CPAP Blog

I 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!

I was asked recently whether I thought the Comfort Curve mask I use is suitable for a side sleeper. People who sleep on their sides for most of the night tend to find that conventional nasal cushion CPAP masks dig in to the pillow, being pushed side ways causing leaks or added pressure on the opposite side which may cause skin irritation and red marks on the face.

Whilst I sleep mostly on my back I do think the Comfort Curve is a decent option for side sleepers. I’ve tried it myself and the extra pressure caused by the contact with the pillow does not cause major interference with how the mask sits. Depending on the pillow type you have, the cheek pad resting on the side of your face can make your cheeks slightly sore. Therefor, I don’t think the Respironics Comfort Curve mask is the best option for someone sleeping on his or her side.

I have no experience with ‘nasal pillows’ myself but have heard great feedback from side sleepers. Unlike a conventional CPAP mask with a cushion that sits around your nose, a nasal pillow literally plugs into your nostrils (or nares as they say in the US) therefor not touching your face at all. No material goes to the side of the nose so you are free to lay on your pillow on your side. With a medium firm pillow that doesn’t cause your face to sink in it completely (like some feature and down pillows) the pillow’s surface won’t get near enough to your nose to disrupt the way the nasal pillow mask is worn.

This image illustrates the point. This man may be lying on his back there but as you can see, nothing would stop him from sleeping on his side. Minimal contact with the most sensitive parts of the face is made so red marks and skin irritation is likely to be avoided with a mask interface like this. Like with wearing a hat or cap, most people don’t get any skin rashes, marks or itching at the forehead.

This examples is a Respironics Comfort Lite 2 but it’s not the only one like this. In the UK you can also get the ResMed Mirage Swift II though with the tube sticking out on one end, this may only be suitable for side sleepers who know which side they sleep on consistently. Puritan Bennett does the Breeze SleepGear CPAP nasal pillow interface and UK/E.U. readers can order it here. Like the Comfort Lite 2, the sides of the face are completely free to be flat on the pillow, making this a great solution for side sleeping CPAP users. Unfortunately, because these types of masks plug into the nose only, they are not suitable for mouth breathers (if you are, keep reading though, solution to follow).

Similar designs, suitable for side-sleepers: Snapp-X by VIASYS and Fisher & Paykel’s Opus.

Having spoken of the various CPAP mask options for side sleepers, did you know you can also change your pillow to accommodate your mask, instead of the other way around?

This clever design features a cut-out where the mask and tube sits, making room for this gear so it doesn’t dig into the pillow, putting pressure on the face. The pillow is called the CPAP Sleep Aid and you can read more about it on the manufacturer’s website here.

So to sum this post up, if you suffer from marks on your face, skin irritation or just generally prefer to sleep on your side you have two options. Go for a ‘nasal pillow’ mask interface or opt to change the actual pillow you sleep on.

Via the people I got my CPAP machine and masks from, I got in touch with Clare Jeffries who runs a Nutritional Therapy Practice in Surrey called Healthy Influence. We all know dietary choices have an effect on our body and sleep apnoea condition so it helps to know the do’s and don’t when it comes to food intake. Clare kindly agreed to be interviewed about how nutrition influences disorders such as OSA. Our forum members also pitched in with a few questions.

Coincidentally, yesterday I was watching The Truth About Food on the BBC in which the volunteers dropped an average of 23% in their cholesterol levels after eating raw fruit and veg only for just 10 days. Many reported weight loss and increased energy so it clearly illustrates how making the right food choices can help sleep apnoea sufferers with very quick results.

Interview with Nutritional Therapist Clare Jeffries:

JMcM: How long have you been a Nutritional Therapist for?

CJ: Studying for 4 years and practising for 1 year.

JMcM: How did you first learn about OSA?

CJ: It came up in my reading on obesity as something many overweight people suffer from.

JMcM: As you know a lot about the human anatomy, can you summarize the effects of sleep apnoea on an otherwise healthy body?

CJ: Because sleep apnoea restricts, sometimes severely, the amount of oxygen being delivered around the body whilst sleeping, cells are not able to get rid of wastes to keep them healthy and this can have many long term effects. Also, the brain registers this drop in oxygen and tells the heart to pump harder to deliver more blood faster. This can then lead to high blood pressure and over time sleep apnoea can cause other heart abnormalities. And of course, due to the lack of good sleep, sufferers will be excessively sleepy in the daytime and may get morning headaches.

JMcM: As we all know, untreated OSA affects blood oxygen levels. Is there anything nutrition-wise sufferers can do to improve the condition of the blood or to make sure the little oxygen in there gets used up best?

CJ: Ideally, you want the blood to be able to carry as much oxygen as it can and having adequate iron levels is required for this. When a person is anaemic, they have reduced capacity for carrying oxygen on their red blood cells. However, most men who eat a varied diet will be getting sufficient levels, unless they have a disorder of some kind that means they are losing blood, such as bowel disorders or haemorrhoids. Another factor that is important is to ensure you are well hydrated. When we don’t consume adequate levels of fluids, the blood becomes slightly ‘thicker’ and therefore harder for the heart to pump around the blood vessels. Think of it like sucking a McDonalds thickshake as opposed to orange juice through a straw! So, make sure you have at least 1.5 litres of water (herbal teas can count towards this) in addition to tea & coffee.

JMcM: A feeling of sleepiness is possibly what bugs us most. Are there any foods specifically full of energy, aiding staying awake and alert?

CJ: B vitamins and magnesium are crucial for energy production and are found in fish, wholegrains, brown rice, mushrooms, green vegetables, beans & pulses, some meats & eggs. It will also be helpful to keep your blood sugar balanced, by not eating too many refined carbohydrates such as white bread, cakes, biscuits, chocolate and sweets, and not leaving very long gaps between meals. When we do eat lots of these foods and leave long gaps (more than 4 hours) between eating, your blood sugar levels resemble a rollercoaster, with big peaks & troughs. In the ‘troughs’, you can feel very tired and lethargic. Aim to eat little and often and have foods that contain fibre (fruits, veg, wholegrains), as these keep the blood sugar on an even keel.

JMcM: What about the use of coffee or energy drinks in a desperate attempt to stay awake; good or bad?

CJ: Understandably, these must be appealing at times, but using them in the long run often disrupts your blood sugar balance as described above, because they push your body to churn out stress hormones like adrenalin & cortisol which can make you feel a bit ‘wired & fired’ but then comes the inevitable crash after they’ve worn off. If you do feel you can’t do without these though, coffee (good quality filter best) is better than energy drinks which are full of caffeine, chemicals & sugar.

JMcM: Many OSA sufferers often feel depressed or easily agitated. Can food help with controlling one’s mood?

CJ: Balanced blood sugar levels is also very important for this as the brain is very sensitive to drops in blood sugar, and one can feel low mood, irritable, angry, get headaches and generally feel under par when levels drop too low. Again B vitamins are important for producing ‘happy hormones’ in the brain and having good intake of essential fats (oily fish, nuts, seeds, olive oil, avocado are all good sources) has been found to reduce depression.

JMcM: With a CPAP machine and a mask on, it can be difficult falling asleep at times. What is the role of food in a good bedtime routine and for promoting a restful sleep?

CJ: Serotonin is needed to induce sleep and this is produced from something called tryptophan. This is a part of protein and is absorbed best from walnuts, milk, soy, eggs, bananas & fish. So eating fish or an omelette for your evening meal or having a snack including these foods 1/2 hour before bed can help you drop off easier. Obviously, its best to avoid coffee, tea or chocolate in the evening due to the caffeine levels and again if you have something very sugary in the evening, your blood sugar levels may drop off too steeply in the night which can then wake you up.

JMcM: Many of us are overweight, contributing to the causes of OSA. What are your best tips on weight management?

CJ: Sorry to be a bore, but keeping you blood sugar balanced, so that the body knows it has a steady supply of energy, encourages it to let go of excess weight, so simply not eating very much may be bad for losing weight in the long run. Eat 3 small meals per day and two healthy snacks. Eat plenty of vegetables & fruit as these are low calorie but high fibre, so keep you satisfied for longer than cakes & biscuits! As a general rule, try to avoid large portions of carbohydrate (bread, potatoes, rice, pasta) with your evening meal and have them at lunch time instead.

JMcM: I’ve been reading about light therapy possibly having a beneficial effect on sleep. Do you happen to know anything about this subject and if so, what are your views on this?

CJ: Light therapy does indeed have a positive impact on sleep. This is because it helps regulate the circadian rhythm, our ‘body clock’. Without adequate levels of light in the day, the body sometimes gets confused as to when it should be sleeping and sadly with modern living and long ours in offices with artificial light, exposure to full spectrum natural light is often inadequate. I certainly think it is something worth considering as part of our overall health.

JMcM: Finally, not necessarily related to OSA, what is your favourite nutrient-rich food and why?

CJ: That’s hard as there are so many, but certainly oily fish (salmon, mackerel, sardines, kippers, anchovies) cannot be underestimated. These oils help protect the heart from damage, be keeping the blood vessels supple, they protect the brain in a similar way. As heart attacks & stroke are more common in those with OSA, I think they are particularly important. But they do lots more not related to sleep apnoea, such as reduce inflammation so helpful in arthritis, they help the body balance weight and regulate hormones. A real super food!

JMcM: Our forum member katiemcewan asked the following question: “My husband doesn’t ever drink any water. I keep saying he should but he just can’t keep it up for longer than a few hours. I’ve heard drinking too little water can cause back trouble etc. but does it also add to the sleep apnoea symptoms he suffers from?”

CJ: As I mentioned above regarding helping the body deliver oxygen, being adequately hydrated is very important for the blood to flow easily, reducing the change of high blood pressure.

JMcM: Another member, aptly named JackTheSnorer, asked: “Not so much coffee, more Red Bull for me to perk me up. I know it’s full of caffeine so how exactly does it work with blood and the heart etc.?”

CJ: As discussed above regarding using stimulants to stay alert, caffeine makes the body produce more stress hormones (hence the jittery feeling some people experience with high levels of caffeine) which often makes the heart pump harder. Although this might seem like a good thing for delivering oxygen around the body, the heart is artificially being stimulated to work harder than is necessary. The occasional red bull is not a problem, but be aware that it contains a similar amount of sugar to coca-cola. There is a sugar free variety, but due to the possible dangers of artificial sweeteners to the health of your brain, I do not recommend having the diet variety.

JMcM: Thank you Clare, that has been some great advice I’m sure all readers can benefit from. Thanks for taking the time to answer them!

CJ: No Problem!

And of course, if you are curious about nutritional advice more tailored to your specific circumstances, you can contact Clare here to arrange a consultation.

Other helpful links related to this post:

• Guide to Lower High Blood Pressure
• Eat well, be well - Blood pressure
• Suitable foods for Diabetics
• BBC: What can diabetics eat?
• Fruits and Vegetables for Weight Loss
• Is Caffeine Your Friend or Foe?
• Energy Drinks and Insomnia

If you would like to discuss nutritional topics with fellow sleep apnoea patients, please visit the forums. You can also leave your feedback in a comment below.