Does My Patient Have Sleep Apnea?
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Although snoring, obesity, and sleepiness are the classic clues pointing toward OSA, clinical studies have shown that they explain only a minority of the risk. In other words, one cannot rely on the classic "Pickwickian" presentation to identify occult OSA in clinical practice. The Epworth Sleepiness Scale correlates so weakly with OSA severity that it should not be used as a screening tool. In fact, many patients with severe OSA (up to half!) have no symptoms of sleepiness by subjective report or even objective testing in the lab.
Given the uncertainties linking symptoms and disease presence, it may be useful to keep in mind other clues. Some of the best predictors of OSA risk are co-morbidities. Cardiac and neurological disorders in particular have been associated with increased risk. Click here for a list of disorders associated with increased prevalence of OSA.
Given the uncertainties linking symptoms and disease presence, it may be useful to keep in mind other clues. Some of the best predictors of OSA risk are co-morbidities. Cardiac and neurological disorders in particular have been associated with increased risk. Click here for a list of disorders associated with increased prevalence of OSA.
Central and Complex Apnea
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Although most apnea is of the obstructive type, some patients exhibit features suggestive of altered respiration control mechanisms. Although both central and obstructive apnea involve recurrent pauses in breathing, the distinguishing observation is persistent breathing effort in obstructive apnea, which is absent during central apnea. Central sleep apnea can be seen in heart failure, in certain neurological disorders, and it can also be idiopathic.
Many patients have a mixture of obstructive and central features on their PSG. Complex apnea refers to the emergence or worsening of central apnea with delivery of positive airway pressure - even if the events initially appear obstructive in nature pre-treatment. Complex apnea is increasingly recognized, and risk factors include cardiac and neurological disorders. Opiate use, including methadone and suboxone, has been associated with complex apnea. The treatment of choice for complex and/or central apnea is known as adaptive servoventilation or ASV.
Many patients have a mixture of obstructive and central features on their PSG. Complex apnea refers to the emergence or worsening of central apnea with delivery of positive airway pressure - even if the events initially appear obstructive in nature pre-treatment. Complex apnea is increasingly recognized, and risk factors include cardiac and neurological disorders. Opiate use, including methadone and suboxone, has been associated with complex apnea. The treatment of choice for complex and/or central apnea is known as adaptive servoventilation or ASV.
Managing CPAP Treatment
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Interpreting the Machine’s Data Card
Modern machines track not only usage patterns, but also aspects of breathing, including mask leak and frequency of obstructions that are occurring. The data is either kept on a card in the machine, which can be mailed to the home care provider for analysis, or in some machines an internal modem can upload the data at any time. This data is an important adjunct to treatment for two reasons. First, some patients feel dramatic improvement in sleepiness or other symptoms once they start wearing the mask at home, yet the efficacy is incomplete. The data card in that case may provide actionable information (the patient may need a pressure change or repeat titration for example). Second, some patients feel no symptomatic benefit despite wearing the mask. In this case, it is critical to establish that the machine is in fact controlling their apnea. If the machine shows good control and adequate usage, then it may be necessary to look for other causes of the symptoms (mood, thyroid, PLMS, etc), or consideration can be given to the "treatment resistant sleepiness" phenomenon. Finally, for patients who are stable users of PAP therapy, but have encountered a change such as return of symptoms, mask intolerance, etc - the first step is often to check a data card for potential clues.
Modern machines track not only usage patterns, but also aspects of breathing, including mask leak and frequency of obstructions that are occurring. The data is either kept on a card in the machine, which can be mailed to the home care provider for analysis, or in some machines an internal modem can upload the data at any time. This data is an important adjunct to treatment for two reasons. First, some patients feel dramatic improvement in sleepiness or other symptoms once they start wearing the mask at home, yet the efficacy is incomplete. The data card in that case may provide actionable information (the patient may need a pressure change or repeat titration for example). Second, some patients feel no symptomatic benefit despite wearing the mask. In this case, it is critical to establish that the machine is in fact controlling their apnea. If the machine shows good control and adequate usage, then it may be necessary to look for other causes of the symptoms (mood, thyroid, PLMS, etc), or consideration can be given to the "treatment resistant sleepiness" phenomenon. Finally, for patients who are stable users of PAP therapy, but have encountered a change such as return of symptoms, mask intolerance, etc - the first step is often to check a data card for potential clues.
Mask fittings
For patients who have discomfort or leakage, the first step is often to undertake a mask fitting session to optimize the interface. This can be done either through the home care company providing the equipment (by faxing them a script for "mask fitting"), or it can be done by appointment at the Wyndham Sleep Lab at MGH, by contacting our office.
Adverse reactions to PAP
Although uncommon, adverse reactions to occur in some patients. Skin irritation or breakdown can occur, especially if the mask is not properly fitted or is too tight. Air-swallowing (aerophagia) can occur, which results in a bloating feeling in the morning - in this case, treating GERD and lowering the pressure may be helpful. For some patients, the humidification setting is either "rain" or "dessert". Usually, simple adjustments can be made to the degree of humidity in patient-controls on the machine. For those with dry mouth despite maximal settings, the humidification may be broken (for example, if the water level has not declined over the night), or in some cases the bedroom is cool enough to cause condensation in the tubing (in this case, adding an insulation wrap may be helpful, as well as placing the machine/hose at the level of the bed and avoiding "uphill" problem of the machine being placed on the floor).
For patients who have discomfort or leakage, the first step is often to undertake a mask fitting session to optimize the interface. This can be done either through the home care company providing the equipment (by faxing them a script for "mask fitting"), or it can be done by appointment at the Wyndham Sleep Lab at MGH, by contacting our office.
Adverse reactions to PAP
Although uncommon, adverse reactions to occur in some patients. Skin irritation or breakdown can occur, especially if the mask is not properly fitted or is too tight. Air-swallowing (aerophagia) can occur, which results in a bloating feeling in the morning - in this case, treating GERD and lowering the pressure may be helpful. For some patients, the humidification setting is either "rain" or "dessert". Usually, simple adjustments can be made to the degree of humidity in patient-controls on the machine. For those with dry mouth despite maximal settings, the humidification may be broken (for example, if the water level has not declined over the night), or in some cases the bedroom is cool enough to cause condensation in the tubing (in this case, adding an insulation wrap may be helpful, as well as placing the machine/hose at the level of the bed and avoiding "uphill" problem of the machine being placed on the floor).
Alternatives to PAP
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There are many alternatives to wearing a mask. Surgical options are provided by otolaryngologists (ENT) and oral surgeons. As it is sometimes difficult to predict who will benefit from these invasive options, it is important to have a consultation with the surgical specialists to review each case. Dental specialists use special mouth-guards that are custom designed to protrude the bottom jaw forward, which opens the airway during sleep.
Conservative measures include weight loss and "positional" therapy. Although it is true that obesity is a major contributor to sleep apnea, it is one of many factors. Thus, pursuing weight loss as the sole intervention should be carefully reviewed with your doctor. For patients with mild apnea, it may be reasonable to pursue a 6-month weight loss plan for example, and then repeat the apnea testing to determine any benefits. However, for the patient with severe apnea, it may be more sensible to begin treatment concurrently with weight loss efforts.
Positional therapy involves using one or more devices to avoid sleeping on one's back. About half of patients with sleep apnea will have substantially more apnea while on the back, compared to sleeping on the side. Vests and shirts for this purpose have something bulky on the back to discourage rolling onto the back. Wedge pillows and "maternity" pillows can also be used. Although these options may sound appealing for some patients, it is challenging to monitor the effectiveness in the home, and several clinical studies have not been optimistic, and thus positional therapy should be used only in select circumstances.
Breathe-right strips, nasal sprays, chin straps, and the like are not considered effective in isolation for treating sleep apnea, but they can be combined with other techniques. For example, nasal congestion can make it difficult to tolerate wearing the mask, and thus managing congestion with nasal spray can be helpful. Similarly, patients who use a nasal mask but open their mouths during sleep may benefit from a chin strap.
Conservative measures include weight loss and "positional" therapy. Although it is true that obesity is a major contributor to sleep apnea, it is one of many factors. Thus, pursuing weight loss as the sole intervention should be carefully reviewed with your doctor. For patients with mild apnea, it may be reasonable to pursue a 6-month weight loss plan for example, and then repeat the apnea testing to determine any benefits. However, for the patient with severe apnea, it may be more sensible to begin treatment concurrently with weight loss efforts.
Positional therapy involves using one or more devices to avoid sleeping on one's back. About half of patients with sleep apnea will have substantially more apnea while on the back, compared to sleeping on the side. Vests and shirts for this purpose have something bulky on the back to discourage rolling onto the back. Wedge pillows and "maternity" pillows can also be used. Although these options may sound appealing for some patients, it is challenging to monitor the effectiveness in the home, and several clinical studies have not been optimistic, and thus positional therapy should be used only in select circumstances.
Breathe-right strips, nasal sprays, chin straps, and the like are not considered effective in isolation for treating sleep apnea, but they can be combined with other techniques. For example, nasal congestion can make it difficult to tolerate wearing the mask, and thus managing congestion with nasal spray can be helpful. Similarly, patients who use a nasal mask but open their mouths during sleep may benefit from a chin strap.