongue? With current technology, we can modify your jaws significantly. But for adults with obstructive sleep apnea, any kind of surgical or dental modification of the jaws is only considered as a last resort.
I describe obstructive sleep apnea as the end extreme of a continuum of sleep-breathing disorders. Similarly, if you look at obstructive sleep apnea as being a craniofacial problem, everyone will have various degrees of jaw underdevelopment. If you have impacted molars, or had to have your wisdom teeth taken out, then your breathing passageways are compromised.
Not only are your jaws more narrow, but the soft tissues that line your breathing passageways will be much more likely to become inflamed and cause even further obstruction. Frequent obstructions can cause a vacuum effect in your throat which literally suctions up your normal stomach juices into your throat, promoting more inflammation and swelling. These juices (which include acid, bile, digestive enzymes and bacteria) can then also reach your nose, sinuses, ears and even your lungs, causing additional inflammation and swelling. If your nose is stuffy, then a vacuum effect is created downstream in your throat and the tongue can fall back much easier, whenever you’re in deep sleep (due to muscle relaxation).
Our Airways Are Like Plumbing
In the medical community, craniofacial problems are generally treated surgically. Even with plumbing, if you only open up one area of multiple clogged areas, the pipes will still be clogged (like doing a UPPP). Sometimes you can put in drano to soften the clogging and open up the passageways (like allergy medications), but after years of buildup and accumulation, you have to physically open up all the blocked areas. You can also use a plunger to force the water down the drain (like CPAP), but you know that sooner or later, it’ll get clogged again. The older the pipes, the worse it becomes (old age).
CPAP and oral appliances are both important and necessary tools to treat the vast majority of people with sleep apnea, but we also need to open our minds to the idea that we shouldn’t have to sleep with gadgets or devices for the rest of our lives.
A Modern, Western Dilemma
It’s commonly known that our brains are getting bigger over time. As modern human’s mid and lower faces get smaller and smaller, I predict that in a few hundred to a few thousand years, everyone will be tethered to a hose while sleeping, like in the science fiction movies. Maybe vocal speech and communication will not be needed anymore, and we’ll be able to communicate with mental telepathy. We’ll all begin to look like that alien in the old Star Trek episode with the huge brain and a tiny face.
Sadly, it’s already started. If you look at the younger generations, you’ll see how narrow their dental arches are, along with flat cheekbones and narrow nasal widths. Recently, I happened to see an Amish chorus singing songs in the Grand Central subway station. I was amazed how most had very prominent cheekbones, well-formed jaws, and good looking smiles. It’s not surprising that cultures that eat organically and off the land will have more fully developed jaws.
So the next time you’re sitting in an auditorium and a public place with lots of people, think about that classic first day of college speech by the dean or president:
“Look to your left…and look to your right. At the end of this year, one of the two that you see will not be here with you.”
Similarly, every other person sitting next to you will most likely have smallish jaws, and have an undiagnosed sleep-breathing problem. From a craniofacial standpoint, they won’t be able to sleep well due to narrowed breathing passageways. If you end up befriending or marrying one of these people, now you’ll understand what makes them tick, or sick.
October 25, 2010
In sleep disorders, obstructive sleep apnea is the most common condition that’s seen, but a significant number of people with obstructive sleep apnea will also have central sleep apnea. Central sleep apnea is thought to be a condition that’s associated with a number of different neurologic problems, as well as heart or kidney failure. During the night, people with central sleep apnea stop breathing when signals in the brain that tells the body to breathe don’t work properly. No effort is even made to inhale. In contrast, with obstructive sleep apnea, an effort is made to breathe in, but because of collapse in the upper airways, air can’t get into the lungs.
One of the hallmarks of central sleep apnea is Cheyne-Stokes breathing, where after a long pause, due to gradually increasing levels of carbon dioxide (CO2), shallow breathing is triggered which gradually becomes deeper and deeper, and then once CO2 reaches a safer level, the breathing becomes more shallow again.
Unfortunately, treating central sleep apnea is more of a challenge than treating obstructive sleep apnea, and the best way of treating this condition is to use a variation of CPAP as a respirator. This is a servo-ventilator feature that’s found in machines that can treat this condition. When it senses that you’re not breathing, it literally breathes for you, rather than applying constant positive pressure for obstructive events. Some people will have a combination of obstructive and central events, which is called mixed or complex sleep apnea.
A number of different neurologic conditions can cause central sleep apnea, but here’s a simpler explanation:
We know that a HUGE number of people have undiagnosed obstructive sleep apnea. Up to 1/4 of all men and 1/10 of all women have it, and by the time you’re 60 or 70, the vast majority will have at least some degree of sleep apnea. If you’re human, and you can talk, then you’re susceptible to breathing problems at night, even if you don’t suffer from any apneas. The reason is that complex speech and language development unprotected our upper airways, and everyone’s tongue can fall back and obstruct your breathing at night, especially when you’re in deep sleep, due to muscle relaxation.
I’ve also talked about how modern humans’ jaws are shrinking, due to a radical change in our diets and the addition of bottle-feeding. This had lead to increased rates of dental crowding, with more and more people needing braces. The smaller the jaws, the less space there is for the tongue, which can take up too much space, ultimately crowding the airway.
We also know that there’s a linear correlation to complications of apneas, even in the very low range, where having an AHI of 4 is significantly worse than having an AHI of 2, although officially, you won’t have obstructive sleep apnea, since you come in below 5. Sleep apnea patients are also known to have thick or viscous blood that tends to clot easier when there are areas of low blood flow or small vessel constriction. People with obstructive sleep apnea by definition have smaller vessels and low blood flow simply due to the massive stress response that naturally constricts blood vessels and causes hypertension.
Numerous imaging studies also show that people with obstructive sleep apnea have much higher numbers of lacunar infarcts, which are small areas of dead brain tissue that’s normally seen in routine CT scans of the brain. Other studies reveal lower blood flow, metabolism and brain tissue density in certain critical parts of the brain that control memory, executive function, and autonomic function. Areas of the brain that address hearing, including the high frequency sound perceiving areas of the inner ear, are also extremely sensitive to instances of low blood flow or stagnation. One recent study showed that people with sleep apnea had lowered auditory brainstem reflexes, but after treatment with CPAP, or after thinning patients’ blood concentrations, these auditory reflexes improved.
One finding that’s fascinating is that parts of the brain that control breathing are also affected preferentially by these events. Knowing that even mild levels of sleep-breathing problems can aggravate various levels of clotting and vessel blockages, if you happen to clot off a small vessel that leads to this area, then your neurologic breathing patterns can be affected. These same areas also control autonomic function, which includes heart rate, temperature, digestion, sweating, and vascular reflexes. Damaging even a small part of the brain in this area can wreak havoc on your breathing patterns, as well as other regulatory functions that control your body’s organs.
Since we know that obstructive sleep apnea is strongly associated with heart disease, it makes sense that central sleep apnea is commonly seen in patients with heart disease. Not only can obstructive sleep apnea cause heart disease, by applying this model it can also cause central sleep apnea. Poor involuntary nervous system control, especially of the heart, can wreak havoc on heart function. It can also cause problems with digestion and even your hormones.
Although we have a way of treating central sleep apnea, the results are not as satisfying compared with treating obstructive sleep apnea. Ultimately sleep doctors don’t have very good answers to why this happens, or how to treat it effectively. Think of it as a permanent neurologic condition, where rather than having weakness of your lower legs, you have weakness of the nerves that control your breathing patterns. Treating the obstructive component probably won’t cure the central sleep apneas, but at least it could prevent it from getting worse.
July 20, 2010
One of the most common excuses for not wanting to use CPAP is that “I travel a lot.” Even after I explain that many people travel just fine with their CPAP machines, some people are stll reluctant. With advances in technology and increased awareness by the lay public, government officials and medical professionals about the importance of using CPAP for obstructive sleep apnea, traveling with CPAP, although initially a challenge, can be done with relative ease. People use CPAP on planes, and even go camping with it. With the FAA’s recent ruling and instructions on carrying and using CPAP on airlines, it’s become even easier to travel with CPAP machine. I know there are various types of PAP devices, but for the sake of simplicity, I’ll call these devices the generic name, CPAP.
Flying with Your CPAP
The Federal Aviation Administration (FAA) recently ruled that airline passengers must be allowed to use respiratory assistive devices, such as a CPAP machine (Nondiscrimination on the Basis of Disability in Air Travel – May 13, 2009). However, don’t think that you’ll just breeze by security checkpoints at the airport. Here are some common tips that are recommended when you fly with your CPAP machine:
1. Never check your CPAP machine.
2. Always have with you a prescription for your CPAP machine and your latest sleep study. You never know if your unit gets lost or stolen, or breaks down.
3. Attach a medical equipment tag, identifying the contents as such.
4. Let the TSA security agent know that you have a CPAP machine. Remove it from the back and have it scanned separately.
5. Request that security agents change gloves and wipe down the table before inspecting your machine. Wrap your device in a clear bag while being scanned to prevent contamination with germs and other chemicals.
6. Keep a record of the model and serial number in hand, just in case.
7. If you’re going to use your CPAP machine in-flight, check beforehand if there’s an outlet next to your seat, and if you have the right adaptor.
8. If the flight attendant says something about your CPAP being another carry-on, let him or her know that it’s a CPAP machine and under the Americans with Disability Act, it’s not counted as an added carry-on.
9. Consider having your doctor give you a letter describing the need for your CPAP machine.
10. Most CPAP units will automatically convert to the correct local voltage. Check with your instruction manual or manufacturer to confirm this. You may, however, need a plug adaptor, as well as an extension cord, in case your outlet is far away.
Tips On Water
Many people are so focused on the logistics of their machines, that sometimes they forget about distilled water. Make sure you have plenty of distilled water available if you’re going to use it on the plane, or at your final destination.
If you’re not going to use your CPAP device on the plane, then make sure you empty and dry the water chamber before flying (check out expedia for available flights!). If you’re planning on using your CPAP device on-board, there are two options to be able to pass large amounts of fluids past TSA security checkpoints: Have your doctor prescribe distilled water in a pharmaceutical grade bottle. A 500 mL bottle should hold about 16 oz. Another option is to purchase papFLASK, which is designed to pass through security checkpoints with ease.
For whatever reason you don’t have distilled water available, using bottled or even tap water is OK, but try to find distilled water as soon as reasonably possible. Mineral deposits in tap water can build up within the PAP machine and can cause damage if it continues long-term.
Camping or Backing Up with CPAP
For travel to areas that don’t have electricity, or in case you have a blackout, there are numerous battery options available. Each manufacturer will usually have a back up battery recommendations and adaptors.
For more extended periods, various people have written about using a 12 volt deep cycle marine battery with a sine wave inverter. There are numerous other battery options so do your research. Different manufacturers have different voltage needs, so also check with your manufacturer. Since a humidifier uses a lot of energy, most people recommend not using the humidifier if you’re only camping for a few days. There’s lots more information about batteries in CPAP support sites such as sleepguide.com, cpaptalk.com, talkaboutsleep.com, or apneasupport.com.
Have A Back Up Plan
Some patients carry around their oral appliances with them whenever they travel, either using it in place of their CPAP machines or just in case the device breaks. Some people use both the oral appliance and their CPAP machines simultaneously. If you’ve never tried an oral appliance and you’re interested in an alternative option, it may be worth giving it a try now before you need to travel for long extended periods.
No More Excuses
With advances in technology and more acceptance by the medical community as well as the lay public, there’s basically no reason (unless it’s psychological) you can’t travel with a CPAP machine. With knowledge and some flexibility and creativity, anyone can travel with CPAP, even in the more remote areas of the world. There have even been descriptions of solar power being used to recharge batteries used for CPAP. If you travel frequently to the same location, consider purchasing a second unit. Prices for middle of the road CPAP models are in the $300 to $700 range.
The first major challenge is in finding a way to make CPAP work for you. The second major challenge is in un-tethering your machine from your bedroom. Many people are living vibrant and normal lives, despite having to use their CPAP machines while traveling. Or is it because they are using their CPAP machines regularly while traveling? You decide.
June 30, 2010
Learn the Insider Secrets of Highly Successful CPAP Users…
Get your FREE access to the audio replay and mp3 download of this interview with Aurelio Henriquez who has extensive experience helping patients with sleep apnea succeed in using their CPAP machine.
Since 2002, Aurelio has helped hundreds of CPAP users overcome their struggles while he was with the NY Methodist Sleep Disordered Center as a Polysomnographic technologist and then later as the technical lab director for the Columbia University Sleep Disorder Center.
• What to expect when you first try CPAP in the lab
• How to avoid the #1 mistake every new CPAP user makes
• Where to get the best CPAP equipment for the best price
• What one thing you MUST do BEFORE using CPAP to dramatically increase your chance of success
• What makes some people fail and some to succeed on CPAP and how you can be successful
February 16, 2010
Are you having problems with your CPAP mask? Are you newly diagnosed with sleep apnea, and want to find out which options you have? If so, hear me interview Chip Smith and Brian Werther of Restoration Medical on "Everything You Ever Wanted to Know About CPAP Masks."
During this information packed hour, you'll learn:
- The key to getting the right fit
- An insider's guide to finding the right mask for you
- How to overcome the most common mistake people make when they're choosing a mask
- Most common problems people have with their CPAP mask and how to avoid them
Title: Everything You Ever Wanted to Know About CPAP Masks
Format: MP3 download
Click here to order.
January 13, 2010
Sleep apnea surgery is one of the most controversial subjects in sleep medicine. There are heated debates within the sleep community as well as in online forums and support groups. Sleep apnea surgery is definitely not for everyone, for some, it can be a life-changing experience. Here are 5 important issues that you must be aware of before considering any form of sleep apnea surgery:
1. Does sleep apnea surgery work?
Yes, but only when done properly. Just like with CPAP or dental devices, if you don't use it properly or use it at all, it won't work.
One of the most common misconceptions about sleep apnea surgery is the relatively low success rate of the uvulopalatopharyngoplasty (UPPP) procedure, which is often quoted at 40%. But performing this operation is like bypassing only one blocked heart vessel when you have 3 other vessels that are blocked. For some strange reason, ENTs are overly obsessed with the soft palate, since this is where snoring usually comes from and we have the most research and procedures for the soft palate.
We now know that if you address the entire upper airway together (nose, soft palate, tongue), then your success rates are much better, approaching 80%. Why only 80%? There's only so much you can do with the soft tissues within the small space within smaller jaws (which is the main anatomic reason for sleep apnea). The more aggressive you are, the higher the success rate, but the more chance of pain and complications.
If you go to the next level and enlarge your jaws (upper and lower), then success rates can reach 90 to 95%.
To put things into perspective, if you bypassed everything with a tracheotomy (placing a breathing tube below your voice box), then you'll have a 100% "cure", but obviously, this is not a very practical option.
One question you must ask then, is, what's the meaning of success? In surgery, one common definition is that the final AHI (apnea hypopnea index) on a formal sleep study drops greater than 50% of the original and the final number has to be less than 20. One of the main criticisms of sleep apnea surgery is that even if "successful", you may still have mild sleep apnea. Surgeons will argue that it's better than not using CPAP at all.
2. Not All Surgeries Are The Same
There are probably dozens of procedures for sleep apnea from various nasal, soft palate and tongue operations to skeletal framework procedures. These can range from minimally invasive to major surgery. The problem is that by definition, they'll all work to a certain degree. For example, procedures for a stuffy nose have been shown to "cure" sleep apnea in 10% of patients. But for the most part, none of these options by themselves have very good success rates.
The key is to examine the upper airway for each individual and figure out where the obstruction is and take care of it simultaneously. Most people have more than one area of obstruction. Surgeons at Stanford have about a 75 to 80% success rate with soft palate and tongue base procedures. This is called multi-level surgery for sleep apnea. You have to look at the airway from the tip of the nose all the way to the voice box.
3. There's No Cure for Sleep Apnea
Unless we all undergo tracheotomies, there's no way to prevent breathing pauses at night. Modern humans' upper airway anatomy is thought to be predisposed to breathing problems at night, which only gets worse as we age. I talk about why this problem has gotten much worse in recent years in my book, Sleep, Interrupted. All of us are on a continuum, where various factors (anatomy, age, weight, inflammation, etc.) contribute to forces that make our tongues and palates to collapse. The older we get, we'll either gain weight, which narrows our breathing passageways, or our throat tissues will sag and collapse easier.
Surgery will shift the line of this continuum downwards, but it won't bring it down completely. This is why it's important to incorporate a healthy diet and lifestyle and exercise regimen into any sleep apnea treatment regimen.
For most people, lowering the numbers significantly will make you feel much better. But sometimes, the numbers will go down dramatically, but you may not feel any better. This just goes to show that there may be other issues besides sleep apnea that have to be addressed. You've had sleep apnea for years or decades. Just by fixing your sleep apnea won't immediately fix problems that can arise from sleep apnea, such as hormonal problems, weight gain, or memory problems and brain fog.
4. Surgery is the Last Resort, But Don't Rule It Out
Admittedly, there are many people who rush to surgery prematurely, but there are also many others that aren't even offered surgery due to misconceptions by physicians. There are also many patients that are turned off by all the conflicting information that's available on the internet.
Before you even think about surgery, make sure you've tried or considered all the other options thoroughly. Most people who fail CPAP do so because of poor counseling, support and follow-up by the medical system. Just like everything else with life, your chances of success depends on which doctors you see. The follow-up and support offered by your CPAP equipment vendor can also play an important role in whether or not you'll benefit from CPAP. The same issues also apply with dental devices for sleep apnea.
This is why it's important to educate yourself about all the treatment options, and not to give up too easily. Too many people give up at this point, and don't consider any further treatments. Surround yourself with a group of trusted doctors and professionals that forms a team. Use their expertise and guidance to find a way to make things work. If nothing works for you, don't rule out surgery just for the sake of avoiding surgery. Learn and educate yourself about surgery before rejecting it.
5. How to Find the Right Surgeon
Finding the right surgeon for your sleep apnea condition can be challenging. Everyone claims to specialize in snoring and sleep apnea surgery. Who are you to believe?
First of all, find someone who's comfortable performing a wide range of procedures in all the three areas of the upper airway (nose, soft palate and tongue). Are they familiar with the minimally invasive procedures as well as the standard options? No everyone will be an expert at all the procedures, but it's important to know about all the other options as well as well as to make appropriate referrals when necessary.
There are a variety of "minimally invasive" procedures out there, especially for the soft palate, but these procedures have to be offered very selectively. Even if successful initially, is your surgeon prepared for relapsed that are likely years later? Is the goal of surgery only to cover up the snoring, or will it treat the underlying anatomic causes?
If your surgeon recommends palatal surgery "just to see," without addressing the entire upper airway from the nose to the tongue, go for a second opinion. If you do decide to undergo a palatal procedure (with or without tonsillectomy), be prepared for a 60% failure rate, which means that the tongue needed to be addressed as well. Sometimes, more needs to be done to the soft palate or the nose has to be addressed. Everyone is different, and the treatment recommendations have to be tailored to the individual.
For a more detailed free report on The Truth About Sleep Apnea Surgery, click here.
November 29, 2009
Finally, useful information on how to use your CPAP without struggle…
Dr. Park’s Expert Interview with Mr. Chip Smith, the President of Restoration Medical is an expert on the proper use of CPAP machines to treat obstructive sleep apnea as well as upper airway resistance syndrome.
As President of Restoration Medical, a durable medical equipment company specializing in supplying CPAP machines to sleep apnea patients, Chip Smith has unique insights into how to manage and effectively choose the right CPAP machine.
Chip Smith is also a passionate advocate for sleep apnea sufferers, having educated and seen the positive effect his CPAP machines have had on the lives of hundreds of his clients who have learned to use their CPAP machine properly.
During this live 62 minute call, Chip answers all your questions about CPAP. You’ll learn:
- How to pick the right CPAP mask for yourself that will be both useful and comfortable
- The most common mistakes every CPAP user makes and what you can do to avoid them
- How to find the right CPAP supplier that will save you time, money and peace of mind
- How you can learn to use your CPAP like a pro in less than 10 minutes a day
Most importantly, you’ll also get answers to your most frequently asked questions like:
• What do you do about dry mouth and nasal stuffiness?
• How can you tell if you’re getting the right amount of pressure?
• How do you find a mask that fits?
• What’s better, a full face mask or nasal pillows?
• And much much more…
Buy your copy of this special event today, available in two easy-to-access formats:
November 16, 2009
CPAP, or continuous positive airway pressure, is one of the first-line ways of treating obstructive sleep apnea. Gentle, positive air pressure is passed through a mask into the nose to keep your throat tissues open. For many people, CPAP works very well, but there are many others that have difficulty adjusting to CPAP and end up giving up.
There are a number of proven, systematic steps that can be taken to improve CPAP usage, and I’ll cover each of these steps in future posts, but theres’s one important factor that determines whether or not you’ll ultimately benefit from CPAP even before you start. This is your mindset.
CPAP compliance, or the number of people who are able to use and ultimately benefit from CPAP, ranges anywhere from 29 to 83%. (Compliance is only a measure of how many hours patients actually use their machines. It doesn’t actually measure how well they are benefiting from CPAP treatment. You can be 100% complaint, but not sleep any better.) In the real world, compliance is much less than 50%. We know that with intensive education, support, and follow-up, CPAP compliance rates can be very high, but in our fragmented health care system with multiple providers for each patients, results are much less than ideal.
However, over the past 11 years in clinical practice, I’ve noticed a few observations: Bus drivers and airline pilots accept CPAP therapy readily and are usually very successful in adapting to and benefiting from their CPAP machines. In addition, newly diagnosed sleep apnea patients who have either friends or relatives who have good experiences with CPAP also tend to do well. On the other hand, if they hear horror stories about CPAP, they tend not do do as well.
What this goes to show is that your mindset and motivation ultimately affects whether or not you end up accepting or rejecting CPAP. Pilots and bus drivers have their jobs on the line. Until they are treated and cleared by a medical doctor, they can’t return to work. A close friend or family member’s experience using CPAP is also a major factor in how well you’ll be able to tolerate and benefit from CPAP. Imagine having the proper mindset, as well as undergoing intensive education, counseling, support and follow-up. CPAP success rates are sure to go up.
What was your motivating factor in succeeding with CPAP? If you couldn’t tolerate CPAP, what was the main reason? Please enter your comments below.
November 10, 2009
One of my biggest pet peeves is how doctors use the word compliance. If a patient doesn’t comply, it usually implies it was the patient’s fault. In sleep medicine, compliance is often used to measure how well patients use their CPAP machines. But compliance is not the same thing as success.
Various studies report CPAP compliance rates at 29% to 83%. The problem is that the definition of compliance changes from study to study. More recently, we’ve adopted the new Medicare requirement for CPAP compliance, which requires that the patients use CPAP at least 70% of the time over a 30 day period, for at least 4 hours every night. Otherwise, the machine has to be returned.
If you sleep 7 hours every night, it comes to 210 total number of hours per 30 days that you’re sleeping. Seventy percent of 210 hours is 147 hours. If you sleep only 4 hours every night, then this figure drops to 88 hours, which means that you have to use your CPAP machine only 40% of the total time that you’re sleeping to be considered "compliant." This doesn’t take into consideration if you’re actually feeling better or if the machine is being used effectively.
Since CPAP works only if you’re using it, if only 40% of people are still using CPAP regularly 5 years after beginning treatment, then the CPAP success rate is at best 40%. But not all people who use CPAP will benefit, so this figure is likely to be much lower. Many more people are likely to stop using CPAP as the years go by.
There are many patients that are 100% compliant with CPAP, using their machines 100% of the time they are sleeping, with no leaks and a low AHI, and still feel no better. Sometimes they can even feel worse than when they don’t use CPAP.
From what I’ve seen with CPAP compliance studies or even with sleep apnea surgery studies, they all manipulate the numbers to make their results look great. In very tightly controlled research studies with frequent follow-up and intensive intervention, results are likely to be good. But in the real world, with fragmentation of care, poor follow-up and lack of patient education, true success (the patient feels much better AND the numbers show it) is disappointingly low, no matter which option you choose.
Despite all these obstacles, there are proven ways to improve CPAP success. With a systematic and formalized education program, along with intense counseling, follow-up, and long-term support, many more people can benefit from CPAP. Ultimately, a major part of poor CPAP compliance is due to the health care system that’s dropping the ball.
Am I being realistic or too pessimistic? Let me know what you think of this issue in the comments box below.