WHEN CPAP DOESN'T WORK: WHAT DO YOU DO NEXT? WHY DO ORAL APPLIANCES MAKE PATIENTS FEEL BETTER?

MANY PATIENTS COMPLAIN THAT THEIR CPAP DOESN'T WORK BUT THAT IS USUALLY NOT THE CASE. THE CPAP DOES USUALLY FIX THE SLEEP APNEA BUT IT OFTEN LEAVES THE PATIENT STILL TIRED. THERE ARE TIMES THERE MAY BE A PROBLEM WITH RESTLESS LEGS OR OTHER PROBLEMS DISTURBING SLEEP. IF A PATIENT IS STILL TIRED EVEN WITH CPAP AN MSLT OR A MWT TEST CAN BE GIVEN TO DETERMINE HOW MUCH OF A PROBLEM THE TIREDNESS IS BASED ON OBJECTIVE FINDINGS.

AN INTERESTING PHENOMENA IS THAT PATIENTS OFTEN FEEL BETTER WITH ORAL APPLIANCE THERAPY EVEN THOUGH OBJECTIVELY IT APPEARS LESS EFFECTIVE THAN CPAP. POSSIBLE EXPLANATIONS ARE THAT THE CPAP DISRUPTS THE SLEEP OR THAT IT HAS BEEN OVERTITRATED AND IS CAUSING CENTRAL SLEEP APNEA OR THERE MAY BE BREAKTHRU CENTRAL APNEA.

THESE EXPLANATIONS STILL DO NOT EXPLAIN WHY SOME PATIENTS FEEL SO MUCH BETTER WITH APPLIANCE THERAP THAN WITH CPAP. A POSSIBLE EXPLANATION IS THAT THE SLEEP APNEA APPLIANCE IS ACTUALLY NOT JUST MAINTAINING AN OPEN AIRWAY BUT ALSO TREATING AN UNDERLYING TMJ DISORDER. CHRONIC TIREDNESS IS ASSOCIATED WITH TMD DISORDERS AND THE NHLBI CONSIDERS SLEEP APNEA TO BE A TMJ DISORDER. THE NHLBI REPORT http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf IS A MUST READ FOR ANYONE HAVING PROBLEMS WITH RESIDUAL TIREDNESS WHILE USING CPAP.

ANOTHER REASON PATIENTS FEEL TIRED WITH CPAP USE IS THAT THEY JUST DO NOT WEAR IT ENOUGH HOURS A NIGHT. CPAP USERS AVERAGE ONLY 4-5 HOURS A NIGHT OF CPAP USE. THE MAJORITY OF PATIENTS DO NOT USE CPAP AT ALL AFTER TIME. THERE IS A GROUP OF PATIENTS WHO WEAR THEIR CPAP ALL NIGHT EVERY NIGHT SO THE 4-5 HOURS AVERAGE MEAN MANY PATIENTS USE IT SIGNIFICANTLY LESS THAN 4 HOURS.

ANOTHER PROBLEM IS SIMPLE SLEEP RESTRICTION. MANY PATIENTS ONLY SET ASIDE 5-6 HOURS A NIGHT FOR SLEEP, NOT NEARLY ENOUGH AND THEREFORE THEY ARE STILL TIRED.