Sleep Watch
For people diagnosed with sleep apnea, never has getting a good night's sleep been more important. Characterized by brief interruptions of breathing during sleep, sleep apnea affects as many as 18 million Americans, according to the American Association of Respiratory Care. AARC estimates that as many as 10 million remain undiagnosed.
Left untreated, sleep apnea can cause many alarming health problems, including high blood pressure, heart attacks and strokes. Yet patients diagnosed with sleep apnea do not always comply with their doctor's orders. The American Academy of Family Physicians claims that up to 50 percent of patients will not wear continuous positive airway pressure (CPAP) devices — the most common, effective treatment for sleep apnea — for an adequate period each night. In addition, many patients stop treatment within the first two to four weeks, estimates Postgraduate Medicine.
Compliance has many obvious benefits for a patient, including the reduction of health risks, a higher quality of life, fewer visits to a physician over time and reduced medical costs. To help consumers achieve compliancy, many industry professionals are tapping new technology, better education and increased patient care.
Join the Club
In some areas of life, going against the grain can create unfathomable success, but being a non-conformist with sleep apnea can be deadly. In fact, the risk of long-term mortality increases for patients that have 20 or more respiratory events per hour during sleep testing, cites the American Academy of Family Physicians. Since patients with sleep apnea typically stop breathing as many as 30 times or more each night, according to AARC, those odds are not worth taking.
Sleep apnea is as common as diabetes, according to the National Institutes of Health, with equally dangerous side effects. Up to 50 percent of those with sleep apnea also have high blood pressure, according to the National Sleep Foundation, and the Mayo Clinic claims that the risk of developing high blood pressure may increase by as much as three times that of someone without sleep apnea.
"There's a direct correlation between time spent with educating the patient and their CPAP compliance." — Tom Smalling, MS, RRT, RPFT, RPSGT |
The list of side effects for sleep apnea is a long one and includes heart attacks, strokes, learning and memory problems, weight gain, impotency, depression, irritability and headaches. What's more, sleep apnea can have a negative effect on a patient's daily life, resulting in job impairment and motor vehicle crashes. Both the National Sleep Foundation and AARC said that sleep apnea patients are three times more likely to have automobile accidents.
Because the common type of sleep apnea, obstructive sleep apnea, is caused by an obstruction in the air passage, usually from the collapse of soft tissue in the rear of the throat, breathing becomes ineffective. As oxygen levels in the lungs decrease, carbon dioxide levels in the blood increase. It is well-documented that oxygen deprivation has a number of physical effects that figure into cardiovascular disease. The cellular lining of blood vessel walls, which helps give vessels the elasticity to regulate blood pressure, can be damaged. Also platelet count, clot-forming blood cells, increases, which may result in heart and blood vessel disease, cites the Mayo Clinic.
Admitting There's a Problem
Patients are not usually the first to spot a problem. A spouse or bed partner notices it first. The reason is that the brain only wakes a person just enough to restart breathing. Patients often wake with a gasp or choking sound, which may disrupt a bed partner's sleep, but do not become fully alert or awake themselves.
AARC projects that 4 percent of men and 2 percent of women have sleep apnea. Overweight men between the ages of 30 and 50 are at the greatest risk for sleep apnea. The propensity for men to have sleep apnea is higher because male hormones can cause structural changes in the upper airway. Weight gain, on the other, explained Tom Smalling, a clinical assistant professor at Stony Brook University's Respiratory Care Program in New York, can significantly narrow the airway.
"When you add weight onto your body, you don't just add weight to the outside. Fatty tissue is added onto the inside. So, patients that gain a lot of weight will also gain fatty tissue on the inside. And then what that does is build up the fatty tissue on the inside of the throat and ultimately narrow the airway."
The AARC concurs that patients with a larger neck are at risk. Because obesity is a common factor, African-Americans, who are typically more overweight than Caucasians, are at an even greater risk, cites the American Lung Association. The lung association also states that in the period between 1986 and 1998, the number of overweight children increased by more than 120 percent among African-Americans and more than 50 percent among Caucasians. In addition, a University of California at San Diego study found that 17 percent of African-Americans had sleep apnea compared to 8 percent of Caucasians.
"Obesity is on the rise, has always been," said Smalling. "It's basically an epidemic."
While symptoms may vary, some tell-tale signs of sleep apnea include:
- Loud Snoring, which can also be a warning sign of hypertension, according to the Mayo Clinic
- Choking sensations
- Excessive daytime sleepiness
- Early morning headache
- Restless sleep
- Poor memory and concentration
- Irritability or a change in personality
- Frequent urination during the night
- Observed episodes of interrupted breathing during sleep
Sleep apnea can occur in those who don't meet the ideal profile, however.
"We always think of the patient, the typical sleep patient, as one who's male, typically overweight, in their 40s or 50s, three chins, really thick neck, and that's not always the case," said Smalling. "You get a wide range of patients. I had a Hispanic patient last week. He was in his 20s, thin, he was in the ideal body weight category and he had apnea."
Physical abnormalities in the nose, throat or other part of the upper way, such as enlarged tonsils or adenoids, a narrow throat or a receding chin, also can cause sleep apnea. A genetic link has not been proved, but sleep apnea seems to run in the family, according to the National Sleep Foundation. Other lifestyle factors may put people at risk for sleep apnea, including smoking, which causes inflammation, swelling and narrowing of the upper airway; and excessive use of alcohol or sedative drugs, which relax the muscle system in the surrounding upper airway.
Obstructive sleep apnea is the most common form of sleep apnea, but patients can also have a rare form called central sleep apnea. Central sleep apnea, resulting from neurological disorders and congestive heart failure, is a condition in which the brain fails to signal the muscles to breathe. Internal Medicine explained that this type is generally caused by head injury or stroke. In rare cases, patients may have both obstructive and central sleep apnea.
Preventing a Relapse
Though many treatments of sleep apnea can ease the side effects of the disorder, non-invasive CPAP devices produce the most effective results. In fact, it is the first line of treatment, said Smalling. A CPAP device weighs about 5 lbs. and fits on a bedside table. A patient wears a mask, containing a tube that connects to the machine, over the nose during sleep and a steady supply of air travels through the tube and applies sufficient air pressure through the nasal passages to prevent tissues from collapsing during sleep. When the use of CPAPs is suspended, episodes return.
Common Complaints and Strategies to Improve Compliance
In addition to being safe for all ages, asserts the University of Maryland Medical Center, CPAP devices restore normal sleep patterns, increase alertness, decrease daytime sleepiness, anxiety and depression, resulting in a better mood, improvements in work productivity, better concentration and memory and fewer accidents; improve heart function and rate; benefit in hypertension and heart failure; decrease frequency of morning headaches; reduce abdominal fat even without weight loss; and have a modest effect on the lungs. In summary, use of a CPAP device can give a patient back his or her life.
A 2005 study by St. Vincent's University Hospital in Dublin, Ireland, found that patients treated with CPAPs had significantly fewer cardiovascular disease-related deaths and events than untreated patients.
Despite the ease and benefits of treatment, many patients refuse to wear CPAP masks, thereby putting themselves at great risk. Some common complaints by CPAP wearers include nasal irritation, drying and congestion; mask discomfort, including facial skin irritation and abrasions; abdominal bloating; mask leaks; sore eyes; headaches and conjunctivitis (redness and discharge surrounding the eye). The University of Maryland Medical Center estimates that all patients complain of at least one side effect and nearly half of those complaints are regarding the mask.
Smalling agreed that most patients complain that the mask is too uncomfortable, but they don't realize that many different masks are available that may be more comfortable than the one being used.
Using new technology and increasing a patient's understanding of the proper use of CPAP devices are the best ways to increase compliance. An American Academy of Family Physicians' study in February 2002 showed that free CPAP devices, extensive education, and follow-up with regular feedback to both patients and physicians achieved a substantial compliance rate. In fact, a PubMed study revealed that only education and humidification proved to increase compliancy and indicated that video education, in particular, that covered the misconceptions of sleep apnea and perceived barriers to CPAP use increased compliance.
Technology has introduced alternatives to encourage compliance. These devices are quieter, better designed and better able to adapt to patients' needs as far as airflow requirements are concerned, explained Smalling. Bi-level positive airway pressure machines or bi-PAP devices, for example, reduce the airflow during exhalation. For a patient who has very high CPAP pressure, said Smalling, it becomes a problem exhaling against that force of air. Lowering the expiratory pressure on a bi-level machine will help those patients breathe out. The bi-level is not the first treatment of choice, however.
"We've seen over time it's become standard practice that bi-level has been used as the rescue therapy for non-compliant CPAP patients," said Jeff Maglin, the product manager for sleep therapy at Respironics Inc., the company that manufactured the first commercial CPAP device in 1985 and also introduced the bi-level machine.
Another device called a smart or auto-PAP regulates air flow based on indicators from the patient during sleep and is generally used on a temporary basis. Auto-titrating technologies provide fixed pressure at both inhalation and exhalation, explained Maglin, but automatically adjust the pressure settings up or down based on patient respiratory events.
"If it's sleep apnea or hyponea, it basically will raise the pressure, and when it's sensing that the patient is breathing normally, it will try to find a more optimal pressure by lowering the pressure," he said.
Respironics also introduced C-flex technology in November of 2002, which reduces the amount of pressure at the beginning of exhalation, when breathing out is most difficult for a patient, and returns to the set pressure by the end of exhalation, said Maglin. A June 2005 study by the journal Chest indicated that after three months, patients using C-flex technology complied with CPAP therapy on average one hour and 42 minutes more per night than patients using standard CPAP devices.
Compliance data tracking devices have been very effective in monitoring consumer compliance. These devices record if the machines are turned on, how long the machines are on and whether or not a patient has used the device. These devices can also help health care providers identify specific patient issues by tracking how many events are occurring during the night and helping to identify system leaks that can cause patient difficulty, said Maglin. Smalling explained that in the past, patients could lie about CPAP use, but these devices make that impossible because the machines can't lie.
Listening to patients and proper follow-up is also essential to increase compliancy. "There's a direct correlation between time spent with educating the patient and their CPAP compliance," said Smalling.
Also Sleep Quest reports that compliancy increases dramatically with high quality patient training, education, communication and follow-up. The American Academy of Family Physicians also states that the short-term nightly use of more than 90 percent can be achieved when close follow-up is provided by a nurse skilled in CPAP use.
"Physicians definitely don't have the time," said Smalling, regarding follow-up. "So it basically falls onto technologists educating the patient when they come in for their titration and when they leave that morning. The other educator is probably the home care company, which would come in and set the equipment up."
Smalling recommended that home care companies start a follow-up program to check on compliancy. "You can get some patients that want to use the device, they get the thing set up at home, and three months later you call them, which is really too late. You want to call them a couple of days after they've got it set up, a week after and then space it out."
With the proper follow-up, common complaints can be addressed with new technology. Mask irritation and leaking is rectified by simply choosing a comfortable, well-fitting mask. Claustrophobia can be eased by using a nasal prong or a nasal pillow. Those who prefer to breathe through their mouth benefit from full-face masks. If patients complain of no affect in sleepiness after a period of time, airflow pressure may not be high enough and patients may require retesting or retitrating, says the University of Maryland Medical Center.
"Do you ever hear of those commercials for the Sleep Number beds — everyone has a different number? It's basically similar to the CPAP machine in that everyone's airway is a different size. There's different mechanisms within the airway and outside the airway, weight being one of them, all different factors that affect that collapsing," said Smalling.
Patient motivation is key. Encouraging patients to get involved with a local support group can go a long way toward ensuring compliance. Smalling said that support groups, such as A.W.A.K.E., have show to be very effective in increasing compliance.
Behavioral treatment in conjunction with CPAP use can also help. Lifestyle changes such as dieting (even losing 10 lbs. can help with sleep apnea), cutting back on alcohol or sedatives and trying different sleeping positions such as on the side or elevating the head are great ways to reduce the symptoms of sleep apnea.
National Sleep Awareness Week
Finally a Good Night's Sleep
Though recent studies suggest that about one-third of patients give up treatment, the numbers are climbing due to better technology and education. Specifically, patient education, support groups, dedicated follow-up, particularly in the first two weeks, and ready access to technologists that can make adjustments as needed significantly improved compliance.
"Definitely one thing that's helped tremendously has been the decrease in the sound output of the machine. I mean, earlier machines sounded like air conditioners. I've been to conferences in the last couple of years where they've turned on these machines and I'm like, 'Is it on?' You can feel the air coming out of the hose but you can't hear the thing," said Smalling.
Maglin asserts that future devices must appeal to the patient's senses and also address issues of acceptance and tolerance to therapy.
One undeniable truth is when patients use their CPAP machines on a regular basis, their condition is managed and they get the sleep they need.
It is important to stay tuned in to the changing needs of patients over time. The American Academy of Family Physicians says that CPAP pressure requirements may change over longer periods, especially as patients age or if there is a significant weight increase or reduction.
"I think also people tend to want instant gratification," said Smalling. "As part of my educating the patient, I say, 'You have to use this machine.' And they say, 'Well, how often should I use it?' And I say, 'Every day.' And I tell them it's like birth control. I say, 'You can't just use it whenever you want. It won't work. With a CPAP machine, you have to use it every day because the benefits are cumulative.' "
Products to Encourage Compliance
National Sleep Awareness Week
National Sleep Awareness week is slated for March 27-April 2, 2006. The awareness week coincides with the change to Daylight Savings Time when clocks "spring ahead" and we all lose a valuable hour of sleep. Thursday, March 31, 2006, is Sleep Apnea Awareness Day. The National Sleep Foundation and the American Sleep Apnea Association join forces to get people to focus on this serious sleep disorder.
Products to Encourage Compliance
Pillow
The unique shape of
Sleep Posture Inc.'s Sleep Posture Pillow prevents sleeping on the back and stomach and increases air flow.
Alarm
Innovative Sleep Solutions' SLEEPTRACKER® monitors sleep patterns to detect the best possible wake-up times through a pre-set alarm window.
CPAP System
Respironics' REMstar Pro 2 captures enhanced compliance data (AHI, leak and snoring) with the Encore® Pro SmartCard® and data management software.
Nasal Mask
Puritan Bennett's Dream Fit™ Nasal Mask's unique bellows chamber swivels between mask and interface to help prevent leaks.
CPAP system
ResMed's S8 Elite™ is a lightweight, travel-friendly all-in-one CPAP system available with fully integrated humidification.
This article originally appeared in the October 2005 issue of HME Business.