Many studies of CPAP compliance rates have been done. Those that use objectively and usually covertly measured compliance, report long-term compliance rates of 41-73%, with most in the 60% range. These rates go up considerably with a compliance program. Key elements to achieving good compliance are education, comfort, and follow-up. Patients that understand the long-term consequences of their disease are more likely to be compliant. Likewise, a proactive follow-up program can provide needed encouragement and earlier identification of problems.
With regard to humidification: Generally speaking it is advantageous to incorporate [heated] humidification into a CPAP/BIPAP delivery device. The human nose heats and humidifies the air we breathe during the course of a normal human breath. When delivering an artificial breath, as with a CPAP or BIPAP machine, often times the flow of air is too fast for the nose to do its job. Many times this leads to dried sinuses, and can cause a great deal of irritation and discomfort for the user. Heated humidification has been proven clinically to adequately heat and humidify the artificial CPAP/BIPAP breath to mimic that function normally handled by the nose.
2009년 12월 5일 토요일
Auto CPAP
Auto CPAP is a newer variant that continuously monitors the patient and sets the air pressure to the lowest value that prevents obstruction. This value may change during the night, and may change over weeks and years. Patients report increased comfort with Auto CPAP, since they are generally exposed to lower pressures throughout the night.
Auto CPAP can be used in lieu of traditional titration when the patient uses auto titration for one or more nights. The clinician reads the profile of the pressure that was used during the trial, to determine the pressure the fixed CPAP unit will have. Alternatively, Auto CPAP can be used on a permanent basis. In this scenario, no titration is necessary, because the device is self Titrating. This model of therapy, is gaining popularity because of its simplicity and increased patient comfort. However, there are not enough outcome studies to show it is more cost effective than fixed CPAP.
Auto CPAP can be used in lieu of traditional titration when the patient uses auto titration for one or more nights. The clinician reads the profile of the pressure that was used during the trial, to determine the pressure the fixed CPAP unit will have. Alternatively, Auto CPAP can be used on a permanent basis. In this scenario, no titration is necessary, because the device is self Titrating. This model of therapy, is gaining popularity because of its simplicity and increased patient comfort. However, there are not enough outcome studies to show it is more cost effective than fixed CPAP.
CPAP (Continuous Positive Airway Pressure)
A mask through the patients nose delivers continuous Positive Airway Pressure (CPAP). A constant stream of room air, often heated and humidified, is sent from a small blower at the patient’s bedside. The pressure is not enough to interfere with normal breathing, but it is thought that the stimulation of the airflow on the upper airway is enough to keep the airway open. Each patient requires a different amount of airflow. The effective airflow for each patient is traditionally obtained in the sleep lab as part of a titration study. In some labs, this study may be done on the same night as the sleep study – a so-called Split Night Study. In others, a titration study is done on the following night.
The technical applies the CPAP and sets the pressure value; the value is increased or decreased, until the lowest effective level is found. The patient is then provided with a CPAP machine fixed at that setting. This model of treatment suffers from the same problems as in-lab diagnostic testing. It requires trained technicians in a sleep clinic. The Patient encounters the same backlog, the same bottleneck, and inconvenience. If the time between diagnosis and treatment is prolonged because of accessibility, the risk of legal liability may become an issue.
CPAP is a treatment, nothing more. It is not a cure. It is worn, every night. The effect on the Apnea/Hypopnea index and overall sleep is immediate. Patients often report waking up the next morning, feeling like a new person. The effect on nocturnal blood pressure is immediate as well. A drop in daytime blood pressure may be seen in a few days or weeks. All of these effects are reversed if the CPAP is not worn.
The American Thoracic Society has an official statement on this matter, “CPAP is effective in eliminating Obstructive Sleep Apnea, Oxyhemoglobin desaturation, and respiratory related arousal from sleep. CPAP is also associated with improved morbidity as manifested in primarily a reduction is daytime sleepiness, and improved cardiopulmonary function. Although the long term effects of nasal CPAP have not been fully determined, available data suggests a possible reduction in mortality.”
The technical applies the CPAP and sets the pressure value; the value is increased or decreased, until the lowest effective level is found. The patient is then provided with a CPAP machine fixed at that setting. This model of treatment suffers from the same problems as in-lab diagnostic testing. It requires trained technicians in a sleep clinic. The Patient encounters the same backlog, the same bottleneck, and inconvenience. If the time between diagnosis and treatment is prolonged because of accessibility, the risk of legal liability may become an issue.
CPAP is a treatment, nothing more. It is not a cure. It is worn, every night. The effect on the Apnea/Hypopnea index and overall sleep is immediate. Patients often report waking up the next morning, feeling like a new person. The effect on nocturnal blood pressure is immediate as well. A drop in daytime blood pressure may be seen in a few days or weeks. All of these effects are reversed if the CPAP is not worn.
The American Thoracic Society has an official statement on this matter, “CPAP is effective in eliminating Obstructive Sleep Apnea, Oxyhemoglobin desaturation, and respiratory related arousal from sleep. CPAP is also associated with improved morbidity as manifested in primarily a reduction is daytime sleepiness, and improved cardiopulmonary function. Although the long term effects of nasal CPAP have not been fully determined, available data suggests a possible reduction in mortality.”
Treatment Options of OSA
Weight loss is an effective treatment for the obese patient. Weight loss studies have shown that as the body mass index (BMI) goes down, the Apnea Hypopnea Index (AHI) goes down as well. While generally effective, effective weight loss requires a life style change, which can be difficult to initiate, and even more difficult to sustain, and naturally, it has no effect on non-obese patients.
CPAP, or continuous positive airway pressure, is the most effective treatment for Obstructive Sleep Apnea. If used properly and consistently, it is highly effective in virtually every patient. There are several variants of CPAP, Bi-level CPAP (BIPAP), Auto CPAP, Etc.
Tonsillectomy and Adenoidectomy is the preferred treatment for children, and is almost always effective. The results for surgery in adults are mixed however. There are many different kinds of surgeries. Radio Frequency Ablation creates scarring to stiffen the palette. Splints can be inserted into the palette for the same reason. LAUPP or Laser Assisted Uvulo-Palato-Plasty, Mandibular Advancement – effective, but major surgery; and methods to tighten, advance, and tie down, or otherwise keep the tongue from falling back into the throat can be complicated procedures, to say the least. Surgical interventions typically measure success as a percentage reduction in the AHI. The AHI is often still above the threshold of OSA – and there is a fair chance of recurrence after several years. Still in all, surgery is a viable option, especially for the non-compliant CPAP user.
Oral appliances are worn at night, to temporarily advance the mandible. They may be used in conjunction with CPAP. The attitude of the sleep community regarding oral appliances is mixed, and this is an area of treatment that is still undergoing significant development. People are now beginning to look at the long-term consequences of wearing an oral appliance every night, such as changes in the teeth and jaw. There is one treatment not listed here: positional treatment. Sewing a tennis ball into the back of the nightshirt; this treatment has been largely discarded by the sleep community as being insufficiently effective, and also difficult to manage.
Of these treatments, CPAP is the overwhelming treatment of choice in the sleep community. Surgery would be suggested only after earnest trials of CPAP have proven ineffective. Drug therapy is the goal for many in the sleep community. There have been some promising early trials, but there is currently no drug treatment for Obstructive Sleep Apnea, and no compounds are near release that has an acceptable efficacy, or side effect profile.
CPAP, or continuous positive airway pressure, is the most effective treatment for Obstructive Sleep Apnea. If used properly and consistently, it is highly effective in virtually every patient. There are several variants of CPAP, Bi-level CPAP (BIPAP), Auto CPAP, Etc.
Tonsillectomy and Adenoidectomy is the preferred treatment for children, and is almost always effective. The results for surgery in adults are mixed however. There are many different kinds of surgeries. Radio Frequency Ablation creates scarring to stiffen the palette. Splints can be inserted into the palette for the same reason. LAUPP or Laser Assisted Uvulo-Palato-Plasty, Mandibular Advancement – effective, but major surgery; and methods to tighten, advance, and tie down, or otherwise keep the tongue from falling back into the throat can be complicated procedures, to say the least. Surgical interventions typically measure success as a percentage reduction in the AHI. The AHI is often still above the threshold of OSA – and there is a fair chance of recurrence after several years. Still in all, surgery is a viable option, especially for the non-compliant CPAP user.
Oral appliances are worn at night, to temporarily advance the mandible. They may be used in conjunction with CPAP. The attitude of the sleep community regarding oral appliances is mixed, and this is an area of treatment that is still undergoing significant development. People are now beginning to look at the long-term consequences of wearing an oral appliance every night, such as changes in the teeth and jaw. There is one treatment not listed here: positional treatment. Sewing a tennis ball into the back of the nightshirt; this treatment has been largely discarded by the sleep community as being insufficiently effective, and also difficult to manage.
Of these treatments, CPAP is the overwhelming treatment of choice in the sleep community. Surgery would be suggested only after earnest trials of CPAP have proven ineffective. Drug therapy is the goal for many in the sleep community. There have been some promising early trials, but there is currently no drug treatment for Obstructive Sleep Apnea, and no compounds are near release that has an acceptable efficacy, or side effect profile.
Pediatric OSA
This presentation focuses primarily on adults, but it is worth talking about pediatric patients for a moment.
Kids are most at risk from the ages of 3 to 9. During this time, the development of the airway is such that the tonsils are largest, in relation to the rest of the airway. These relatively large tonsils and adenoids are the leading cause of OSA in kids.
The link between ADD of ADHD and Obstructive Sleep Apnea has received a lot of attention in the popular press, but they may have overstated the case. The exact overlap between Obstructive Sleep Apnea and ADHD patients is unclear.
OSA does result in poor sleep, tired adults get sleepy, tired kids get cranky fussy, and have a short attention span, just like kids with ADHD. In adults, a suspicion of depression should trigger a suspicion of OSA. In kids, a suspicion of ADHD should trigger a suspicion of OSA as well. Remember, ADHD and Obstructive Sleep Apnea are two very different diseases, but they share many of the same symptoms. The overall prevalence in kids is about the same as in adults.
In summary, we begin with the clinical definition of Obstructive Sleep Apnea: A total closure of the upper airway resulting in reduction or cessation of airflow, despite persistent respiratory effort.
Unfortunately nobody knows what causes sleep apnea, but major symptoms of the disease include snoring, gasping and/or choking while sleeping, daytime sleepiness, and chronic fatigue. It should be noted that several of these symptoms are similar to those found in adult depression.
In addition, OSA is more common in obese patients, than in the rest of the population. The prevalence of OSA in the US is approximately 4% for men, and 2% for woman; and, even more so than diabetes, a significant portion of people with obstructive Sleep Apnea has not been diagnosed.
Finally, we discussed the prevalence of OSA in children, approximately the same as in the adult population, and noted, symptoms commonly associated with ADHD, should trigger a suspicion of OSA as well.
Kids are most at risk from the ages of 3 to 9. During this time, the development of the airway is such that the tonsils are largest, in relation to the rest of the airway. These relatively large tonsils and adenoids are the leading cause of OSA in kids.
The link between ADD of ADHD and Obstructive Sleep Apnea has received a lot of attention in the popular press, but they may have overstated the case. The exact overlap between Obstructive Sleep Apnea and ADHD patients is unclear.
OSA does result in poor sleep, tired adults get sleepy, tired kids get cranky fussy, and have a short attention span, just like kids with ADHD. In adults, a suspicion of depression should trigger a suspicion of OSA. In kids, a suspicion of ADHD should trigger a suspicion of OSA as well. Remember, ADHD and Obstructive Sleep Apnea are two very different diseases, but they share many of the same symptoms. The overall prevalence in kids is about the same as in adults.
In summary, we begin with the clinical definition of Obstructive Sleep Apnea: A total closure of the upper airway resulting in reduction or cessation of airflow, despite persistent respiratory effort.
Unfortunately nobody knows what causes sleep apnea, but major symptoms of the disease include snoring, gasping and/or choking while sleeping, daytime sleepiness, and chronic fatigue. It should be noted that several of these symptoms are similar to those found in adult depression.
In addition, OSA is more common in obese patients, than in the rest of the population. The prevalence of OSA in the US is approximately 4% for men, and 2% for woman; and, even more so than diabetes, a significant portion of people with obstructive Sleep Apnea has not been diagnosed.
Finally, we discussed the prevalence of OSA in children, approximately the same as in the adult population, and noted, symptoms commonly associated with ADHD, should trigger a suspicion of OSA as well.
Prevalence of OSA
Estimates to the prevalence of Obstructive Sleep Apnea in the Unites States are 2% for woman, and 4% for men.
There are many studies giving higher prevalence number for specific populations - 9% for middle-aged white males, up to 24% and even 40% in some populations.
The links between OSA, age and obesity, lead most to conclude that the number of Obstructive Sleep Apnea will continue to grow. This prevalence of 18 million people with OSA is on par with Diabetes and Asthma. It is estimated that 50% of the people that have diabetes, don’t know it.
These are the people commonly referred to as the missing 10 million. There is a lot of effort in healthcare to reach out to these individuals to encourage treatment. The picture for OSA is bleaker than that; only about 10% of the people suffering for OSA have been diagnosed.
Remember that each one of these undiagnosed patients is costing the health care industry twice as much as everyone else, and getting into 6 times as many car accidents.
There are many studies giving higher prevalence number for specific populations - 9% for middle-aged white males, up to 24% and even 40% in some populations.
The links between OSA, age and obesity, lead most to conclude that the number of Obstructive Sleep Apnea will continue to grow. This prevalence of 18 million people with OSA is on par with Diabetes and Asthma. It is estimated that 50% of the people that have diabetes, don’t know it.
These are the people commonly referred to as the missing 10 million. There is a lot of effort in healthcare to reach out to these individuals to encourage treatment. The picture for OSA is bleaker than that; only about 10% of the people suffering for OSA have been diagnosed.
Remember that each one of these undiagnosed patients is costing the health care industry twice as much as everyone else, and getting into 6 times as many car accidents.
Obesity and OSA
Here are the results of a few studies looking at obesity and Obstructive Sleep Apnea. There is a clear and strong link between obesity and sleep apnea.
Fat deposits in the neck narrow the airway, greatly increasing the chance of acquiring sleep apnea. OSA is seen as a disease of obesity, and this is a fair assumption. But don’t be fooled, not all of OSA patients are obese.
Certain Asian populations have a equal susceptibility to OSA as the U.S. despite having much lower rates of obesity. This is likely due to Cranial Facial differences. Looking at the first study, remember that although 2/3 of the participants were obese, 1/3 were within 30% of their ideal bodyweight.
Fat deposits in the neck narrow the airway, greatly increasing the chance of acquiring sleep apnea. OSA is seen as a disease of obesity, and this is a fair assumption. But don’t be fooled, not all of OSA patients are obese.
Certain Asian populations have a equal susceptibility to OSA as the U.S. despite having much lower rates of obesity. This is likely due to Cranial Facial differences. Looking at the first study, remember that although 2/3 of the participants were obese, 1/3 were within 30% of their ideal bodyweight.
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