DEFENDING THE CHARGE: I HATE CPAP! ACCUSED OF MISLEADING PATIENTS

The following response was sent to me on the I HATE CPAP site and because it was from a Registered POLYSOMNOGRAPHIC TECHNOLOGIST I felt it should be posted and responded to. I would appreciate your feedback as well.

Madeleine H RPSGT

comments : How do you address criticisms that your website and information misleads patients with moderate to severe apnea? It is well documented that oral appliances are not effective for most patients with sleep apnea. It seems you efforts would serve patients better if you helped them adjust to CPAP versus feeding anxieties around the gold standard treatment for sleep apnea.

Dear Madeleine,

I take very seriously criticisms that I mislead patients because it is not true. All of the information that is found on the I HATE CPAP site is backed by scientific evidence. The American Academy of Sleep Medicine now considers oral appliances to be FIRST LINE TREATMENT for mild to MODERATE sleep apnea along with CPAP. Further, the AASM considers oral appliances as an alternative to CPAP for patients with severe apnea who do not tolerate CPAP. It is documented that oral appliances do work for severe sleep apnea but they may not be as effective as CPAP especially in the morbidly obese., That is why it is essential that all patients receiving an oral appliance have a follow-up sleep study to insure efficacy. I have had patients with severe apnea (indexes over 100 AHI with de-sats into 50-60's) with complete response to oral appliances. I also have patients that use combinations of CPAP and appliances to lower CPAP pressure from 24 cm or more of pressure (which can damage lung alveoli) to 6-8 cm pressure by combination treatment.

I believe it is cavalier attitudes that patients need to be taught to adjust to their CPAP are more dangerous. While it is true that CPAP is considered the Gold Standard it is only because compliance is not factored into success. Published studies show that the majority of patients abandon CPAP use and even patients who use CPAP average only 4-5 hours of nightly use not the 7 1/2 hours recommended. Strokes are most common in the early morning hours with Sleep Apnea, most patients have already quit using their machines by then. There is a subgroup of patients who love their CPAP from first use and are very successful with CPAP use. That group only makes up 25% of the total population. I do not want patients who are successful and happy with CPAP to abandon it, I am more concerned with the 75% of patients who are untreated or under-treated.

I have seen thousands of patients in the last 28 years of treating sleep apnea who were only offered CPAP so chose no treatment. These untreated patients are left to suffer severe medical consequences because they are not offered alternatives they can accept.

You should seriously consider that a full night of oral appliance use is probably far superior to CPAP that is not used or only used for a couple of hours. I do not feed anxieties of patients but I do recognize them. This website took its name from what patients who came to my office told me, "I HATE CPAP!"

I do not Hate CPAP, but I offer a comfortable alternative for patients who do hate it. My goal is for every patient to know all of the options available to treat their sleep apnea including changes in health habits, cpap, oral appliances, surgery position etc.

As you are probably aware the NHLBI considers sleep apnea to be a TMJ disorder. Please read their report "CARDIOVASCULAR AND SLEEP-RELATED
CONSEQUENCES OF TEMPOROMANDIBULAR
DISORDERS" http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf

If you talk to anyone who knows CPR you will be aware that the first step is to check airway and if the patient isn't breathing the airway is opened with a jaw thrust.

Ira L Shapira DDS, D,ABDSM, D,AAPM, FICCMO

I am posting you question and my response on the I HATE CPAP blog. I will not post your full name or e-mail unless you give me permission.

Madelaine H RPGST Response: Please note that "success" in most apnea studies is defined as 50% or greater reduction in AHI. This is not the clinical definition of "success", though, even as defined by the AASM and Stanford University's suggested protocols.

While oral appliances may be helpful for some patients, I hope your organization is responsible enough to inform patients when they could benefit from cpap or bipap treatment.

Thank you for your prompt response.

I define success as an AHI under 5 and ideally "0" and no snoring. For the majority of my patients we achieve that success though we sometimes have to cheat and combine positional therapy with oral appliance therapy.

The most difficult patient for oral appliances are the morbidly obese, Cheyne Stoke Breathing and Central apnea, and patients who have had severe pharyngeal scarring after UP3 surgery.

It is important to note that to get these high success rate we usually work with sleep techs who have been taught how to titrate an appliance. Rem supine sleep with high AHI on patients who must sleep on their back can be a difficult situation. I have many patients who we try to place on CPAP who again fail. In those patients oral appliances are used to make their disease less severe. Some treatment is better than no treatment. Many appliance patients that are "merely partially improved" polysomnographically have total relief of EDS and cognitive consequences during the day.

I also hope that all those involved with patient care recognize that less than 50% of CPAP patients continue use and are responsible enough to refer those who do not use CPAP for oral appliance therapy. CPAP success is defined as 4 hour use 4 nights a week in most studies and as you say this is not clinical success. 7- 7 1/2 hours nightly is needed for full benefit.

Dr Shapira

WHILE IT IS TRUE IT IS NOT ALWAYS POSSIBLE TO ACHIEVE 100% SUCCESS IN ALL PATIENTS THE MAJORITY OF PATIENTS WITH MILD TO MODERATE APNE ASHOW EXCELLENT RESULTS WITH ORAL APPLIANCE TREATMENT. PATIENTS OFFERED A CHOICE BETWEEN ORAL APPLIANCES CHOSE AN APPLIANCE 90-95% OF THE TIME. IN SOME CASESIT IS NECESSARY TO USE CPAP OR COMBINATION THERAPY SUCH AS TAP-PAP TO ACHIEVE COMPLETE CONTROL OF SLEEP APNEA.

APPLIANCE DESIGN IS ALSO VERY IMPORTANT AS WELL AS HAVING A DOCTOR WHO CAN "TROUBLESHOOT" A PATIENT WHO HAS LESS THAN COMPLETE CONTROL OF SLEEP APNEA. IT IS VITAL TO HAVE A FOLLOW-UP SLEEP STUDY TO INSURE THAT THE MEDICAL PROBLEM IS RESOLVED. SOME PATIENTS ARE RESISTANT TO DOING A FOLLOW-UP STUDY IF THEIR SNORING IS RESOLVED AND THEIR DAYTIME SYMPTOMS RELIEVED. POLYSOMNOGRAPHY AND APPLIANCE TITRATION COMBINED WILL LEAD TO SUPERIOR RESULTS. MADELAINE IS CORRECT THAT SOME DOCTORS AND PATIENTS DO NOT TAKE THE RESPONSIBLE ROUTE OF DOING FOLLOW-UP POLYSOMNOGRAPHY WHEN TREATING SLEEP APNEA.

Tom Farrell has left a new comment on your post "DEFENDING THE CHARGE: I HATE CPAP! ACCUSED OF MIS...":

Agree with the use of oral appliances as a potential treatment for SDB. Especially think the concept of combination treatment- cpap and an oral appliance- needs further study. Great idea.

As far as I know, most sleep labs- and most of the physicians who medically direct them- are strictly cpap-oriented. But I agree that all methods of relieving SDB should be evaluated when looking at treatment options.
Second: most people may not know this, but all registered sleep techs and any and all techs working in a hospital and/or accredited sleep facility are CPR credentialed, and in some cases ACLS certified.
My best to you,

Tom Farrell, BS, RPsgT, RPFT, CRT