SLEEPINESS DESPITE CPAP
“Nobody who has Sleep Apnea and sleeps with a CPAP machine is normal!” was the provocative opening statement by Dr. Fred Nachtway in his talk before the Support Group at the January 17th meeting. He went on to explain the subject of his talk would be to assist patients in achieving as much normalcy as possible.
People use CPAP to overcome the adverse effects of Sleep Apnea caused sleep deprivation and medical side effects such as; heart, cardiovascular and blood pressure side effects but all too frequently other factors prevent achieving the full benefits of CPAP.
Chief among these reasons; failure to change the CPAP mask (or nasal pillows) at the recommended 4-6 month interval, uncomfortable nasal “dryness” caused by low humidity and easily resolved by the use of a humidifier in the CPAP circuit, and too low or too high CPAP pressure for the patient’s needs.
Dr. Nachtway concluded his talk with the comment that about 1/3 of CPAP users report 80% or greater satisfactory treatment of their Sleep Apnea with CPAP. For the others there are alternatives; trying a different mask, a different CPAP machine technology (e.g. bi-PAP), adjustment in pressure, medication, dental appliances and surgery. Don’t give up hope!
A lively Question and Answer session followed and your editor noted two items of interest from these exchanges with the doctor. One – sleeping pills (e.g. Ambian or Lunesta) are safe to take occasionally if you have Sleep Apnea as they do not affect the Central Nervous System and impair your ability to recover from an apnea. The opiates to avoid are Morphine or any product containing a morphine based-derivative. Two – If you are facing hospitalization be sure to bring your CPAP Mask with you and your pressure setting. The hospital will furnish the CPAP machine. AND if you are undergoing surgery where a general anesthetic will be used you should be absolutely certain the anesthesiologist is aware you have Sleep Apnea.
“RESTORATIVE ” SLEEP MAY PREVENT TYPE 2 DIABETES
Another motivation emerges for achieving effective compliance in the treatment of Sleep Apnea.
Researchers at the Dept. of Medicine at the Univ. of Chicago writing in the Proceedings of the National Academy of Science (Jan 2008) have linked reduced Deep Sleep, which they characterize as “Slow-wave sleep,” with a possible increase in the risk of Type 2 Diabetes.
Extracting from their report: “Deep nonrapid eye movement (NREM) sleep, also known as slow-wave sleep (SWS), is thought to be the most “restorative” sleep stage, but beneficial effects of SWS for physical well being have not been demonstrated. The initiation of SWS coincides with hormonal changes that affect glucose regulation, suggesting that SWS may be important for normal glucose tolerance. Therefore, suppression of SWS should adversely affect glucose homeostasis and increase the risk of type 2 diabetes.
(Our studies show) that all-night selective suppression of SWS, without any change in total sleep time, results in marked decreases in insulin sensitivity without adequate compensatory increase in insulin release, leading to reduced glucose tolerance and increased diabetes risk. Importantly, the magnitude of the decrease in insulin sensitivity was strongly correlated with the magnitude of the reduction in SWS.”
They go on to say, “These findings demonstrate a clear role for SWS in the maintenance of normal glucose levels. Our data suggests that reduced sleep quality (as would occur with ineffective OSA treatment compliance) resulting in low levels of SWS, as occurs in aging and in many obese individuals, may contribute to an increase in the risk of type 2 diabetes.”
AIRPORT SECURITY & CPAP
The Transportation Security Administration (TSA) has amended the rules concerning mandatory CPAP Machine X-raying to include the following:
“Once out of the carrying case, you can place your CPAP machine in a clear plastic bag before placing the device in the bin. You will need to provide/bring your own plastic bag.Upon request, TSOs will change their gloves prior to performing the visual and physical inspection, and ETD sampling of your CPAP machine. The CPAP will need to be removed from the plastic bag by the TSO to conduct the ETD sampling.Upon request, TSOs will clean the table where the ETD sampling will be conducted.”
AIRPORT SECURITY & CPAP
In a proposed decision memo, Medicare is indicating the intention to limit benefits to 12 weeks for CPAP equipment, supplies and visits UNLESS patient results, as certified by a licensed physician, indicate positive benefit is being derived. In the same proposed decision memo they are proposing the authorization of home studies for Sleep Apnea using authorized study equipment supervised by authorized study personnel. No date has been set for enacting this decision memo and comment from the Medical community and public is being sought. The entire proposed memo may be viewed at: cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=204
NOTE: See Dr. Michael Cohen’s personal opinion letter in “The Physician’s Corner” column to the
√ A CHECKLIST FOR SLEEP APNEA HOSPITAL PATIENTS
The American Sleep Apnea Association has compiled a “Hospital Checklist for Sleep Apnea Patients.” It covers procedures for use of your or the hospital’s CPAP, your mask, being sure your Physician(s) and your anesthesiologist are aware of your operative and post operative needs as a Sleep Apnea patient, and more….. You may wish to download a copy and keep it where you and/or your significant other can recall it if needed. You can download your own copy at: sleepapnea.org/resources/pubs/hospitalcpal
MEDICARE & HOME SLEEP TESTING
(A personal opinion letter by Dr. Cohen, Medical Director of the Contra Costa Sleep Center, in response to Medicare’s “Proposed Decision Memo”)
At the instigation of an ENT surgeon (from Davis, California), Medicare reopened consideration of reimbursement for portable home studies for diagnosis sleep apnea. One hopes the intent of the surgeon was not to stimulate more operations for sleep apnea; but rather to offer testing to more people, especially in areas where there are no Accredited Sleep Centers.
The major medical organizations – American Academy of Sleep Medicine, American Thoracic Society, American College of Chest Physicians, and National Association of Medical Directors of Respiratory Care – all feel that there is a specific role for home studies, but only under carefully controlled circumstances:
The testing cannot be performed by any and all. It can only be performed by a physician knowledgeable in sleep medicine, after the physician performs a clinical examination. For example, it cannot be performed through Walmart.
The study should be performed as an integral part of diagnostic testing by an Accredited Sleep Center; and should be interpreted by a Sleep Medicine physician affiliated with an Accredited Sleep Center.
The potential problems that I foresee :
1. There will be an increase in home studies, many of which will be of poor quality.
2. Many studies will have to be repeated.
3. These two factors will not lower the cost to Medicare.
4. I anticipate a reduction in CPAP compliance. Patients will be given a mask and will have to perform their own CPAP titrations at home. If it’s the wrong fitting mask, there may be problems with getting another mask from the supplier. Patients will no longer have the opportunity to change masks and have the support of a sleep technician while they are being introduced to CPAP.
Medicare is presently in final discussions and is fine-tuning their criteria for reimbursement. Hopefully, Medicare’s final determination will eliminate the above-mentioned flaws.
These are my personal opinions.
Michael L. Cohen, M.D.
Diplomate, American Board of Sleep Medicine
Medical Director
Contra Costa Sleep Center
Walnut Creek, California