How To Make Sure CPAP Therapy Succeeds
October 17I read an interesting blog post today by a self-proclaimed born skeptic of just about everything. He wrote this post called “Sleep Apnea Skeptic“. It’s quite an entertaining read in many ways, yet sad too. This person ends his post with “I am open to being proven wrong, so if anyone out there wants to straighten me out, feel free.” but then locks the post from comments and pings so hopefully, somehow, this person will get to read me straightening him out.
Let’s start with where I agree with “LostInLouisville”. This person has a problem with how quick a manufacturer of XYZ supplies recommends their product when a new patient is diagnosed with just a simple test. This appears to border on commercial intentions only. Let’s diagnose loads of people and make sure we flog them our goods. Especially in pharmaceuticals, I agree to an extent that it often looks this way. Treating the symptoms forever (recurring money!) instead of removing the underlying cause just once seems to be the motto.
However, in the case of sleep apnea and CPAP, I couldn’t disagree more. Unlike more mysterious health problems such as CFS, UTI, cancer and many others, sleep apnea comes with a distinct set of symptoms and can be diagnosed in a scientifically and clinically proven way fairly easily. In the case of Obstructive Sleep Apnea, cause and effect becomes even clearer.
The blogger in question is of the opinion that CPAP as an air splint to keep the airway open is an “extraordinary claim”. He then sets out to go find “extraordinary evidence” which should comfort his mind. I only have to dig out one link which has over 500 pages of this extraordinary evidence to support CPAP is a suitable means of treating sleep apnea:
http://guidance.nice.org.uk/page.aspx?o=452425
Pretty much every bit of research since Sullivan first invented CPAP in1981 is referenced in the documents there. But even if we forget about getting all scientific about it, in layman’s terms it’s quite easy to grasp. Airway gets blocked by tissue at the back of the throat, CPAP pumps air under slight pressure into the airway to open up airway and allow patient to breathe. Without CPAP, no breathing. No breathing, no oxygen. No oxygen, fatigue, disease and death. With CPAP, yes breathing. Breathing = oxygen = no immediate death.
LostInLouisville didn’t mention finding any of this evidence but with the simplicity of Google nowadays, let’s assume he did and just ignored to blog about it. He did mention:
So when I turned to the internet to explore my uneducated skepticism about the subject, I expected to find some like-minded people exploring the topic. No luck. I can’t seem to find anyone with anything negative to say about the increasingly popular diagnosis.
What a surprise! He didn’t find anything against CPAP as a therapy for sleep apnea, he did find evidence in favour of it (I assume), yet still remains skeptical:
I don’t have any evidence that the claims are over-reaching. I only have my skeptical impulse. The sleep doctor my wife visited conducted a standard overnight test and (surprise!) determined that she had sleep apnea. And if she would only step next-door she would find a conveniently located store which sells the sleep apnea-eradicating CPAP machine. I wonder how many people go to the sleep doctor and are told, “No, you don’t need the CPAP.”
I don’t have hard figures but feel confident to say that the sleep tech wouldn’t recommend CPAP if there were suitable alternatives. Some people’s obstructions are clearly caused by an enlarged uvula. Laser treatment could work. Others have a lower jaw of such a shape that the person’s throat is more prone to collapse. A dental splint could well work better than CPAP here. But in most cases of ‘regular’ sleep apnea, CPAP definitely is the way to go. As recommended by thousands of sleep experts world wide.
Then comes the sad part. With the ’support’ of her caring husband, she gets her CPAP machine (which more likely than not, by this time has probably been written off already), ‘tests’ it and finds it makes her sleep worse. So the conclusion by this person is, this was all a scam.
Hold on a second. She shouldn’t be ‘testing’ the CPAP. The sleep lab should have done that to establish within comfortable margins that CPAP works. The standard overnight test he speaks of usually consists of one part multi-channel data gathering (respiratory flow, blood oxygen saturation, pulse etc.) and one part auto-titrating CPAP along with more data gathering to see if the symptoms improve. Perhaps she didn’t get this form of a standard test and indeed had to try it out herself at home. That would make for the worst scenario for starting CPAP users.
It is now common knowledge in the world of sleep apnea and CPAP that patient education improves compliance. Talk About Sleep discusses it to great length in this article. A PowerPoint presentation here talks in-depth about CPAP compliance and even mentions the involvement of the partner. With a skeptical partner and DIY trials, you have the ingredients for failure.
Clinical trials have been done with regards to patient education prior to CPAP therapy and every time they find that with proper motivation, education and assistance, compliance improves significantly. Jean Wise et al did such a trial with video education. Melanie Means and colleagues came to similar conclusions in their journal. This PDF by Chest Journal investigated the effects of group education sessions and also concluded that with the right support, compliance increased. There are many more studies done with the same results.
So let’s compare what science knows to how this person and his wife approached the situation. On one hand we know that assistance, education, monitoring, acceptance and awareness improve success rate and compliance yet on the other hand we have couple with a highly skeptical approach bordering on being naive and hating the industry, DIY/suit yourself trial period and ultimately aborted therapy.
I believe that had they adopted an attitude of “The evidence is there, it works for thousands of others, let’s make this work for us!” and a balanced patient-provider relationship, this woman could have been sleeping well, with CPAP, and subsequently feeling much better.
These quotes form the Talk About Sleep article linked above illustrate the point:
Dr. Fox went on to say, “”Yes, everyone has a hard time from the get go. It may take time; the first issue to overcome is psychological -accepting the therapy. The next biggest barrier is mask fit, finding the right tolerable mask. Follow up helps with long term compliance. When symptoms are apparent it helps patients when they actually see results and benefit from CPAP therapy.”
Attitude also plays a role in the critical adjustment period of CPAP therapy. I wanted to have a better understanding of psychological issues that may interfere with or challenge the newly diagnosed patient.
[…]
Dr. Schmitz, as part of the sleep team, believes, “the better a patient understands their sleep disorder and its treatment the greater the chance they will be able to follow through with prescribed treatment.. A collaborative and supportive process of education, from initial consultation to follow-up care, provides a strong foundation towards helping patients successfully adjust to CPAP treatment. Supportive education also may help reduce psychological barriers to treatment such as fear and anxiety about the use of CPAP. While adequate education does not guarantee compliance, it is an essential part of the process. Similar to other chronic conditions such as diabetes, which often require daily involvement or intervention by the patient, one would certainly want to provide the level of education and support for people with OSA needed to help them successfully manage and adjust to their condition.”
I see it often in the various CPAP related forums. Patients with almost a hostile approach to their CPAP equipment always struggle with keeping up the therapy. On the other hand, patients who thoroughly understand their disorder and how the equipment will help, look forward to CPAP like a child in the run up to Christmas. These patients worship their machine and even on the inevitable rough night, appreciate the benefits rather than focus on the negatives. Acceptance is key here. Starting off being skeptical certainly doesn’t help. To then be thrown in at the deep end with a DIY trial period makes for a disaster recipe.
So if you suspect you suffer from a sleep disorder like sleep apnea, do your own homework first and then listen carefully to your medical professional who knows about sleep. Ask your questions, clear any doubts you may have. Then do your homework on the sleep lab process. Know what is involved. Ask questions to the lab personnel or in forums online. Understand the sleep test results and how this is proof of your symptoms. Start to realize that with proper treatment these symptoms can go and you can feel your old self again. Realize the journey won’t be easy, especially in the beginning, but focus on medium to long-term goals, on the positives, on the benefits.
You feel bad now. CPAP will be your best friend. For a long time. Make sure you have a healthy relationship with this new best friend. Considering you’ve probably been suffering from sleep apnea for years, how much effort is giving CPAP a good try for just 6 weeks? Do you really want to feel better? Embrace proven technology and get on with life!
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(but without the effort).