Overweight and are unwilling or unable to use CPAP: Learn about new study

The majority of patients are unable to use CPAP and oral appliances are usually the single best treatment. Katy McNulty has informed me of a free study for overweight patients unable or unwilling to utilize CPAP. The study is done in Atlanta but you do not need to live in Atlanta. Morbid obesity is a contraindication to a comfortable oral appliance but merely being overweight is common and oral appliances are usually a comfortable and effective alternative to CPAP.

Please mention I HATE CPAP if you contact Katy and send me your feedback.

STUDY INFORMATION FOLLOWS:

We are conducting a clinical trial in Atlanta that your audience might find interesting. It's for people who are overweight and are unwilling or unable to use CPAP. I pasted the link to the study information below.

http://www.atlantasleep.com/osaovw

	Katy	McNulty
Contact Email:		kmcnulty@neurotrials.com
Contact Phone:		404-851-9934

Why CPAP is not effective in treating resistant hypertension. Does CPAP fail to reduce stroke risk and myocardial risk?

I have reviewed several article recently on why CPAP doesn't seem overly helpful in treating hypertension. A new article in Sleep Medicine Review "A systematic review of CPAP adherence across age groups: Clinical and empiric insights for developing CPAP adherence interventions." clearly explains why CPAP is ineffective intreatment of hypertension. IT ISN'T USED or it isn't used enough. The article clearly states "Continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA) but adherence to the treatment limits its overall effectiveness across all age groups of patients", in simple English, CPAP does not work because CPAP is not used!

Numerous studies have shown low CPAP compliance with only 23-42% of patients utilizing CPAP and a recent study showed 60% quit CPAP completely.

CPAP SUCCESS IS DESCRIBED AS USING CPAP 4-5 NIGHTS FOR 4-5 HOURS A NIGHT, THIS TYPE OF SUCCESS CAN KILL YOU OR LEAD TO CARDIOVASCULAR ACCIDENTS AND STROKES. More importantly this horrendous description of success lulls cardiologists into a false sense of security with treatment.

Studies have shown that most heart attacks and strokes occur between 3-5 AM. The typical patient only wears their CPAP for 4-5 hours/ night. Patients who go to sleep with their CPAP at 10 PM and wear it 4-5 hours will be untreated during the critical hours of 3-5 AM.

It is time for the sleep community to recognize that part-time CPAP use can result in deadly outcomes. An article in the Journal of Human Hypertension "Resistant hypertension, obstructive sleep apnoea and aldosterone." state that "CPAP studies do, however, indicate a wide variation in the BP effects of CPAP, with some patients manifesting a large antihypertensive benefit such that a meaningful BP effect can be anticipated in some individuals. OSA is particularly common in patients with resistant hypertension (RHTN)" The wide variation is likely based on CPAP use. CPAP used 4 hours a night is at best 50% effective, and totally ineffective during times of highest risk.

Treatment of Obstructive Sleep Apnea is essential for many reasons. A recent study showed that oral appliances and CPAP are equivlant when objectively titrated. Oral appliances show much higher compliance than CPAP in both time of use and frequency of use. This could correct hormonal changes that occur due to sleep disruption.

"Diagnosis and treatment of primary aldosteronism" is an article published in
Endocrinology Metabolism Clinics of North America (2011 Jun;40(2):313-32) states that "A few simple rules can allow physicians to successfully identify many patients with arterial hypertension caused by PA among the so-called essential hypertensive patients. The hyperaldosteronism and the hypokalemia can be cured with adrenalectomy in practically all of these patients.

The removal of the adrenal gland may cure the hypertension but the cause of adrenal excess is obstructive sleep apnea that is not effectively treated due to short time use of CPAP.

IF PATIENTS ARE NOT RESOLVING HYPERTENSION PROBLEMS AN ORAL APPLIANCE TRIAL SHOULD PRECEDE ADRENALECTOMY.

Many sleep physicians are "married" to CPAP and their blinders make them declare 70-90% success rates in their patients even though objective studies show that their success is due not to high patient compliance but rather success described as 4-5 hours of use.

Cardiologists, endocrinologists and vascular surgeons need to demand higher levels of success from the sleep community. Unfortunately CPAP is the fiscal engine that drives much of sleep medicine. The elimination of stage 4 sleep from sleep reports was due to the inability of CPAP to return a normal Delta Sleep percentage. Research at University of Chicago showed that Growth Hormone is produced during the first period of Delta Sleep as a quick example. Dumbing down of sleep medicine is inexcusable. Currently Sleep Labs Accredited by the AASM are not even allowed to break Slow Wave sleep into stage 3 and 4.


Sleep Med Rev. 2011 Jun 6. [Epub ahead of print]
A systematic review of CPAP adherence across age groups: Clinical and empiric insights for developing CPAP adherence interventions.
Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE.
Source

University of Pennsylvania School of Nursing, Biobehavioral Health Sciences Division, USA; Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA.
Abstract

Continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA) but adherence to the treatment limits its overall effectiveness across all age groups of patients. Factors that influence adherence to CPAP include disease and patient characteristics, treatment titration procedures, technological device factors and side effects, and psychological and social factors. These influential factors have guided the development of interventions to promote CPAP adherence. Various intervention strategies have been described and include educational, technological, psychosocial, pharmacological, and multi-dimensional approaches. Though evidence to date has led to innovative strategies that address adherence in CPAP-treated children, adults, and older adults, significant opportunities exist to develop and test interventions that are clinically applicable, specific to sub-groups of patients likely to demonstrate poor adherence, and address the multi-factorial nature of CPAP adherence. The translation of CPAP adherence promotion interventions to clinical practice is imperative to improve health and functional outcomes in all persons with CPAP-treated OSA.

Copyright © 2011 Elsevier Ltd. All rights reserved.

J Hum Hypertens. 2011 Jun 9. doi: 10.1038/jhh.2011.47. [Epub ahead of print]
Resistant hypertension, obstructive sleep apnoea and aldosterone.
Dudenbostel T, Calhoun DA.
Source

Vascular Biology and Hypertension Program, Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA.
Abstract

Obstructive sleep apnoea (OSA) and hypertension commonly coexist. Observational studies indicate that untreated OSA is strongly associated with an increased risk of prevalent hypertension, whereas prospective studies of normotensive cohorts suggest that OSA may increase the risk of incident hypertension. Randomized evaluations of continuous positive airway pressure (CPAP) indicate an overall modest effect on blood pressure (BP). Determining why OSA is so strongly linked to having hypertension in cross-sectional studies, but yet CPAP therapy has limited BP benefit needs further exploration. The CPAP studies do, however, indicate a wide variation in the BP effects of CPAP, with some patients manifesting a large antihypertensive benefit such that a meaningful BP effect can be anticipated in some individuals. OSA is particularly common in patients with resistant hypertension (RHTN). The reason for this high prevalence of OSA is not fully explained, but data suggest that it may be related to the high occurrence of hyperaldosteronism in patients with RHTN. In patients with RHTN, it has been shown that aldosterone levels correlate with severity of OSA and that blockade of aldosterone reduces the severity of OSA. Overall, these findings are consistent with aldosterone excess contributing to worsening of underlying OSA. We hypothesize that aldosterone excess worsens OSA by promoting accumulation of fluid within the neck, which then contributes to increased upper airway resistance.Journal of Human Hypertension advance online publication, 9 June 2011; doi:10.1038/jhh.2011.47.

PMID:
21654850
[PubMed - as supplied by publisher]

Prog Cardiovasc Dis. 2009 Mar-Apr;51(5):371-80.
Sleep apnea, aldosterone, and resistant hypertension.
Pimenta E, Calhoun DA, Oparil S.
Source

Department of Hypertension and Nephrology, Dante Pazzanese Institute of Cardiology, Sao Paulo, SP, Brazil. espimenta@hotmail.com
Abstract

Obstructive sleep apnea, aldosterone excess, and resistant hypertension are common comorbidities in obese patients. The mechanisms that link these conditions are not fully elucidated, but sympathetic nervous system activation, sodium retention, renin-angiotensin-aldosterone system stimulation, endothelial dysfunction, and increased production of reactive oxidative species may be contributing factors. Patients diagnosed with this triad should be treated with low-salt diet, weight-loss counseling, and continuous positive airway pressure, as well as aggressive antihypertensive therapy, usually with multiple agents, including a mineralocorticoid receptor antagonist. Patients with aldosterone-producing adenoma may require adrenalectomy.

PMID:
19249443
[PubMed - indexed for MEDLINE]

Endocrinol Metab Clin North Am. 2011 Jun;40(2):313-32.
Diagnosis and treatment of primary aldosteronism.
Rossi GP.
Source

Molecular Hypertension Laboratory, Dipartimento di Medicina Clinica e Sperimentale (DMCS) 'G. Patrassi' - Internal Medicine 4, University of Padua, University Hospital Padua, Via Giustiniani, 2, 35126 Padua, Italy.
Abstract

Moreover, in a substantial proportion of them, the blood pressure can be normalized or markedly lowered if a unilateral cause of PA is discovered. Hence, the screening for PA can be rewarding both for the patient and for the clinician, particularly in those cases where hypertension is severe and/or resistant to treatment, in which the removal of an APA can allow blood pressure to be brought under control despite withdrawal of, or a prominent reduction in, the number and doses of antihypertensive medications.

Copyright © 2011 Elsevier Inc. All rights reserved.

PMID:
21565669
[PubMed - in process]

Can Carbon Dioxide help treat central and mixed sleep apnea? Should CO2 be added to CPAP Flow to Treat Central Sleep Apnea & Cheyne-Stokes Breathing?

Patients with central and mixed sleep apnea are different than obstructive sleep apnea patients. There has been work done with increased dead space in CPAP units and addition or carbon dioxide to treat central sleep apnea and Cheye-Stokes breathing. It is actually a build-up in CO2 that cause awakening and breathing in all apnea patients.

If Carbon Dioxide can be judiciously supplied to these patients it could solve the problems of central sleep apnea and emerging central apnea in patients treated with CPAP or Oral Appliances.

It may also explain why appliances like the TAP that limit opening seem more effective in some patients than Herbsts, Suad,, or Somnomed appliances. Appliances that allow easier oral opening and breating are more likely to have decreased CO2 levels.

Remember, it is the rise in CO2 (carbon dioxide) that turns on the drive to breathe.

OBESITY A PROBLEM? YOUR ANSWER CAN COME TO YOU IN YOUR SLEEP.

A new article "Chronic intermittent hypoxia caused by obstructive sleep apnea may play an important role in explaining the morbidity-mortality paradox of obesity." in Medical Hypothesis (abstrct below) may explain the problems of morbidity and mortality related to obesity. Obesity has become pandemic according to the article and "threatens the health of millions of people and is associated with numerous morbidities such as hypertension, type II diabetes mellitus, dyslipidemia, cor pulmonale, gallbladder disease, obstructive sleep apnea (OSA), certain cancers, osteoarthritis, increased surgical risk and postoperative complications, lower extremity venous and/or lymphatic problems, pulmonary embolism, stroke/cerebrovascular diseases and coronary arterial disease"

The article sttes that it may be the repetitive intermittent hypoxia from sleep apnea that is responsible for the adverse health effects of obesity.

TREATMENT OF SLEEP APNEA HAS BEEN SHOWN TO HELP A WIDE ASSORTMENT OF MEDICAL CONDITIONS ASSOCIATED WITH OBESITY. UNFORTUNATELY MOST PATIENTS DO NOT TOLERATE CPAP. IN PATIENTS THAT DO NOT TOLERATE CPAP ORAL APPLIANCES MAY BE A LIFE-SAVING THERAPY.

Med Hypotheses. 2010 Sep 3. [Epub ahead of print]

Ozeke O, Ozer C, Gungor M, Celenk MK, Dincer H, Ilicin G.

Bayindir Hospital Sogutozu, Department of Cardiology, Ankara, Turkey.
Abstract
Obesity has reached global pandemic that threatens the health of millions of people and is associated with numerous morbidities such as hypertension, type II diabetes mellitus, dyslipidemia, cor pulmonale, gallbladder disease, obstructive sleep apnea (OSA), certain cancers, osteoarthritis, increased surgical risk and postoperative complications, lower extremity venous and/or lymphatic problems, pulmonary embolism, stroke/cerebrovascular diseases and coronary arterial disease. Despite all these adverse associations, numerous studies and meta-analyses have documented an "obesity paradox" in which overweight and obese population with established cardiovascular disease have a better prognosis than do their lean counterparts. There are potential and plausible explanations offered by literature for these puzzling data; however, it still remains uncertain whether this phenomenon is attributable to a real protective effect of high body fat mass. In recent years, the survival advantage of patients with OSA, combined with the potential cardioprotective effects of chronic intermittent hypoxia, raise the possibility that apneas during sleep may activate preconditioning-like cardioprotective effect. Chronic intermittent hypoxia, one of the physiological markers of OSA, is characterized by transient periods of oxygen desaturation followed by reoxygenation, and is a major cause of its systemic harmful (oxidative stress, inflammation, sympathetic activity, vasculature remodelling and endothelial dysfunction) and/or protective (preconditioning-like cardioprotective) effects. Since many OSA subjects are obese, and obesity is an independent risk factor for many comorbidities associated with OSA; and also most OSA has never been diagnosed in obese patients, we hypothesed that the chronic intermittent hypoxia caused by OSA in obese patients may be one of the underlying mechanisms in morbi-mortality paradox of obesity.

PMID: 20822856 [PubMed - as supplied by publisher]

CPAP FAILURE: Recent article discusses surgical options.

A recent article (abstract below) discusses surgical options for treating sleep apnea in patients who do not tolerate CPAP. The author states " Uvulopalatopharyngoplasty is still the standard procedure for many patients with moderate OSA" This statement is untrue and dangerous. Numerous studies have shown minimal reduction in apnea from UP3 surgery, high morbidity and most patients still need CPAP or oral appliances.

AVOID UVULOPALTOPHARYNGEALPLASTY AS A FIRST LINE TREATMENT OF APNEA!

Patients who undergo UP3 surgery first are more likely to have problems with velo-insufficiency related MaxilloMandibular Advancement surgery which according to the author "is as effective as CPAP in severe OSA"

The author also stated "Tonsillectomy and maxillomandibular advancement may be offered as a first-line treatment in certain patients."

Again probably poor advice in most adults. The exception may be the patient with a severely recessive maxilla and mandible. In general, Maxillomandibular advancement should usually be preceded by oral appliance therapy to find an effective position of the jaw to eliminate apnea before doing surgery.

Tonsilectomy is a first line treatment for pediatric apnea but new studies show it should usually be done in conjunction with maxillary expansion.

The author never mentioned oral appliance therapy, but many physicians arre still taking the ostrich approach to oral appliances. Pretend it doesn't exist and it will go away.

Curr Opin Pulm Med. 2010 Sep 14. [Epub ahead of print]

Surgical treatment of obstructive sleep apnea: standard and emerging techniques.
Maurer JT.

Department of Otorhinolaryngology, Sleep Disorders Center, University Medicine Mannheim, Medical Faculty Mannheim of the Ruprecht-Karls-University Heidelberg, Mannheim, Germany.

Abstract
PURPOSE OF REVIEW: Patients with obstructive sleep apnea (OSA), as well as their physicians, seek alternative therapies to continuous positive airway pressure (CPAP) due to problems with CPAP adherence. A large variety of surgical options exist, and each intervention must be individually evaluated. The author performed a literature search concerning surgery for sleep apnea until May 2010. The studies were evaluated according to evidence-based medicine criteria.

RECENT FINDINGS: An increasing number of controlled and even randomized controlled trials are available. Minimally invasive surgery remains under debate due to the very limited efficacy versus very low morbidity. Uvulopalatopharyngoplasty is still the standard procedure for many patients with moderate OSA, whereas maxillomandibular advancement is as effective as CPAP in severe OSA. Multilevel surgery is reserved to secondary treatment after CPAP failure. Tonsillectomy and maxillomandibular advancement may be offered as a first-line treatment in certain patients. There is increasing evidence that upper airway surgery has a positive impact on arterial hypertension, markers of cardiovascular disease, insomnia, daytime symptoms, quality of life, and CPAP adherence.

SUMMARY: Patients who are nonadherent to CPAP must be thoroughly evaluated before choosing any of the available surgical options. Upper airway surgery may improve disease markers of OSA, if appropriately chosen and properly indicated and performed.

PMID: 20842037 [PubMed - as supplied by publisher]

IS INSOMNIA A RISK FACTOR FOR POOR CPAP COMPLIANCE? THIS IS PROBABLY THE CASE ACCORDING TO AN ARTICLE IN SEPTEMBER SLEEP MEDICINE.

THIS ARTICLE IN SLEEP MED SEES LOW ADHERENCE TO CPAP AS A SERIOUS PROBLEM AND A "significant challenge for sleep medicine clinicians". THIS STUY FOUND THAT PATIENTS WITH PRE-TREATMENT COMPLAINTS OF INSOMNIA AS MEASURED BY " Difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening". THE STUDY FOUND THAT "sleep maintenance insomnia displayed a statistically significant negative relationship with average nightly minutes of CPAP use (p<.05) as well as adherence status as defined by the Centers for Medicaid and Medicare Services (p<.02)."

PATIENTS WITH COMPLAINTS OF INSOMNIA, PARTICULARLY SLEEP MAINTENANCE INSOMNIA MAY NOT BE GOOD CANDIDATES FOR CPAP TREATMENT. ORAL APPLIANCES ARE AN EXCELLENT ALTERNATIVE TO CPAP FOR PATIENTS WITH SLEEP MAINTENANCE INSOMNIA.

Sleep Med. 2010 Sep;11(8):772-6. Epub 2010 Jul 31.
Sleep maintenance insomnia complaints predict poor CPAP adherence: A clinical case series.
Wickwire EM, Smith MT, Birnbaum S, Collop NA.

Center for Sleep Disorders, Pulmonary Disease and Critical Care Associates, Columbia, MD 21044, USA. ewickwire@pulmdocs.com
Abstract
BACKGROUND: Although CPAP is a highly efficacious treatment for obstructive sleep apnea (OSA), low adherence presents a significant challenge for sleep medicine clinicians. The present study aimed to evaluate the relationship between insomnia symptoms and CPAP use. We hypothesized that pre-treatment insomnia complaints would be associated with poorer CPAP adherence at clinical follow-up.

METHODS: This was a retrospective chart review of 232 patients (56.5% men, mean age=53.6+/-12.4years) newly diagnosed with OSA (mean AHI=41.8+/-27.7) and prescribed CPAP in the Johns Hopkins Sleep Disorder Center. Difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening were measured via three self-report items. CPAP use was measured via objective electronic monitoring cards.

RESULTS: Thirty-seven percent of the sample reported at least one frequent insomnia complaint, with 23.7% reporting difficulty maintaining sleep, 20.6% reporting early morning awakening and 16.6% reporting difficulty initiating sleep. After controlling for age and gender, sleep maintenance insomnia displayed a statistically significant negative relationship with average nightly minutes of CPAP use (p<.05) as well as adherence status as defined by the Centers for Medicaid and Medicare Services (p<.02).

CONCLUSIONS: To our knowledge, these are the first empirical data to document that insomnia can be a risk factor for poorer CPAP adherence. Identifying and reducing insomnia complaints among patients prescribed CPAP may be a straightforward and cost-effective way to increase CPAP adherence.

PMID: 20673741 [PubMed - in process]

Respiratory Care Article Details Problems with CPAP Adherence.

The Respiratory Journal looks at problems related to CPAP adherence. The September 2010 article states "Adverse effects such as nasal congestion, dry mouth, or skin irritation occur in approximately 50% of CPAP users" These side effects are only a few of the problems patients experience that lead to CPAP non-compliance. There are many advances in CPAP treatment that have little effect for most patients on CPAP success. The article states "The use of sophisticated therapy modalities such as auto-titration or bi-level PAP units has been shown to improve adherence in certain subsets of OSA patients" but other research shows little change in CPAP compliance rates. The problems associated with CPAP are the reasons so mmany patients exclaim "I HATE CPAP!".

What kind of patient does not do well with CPAP? The article further states " though a search for consistent predictive factors related to CPAP adherence has proven elusive. Other influences, such as sex, age, socioeconomic status, and personality traits are less robust predictors." In essence all types of patients in every category do not tolerate or adhere to CPAP treatment.

Cpap is a very effective treatment but it is not the best sleep apnea treatment for those patients who do not use it. A recent study showed 60% of patients abandon CPAP. In other words when compliance is factored in the majority of patients are not helped by CPAP'

Dental Sleep Medicine and Oral Appliances may be the best sleep apnea treatment for the majority of patients. Even though they may not be as effective as CPAP they are far more effective than no treatment.

Cardiologists recognize that "the undertreated OSA patient at risk of development or worsening of comorbid medical conditions, including hypertension and cardiovascular disease.". They are also aware of the poor compliance that plagues CPAP.

The concerned and informed cardiologists are now recognizing that CPAP is a dismal failure for the majority of sleep apnea patients and are starting to refer more patients for oral appliance therapy. When patients lives are at stake there must be alternatives to CPAP offered to the patients who do not tolerate CPAP. Regardless of the effectiveness of CPAP it is a worthless treatment if it is not used.

Dental Sleep Medicine offers life-changing alternatives to CPAP to cardiac patients who do not tolerate CPAP.

Respir Care. 2010 Sep;55(9):1230-9.
Encouraging CPAP Adherence: It Is Everyone's Job.
Bollig SM.

Hays Medical Center-Sleep and Neurodiagnostic Institute, 2500 Canterbury Drive, Suite 108, Hays KS 67601. suzanne.bollig@haysmed.com.
Abstract
Obstructive sleep apnea (OSA) is a chronic disease treated effectively with the use of continuous positive airway pressure (CPAP) therapy. Patient adherence to prescribed CPAP is variable, however, leaving . The severity of disease and the presence of daytime sleepiness appear to have some predictive quality for subsequent adherence, though a search for consistent predictive factors related to CPAP adherence has proven elusive. Other influences, such as sex, age, socioeconomic status, and personality traits are less robust predictors. The use of sophisticated therapy modalities such as auto-titration or bi-level PAP units has been shown to improve adherence in certain subsets of OSA patients. Adverse effects such as nasal congestion, dry mouth, or skin irritation occur in approximately 50% of CPAP users, and addressing these adverse effects may improve adherence in some patients. More encouraging, studies on the use of intensive patient education and behavioral interventions have shown more positive effects on adherence, leading to the conclusion that improvement in patient adherence to CPAP therapy requires a multi-layered approach, using combined technological, behavioral, and adverse-effect interventions.

PMID: 20800003 [PubMed - in process]

Lexi has left a new comment on your post "New Medicare Guidelines for CPAP":

We are currently doing research on CPAP compliance and Medicare converage. However, I cannot find a Medicare definition of CPAP Compliance. Could you please tell me where you found this information where Medicare defined CPAP compliance as, "at least 4 hours a night and wear CPAP 70% of the time for a 30 consequtive day period"?

Thank you in advance,
Alexia Adams

Dear Lexi,
I cannnot reply directly as you did not leave an e-mail address

This is from ResMed "CONTINUED COVERAGE BEYOND THE FIRST THREE MONTHS OF THERAPY:
Continued coverage of a PAP device (E0470 or E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy,
documentation of clinical benefit is demonstrated by:
Face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of obstructive sleep apnea are improved; and,
Objective evidence of adherence to use of the PAP device reviewed by the treating physician.
*************
********Adherence to therapy is defined as use of PAP > 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.
If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as not medically necessary.
Beneficiaries who fail the initial 12 week trial are eligible to requalify for a PAP device but must have both:
Face-to-face clinical re-evaluation by the treating physician to determine the etiology of the failure to respond to PAP therapy; and,
Repeat sleep test in a facility-based setting (Type 1 study)." It came from
http://www.resmed.com/us/dealers/reimbursement/cpap.html?nc=dealers
For more info use Google search "medicare cpap coverage minimal usage for coverage" it was hard to find, I know it from many different sources.

Medicare has issued these new rules because they are tired for paying for CPAP that is not used. Statistics show only 60% of patients use CPAP long term and the fact that 4 hours a night is not acceptable treatment but it is certainly better than no treatment. Sleep Apnea is a dangerous and serious condition and most heart attacks and strokes are in the early morning hours when patients have abandoed their CPAP.

Dr Shapira

Dr Shapira

Why Don't Sleep Doctors, Sleep Centers, Sleep Techs and DME's tell patients that CPAP fails most patients?

A Recent John Hopkins University study published in August 2009 in PloS Medicine has indicated that snoring with severe obstructive sleep apnea doubles the chance of premature deaths in men aged 40 to 70 years. PloS Medicine is a peer-reviewed open-access journal published by the Public Library of Science.

This is not new information but just another study showing the severe risks associated with untreated sleep apnea. Other facts are that patients with untreated sleep apnea have a six fold increase in motor vehicle accidents and they are more likely to die in their sleep that while exercising.

I see so many patients who are not being treated for sleep apnea because they hate CPAP or could not deal with problems associated with CPAP use. The Sleep Centers, Doctors , Sleep Techs and DME companies that fail to refer patients for alternative therapies must bear the brunt of responsibility. 60 % of patients abandon CPAP use but there is no concerted effort to refer them for oral appliances.

The real question is why aren't more patients referred for appliance therapy.

I think ignorance is the primary cause, many sleep professionals are unaware of the high success rates of oral appliances, and some just do not know much at all. There is a subgroup that has vested interests in CPAP prescriptions. The sleep centers are often own DME companies, Sometimes the doctor's wife or children own the DME company. I do not find this to be a problem as long as patients who do not tolerate CPAP are then referred for oral appliances or surgical intervention.

I have patients tell me that they are made to feel like it is their failure when they can't tolerate CPAP. They are not told the the majority of patients are CPAP intolerant and/or fail CPAP. CPAP is a excellent treatment for a significant number of patients with very high eficacy, unfortunately more patients fail with CPAP then succeed.

It is the makers or CPAP, Distributors and DME companies and all sleep professionals to honestly explain to patients that the majority of patients never learn to tolerate CPAP and to help them find alternative treatments.

Insurance companies are probably most at fault because they share a common interest with patients. Finding alternative treatments for patients who fail CPAP will save insurance companies enormous amounts of future medical expenses. Insurance companies are aware that oral appliances are more expensive than CPAP in the short run but pale compared to costs for treating heart attacks or strokes. Insurance companies should review their files and identify patients prescribed CPAP who do not order additional supplies. In all likely-hood these patients are not using CPAP and therefore are at a greatly increased risk not just of cardiovascular events but also faced increased risks related to diabetes, motor vehicle accidents, and other serious medical problems.