“WHAT’S NEW IN SLEEP APNEA”

Dr. Harry MacDannald, a Pulmonary and Sleep Physician in the John Muir Physician Network, spoke at the fall meeting of the Support Group on “What’s New in Sleep Apnea” – a review of Sleep Apnea basics updated with the latest in research findings. He opened with the question, “Why Do We Sleep?” All animals sleep. We cannot function without sleep. Sleep is restorative and the amount of sleep we need changes with age from 15 hours/day as infants to 6 hours for those over 70 years of age.

Sleepiness, or its more serious form – sleep deprivation, predisposes an individual to developing serious performance decrements in multiple areas of function, potentially lifethreatening domestic, work-related and driving accidents, social embarrassment, memory and concentration difficulties, depression and a general impaired quality of life.

Excessive sleepiness is a sign of sleep deprivation. It has many causes. Chief among them is Sleep Apnea. Simply stated, Sleep Apnea is a very common physical disorder that causes some people to frequently cease breathing while sleeping. Sleep Apnea is a very serious health problem if left untreated. It has been estimated that 90% of people who have Sleep Apnea don’t know they have it! One measure of sleepiness is a very simple questioner called the Epworth Sleepiness Scale which can be self-administered (see following article).

Another potential indicator of the propensity for Sleep Apnea is the patient’s Body Mass. A Body Mass Index can be calculated by taking one’s weight in kilograms and dividing it by the height in meters squared (BMI = weight ÷ height in meters2 ) A result of 18.5-24.9 is considered healthy weight, 25.0 to 29.9 is overweight, 30.0-39.9 is obese and 40 and above is considered to be severely obese. It has also been found that the risk of Sleep Apnea increases with neck size. For men the suspect range is a 17” collar, for women it is a 16” collar.

The only positive means of making a positive diagnosis of Sleep Apnea is via a clinical study with the tongue twisting title of a “Polyomnography Montage” (a.k.a. a “Sleep Study”). These studies, performed in a sleep center, measure every physical aspect contributing to Sleep Apnea; sleep staging, respiratory measures, electrocardiography, oxygen saturation, limb movement, position monitoring, carbon dioxide emission and video monitoring. The sleep physician is looking for indications of Apneas and Hypopneas – [the total number of complete cessations (apnea) and partial obstructions (hypopnea) of breathing occurring per hour of sleep]. These pauses in breathing must last for 10 seconds and are generally associated with a decrease in
oxygenation of the blood.

The net result of these studies indicate a patient’s REM (“rapid eye movement”) sleep time compared with a norm for adults of 14- 19% and Apnea/Hypopnea Index (AHI) in the following ranges: Normal = 5/hr, Mild = 5- 15/hr, Moderate = 16-30/hr and Severe = more than 30/hr.

A very intensive and thorough question and answer session followed Dr. MacDannald’s talk with no question left unanswered!

THE EPWORTH SLEEPINESS SCALE

Are you always sleepy or exhausted? Do you suspect you have a sleep disorder? Do you know someone who you think might have a sleep disorder? The Epworth Sleepiness Scale questionnaire (below and previous article), developed by sleep researchers in Australia is a quick and convenient way to screen for extreme daytime sleepiness, which is usually caused by a sleep disorder such as Sleep Apnea. What is your likelihood of dozing off while
(indicate; None=0, Slight=1, Moderate=2, High=3):
___ sitting and reading?
___ watching TV?
___ sitting in a theater or classroom?
___ riding in a car for hour or more?
___ lying down to rest during the day?
___ sitting and talking to someone?
___ sitting by yourself after lunch ?
___ sitting in a car stopped in traffic for a few minutes?

0-9 = Normal daytime sleepiness range. This normal range overlaps with scores of people who have milder sleep disorders, so if you feel you have trouble sleeping or you wake up tired, go ahead and talk to your doctor about your symptoms. Ask if you could benefit from an evaluation at a sleep clinic.

10-15 = Moderately high daytime sleepiness, which often signals a sleep disorder such as sleep apnea. You should talk to your doctor about your symptoms soon, and also ask about a referral to a sleep clinic.

16 and over = Very high daytime sleepiness, which is a likely sign of a significant sleep disorder You should talk to your doctor about your symptoms as soon as possible, and get a referral to a sleep clinic.

SLEEP APNEA AND HYPERTENSION

A study conducted by the Dept. of Respiratory Medicine and Hypertension Clinic, at the Austin Medical Centre, Victoria, Australia revealed a strong link between the presence of (untreated) Obstructive Sleep Apnea and both untreated and treated hypertensive patients. Their analysis showed that body mass index, age, sex, treated hypertension and untreated hyper-tension were all associated with the presence of (untreated) sleep apnea.

OSA & GASTRIC REFLUX

(from “Wake-Up Call”)

The relationship between sleep apnea and gastric reflux – the entry of acidic stomach fluids into the esophagus or swallowing tube in the chest has been clearly established. It has been found in a number of studies that when people breathe against an obstructed airway, they generate very negative pressures in the lung and chest cavity as the diaphragm contracts strongly. That tends to violate the juncture between the stomach and esophagus and allow the reflex of gastric contents into the esophagus.

When sleep apnea is adequately treated – and with CPAP in particular – the negative pressure generated from breathing against the (obstructed) airway is relieved. That tends to decrease the propensity for stomach contents to enter the esophagus. Hence proper sleep apnea therapy can dramatically reduce systems of gastric reflux.

Sleep Cycle Disorders

All animals on this earth are in synchronization with the sun. Likewise, we humans tie all of our activities to the day and night rhythms of the sun. Our workdays, schools, commerce and personal activities are dictated by the time of day and these cyclical rhythms are called Circadian Rhythms (from the Latin; meaning about one day). We arise about the same time each day and retire about the same time each night, if our workday is daytime. When our sleep-wake patterns become altered, we try to adapt to the new hours, and sometimes this is difficult and we experience a Sleep Cycle Disorder.

There are a number of situations when we have to adapt our waking hours. Twice a year we have to adapt to Daylight Savings Time changes. Traveling across different time zones obviously requires us to adapt to the new time zone. Traveling in an easterly direction is more difficult than traveling westward as we have to arise earlier and fall to sleep earlier that we are accustomed to and are more likely to experience “Jet Lag” when traveling east. If we have the misfortune to have a job with rotating shifts, then every shift rotation causes an upheaval of our sleep patterns. Other Circadian Rhythm disorders are the Advanced Sleep Phase Syndrome when people fall asleep earlier than normal. The Delayed Sleep Phase Syndrome occurs when people fall asleep more than two hours later than their desired bedtimes.

Some symptoms that one can experience with sleep cycle disorders are feeling lethargic one moment and energetic the next. The result is that we feel excessively sleepy during the day or wide-awake at night. People may experience circadian rhythm disorders in varying degrees. The body is reacting to a change in the schedule of normal activities. People experiencing sleep cycle changes have a difficult time maintaining their internal, routine sleep-wake pattern in their new time change, because external stimuli, like sunshine and local timetables, dictate a different pattern of activities. For this reason, In general, the severity of symptoms is directly related to the number of time zones crossed by a flight or the number of hours of shift work change.

All age groups are susceptible, but individuals over the age of 50 are more likely to develop symptoms than those under the age of 30. Also, individual susceptibility tends to vary considerably and it is possible that pre-existing sleep deprivation will intensify symptoms. Jet lag is a unique sleep disorder because its onset is not necessarily caused by abnormal sleep patterns, like insomnia. Travelers who sleep normally prior to trans-meridian travel are not immune to jet lag

A COMPREHENSIVE REVIEW OF SLEEP APNEA AND ITS TREATMENT

The Spring 2009 Support Group meeting was treated to a comprehensive review of Sleep Apnea and its treatment by Dr. Manjari Nathan.

She opened her review with the statement that 70 Million people suffer from sleep disorders and 25 Million of these are related to sleep disordered breathing.

Dr. Nathan defined Sleep Apnea as a chronic respiratory sleep disorder characterized by recurrent episodes of partial or complete upper air obstruction during sleep (apneas, hypopneas) and are associated with repeated disruptions of sleep resulting in excessive daytime sleepiness and other medical problems.

An Apnea is a complete cessation of breathing lasting 10 seconds or more whereas a Hypopnea is reduced airflow to about 50% lasting 10 seconds or more. An Apnea Hypopnea Index (AHI) is the number of these occurrences totaled per hour. Mild Obstructive Sleep Apnea (OSA) would be represented by an AHI of 5-15, Moderate by 15-30 and Severe above 30.

The risk in Sleep Disordered Breathing is multifold; increased traffic accident mortality, lower productivity, a whole host of physical problems including sudden death, and impaired; mood, vigilance, concentration and memory functions.

Of particular concern are the cardiovascular effects of Sleep Apnea. The odds, she stated, of a person with untreated moderate sleep apnea (AHI >20) suffering a stroke in the next four years are significantly higher.

There are also negative metabolic and pulmonary effects.

Many options exist for the treatment of Sleep Apnea, Dr. Nathan stated. Weight loss, avoidance of drug and alcohol use, smoking cessation, postural training, nasal patency, dental appliances, CPAP/BiPAP and Surgery. She noted that CPAP compliance is poor in up to 40% of patients and needs to be used at least six hours nightly.

Surgery, particularly UPPP has a 50% success rate. Other surgical techniques include tongue advancement, hyoid bone elevation, repositioning of the upper and/or lower jaw and radiofrequency removal of excess airway tissue. An extended question and answer session followed presentation.

INSIGHTS INTO REM

REM (Rapid Eye Movement) sleep is a period of intense brain activity, vivid dreams and oxygen and glucose consumption equal to or higher than in the brain while in a waking state. “The implication is that the brain, which generates and evidently benefits from sleep, seems to be to busy to get any sleep itself.” This insight into REM comes from an article in the Smithsonian magazine (Oct 2003) discussing the work of Eugene Aserinsky and Nathaniel Kleitman who they cite as the discovers of REM in 1953.

The article goes on to say, “ Today it’s well established that normal sleep in human adults includes between four and six REM periods a night. The first starts about 90 minutes after sleep begins; it usually lasts several minutes.

Each subsequent REM period is longer. REM sleep is characterized by not only brain-wave activity typical of waking but also a sort of muscular paralysis which renders one incapable of acting on motor impulses. (Sleep walking most often occurs during non-REM sleep.) In men and women blood flow to the genitals is increased. Parts of the brain burn more energy. The heart may beat up to 10% faster and respiration 20%.”

“Adults spend about two hours a night in REM, or 25% of their sleep in REM. If you deprive a person of REM sleep, they’ll recoup it at the first chance, plunging directly into the REM phase – a phenomenon discovered by Dr. William C. Dement at Stanford.”

A LIGHTWEIGHT CPAP BATTERY BACKUP

Looking for a small, sleek, ultra-portable, way to power your CPAP or BiPAP? Available in 2 different sizes, this Lithium-Ion battery is sure to work with your device and provide a full night’s (or two with the larger size) sleep without recharging.

The TSA approved “Super CPAP battery” is small enough to take on a red-eye flight and powerful enough to keep CPAP machines running throughout long international flights. The leather travel case and international AC charger makes it an ideal travel companion. For more information and prices go on the web and search for: Super CPAP Battery.

UNTREATED OSA MAY DAMAGE BRAIN

June 4, 2009 – University of New South Wales researchers have found snoring associated with untreated sleep apnea may impair brain biochemistry like people who have had a severe stroke. The study used magnetic resonance spectroscopy to study the brains of 13 men with severe, untreated, obstructive sleep apnea.

The findings show that “lack of oxygen while asleep may be far more detrimental than when awake, possibly because the normal compensatory mechanisms don’t work as well when you are asleep similar to what you see in somebody who has had a very severe stroke or is dying.”

WHEN THINGS GO WRONG WITH CPAP

(Courtesy: the American Sleep Apnea Association)

CPAP is, at the present, the most effective treatment for obstructive sleep apnea. It is, however, only a treatment and has no benefit if it is not used. Current research estimates that the compliance rate for CPAP (how many people use CPAP more than a few months) is approximately 60%. One reason for this may be that CPAP users often experience disagreeable side effects and simply stop using CPAP. Many of these side effects can easily be addressed if a health professional is made aware of the problem or if the CPAP user is educated about ways to manage these problems.

Mask discomfort This problem usually arises because either the patient adjusts the headgear too tight or because the mask does not fit properly. A CPAP mask should fit the face snuggly to avoid air leak but not so tight that is feels uncomfortable or causes pain. If a mask has to be pulled tightly to prevent leaks the mask does not fit properly! You should contact your sleep specialist and let them know that your mask may not fit well and you would like to try another size or style mask. There are a number of makers of CPAP masks and not every nose can wear every mask. Do not let anyone tell you that a sore on your nose is to be expected!

Nasal congestion, irritation or runny nose that seems to be caused by using CPAP Your nose is your airway’s humidifier. It warms and humidifies the air that you breathe. If the CPAP begins to dry your nose, your body will increase the production of mucus in the nose to add more moisture to the inhaled air.

Unfortunately, this may cause nasal congestion and a runny nose. In some cases the dryness will cause irritation, burning and sneezing. These symptoms can be alleviated by the use of a humidifier with your CPAP. Some sleep specialists order a passover (cold water) humidifier with the initial CPAP order. If you do not have one of these speak with your sleep specialist. If you already have a humidifier and still experience these symptoms you may need a heated humidifier. This is a water pan that sits on a heating unit and is attached to CPAP just like the passover humidifier. Heating the air and the water will allow the air to carry more moisture as it travels to your nose (just like the summer air is more humid than winter air). In almost all cases this resolves nasal congestion and irritation if it is caused by CPAP.

Difficulty breathing through your nose If you have allergies, chronic sinus problems or a deviated septum (your nose is crooked on the inside) you may have trouble using CPAP. CPAP is usually applied through the nose. If during the day you often find yourself breathing through your mouth, CPAP may be difficult to use. If the problem is allergies speak with your doctor about treatment. There are a number of good nasal steroid sprays and allergy medications that can treat your nasal congestion. Individuals with a deviated septum or other structural problems in their noses may benefit from seeing an Ear Nose and Throat specialist if CPAP cannot be tolerated. Finally, there are CPAP masks that fit over both the mouth as well as the nose. People have used these with varying success but it may be worthwhile to try a “full face mask” before looking into other alternatives.

Headache or ear pressure Although treating sleep apnea usually eliminates morning headache, some CPAP users develop headaches on CPAP. Others find that their ears develop pressure or pain in them. Most of this relates to underlying sinus congestion due to allergies or to CPAP itself. It is much like traveling in an airplane when you have a cold. The congestion can block the ear canals and changes in air pressure can cause pain when air gets trapped. It is best to avoid using CPAP when you have a cold or sinus infection to avoid these problems. Sometimes the congestion remains in the ears and sinuses after the acute symptoms of the cold are gone. If you develop headache or ear pain on CPAP, speak with you sleep specialist. In the interim you may try decongestants or antihistamines. (Always check with your doctor before you take these medications).

Dr. MacDannald TALKS ON“SLEEP IN REVIEW”

Although marred by an electronic failure of a video projector, Dr. MacDannald rose to the occasion at the October Support Group meeting and gave a comprehensive review (without lecture notes) of the history of sleep apnea and current treatment methods followed by an extensive question and answer session.

Pointing out that the Support Group (of Central Contra Costa County) was formed in 1994, just 7 years after Dr. Colin Sullivan in Australia had identified Sleep Apnea, he commented that in the beginning there was only one mask and one big noisy CPAP machine. During the mid- 1980s there were only two sleep labs in Northern California; one in San Francisco and one at Stanford University. In 1991 John Muir Medical Center established a sleep study program.

Measuring Hypopnias and Apneas. By 1994 (when your editor was studied) this program had expanded to measure airflow at the nose and mouth, movements of the chest and abdomen, arterial oxygen saturation, heart rate and body position.

In 1999 the Contra Costa Sleep Center was formed to conduct “state of the art” detailed sleep studies including brain wave studies. Items of information gleaned from the balance of Dr. MacDannald’s talk and from the Q&A session that followed are covered below:

– Bed partners are frequently the initial diagnosticians of sleep apnea noting their partner’s interrupted sleep, snoring, gasping and teeth grinding. But, Dr. MacDannald cautioned, a full sleep study is still required to determine the underlying cause of the problem.
– Juvenile sleep apnea can be caused by tonsils or adenoids. However, unlike adult sleep apnea, which manifests itself in daytime sleepiness, the juvenile displays just the opposite – hyperactivity! – There is not a direct correlation between snoring and sleep apnea. 50% of people snore, but of the general population only 5% of males have sleep apnea and 2.5% of females.
– Snoring is caused by vibrations of the soft pallet whereas most Sleep Apnea emanates from the area of the throat below the soft pallet. There are surgical and dental corrective measures that can reposition the tongue and can, in many cases, eliminate mild sleep apnea.
– If a person has Sleep Apnea weight gain will generally worsen the problem. Conversely, weight loss will improve it.
– A Hypopnia index of 5 or less per hour without CPAP is considered normal. 5 to 15 Hypopnia is considered “mild sleep apnea.”
– The problem with Sleep Apnea is the brain arousals when re-breathing which fragments sleep and causes daytime tiredness.
– Untreated Sleep Apnea can also cause low oxygen levels and cause the right side of the heart to be stressed, swelling in the legs and bloating in the belly.
– The most important sleep occurs in Stage 3 &4. Roughly 20% of the night is spent in these two stages. Every 90 minutes you have a “burst” of REM (Rapid Eye Movement) sleep – this is the dreaming stage. In REM sleep you cannot move anything but your eyes and your diaphragm. REM is not essential for life but stage 3 & 4 sleep is!
– Nasal sprays can aid in keeping the air passages clear during CPAP. Plain saline spray (e.g. “Ocean”) can help. If more relief is needed ask your doctor for a proscription for ASTELIN Nasal Spray. Avoid using nasal sprays designed to relieve allergies containing phenylephrine due to the “rebound” effect of requiring more and more to be used in order to achieve relief.
– A question was posed regarding how often CPAP masks and nasal pillows should be replaced. The below article provides the Medicare reimbursement schedule which can be used as a guide.

SCHEDULE FOR CPAP EQUIPMENT REPLACEMENT

Medicare will reimburse your Durable Medical Equipment (DME) supplier for CPAP equipment as follows;
• Nasal pillows – 2 per month
• Mask cushions – 1 every 3 mo
• Headgear – 1 every 6 months
• Hoses – 1 per month
• Filters (disposable) – 2 per mo
• Filters (washable) – 1 every 6 mo
• CPAP machines and humidifiers are assumed to have a life of five years or when repair is uneconomical or parts are no longer available to return it to service.

(Note: with proper cleaning and handling care you may not need to replace on this schedule. For any clarification or questions regarding replacement contact your DME provider.)

 The Physician’s Corner

by Harry J Macdannald MD

 

 

Drowsy Driving

While there are many hazardous conditions that we cannot avoid, driving while drowsy or sleepy is not one of them. Getting behind the wheel of your automobile when you’re in this condition is just plain dangerous. Drowsy driving results in slower reaction time, decreased awareness, impaired judgment and an increased risk of getting involved in an accident.

Nearly nine out of every ten police officers responding to an AAA Foundation for Traffic Safety Internet survey reported they had stopped a driver who they believed was drunk, but turned out to be drowsy.

Each year tens of thousands of accidents are the result of someone falling asleep behind the wheel. About half of them occur from the hours of 11 p.m. to 8 a.m. Young men from the ages of 16 to 24 are also likely culprits

Drowsy driving is the direct cause of approximately 100,000 police-reported crashes annually, resulting in an estimated 1,550 deaths, 71,000 injuries and $12.5 billion in monetary losses.

Here are some signs that should tell a driver to stop and rest:
• Your eyes close or go out of focus by themselves
• You have trouble keeping your head up
• You can’t stop yawning
• You have wandering thoughts and daydreams
• You don’t remember driving the past few miles
• You drift between lanes, tailgate, or miss signs
• You have drifted off the road and narrowly missed crashing

There are three main causes of drowsy driving:
1. Sleep restriction: Persons getting less than the recommended seven-to-eight hours of sleep each night are more likely to feel tired the following day, which can ultimately affect their cognizance behind the wheel. Not getting enough sleep on a consistent basis can create “sleep debt” and lead to chronic sleepiness over time.

2. Sleep fragmentation: causes an inadequate amount of sleep and can negatively affect a person’s functioning during the daytime. Sleep fragmentation can have internal and external causes. The primary internal cause is sickness, including untreated sleep disorders. External factors that can prevent a person’s ability to have a full, refreshing night of sleep include noise, children, bright lights and a restless bed partner.

3. Undiagnosed Sleep Disorders Sufferers- A surprising number of people are tired because they have a sleep disorder. Disorders such as chronic insomnia, sleep apnea, narcolepsy, and restless leg syndrome- all of which lead to excessive daytime sleepiness- afflict an estimated 50 million Americans.

The American Academy of Sleep Medicine (AASM) offers the following ways to avoid becoming drowsy while driving: Get enough sleep – adults need seven-toeight hours of sleep each night in order to maintain good health and optimum performance. Take breaks while driving –If you become drowsy while driving, pull off to a rest area and take a short nap, preferably 15-20 minutes in length. Do not drink alcohol –Alcohol can further impair a person’s ability to stay awake and make good decisions. Taking the wheel after having just one glass of alcohol can affect your level of fatigue while driving. Do not drive late at night –Avoid driving after midnight, which is a natural period of sleepiness.

Unfortunately, It is a fact that your body CANNOT predict sleep onset. Now, we have all experienced that buzz behind the eyes that makes us say….”I just need to close my eyes for ONE SECOND”….but did you know that even though you may have every conscious intention of re-opening your eyes, the body may feel different. . If you have ever fallen asleep at the wheel and lived to tell the tale, don’t EVER say you are an unlucky person!

Next issue we will have a quiz testing your knowledge of some the myths about drowsy driving and what YOU can do about it.

THIS ISSUE IS DEVOTED TO THE GREATEST BARRIER TO EFFECTIVE SLEEP APNEA TREATMENT !

COMPLIANCE (def): the act of conforming or agreeing to do something

The treatment of Sleep Apneas involves three steps; Diagnosis (professional medical identification of your condition), Prescription (the therapy required to control your symptoms) and, lastly, and most importantly, Compliance (your role as the patient in the treatment).

Once the initial shock of a diagnosis of Sleep Apnea has worn off and the routine of CPAP treatment is underway, all too many patients find every night, all nightlong compliance is not all that easy. Problems can arise with uncomfortable masks or nasal pillows, irritation of the nasal membranes, the cleaning of the headgear or just plain motivation to adhere to the prescribed new life style occasioned by CPAP treatment.

If so, you are not alone! It is the rare patient that has not experienced one or more of these problems and “taken a night off.” Fortunately, most promptly return to CPAP therapy. However, some don’t or they return with irregularity. The following comments are designed to assist this later group.

Motivation to maintain compliance is the key. Sometimes we forget that Sleep Apnea can be a life-threatening disorder, if not shortening of your life or that of someone else’s after falling asleep at the wheel!

Prolonging life should be a more than sufficient motivation to re-establish treatment. Perseverance!

Effort can then be concentrated on solving the other problems of comfort, nasal irritation and the boring routine aspects of CPAP treatment.

As to comfort…….there are so many masks and nasal pillows on the market now that finding one that fits and is comfortable becomes a matter of working with your equipment specialist. Don’t give up – the perfect fitting mask for you is out there somewhere. Again…. Perseverance!

As to nasal irritation, there are over-thecounter saline nasal sprays to relieve irritation. If this doesn’t do it then talk to talk to your Respiratory Physician about prescription medications. Nasal irritation due to CPAP can be controlled and almost totally eliminated. Again…. Perseverance!

As to the bother of cleaning masks, headgear, tubes, etc. You probably spend more time cleaning the windows of your car or your kitchen counter in a week. The complete disassembly, washing and reassembly of a complicated mask (like my ResMed’s Mirage Activa) takes less than 15 minutes a week! Again…. Perseverance!

As to a boring night after night routine – yes it is boring…but its sure beats the alternative!

Lack of compliance is the same as having untreated sleep apnea. It brings with it all of its potential risks and complications present before you were diagnosed and before therapy was prescribed.

If you need help in maintaining compliance; first have a good motivational talk with yourself, then seek help from your equipment specialist, your Respiratory Physician and your Support Group. Remember you are not alone and your problems are not unique!

 

LOWER PG&E RATE FOR CPAP USERS

Chuck Carroll of Walnut Creek, a reader of the “Sound Sleeper” (now I know I have at least one!) passes along the following:

PG&E considers CPAP “life saving medical equipment.” As such, it qualifies for reduced electricity rates. Chuck writes, “After registering with PG&E as a CPAP user, I am saving several hundred dollars per year from my electricity bill. Fellow Sound Sleeper readers may profit from my experience.”

To obtain these rates, you must submit a form signed by your doctor.

Information on the “Medical Baseline Program,” instructions and application forms can be found at: www.pge.com/myhome/customerservice/financialassistance/medicalbaseline/index.shtml Fill out the form and mail it to your CPAP doctor for signature. Mail the form to PG&E. You may wish to follow up with PG&E to see how your approval is going. Eventually, your monthly PG&E bill should indicate that you are getting a medical rate, which will be lower.

THE PHYSICIAN’S CORNER
by Harry J MacDannald MD

 

CPAP COMPLIANCE (sticking with it!)

 

Continuous positive airway pressure (CPAP) is an effective therapy for obstructive sleep apnea syndrome (OSAS). CPAP is a device that uses air pressure as a pneumatic splint to hold the airway open, and prevents collapse of the airway. The key to improving CPAP compliance is maximizing success in the early treatment period.

CPAP significantly reduces the OSAS symptoms for a vast majority of patients. Some symptoms include, morning tiredness, excessive daytime time sleepiness and fatigue, poor daytime mental functioning, snoring, hypertension, relationship discord, sexual dysfunction, mood changes, and depression. Successful application of CPAP can dramatically improve these symptoms and health-related quality of life for patients, transforming somnolent individuals into energetic and more productive people. Moreover, the use of CPAP can decrease systemic blood pressure and improve cardiovascular performance, and thereby decrease cardiovascular related disease and death associated with OSAS. A recent study showed that patients whose sleep improved the most on their first CPAP night had the highest levels of CPAP compliance.

However, CPAP therapy is often difficult for patients to tolerate and many stop using it because of discomforts, claustrophobic reactions, poor understanding of its benefits, or difficulties in using the equipment. The nasal mask interface may cause pressure sores, persistent air leakage, nasal congestion, and other side effects that may lead to sub-optimal compliance.

Studies have shown that the most crucial period for CPAP success is the first four days, and that patient instruction and understanding is vital for success. A successful program for maximizing CPAP compliance should include the following activities:

– Maximize comfort with the patient device interface. Identify the best mask for the patient.
Styles include nasal masks, oral/nasal masks and masks that allow the patient to breathe through their mouth only. Other comfort features include a ramp function, where pressure builds up gradually after the patient falls asleep.

– Optimize the patient’s experience with CPAP during the early treatment period.
Patients should receive anticipatory guidance, extensive education on what to expect and how to use CPAP. Frequent follow-up provides support and troubleshoots problems and insure that the equipment is correct. Sedative medication may help patients to relax and sleep when first starting on CPAP.

– Treat side effects.
Humidification reduces nasal and pharyngeal dryness, improving tolerance. Congestion and rhinorrhea typically resolve after a short period of adaptation but may require nasal steroids, anticholinergic nasal sprays or decongestants. Bi-level PAP may be helpful for people complaining of high pressure and leaks.

– Provide long-term support.
This includes follow-up with medical personnel and patient support groups. Programs utilizing these features have been shown to improve CPAP compliance.

– Educational and Support Activities
Most patients will go to their training alone; however, many clinics and educators involve spouses and bed partners as well. Here are some topics to cover:
• Training on use of equipment–mask, flow generator, humidifier, etc
• Training on how to clean equipment– mask, tubing, humidifier, etc
• Possible side effects and how to treat them; autotitration and humidification to treat nasal irritation and sensitivity to higher pressures, mask selection and fitting for facial discomfort, etc
• Education on the associated health risks of untreated sleep deprivation; auto accidents, depression, stroke (and TIA), hypertension heart disease, etc
• Introduction to support groups and online chat rooms and message boards–see list below
• Follow-up visits with primary physicians and homecare providers especially in the first months of treatment

 

Useful Web Sites for Patients

American Sleep Apnea Association: http://www.sleepapnea.org
American Academy of Sleep Medicine: http://www.asda.org
National Sleep Foundation: http://www.sleepfoundation.org
Sleep Quest: http://www.sleepquest.com
Talk About Sleep at: www.talkaboutsleep.com