The person in the CPAP mask

Submitted by Jerry on Thu, 06/18/2009 - 16:06

Do you feel like the "man in the iron mask," a prisoner of your CPAP mask? Many people living with sleep apnea, regardless of the success of their treatment, wish they could be rid of the mask.

Their choices include to find another treatment, to abandon treatment, or to continue with CPAP. While the conventional wisdom is that they will continue to need CPAP to manage their apnea, in fact there are treatment options. And don't overlook the wide variety of masks and alternatives to masks. In addition, there are announcements from time to time of new ideas that might lead someday to a breakthrough.

If not CPAP, what to choose?

Let's take a look at some of the alternatives to CPAP, including concepts from short preliminary reports presented this June at the 2009 annual meeting of the Associated Professional Sleep Societies in Seattle, Washington. SLEEP, Volume 32, Abstract Supplement, 2009

Can making music banish apnea?

Can making music reduce the risk of having sleep apnea--and thus the need for CPAP treatment? Training the muscles involved in respiration can help resist airway collapse and thus, apnea. It has been shown that use of an Australian aboriginal wind instrument, the didgeridoo, can reduce apnea symptoms. Can other musicians take advantage of this observed benefit? Questionaires that help to assess the risk of apnea were given to 847 professional musicians. The musicians who play wind instruments with a lot of resistance were less likely to be at risk of apnea. Double-reed instruments like the oboe and the bassoon were the best at reducing the risk. Of course, if you play one of these instruments and nevertheless have sleep apnea, you still need treatment.

Risk of obstructive sleep apnea in wind musicians Ward CP, York KM, Vance KK, Calzadilla AS, Walch FJ, Song JJ, Sharf M. University of Houston-Clear Lake, Houston, TX, USA, North Florida/South Georgia VHS, Gainesville, FL, USA, University of Florida, Gainesville, FL, USA

Nutritional treatment

Can vitamins and anti-oxidants replace CPAP? Cardiovascular complications of apnea affect the heart and blood vessels, and include atherosclerosis (hardening of the arteries, and plaque buildup) as well as heart attack and stroke. Obstructive apnea causes oxidative stress and increases the risk of atherosclerosis.

To test the value of vitamins and anti-oxidants compared to CPAP, three similar groups of patients were evaluated in an experiment at the Technion in Haifa, Israel. One group was treated for three months with vitamins and antioxidants; a second group was given a placebo treatment; and a third group used CPAP. Vitamins did not affect apnea and had only small improvements in oxidative stress and endothelial function. CPAP treatment reduced apnea symptoms and the markers of atherosclorosis risk. The placebo had no effect. Vitamins and anti-oxidants were not shown to effectively treat apnea.

Effect of treatment with vitamins and antioxidants on endothelial function in sleep apnea Lavie L, Itzhaki S, Pillar G, Lavie P

Just say "No" to CPAP?

Can people with mild sleep apnea do without CPAP treatment? People with untreated apnea have an increased risk of cardiovascular disease (affecting the heart and blood vessels, including atherosclerosis) and stroke, and a higher risk of death. CPAP treatment is known to improve daytime functioning and reduce the risk of cardiovascular disease. Blood pressure is considered an indicator of cardiovascular risk. CPAP treatment can reduce blood pressure. In one trial of people with mild sleep apnea, those who were treated with CPAP for two years had a slightly lower blood pressure at the end, while the untreated had an increase of almost 10 points. A 12-point difference in blood pressure is a valuable improvement in cardiovascular health gained by CPAP treatment.

CPAP treatment vs. conservative treatment in mild obstructive sleep apnea: implications on cardiovascular morbidity Budur K, Jaimchariyatam N Cleveland Clinic Sleep Disorders Center, Cleveland Clinic, Cleveland, OH

Can surgery cure?

Will surgery cure sleep apnea, and thus eliminate the need for CPAP? One form of surgery, maxillomandibular advancement (MMA), is reported to produce a cure for 13 out of 23 patients treated at the Mayo Clinic. This MMA operation is a series of surgical and dental procedures to increase the length of the lower jaw, creating a larger airway in the throat. This procedure needs to be matched with suitable patients who are prepared to undergo a significant surgery.

The role of maxillomandibular advancement surgery in obstructive sleep apnea: the mayo clinic experience Varghese R, Adams NG, Slocumb NL, Olson EJ, Viozzi CF, Ramar K Mayo Clinic, Rochester, MN, USA

Will weight loss work?

If I lose weight, can I 'graduate' from CPAP? Yes, and this is an excellent choice, but your chances are small. In a total of over 1400 patients on CPAP, only 6 patients were able to go off CPAP; they had an average drop in body mass index of 1.71, and they did not use an oral appliance or have surgical treatment. In a review of studies relating changes in weight (BMI) and apnea severity (AHI) there was no clear relationship between weight loss and apnea. And many non-obese people with excessive daytime sleepiness have sleep apnea.

Graduation from CPAP: is it really possible? Kawai M, Fujii S, Yamamoto K, Koike S. Japan
The impact of weight loss on obstructive sleep apnea (OSA) severity: results of a meta-analysis Comondore VR, Wenner J, Fox J, Schultzer M, Mak E, Ayas NT
Obstructive sleep apnea in non-obese patients: age, gender and severity Yeligulashvili T, Rose M SleepTech, Wayne, NJ, USA

Just don't sleep on the back?

Can positional therapy replace CPAP? Some people have more severe apnea symptoms when they are sleeping on their back. So, if a person with positional apnea were to avoid sleeping on their back, would that work? In theory, yes, but people move during sleep and may roll onto their backs. Thus, there have been many advocates of this approach but many skeptics also. Finally, a group of researchers investigated this method in the home, using a new vest device that discourages sleeping on the back. They found that most of the patients made reasonable use of the system over a 3-month period and that their apnea was controlled.

Positional therapy for obstructive sleep apnea: an objective assessment of its efficacy and usage at home
Heinzer R, Rey V, Lecciso G, Vodoz J, Pellaton C, Delessert A, Manzini C, Tafti M, Lavigne G. Switzerland & Canada

Oral appliances

Oral appliances, according to B Gail Demko, DMD, are "a piece of plastic or silicone that fits completely or partially within the mouth and holds oral structures in a position that allows easier breathing when you sleep." Such devices are now an established treatment suitable for some people with sleep apnea. Recent reports continue to reinforce that devices that are carefully matched to the needs of individual patients can provide significant relief. For an introduction to oral appliances, see SleepApneaDentist.

Benefit of mandibular repositioning device therapy in patients with moderate and severe OSA Levendowski DJ, Morgan T, Melzer V, Popovic D, Scarfeo D, Westbrook P

A really new idea?

New ideas have a difficult time being accepted, especially in medicine. The conservatism of the medical system can keep a good idea from being applied for a long time, or it can prevent hasty action that might prove dangerous. That's why new ideas need to be tested and demonstrated in order to establish scientifically the validity of the new treatment or device. And so it is for a new device that is intended to treat snoring and sleep apnea as an alternative to CPAP. The method is called "Nasal Expiratory Positive Airway Pressure (nePAP)."

At the point in breathing when exhalation is ending, the upper airway is vulnerable to collapse. CPAP works by introducing air under pressure into the nose in order to keep the upper airway from collapsing during inspiration. The new device sticks to the nose, inserted into the nasal openings and consists of a valve over each nostril. The valve opens to allow inspiration, and closes to restrict the flow of air during exhalation. This builds up an increase of pressure during exhalation in order to keep the upper airway from collapsing--and thus to prevent a blockage or apnea.

According to the information in current abstracts (most of the authors have a stake in the product), a small number of people have been tested using the new device based on this concept (Provent™ Professional Sleep Apnea Therapy). In two studies, a total of 58 people were tested and the apnea-hypopnea index was reduced in many subjects, with few reported side effects. However, the new system is not as effective as CPAP in the reduction of disturbed breathing.

The investigators of the new system argue that although the Provent is less effective than CPAP, it is used more consistently than the CPAP, and thus it has a greater overall impact on sleep disordered breathing. They posit a new model for comparing and evaluating these two treatments--this is an hypothesis, not an experimental result. However, although additional research may be underway, they have failed to date to demonstrate with evidence that the use of nePAP/Provent is comparable to or better than CPAP in restoring sound sleep, or eliminating near-term and long-term effects of apnea. Provent is not readily available and costs $135/month.

Success rates of nasal expiratory positive airway pressure (nePAP) via expiratory resistive load for the treatment of obstructive sleep apnea Westbrook P, Doshi R, Loomas B

Modeling the effectiveness of treatments for obstructive sleep apnea/hypopnea; Abreu A, Doshi R, Loomas B, Westbrook P.

Selecting A Treatment

Let's keep in mind that CPAP has demonstrated significant benefits for people that use it faithfully; that many of the issues that bother users can be resolved; and the new alternatives need to be carefully evaluated in a discussion between doctor and patient. In comparing and selecting treatments, consider these criteria from Sleep Apnea:the Phantom of the Night--

  • What are the risks or complications of each treatment?
  • Does the treatment eliminate apnea and enable normal breathing during sleep, good quality sleep, and normal daytime function?
  • Does the treatment prevent the medical complications or death associated with sleep apnea?
  • Is it acceptable to the patient and bed partner, is the cost affordable, and is the treatment readily available?

Apnea Dreaming--a lighter view from Gloria

There once was a man with a mask
who had an odd question to ask:

"Does having a hose
coming out of my nose
make kissing too awkward a task?"

---Copyright 2010, Gloria Avner. Used by permission.

Gloria thinks this ditty might help in an "evolving relationship with potential bed-partner. It could introduce a discussion on how to tell someone you are dating that you don't want to startle them by what you must wear before you go to sleep, a jocular ice-breaker prior to educational efforts. "

Thanks for sharing this, Gloria.