Adherence to CPAP Improves Quality of Life, Oral Appliances are as Effective as CPAP but show Higher Compliance.

A recent study in Sleep and Breathing Journal,"Adherence to CPAP therapy improves quality of life and reduces symptoms among obstructive sleep apnea syndrome patients"showed significant improvement in patients who used CPAP for 6 months.

A more careful look at the study also shows the major problem with CPAP.

This study looked at 50 patients, 41 men and 9 women who were "compliant" with CPAP usage. This means that they wore CPAP an average of 4-5 hours/night. It is well established that 7-7.5 hours/night is ideal CPAP usage. Standardized tests showed subjective improvement in quality of life but a large group of patients still reported "excessive fatigue" (54.5%), and "decreased energy" (55.3%).

The real danger to using CPAP for 4-5 hours a night is the risk of cardiovascular events including heart attack and stroke. Patients with untreated sleep apnea have an enormous and dangerous increased risk of myocardial infarction and cerebral vascular accidents in the early morning hours, usually between 3 and 5 AM. Patient who wear CPAP for only 4-5 hours are no longer utilizing it during the hours of greatest risk!

The danger of unacceptably low CPAP use (4-5 hours /night) was well documented by an article in Sleep (2011 Jan 1;34(1):105-10.) "Reliable calculation of the efficacy of non-surgical and surgical treatment of obstructive sleep apnea revisited."

The article concludes "Using a mean AHI in CPAP therapy is more realistic than using arbitrary compliance rates, which, in fact, hide insufficient reductions in AHI." Clearly stating 4-5 hour compliance is a poor measure of success.

Compare this information to a recent article in Chest (2011 Jun 2) "Efficacy of An Adjustable Oral Appliance and Comparison to Continuous Positive Airway Pressure For the Treatment of Obstructive Sleep Apnea Syndrome." Where they found high effectiveness of Oral Appliances. Oral Appliances are utilized by most patients for the entire night.





Sleep Breath. 2011 Jun 11. [Epub ahead of print]
Adherence to CPAP therapy improves quality of life and reduces symptoms among obstructive sleep apnea syndrome patients.
Avlonitou E, Kapsimalis F, Varouchakis G, Vardavas CI, Behrakis P.
Source

Sleep Laboratory, Henry Dunant Hospital, Athens, Greece.
Abstract
PURPOSE:

The aim of the study was to asses quality of life and symptoms of obstructive sleep apnea syndrome (OSAS) patients after adhering to 6 months of continuous positive airway pressure (CPAP) treatment.
METHODS:

A group of 50 patients (41 men and 9 women) were diagnosed by polysomnography and treated with CPAP therapy for 6 months. Their symptoms and health-related quality of life were assessed by administering a validated and translated version of the sleep apnea quality of life index (SAQLI). Sleepiness was measured using the Epworth Sleepiness Scale (ESS) and through electronic monitoring of CPAP usage per night of sleep.
RESULTS:

Mean CPAP usage was 4.5 ± 0.5 h per night. Comparisons between quality of life indexes before and after CPAP treatment showed an improvement in the total SAQLI score (3.8 ± 0.9 vs. 5.8 ± 0.8 after CPAP, p < 0.01), in daily functioning (4.2 ± 1.4 vs. 6.0 ± 0.9, p < 0.01), social interactions (4.8 ± 1.3 vs.6.3 ± 0.7, p < 0.01), emotional functioning (4.4 ± 1.4 vs. 5.7 ± 1.0, p < 0.01), symptoms (1.6 ± 0.8 vs. 5.8 ± 1.2, p < 0.01), and in the ESS (13.7 ± 6.5 vs. 3.9 ± 3.8, p < 0.01). Regarding the patients' symptoms, improvement was noticed for "sleepiness while watching a spectacle" (96%), "reading" (95%), "carrying on a conversation" (95%), "driving" (92.9%), "restless sleep" (87.8%), and "urinating more than once per night" (84.8%). Smaller improvements were observed for the reported "dry mouth-throat upon awakening" (36.1%),"excessive fatigue" (54.5%), and "decreased energy" (55.3%).
CONCLUSION:

We conclude that OSAS patients who adhere to nighttime CPAP therapy show significant improvement of their quality of life, daytime sleepiness, and other symptoms after 6 months of treatment with CPAP. The article explains mathematically the problems of considering 4-5 hours as "success. "The more severe the AHI, the more percentage of total sleep time (TST) CPAP must be used to significantly reduce the AHI. Patients with moderate OSA reduce the AHI by 33.3% to 48.3% when using CPAP 4 h/ night (AHI 0-5, respectively). The required nightly percentage use rises as one reduces the AHI target to < 5. CPAP must be used 66.67% to 83.33% per night to reduce the AHI below 5 (AHI of 0 while using CPAP). By using these definitions most CPAP usage of 4-5 hours a night is actually only partial treatment leaving the patient at risk.



Sleep. 2011 Jan 1;34(1):105-10.
Reliable calculation of the efficacy of non-surgical and surgical treatment of obstructive sleep apnea revisited.
Ravesloot MJ, de Vries N.
Source

Sint Lucas Andreas Ziekenhuis, Department of Otolaryngology/Head Neck Surgery, Amsterdam, the Netherlands. m.ravesloot@slaz.nl
Abstract
BACKGROUND:

Various treatment methods exist to treat obstructive sleep apnea (OSA); continuous positive airway pressure (CPAP) is considered the gold standard. It is however a clinical reality that the use of CPAP is often cumbersome. CPAP treatment is considered compliant when used ≥ 4 h per night as an average over all nights observed. Surgery, on the other hand, is regarded as successful when the apnea hypopnea index (AHI) drops at least 50% and is reduced below 20/h postoperatively in patients whose preoperative AHI was > 20/h. The effectiveness of CPAP compliance criteria can be questioned, just as the effectiveness of surgical success criteria has often been questioned.
STUDY OBJECTIVES:

The aim of the study was to compare non optimal use of optimal therapy (CPAP) with the continuous effect (100%) of often non optimal therapy (surgery).
DESIGN:

Using mathematical function formulas, the effect on the AHI of various treatment modalities and their respective compliance and success criteria were calculated.
RESULTS:

The more severe the AHI, the more percentage of total sleep time (TST) CPAP must be used to significantly reduce the AHI. Patients with moderate OSA reduce the AHI by 33.3% to 48.3% when using CPAP 4 h/ night (AHI 0-5, respectively). The required nightly percentage use rises as one reduces the AHI target to < 5. CPAP must be used 66.67% to 83.33% per night to reduce the AHI below 5 (AHI of 0 while using CPAP).
CONCLUSION:

Using a mean AHI in CPAP therapy is more realistic than using arbitrary compliance rates, which, in fact, hide insufficient reductions in AHI.

PMID:
21203364
[PubMed - indexed for MEDLINE]
PMCID: PMC3001787
[Available on 2011/7/1]

Chest. 2011 Jun 2. [Epub ahead of print]
Efficacy of An Adjustable Oral Appliance and Comparison to Continuous Positive Airway Pressure For the Treatment of Obstructive Sleep Apnea Syndrome.
Holley AB, Lettieri CJ, Shah AA.
Source

Pulmonary, Critical Care, and Sleep Medicine, Walter Reed Army Medical Center.
Abstract
BACKGROUND:

We sought to establish the efficacy of an adjustable oral appliance (aOA) in the largest patient population studied to date, and provide a comparison to CPAP.
METHODS:

Retrospective analysis of patients prescribed an aOA. Results of overnight, PSG with aOA titration were evaluated and compared to CPAP. Predictors of a successful aOA titration were determined using a multivariate logistic regression model.
RESULTS:

A total of 497 patients were prescribed an aOA during the specified time period. The aOA reduced the mean AHI to 8.4±11.4, and 70.3%, 47.6%, and 41.4% of patients with mild, moderate, and severe disease achieved an AHI<5, respectively. Patients using an aOA decreased their mean Epworth Sleepiness Score (ESS) by 2.71 (95% CI: 2.3-3.2; p<0.001) at follow-up. CPAP improved the AHI by - 3.43 (95% CI: 1.88-4.99; p<0.001) when compared to an aOA, but when adjusted for severity of disease, this difference only reached significance for patients with severe disease (-5.88 (95% CI: -8.95 - -2.82; p<0.001)). However, 70.1% of all patients achieved an AHI < 5using CPAP, compared to 51.6% for the aOA (p<0.001). On multivariate analysis, baseline AHI was a significant predictor of achieving an AHI < 5 on aOA titration, and age showed a trend toward significance.
CONCLUSIONS:

In comparison to past reports, more patients in our study achieved an AHI < 5 using an aOA. The aOA is comparable to CPAP for patients with mild disease, while CPAP is superior for patients with moderate to severe disease. A lower AHI was the only predictor of a successful aOA titration.

I NEED HELP WITH MY CPAP MASK!

TOM:

I NEED HELP WITH MY CPAP MASK. I HAVE TRIED SEVERAL BUT HAVE CONTINUOUS PROBLEMS WITH LEAKS AND DRY EYES. THE NASAL PILLOWS WERE AN IMPROVEMENT OVER THE NASAL MASK FOR A WHILE BUT THE QUIT WORKING. I AM NOW USING A FULL FACE MASK WHICK IS OK ON SOME NIGHTS BUT I FEEL WORSE THAN I DID BEFORE CPAP. MY DOCTOR TOLD ME I AM NOT A CANDIDATE FOR AN ORAL APPLIANCE BECAUSE MY APNEA IS SEVERE. I QUIT BREATHING 50 TIMES AN HOUR. I USUALLY MANAGE TO GET AN HOUR OF TWO OF SLEEP BEFORE I GIVE UP ON IT. HELP!

DR SHAPIRA RESPONSE: Tom, I understand your frustration and I commend you on your efforts to comply with treatment. 60% of patients give up on CPAP and that is very dangerous. I suggest that you get a copy of your sleep study and contact a dentist who is experienced in treating sleep apnea. Oral appliances are a comfortable alternative to CPAP and are a first line choice for treatment of mild to moderate sleep apnea according to the American Academy of Sleep Medicine. They are an acceptable alternative to CPAP for severe sleep apnea when patients do not tolerate or want CPAP treatment.

I advise you to continue to use your CPAP with your appliance until after a sleep study show the it is effective. Recent studies have shown that properly titrated appliances are as effective as CPAP and can be used for severe apnea in many patients. It is vital that a titration sleep study be done to find the ideal position to maintain an open airway.

An appliance that is not properly adjusted is a "POP" or piece of plastic not an effective treatment unless your problem is a congenital lack of plastic.

I frequently see patients who say they tried an appliance and it didn't work. This is usually because the dentist did not choose the right appliance or properly adjust it for effective treatment. Their is both art and science to the field of Dental Sleep Medicine. Many doctors take a single course from a manufacturer of appliances and only have one tool in their belt. When I teach my courses I purposely limit class size to six dentists and their teams to insure that each dentist has a comprehensive understanding of sleep medicine and the role of the dentist. It is also important to understand the basic principles and how different anatomy may demand different types of appliances. I do have my favorits based of effectiveness.

I am frequently asked by dentists what is the best oral appliance. The answer is that it depends on many factors and different appliance are best for different patients.

Surgery is also an option for treating sleep apnea but is no longer considered a first line treatment because of high morbidity and poor results. I stronly suggest you avoid soft palate surgery ie UP3, LAUP, Somnoplasty, Pillars. Tongue reduction is a more useful surgery but can be brutal. If contemplating base of tongue surgery somnoplasty is a good choice but several procedures will probably be necessary. Nasal surgery can be helpful but is rarely a cure. It can make both oral appliance therapy and CPAP more effective and comfortable and can improve your quality of life if you live with chronic impaired breathing 24/7.

Bimaxillary advancement or madibular advancement or chin advancement can be very effective but a trial with an oral appliance is recommended prior to surgery to determine the amount of advancement that is necessary. You do not want to go thru traumatic surgery and still need CPAP afterwards.

If you are in the midwest, Illinois or Wisconsin feel free to see me in Chicago, Gurnee, Skokie, Vernon Hills or Schaumburg.
Good Luck Tom

What do patients feel about wearing an oral appliance vs CPAP?

I just received a e-mail from a patient who recently switched to a comfortable oral appliance from CPAP. I think he clearly stated the answer to how comfortable an oral appliance is so I copy and pasted his answer below.

Niiiiiiiiiicccceee!

Why do patients abandon CPAP? They appreciate the benefits but dislike the mask, hose and entire CPAP set-up. Give most patients an appliance and they blown away by how small and non intrusive appliances are. This is especially true for patients who feel claustrophobic when using CPAP. Some patient may feel a little claustophobic with an appliance initially but it is rare. Patients who switch from CPAP to appliance therapy tend to agree with Gene, ie Niiiiiiiiiicccceee!

BiPAP, ramping, APAP, humidification, heated CPAP hoses all increase the comfort of the patient using CPAP but none of these statistically increase compliance.

The best method of increasing compliance in non-compliant CPAP users is to offer a more comfortable treatment alternative. Oral Appliances are not perfect but the have a 90+% compliance. This is especially impressive because there is an adverse selection of patients, ie, those who have already failed another treatment.

Studies have shown the huge ajority of patients offered a choice between CPAP and Oral Appliances chose the appliance.

Oral APPLIANCES AND NASAL CPAP ARE EQUAL IN EFFECTIVENESS ACCORDING TO NEW ARTICLE IN RESPIRATION.

A recent article " Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial" in Respiration compared oral appliance therapy and nasal CPAP therapy in treating mild to moderate sleep apnea. The article looked at carefully controlled studies in which both the CPAP and the oral appliances were carefully titrated. The article concluded that "There is no clinically relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objectively."

It is important to note that the article clearly states that treatment is equal when there is objective titration of the oral appliances. I have strongly been recommending titration on all oral appliance therapy for over ten years. This is trtuly a landmark study because while CPAP has always been considered "the gold standard for treatment of sleep apnea" that statement is no longer true for mild to moderate sleep apnea.

This study did not cover severe sleep apnea therefore CPAP is still considered the gold standard of treatment for severe sleep apnea and oral appliances are an alternative for patients who do not tolerate CPAP.

The major problem with CPAP has always been low compliance. A recent study showed 60% of patients do not tolerate CPAP treatment. If compliance is factored in then it is clear that oral appliances are now the "Gold Standard" of treatment for mild to moderate sleep apnea.



PubMed abstract:
Respiration. 2010 Oct 20. [Epub ahead of print]ral Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial.
Aarab G, Lobbezoo F, Hamburger HL, Naeije M.

Department of Oral Kinesiology, Academic Center for Dentistry Amsterdam, Research Institute MOVE, University of Amsterdam and VU University Amsterdam, The Netherlands.
Abstract
Background: Previous randomized controlled trials have addressed the efficacy of mandibular advancement devices (MADs) in the treatment of obstructive sleep apnea (OSA). Their common control condition, nasal continuous positive airway pressure (nCPAP), was frequently found to be superior to MAD therapy. However, in most of these studies, only nCPAP was titrated objectively but not MAD. To enable an unbiased comparison between both treatment modalities, the MAD should be titrated objectively as well. Objective: The aim of the present study was to compare the treatment effects of a titrated MAD with those of nCPAP and an intra-oral placebo device. Methods: Sixty-four mild/moderate patients with obstructive sleep apnea (OSA; 52.0 ± 9.6 years) were randomly assigned to three parallel groups: MAD, nCPAP and placebo device. From all patients, two polysomnographic recordings were obtained at the hospital: one before treatment and one after approximately 6 months of treatment. Results: The change in the apnea-hypopnea index (ΔAHI) between baseline and therapy evaluation differed significantly between the three therapy groups (ANCOVA; p = 0.000). No differences in the ΔAHI were found between the MAD and nCPAP therapy (p = 0.092), whereas the changes in AHI in these groups were significantly larger than those in the placebo group (p = 0.000 and 0.002, respectively). Conclusion: There is no clinically relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objectively.

Copyright © 2010 S. Karger AG, Basel.
PMID: 20962502 [PubMed - as supplied by publisher]

Occupational Medicine And Sleep Apnea Treatment. Creating a Safe and Healthy Workplace.

This blog entry is a a reprint of a recent press release about Slee Apnea and Occupational Medicine

Occupational Medicine is acutely aware of the importance of Sleep Apnea Treatment. Occupational Medicine Physicians recognize that poor CPAP compliance is a major problem for patients health and workplace safety.

A recent article "Obstructive Sleep Apnea Syndrome (OSAS): The role model of the Occupational Health Physician in specific clinical cases." (see PubMed abstract below) in Clin Ter. 2010 May-Jun;161(3):269-72 recognizes the importance of sleep apnea treatment in optimal health and as an ntegral part of Occupational Medicine.

The article states " they ( sleep apnea) are involved in reduction of working performances and increased risk of work accidents". Successful treatment is extremely important and CPAP is failing in that role. CPAP is extremely successful when it is used but recent studies show 60% of patients abandon CPAP use completely and even those patients who use CPAP average only 4-5 hours of daily use.

Oral Appliances are accepted by the American Academy of Sleep Medicine as a first line approach to treatment of mild to moderate sleep apnea. Dr Ira L Shapira a Chicago Dentist and Diplomate of the American Board of Dental Sleep Medicine has created the website http://www.ihatecpap.com to spread the word about Dental Sleep Medicine and about comfortable Oral Appliances that most patients prefer to CPAP.

Dr Shapira treats patients in Chicago, Chicago Suburbs, Northern Illinois and Southern Wisconsin. He works with accredited sleep labs across the Chicago metropolitan area.

Patients who desire oral appliance therapy should contact Dr Shapira at 1-8-NO-PAP-MASK OR THRU HIS WEBSITES.
http://www.chicagoland.ihatecpap.com/
http://www.delanydentalcare.com/sleep_apnea.html
http://WWW.IHATECPAP.COM
http://www.IHATEHEADACHES.org

Sleep apnea is a serious disease that can severely endanger your health and the safety of your workplace. CPAP while effective fails the majority of patients. Oral Appiances may be the first line treatment best accepted by patients with mild to moderate sleep apnea.

Clin Ter. 2010 May-Jun;161(3):269-72.
[Obstructive Sleep Apnea Syndrome (OSAS): The role model of the Occupational Health Physician in specific clinical cases.]
[Article in Italian]

Proietti L, Sciacchitano C, Strano S, Scifo N, Rapisarda V.

Dipartimento di Medicina Interna e Patologie Sistemiche, Sezione Medicina del Lavoro, Università degli Studi di Catania, Italia. proietti@unict.it
Abstract
Nowadays Sleeping disorders are a very interesting topic in Occupational medicine, they are involved in reduction of working performances and increased risk of work accidents (in work environment or while driving). Medical surveillance made from the Occupational Health Physician can be very helpful in early diagnosis of this kind of disease; during 2008 we fi nd out Obstructive Sleeping Apnea Disease (OSAS) in some Healthcare workers. We reported some clinical cases that show the role model of the occupational health physician in this kind of sickness. Our Experience shows the duty of Occupational health physician it's not limited to medical surveillance, but also to Health Promotion (as wrote in D.Lgs 81/08). This can be obtained by clinical and occupational solutions, like correct work shift planning and lifestyle changes; so the interest of the occupational physician have to be focused on introducing in medical surveillance also measures of health promotion regarding sleep disorders with the aim of preserving health condition in workers.

PMID: 20589361 [PubMed - in process]

Dr Shapira is the founder of I HATE CPAP LLC that promotes awareness of the dagers of sleep apnea and value of Dental Sleep Medicine.

Dr Shapira is a Diplomate of the American Board of Dental Sleep Medicine and founder of Chicagoland Dental Sleep Medicine Associates. He is a former Assistant Professor at Rush Medical School's Sleep center and has been involved in research and treatment of sleep apnea with oral appliances since the early 1980's. Dr Shapira also founded I HATE Headaches LLC and the website www.ihateheadaches.org. He has several device and/or method patents on collection of stem cells from the jaws and developing wisdom tooth buds.

Dr Shapira is the Dental Section Editor of Sleep and Health Journal and has chaptered a chapter in a bmedical textbook on Anti-Aging Medicine.

Delany Dental Care was founded in 1984 as a general dental practice with special emphasis on treating sleep apnea, snoring, headaches, migraines and Temporomandibular (TMJ) disorders.

American Acaemy of Dental Sleep Medicine Meeting in San Antonio

I am attending the AADSM in San Antonio Texas this weekend. I spend way too much time on continuing education but I will pass on new information that is relevant to my readers.

As I reported a compliance device for oral appliances was shown at the trucking and sleep apnea meeting last month in Baltimore. Being able to measure compliance is the last piece needed to make dental sleep medicine overtake CPAP as the "Gold Standard"

While not perfect oral appliances are preferred by the majority of patients offered a choice of CPAP or Oral Appliances.

Please watch for posts on new developments in Dental Sleep Medicine.