CPAP is the gold standard for the treatment of patients with severe sleep apnoea syndrome. Several methods for the assessment of the effective CPAP-level exist. Low compilers CPAP may improve their adherence when moving to pressure relief-devices, largely available.
Although this article is a bit old, you may find something you need on this article of mine
We are now doing a study relating to the use of the magnetic mandibular advancement device (2M2A) in order to increase the airway during sleep. All the patients are treated by ENT physician first, but the treatment results are negative. Then all of that group of patients are referrred to me to try this device.
Since CPAP remains the gold standard in the treatment of sleep apnea, it should be initiated in moderate-to-severe forms of apnea (AHI >15), especially if the patient suffers from daytime symptoms like morning headaches, reflux, cognitive deficits, hypertension etc. We usually perform two separate PSGs with one being a diagnostic night and the other used for CPAP titration. As stated by others the management of sleep apnea patients should involve other disciplines like ear-nose-throat doctors, internal medicine specialists etc. Follow-up ambulatory apnea checks are mandatory with the first being performed after 3 months (including analysis of compliance data).
CPAP remains the most efficacious treatment for sleep apnea, but compliance continues to be a challenge. As previously mentioned, the use of pressure-relief devices could be helpful, however that would be beneficial for patients who specifically have tolerance issues to the pressure and require higher therapeutic pressures. When it comes to compliance to PAP therapy there are usually three factors- equipment factors, patient factors, and provider factors. Some of the best data that supports improved compliance is tied to patients who have received a thorough and timely follow-up with their provider and have a sound management program in place.
Unfortunately, CPAP remains the only long-term remedy for OSAS.
Despite advancements in various types of operations and surgical techniques, most do not have long-term term benefit beyond, on average, 2 years. I suppose this is because the body does not "like" any "abnormal" spaces created artificially...just like any cavity caused by disease will eventually "close-up" provided there is nothing to impede the healing process.
Weight reduction works for some patients if it is significant and for long term. Only a few of obese patients manage to loose significant amount of weight in order to modify AHI
Follow-up is very important for CPAP users. Some devices, like AUTO-CPAP FLEX, are easyer to use for less compliant. Education of patients with few symptoms increases the number of hours with CPAP.
While it is true that weight loss helps in treatment of OSAS, it is actually a case of "chicken and egg" because without using CPAP, weight loss is going to be difficult due to the reduced efficiency of aerobic metabolism. Severe OSAS patients will have increased anaerobic episodes which leads to eventually a poorer metabolic rate, hence the weight increment or difficulty in losing the excess kg.
CPAP along with a regime of diet control and exercise is mandatory for efficient and effective treatment of OSAS with or without some adjuvant surgical procedures (in my practice, surgical procedures are secondary) which will eventually prove impermanent...
I would argue that CPAP is not necessarily "gold standard", due to limitations in clinical utility and acceptability for clients. Perhaps also consider emerging evidence for oropharangeal exercises for moderate OSA. Speech paths do these.
The question seeks to determine the best procedure to establish effective continuous positive airway pressure (CPAP) to treat patients with obstructive sleep apnoea.
I my opinion the best procedure to establish effective treatment begins with finding the proper interface. In many cases this is accomplished by trial and error, though the curve is not as steep if it is determined early that the patient is a mouth breather so nasal masks and pillows can be excluded.
The second element is determining whether therapy can a continuous pressure or whether auto-titrating is required due to different pressure requirements are needed for REM and NREM sleep.
The third element to establishing effective treatment is having the patient experience periods of refreshing sleep using therapy. This can occur during in-lab titration. It is more challenging when occurring outside the lab. Patients are more likely to be motivated to replicate the steps they took to experience good sleep, especially if they have suffered for many years with un-refreshing sleep.
My suggestion to patients that they start slowly with adapting to the mask and the device - perhaps using during napping initially and then to using during the night of sleep.
The challenge of establishing an effective procedure is that it requires *time* with the patient - to listen to their concerns, to provide encouragement and to monitor their progress in the early stage of treatment. It is likely the case that a properly trained (in sleep) allied health professional could provide these services to the patient.
As a sleep technologist for 29+ years, a CPAP user for 15+ years, obese and hypertensive and constantly with yoyo weight loss no matter how hard i try, I am slipping down the slippery slope of Metabolic syndrome even with religious use of CPAP. I cannot sleep without CPAP...if I want to breath.
We HAVE to be missing something.
Researching sugar in our diets http://www.youtube.com/watch?v=dBnniua6-oM and Testosterone degradation over our lifespans, there are other factors that we are still being stitched together in the fabric of this "disease," if OSA is to be considered the disease, and not just a symptom, as possibly Insulin resistance. http://www.tedmed.com/talks/show?id=18029 Is it a symptom, and not the disease.
We need to stop thinking we are the end-all, be-all just because we figured out a way to keep a collapsing airway open. "Why" is the remaining question.
As to the Original post; get a lab titration in a reputable facility. That will allow you access to varied interface types, provide some education, document REM sleep and Supine position sleeping with requisite pressures and provide needed mode changes, BPAP,etc., if circumstances require. I loathe Auto-pap. It does nothing except guarantee you having arousals as it tests the lower pressure thresholds.
Just my $.02
Agree with Dr. Grandi... However, disagree on in-lab titration because unless patients are already in such a fatigue atate, they can never replicate their sleep in their natural environment. Out-of lab, natural and home situation is best. Although challenging with logistics and personnel posing the major obstacles, I think conditions at home would be more conducive to produce more accurate and useful recording over a certain period of time to ascertain sleep pattern variations, at least over one week to provide a better understanding of a patient's problem; this being especially appropriate in less than severe cases of OSA sufferers.
I completely agree with Claude, a very experimented sleep technician. Education, the appropiate interface and a Sleep Medicine Center are the key ingredients for CPAP treatment.
Thank you Grandi for your excellent comments.
For a patient, first encounter with a sleep clinic and with devices is important for
long term compliance.
Several methods for the assessment of the effective
CPAP level exist and are used currently: manual CPAP titration, autoadjustable-
CPAP (APAP) and prediction formulae.
For severe OSAS , although CPAP is the most effective treatment modality but it is inconvenient for the patient to use CPAP all the time. Therefore otolaryngologists must think of doing LAUP ( Laser assisted uvulopalatoplasty ) as the surgical modality of choice for a long term cure.
Most surgical procedures, including LAUP are short to medium term remedy for snoring, disguising the absence of snoring as "cure" of OSAS.
It is more important to identify the site of the obstruction and not advocate a certain procedure as the "best" or even "most accepted". LAUP may be useful in the short and medium term but studies have shown that it does not provide long-term relief of OSAS, especially if the obstruction is below the velopharyngeal level...
Surgical treatment may be considered in patients with mild OSA when obstructing anatomy can be identified and if other treatment such as positive airway pressure ventilation or oral devices are not accepted or tolerated by the patient or provide an unacceptable improvement of clinical symptoms.
Laser-assisted uvulopalatoplasty is not recommended for the regular treatment of obstructive sleep apnoea.
True, true... Unfortunately, advocates for surgery in my country advices operative procedures almost as if these are the end-all solution.
It is my belief that CPAP must be at one time or another be instituted to complement and supplement any other treatment regime, whether operstive procedures or otherwise. This may be difficult in some patients, especially those who fall under the mild to moderate category, who will almost inevitably be resistant to using CPAP as well as those are claustrophobic...(I have a patient who is very claustrophobic in whom I have much trouble convincing to start using CPAP. Any suggestion?)
It is true that operative procedures are not the end-all solution. However, a recent, Swedish RCT indicates that also surgery should be considered as a treatment option. In my opinion both anatomy and psychology should be emphasized in the search for the optimal treatment for OSA. May the claustrophobic patient benefit from an oral device?
Thank you for your suggestion. Unfortunately, he has already tried many oral/dental devices and undergone two surgical procedures, i.e., mandibular advancement and debulking of the base of tongue with LAUP in a neighbouring country. His problem is retrognatia and while immediate post-op he appeared to have improved, his symptoms recurred after 4 to 20 months; this is despite the use of oral devices prescribed to him...
CPAP seemed the only answer for him if he wears it through the night. The only time he is able do so is when he has taken a "sleeping pill" (he feels refreshed the following morning; "sleeping pills" alone leaves him with a severe hangover)). Even so, he is determined to not be dependent on "sleeping pills". Referral to my psychiatric colleagues has not borne the desired result...yet. I am still hopeful that with persistence he will eventually come round to CPAP...
Feeling of being suffocated and CPAP mask anxiety is only temporary. Relaxation exercises, such as progressive muscle relaxation, may help reduce anxiety and claustrophobic feeling. It may help to get a different size mask or try a different style, such as one that uses nasal pillows.
Can you recommend specific relaxation exercises or validated techniques? I also have some patients that remove their mask while sleeping without being aware of the removal. Any suggestions?
Patients moving a lot in the sleep, may find that a full face mask will stay better. For congested noses, adding a CPAP-heated humidifier may help. A chin strap also may help keep the device on the face.
Progressive muscle relaxation is helpfull - Sleep Breath. 2012 Dec;16(4):1049-57. doi: 10.1007/s11325-011-0600-3.
Educational, supportive and behavioural interventions may help people with obstructive sleep apnoea recognise the need for regular and continued use of continuous positive airway pressure.
These are the conclusion from Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007736. doi: 10.1002/14651858.CD007736
There is some evidence that a supportive intervention which encourages people to continue to use their CPAP machines leads to greater levels of CPAP machine usage than control, although the variation across the studies introduces some uncertainty over how consistent this effect is. We could not find evidence that a short-term educational intervention led to improvements in usage. Cognitive behavioural therapy led to the largest increases in average machine usage, partly because more participants were prepared to try out the treatment. Studies generally recruited CPAP naive patients whose sleep apnoea was severe. Trials in patients who have struggled to persist with treatment are required, as there is currently little evidence in this population. This could make a valuable contribution to our understanding of the complex relationship between initial motivation, ongoing perception of benefit and long-term health benefits.
My patient is currently being seen by my colleagues in psychiatry and psychology for claustrophobia. They are teaching him various relaxation techniques as well as putting him on medication... Counseling is also being provided and is on-going.
As to the various mask sizes and nasal pillow, unfortunately all have been tried without any success. the moment he puts on anything over his face/ nose he starts hyperventilating and becomes very anxious. He will almost immediately pull the mask/nasal pillow off.
Every patient is different, indeed. It takes time to get the best outcomes when the situation is complex, as mentioned. A sleep medicine center has a psychologist/psychiatrist for complicated cases.
That is the best we can do, according to guidelines. Follow-up is mandatory in order to increase the long term compliance.
Check the pressure level ( titulation PSG) and a lot of continous education of the patient. Monitoring of use by checking reading cards.
Interesting thread!
CPAP acceptance: I believe it is very important to educate the patient about the disease. Show the patient detailed information from the study, especially diagrams and when possible video. Explain how the airway collapses. I agree with Ed Grandi that interface match is fundamental and that an in lab titration is the optimal way to get a patient "fitted" with best PAP option.
At the same time the approach to OSA should not be a "one size fits all". Just because CPAP can stabilize the airway does not mean every patient can or even should accommodate to this major habit modification. To change human behavior is one of the most difficult goals to achieve.
Appropriate therapies must be selected and matched to the patient, including PAP, oral appliance therapy, targeted upper airway surgery by an expert, weight loss and exercise. I know a number of physicians, including sleep physicians who when diagnosed with OSA quickly sought alternatives to PAP...
I must reply on the topic of sleep apnea surgery as well, being a sleep apnea surgeon...
1. LAUP is not generally recommended for the treatment of OSA due to state data on effectiveness.
2. Surgery is NOT just for mild OSA for several reasons. There are studies showing AHI severity is not related to successful outcome.
More importantly, think about who needs treatment: A mild OSA patient by AHI with mild symptoms or a patient with severe OSA by AHI, hypoxemia, hypersomnia, who has failed CPAP? The severe patient clearly needs treatment and even if surgery results in mild OSA persistence, the patient has improved status.
3. Surgery is not necessarily a short term treatment. I admit long term data is sparse but not absent. For example see "15-year efficacy of uvulopalatopharyngoplasty..." by Browaldh (PMID: 22074106).
4. Surgery for OSA is not UPPP. Surgery is site-directed and can includes many different procedures including palatopharyngoplasty. Shortening of the soft palate is not the goal of treatment, but rather expansion of the airway in the coronal and saggital airway through tissue rearrangement and judicious tissue removal.
To Ann Chong. You may wish to consider for your claustrophobia patient a visor style interface, for example FIT-Life interface from Respironics . The unobstructed view of this type of interface has been effective in some of my claustrophobic patients.
I do not have any ties to Respironics.
Dear Professor Jacobowitz,
Excellent overview!
Thank you for your clear recommendation regarding site-directed surgery in OSA.
Stefan
Thank you Prof Jacobowitz for a very enlightening solution. I have not been made aware of the FIT-Life interface because the claustrophobic patient had tried out the CPAP from another manufacturer.
I shall certainly try to contact Respironics to enquire about the interface "device".
You may also want to use the insomnia severity index, epworth sleepiness scale (ESS) , and general anxiety to get a better profile the patient. From what I've read those with high anxiety scores will tend to have more difficulty with PAP. It has been reported that many as 50% of OSA patients have comorbid insomnia, so CBT-I in conjunction with PAP may be beneficial. Especially trying to get PAP use up to 4 hrs if there is comorbid sleep maintenance insomnia. Those with higher ESS may likely perceive a more dramatic treatment effect which will provide positive reinforcement for PAP use.
Some patients have benefitted by using a dental appliance with CPAP
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