Professional Attitudes about Sleep Technology Equipment: Part III

Nowadays, nearly anyone can make a serious stab at PAP because there are hundreds of different masks and mask styles to accommodate different facial features. This particular area is acknowledged by most sleep professionals who realize they must accommodate their patients’ needs to find comfortable, well-fitting masks to prevent skin irritation, soreness, and pain, in addition to solving problems with leaks and related issues with mask seals. For most sleep professionals, whether sleep technologists or sleep specialists, efforts to arrange or prescribe new masks is a no-brainer for struggling patients.

Many of these same PAP vendors have also developed changes in their pressure delivery mode technology, yet as we have been discussing, this area is not embraced by most sleep professionals. Instead, the singular concept that holds back sleep physicians and technologists from using these advanced devices is similar to the clinical experience of dealing with pharmaceutical companies proffering the latest and greatest new medication, which in fact may not have greater effectiveness compared to the older and less expensive version of the drug. These encounters and the resultant mindset makes a lot of medical professionals gun-shy in prescribing drugs until such time as the physician can go through various educational steps such as talking with drug reps about benefits and side-effects, reading scientific evidence, talking with colleagues at conferences, and eventually trying out the new meds on their patients to see the outcomes for themselves.

In my opinion, we have still not entered this last phase of “testing the waters” with new PAP technology for most sleep specialists, many of whom never try out anything on their patients save CPAP in the sleep lab. While they might still prescribe CPAP with EPR or APAP with EPR, which can be considered forms of advanced technology, they are likely to reserve BPAP for only a few patients and ABPAP or ASV for rare patients. Clearly, some centers and labs are moving forward in these areas, but from what I have been exposed from numerous second opinion patients at our center and in conversations with numerous colleagues, a pervasive mentality regarding CPAP and only CPAP appears to drive most sleep professionals to stick with this mode of therapy exclusively. Given the current state of research papers on the topic declaring there is no rationale to routinely prescribe anything but CPAP, it seems reasonable most sleep physicians follow this advice.

However, the flaws or pearls in these issues (depending on your point of view) are that certain questions must be asked and answered about the manufacturers who continue to fine-tune and upgrade their PAP pressure delivery modes. Do PAP manufacturers like ResMed and Respironics keep innovating devices to make them smaller and more portable? The answer to that one is easy, because there is always a convenience market for smaller and more travel suitable devices. What about all the mechanics of the device involving how the tubes connect to the compressor box and the mask, how the settings’ buttons can be manipulated by the patient, and how the humidifier water tank can be managed—do manufactures attempt to innovate in all these areas to make for a better product? Yes, of course. What about reliability, would these vendors want to produce devices that are durable since per insurance standards they must last at least five years? Again, yes, of course.

So how then would we describe the driving forces at ResMed and Respironics to make a “better” machine? Actually, it is the same drive found at Apple to make a better phone, or the same drive at Firestone to make a better tire, or the same drive of any entrepreneur to build a better mousetrap. In our realm of CPAP devices, the main driving force of manufacturers is to build something that gives the patient a better night of sleep and that means going beyond the basics of masks and tubes and durability. It means actually delving deeply into the science of respiration and sleep and finding a better way to deliver pressurized airflow. And, this drive to make a better CPAP machine is the most intelligent and business-friendly motivator that a manufacturer would be harnessing, because eventually if they do not pursue such innovations someone else will develop a better machine, and the older model will appear as useless, lower quality, or outmoded.

If you want to argue that cars with new designs changing every year are simply trying to capture market share by attracting people who want “upgrades,” I would not discount that point of view. But, the bells and whistles of a PAP machine can only produce so much consumer interest, because anyone who has ever tried a PAP device and benefited knows something about what they truly want more than anything else, namely, a better night of sleep. And, if a better machine comes along yielding an even better night of sleep than was provided with a standard fixed pressure CPAP device, then the consumer (patient) will want that device. 

Indeed, these are the exact words out of the mouths of hundreds (if not thousands) of former CPAP users who switched to ABPAP or ASV devices, “Why wasn’t I given this device years ago?” or “I’m very frustrated that my sleep doctor did not give me the choice of using this newer device when I inquired about advances in the field years ago.” Numerous variations on these themes have been heard at our sleep center, dating back to 2005 when we first transitioned into regularly prescribing dual pressure devices.

Thus, we come to the crux of the matter. If CPAP manufacturers are trying to give you the patient a better night of sleep, sooner not later, the technology will outpace the sleep medical professional community, because the consumer will recognize the gains and benefits faster than the stodgy medical professionals who keeping sticking to what they perceive as a tried and true model of care. Interestingly, many of the changes we have been discussing will start happening for ironic and unexpected reasons. Due to the home testing craze, more and more people will be exposed to auto-adjusting devices, which means more people will be providing feedback to sleep doctors that they do not want a fixed pressure setting. Instead, they will experience unanticipated benefits from the auto-adjusting device and politely demand a trial of the auto-adjusting model at home for much longer than a week or a month. Eventually, some will refuse to be treated with fixed CPAP.

Finally, from the vendor’s point of view, can you imagine the frustration from spending gobs on research and development to build a better mousetrap while being confronted daily with professional attitudes that balk at prescribing advanced technology? Instead of consumers having an easy outlet through which to see and make decisions about the “product” they wish to purchase and use, they must run a figurative gauntlet in dealing with physicians, sleep techs, insurance carriers, government regulators and ultimately DMEs before they can obtain a PAP system. Insofar as this process works to deliver CPAP devices, there are plenty of ways in which a more streamlined approach could be implemented, but that is another story. Insofar as our topic of discussion on advanced technology, nearly all these professionals and entities at key points in the process may serve more as barriers than facilitators largely because of the limited views held by many in the field of sleep medicine.  

Will such views eventually change and create greater consumer choices to obtain advanced PAP technology? I believe the answer is that change is coming, but it will most likely be much slower than it needs to be for all the reasons discussed in these three posts.

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

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