Snoring is a cry for help: what took the media so long to notice?

Submitted by Jerry on Mon, 10/06/2008 - 17:59

News about sleep apnea is welcome because it can encourage more people to seek treatment. Driving the news are reports of research that shows how dangerous sleep apnea really is, and findings that treatment does help. In addition, sleep can now be studied at home in addition to sleep centers, opening up the potential for treating many more people.

Sleep apnea is a major public health problem. The people who are living with sleep apnea may be the best resource for solving it--but first they need to be treated so they have the energy to be a part of the solution. The media can help teach people to recognise if they (or their bed partners) might have sleep apnea and point them to sources of help.

Thank you, Betty Ann Bowser! You are helping get some traction for the idea that snoring is a cry for help (an article I wrote in 1995). In fact, as your report notes, many people with sleep apnea come in for treatment because a spouse or partner is concerned about their snoring.

I applaud two excellent broadcasts on obstructive sleep apnea reported by Bowser that recently aired on the PBS show, Newshour with Jim Lehrer. Apnea is a major public health problem, and the Health Unit reports can give a tremendous boost to getting people diagnosed and treated. The broadcasts describe sleep apnea, mention some of the health impacts on individuals as well as public health issues, and show individuals undergoing diagnosis and treatment in the Johns Hopkins Hospital Sleep Disorders Center in Baltimore, Md. The second program, broadcast on 2 October 2008 Doctors Aim to Better Diagnose Troubling Sleep Apnea, ends with the thought that snoring, one of the symptoms of apnea, is "...not just annoying. It may be a cry for help."

Why are snoring and sleep apnea making news now?

What is driving the current news interest in sleep apnea? I suspect it is a combination of factors.

  • There is a spate of new research confirming and demonstrating the negative health impact of untreated apnea--and the benefits of treatment.
  • There is a new growth opportunity in diagnosis and treatment as home testing is accepted by insurers including Medicare and experts in sleep disorders.
  • Home testing presents a new set of challenges for traditional methods and the professional and business model of accredited sleep centers or labs. The PBS reports so far have focused on the traditional full-service sleep lab.

Research shows dangers of apnea, benefits of CPAP treatment.

Sleep relaxes the muscles of the upper airway (from the nose down to the neck and throat). As a result, the tissues of the airway may begin to flutter, causing snoring. As the lungs draw air through the airway, the tissues can be drawn together, collapse, and completely block the airway, resulting in an apnea as the flow of air is stopped. As the body struggles to breathe, the sleeper must awake to breathe and the normal stages of sleep are disrupted.

Treatment usually involves the use of a device to blow air into the nose and/or mouth to keep the airway open during sleep. A mask or some other "interface" guides the air into the patient's nose and/or mouth. This form of treatment is called CPAP for Continuous Positive Airway Pressure.

Recently published studies reinforce the idea that sleep apnea increases the risk of death and exposes people to a wide range of health problems. Sleep professionals have believed that treatment may protect against some of these problems. Treatment has been shown to reduce the risk of death related to untreated apnea. Can CPAP Save Your Life?

Home studies

After over a decade of advances in technology and clinical experience, manufacturers are now marketing devices that enable people to be evaluated for sleep apnea at home. Until now, one of the barriers to treatment of the very large population suspected to have apnea, was the fact that testing required one or two nights in a sleep lab, preferably an accredited facility. This procedure, while capable of providing detailed data on a variety of sleep disorders as well as sleep apnea, is expensive and often requires long waits.

Unfortunately, there aren't enough accredited sleep labs to handle the vast number of undiagnosed people with sleep apnea. See: Sleeping Beauty: Who Can Awaken Her? Testing at home might remove many of the barriers to treatment (time, expense). Many more people can now be evaluated. This has created a growth opportunity for manufacturers of evaluation and treatment equipment, software, and other related technologies; opportunities for providers of services including diagnostics, evaluations, and treatment; and new opportunities for primary care and other physicians to play a positive role in treating sleep disorders. There is a huge economic prize here. Insurance coverage for home studies is driven by the decisions of The Centers for Medicare & Medicaid Services (CMS). The professional standards for the appropriate use of home sleep studies/portable monitoring are defined by the Portable Monitoring Task Force of the American Academy of Sleep Medicine (AASM). Acceptance of home studies were delayed for a long time because of concerns that home studies may not be as accurate, comprehensive, and reliable as attended studies in an accredited institution, or that home studies may not be used appropriately. Also the home study movement could be a the threat to the primacy of accredited sleep labs, which had enjoyed a protected position despite the fact that this had severely limited the numbers of people with apnea that could be treated. The sleep labs will have to adjust to the new environment and develop a new role, or justify their role in providing a superior level of service. For example, a full attended polysomnogram interpreted by a board-certified expert may prove more accurate in diagnosing other sleep disorders which home studies may miss. There is also a need for better followup to cut down on the numbers of patients who have been diagnosed but abandon treatment; better methods for intervention and followup could be led by accredited sleep centers.

Treatment success and failure

The PBS report does not mention the new home study movement but does present an overview of the problems and issues in treating sleep apnea, and shows the experiences of patients in an accredited sleep center. Although the PBS report recognizes the fact that many patients do not succeed with their treatment (citing a very low success rate of 25%), the report does not deal with solutions to the problems that can cause treatment to fail.

The PBS report showed one happy, energetic patient whose life improved with therapy for his apnea. They also presented two others who brought up objections and problems in their initial treatment, without closing the loop by showing the available fixes. This could discourage some people with apnea from seeking help--clearly not the intent of the program.

Based on what I observed in the PBS report--and without judgement or criticism of the sleep center--here are a few indications of problems that could be resolved easily and which may have been addressed off-camera.

The 50-year old journalist had 3 complaints.

  • After 6 hours of treated sleep, he did not feel better.

Six hours is perhaps not enough sleep for him in one night; it may take several nights of treatment for him to begin to recover from his sleep debt. Not everyone reacts the same way to sleep loss or to treatment; some are very sensitive, others don't notice much difference. However, untreated apnea can do damage regardless.

  • He didn't like the mask because he wouldn't be able to read in bed.

Of course not, no one likes to wear a mask to bed. But there are many types of "patient interface" or ways to deliver air pressure to the patient, including some that are relatively unintrusive and would allow him to read in bed and provide him with relative comfort. And who says he has to wear it while reading? He could wait until 'lights out' to don the mask.

  • He didn't like the idea of having to use a device to maintain his health.

He needs to be helped to balance the very real and serious threats to his health and wellbeing if he is not treated against the minor inconveniences of treatment. There are a wide range of treatment devices that would minimise any intrusion on his lifestyle. In addition, there are oral devices that can treat apnea, and this may be less objectionable to some people.

Another patient who enjoyed a good sleep and felt awake after his treatment, did find that breathing out against the device pressure was uncomfortable. Some newer devices have the ability to reduce the pressure during the patient's exhalation in order to make the treatment more comfortable.

Empower people with apnea for successful treatment

A number of studies have reported higher rates of success in treatment, compared to the 25% cited in the broadcast. The problems leading to failure can often be overcome by empowering the patient in a collaboration with the health care expert: this requires patient education, offering the patient alternatives and options, and support by peers as well as professionals.

Increasing awareness of sleep apnea and other sleep disorders as well as the use of home studies will increase the need for patient support and education. If patients in an excellent, fully equipped sleep lab have problems of adjustment, how much harder it will be for them trying to make things work on their own. New technologies cannot replace the personal interaction of doctor and patient, and patients will need trouble-shooting, support, and education. The old model for success was "compliance" meaning the patient followed the instructions of the doctor. A new model is "adherence to treatment" which involves a collaboration of the person and their treatment team.

How can people with apnea help solve the public health problem?

  1. They have to know they have a problem. Snoring is one clear signal that something is wrong. If they know they have a problem, they can seek out treatment.
  2. They need need to know that untreated apnea is dangerous; and that the treatment will truly benefit them-- and new research shows that treatment can indeed help.
  3. The treatment needs to be as readily available and inexpensive as possible, consistent with quality. And new methods for testing at home are now available.
  4. Treatment is not that difficult but neither is it fun. So people living with apnea need to be actively involved in making their treatment work. They need education, motivation, support, and good interaction with their caregivers.
  5. Treated patients can be the vanguard of changing the health care system so that more people living with apnea get treated. How might this work? See Sleeping Beauty: Who Can Awaken Her?
  6. Do you have any ideas how to implement this change? Please comment below or write.

References:

T. Scott Johnson MD, William Broughton, MD, and Jerry Halberstadt; with contributions by B. Gail Demko, D.M.D. Forewords by Carl E. Hunt, M.D., Director, National Center on Sleep Disorders Research, NHLBI, NIH, William C. Dement, M.D., and Colin E. Sullivan, M.D. Sleep Apnea--the Phantom of the Night, Peabody MA: New Technology Publishing, Inc., 2003. The book provides information and a model of collaborative effort of doctor and patient.

Phantom Sleep Resources

The Sleep Apnea Newsletter

Doctors Aim to Better Diagnose Troubling Sleep Apnea

Accredited facilities:

An accredited sleep lab or sleep center has met the standards of the American Academy of Sleep Medicine (AASM). A sleep lab treats sleep apnea and related conditions. A sleep center is qualified to treat all types of sleep disorders. See a listing of accredited facilities.