Reliability of Objective Data Download Information: Part II

Checking the hours of use opens up many important discussions with OSA/UARS patients. Naturally, we always want patients to use the device as much as possible, and ideally they will use PAP every period of sleep, even during lengthy daytime naps. Somewhere between this pivotal objective and reality, we see various patterns of use indicating that patients need additional coaching and encouragement to reach more optimal levels. There are many different observable patterns that may not fit into a clear-cut framework, so we will review a few of the more common ones.

One of the most peculiar patterns is seen in the person who has paid too much attention to the arbitrary Medicare compliance guidelines and intentionally monitors sleep to achieve just over four hours of sleep five nights per week and no more. These individuals therefore are averaging only about 20 hours of PAP use per week, which certainly is a notable milestone. But, when questioned about the other time spent in bed sleeping without the mask, it is not surprising to hear the individual sleeps another two to three hours on many nights. This individual may also be skipping two nights out of the week by defaulting to the Medicare compliance guidelines. Missing the two nights seems harmless, because the requirement only calls for 5 nights per week.    

Among this “by the numbers” group, there are usually two subtypes of patients. The first category prefers to use the mask as little as possible and yet still comply with their doctors’ orders to achieve compliance with PAP therapy. As you might expect, they are not interested in learning about how to expand their use of the device. The second category is much more receptive to increasing hours on PAP, because they did not realize initially there was a goal to go beyond compliance numbers. When they learn more hours on PAP provide more benefit, they rapidly expand their time on the device.

A similar category are those patients who can only tolerate 3 to 5 hours with device, but then want more sleep afterwards without PAP. These patients are some of the most challenging, because the discomfort factor due to mask, headgear or pressurized air, not to mention psychological sensitivities, affect them so consistently they rarely overcome the distressing sensations, discomfort, or pain to attain longer use. Most of these patients report benefits and are motivated to continue using the device. But, at the same time, they are at high risk for the scales to be tipped away from maintaining use, because any of their discomfort factors can trigger a sudden cessation of use for a week or two. These are the vulnerable individuals who often report skin irritation on the bridge of the nose or headaches from headgear positioning or feelings of excess pressure when they awaken after 3 to 5 hours of use.  

Helping these individuals maintain regular use or coaching them to expand use falls into the classic medical categorization of chronic disease management. To succeed at the reasonable level of insurance-based compliance always requires extensive follow-up, including regular telephone support, clinical coaching at the sleep center, more frequent retesting at the sleep lab (often annually or in some cases more frequently) as well as routine interactions with their DME companies to insure proper replacement of mask cushions, filters, and tubes. Sometimes, the addition of a single new item such as REMZzzs mask liners, nasal gel pads (such as Boomerang gel pads), Pad-a-Cheek, or nasal strips will immediately lead to increased hours. And, of course, switching out older styles of masks with new innovative ones may lead to immediate improvement in comfort and thus more hours. This same group often responds to very minor changes in pressure settings. Overall, without extensive follow-ups these patients are at extremely high risk for dropping out of care.

Broken or split pattern sleepers are another unusual but not necessarily uncommon group. We tend to think of these patients as shift workers, which is certainly the case, but there are also other sub-types. I saw a patient last week who fit into the above category in terms of distressing factors limiting her use to only 2 to 3 hours in a night. She was motivated to use her device, but was discouraged about the prospects of meeting her insurance-based compliance criteria. It turned out she was napping every day for at least two hours, so we explained to her the option of putting on the mask for another two hours during the day so her total daily hours would rise above 4 hours in every 24-hour cycle. With this knowledge, the realized she could easily become compliant and keep her device even if for the present she could never sleep more than 2 to 3 hours with PAP at any given time.

Shift workers suffer their own external difficulties in terms of finding a reasonable environment in which to sleep during the daytime while at the same time blocking off diurnal interval in order to avoid social and related lifestyle responsibilities. The environment itself might prove the easiest in terms of blocking out noise and light, because there are sufficient technological solutions to each of these problems, albeit the shift worker needs to appreciate how valuable such steps will be in promoting a deeper quality of sleep. When I was younger, lived alone and worked in emergency medicine, it was extremely useful to tape black plastic bags across my windows and use earplugs, and I was pleasantly surprised I could gain anywhere from 5 to 7 consecutive hours of sleep from about 10 am to 3 to 5 pm. The trick however was finding a way to drive home safely, because the level of sleepiness at 8 am was extraordinarily high and potentially dangerous. Finally, I was fortunate to rent a nearby, dark basement apartment to use during my annual one month of night shifts. 

The larger burden for shift workers is to commit to a system for one long sleep period during the day or rigorously adopt a daytime split schedule, such as sleeping after the shift from 9 to noon, then after some level of activity, committing to return to sleep at 5 pm for another 3 hours of slumber. Then, upon awakening at 8 pm, determine how to manage time and tasks before heading back to work.

Unfortunately, many shift workers prefer to burn the candle at both ends. They drink sufficient amounts of caffeinated beverages to stay awake through the morning, complete a short sleep period in the afternoon, and then continue the caffeine through the evening and the night shift. These individuals often use PAP therapy below or barely at compliance levels of 4 hours and will frequently declare they never need more than 4 hours of sleep with or without PAP. Candidly, these patients almost never revise their schedules in line with more reasonable judgments about their biological need for sleep until a crisis emerges. The most common occurrence would be an accident driving or in the workplace, which clearly is attributable to poor judgments or decision-making from chronic sleep deprivation. Another common crisis is a mental breakdown of sorts that manifests as emotional outbursts or greater reliance on substances including increased cigarette smoking for waking stimulation or alcohol consumption to promote sleep. The other and usually worse variant is the use of prescription or illicit stimulants while awake and prescription or illicit sleeping pills for the sleep period.

The majority of shift workers do not act in this irresponsible manner, but many shift workers go through periods where they cannot adjust their schedules in healthy ways and therefore simply presume they need to take care of business whenever they find themselves awake. Theoretically, such a perspective might start out as a very healthy way to avoid the negative conditioning that arises when someone tries to force sleep when not sleepy. One good piece of news for these individuals is at least the quality of their sleep is better when they use PAP therapy. The downside is many shift workers are sleep deprived and would benefit greatly from using PAP closer to the 6 to 8 hour range in every 24 hour cycle. Precise monitoring of the sleep cycle with data downloads will spur some patients to aim for more hours, but it is not unusual for the process to take months or years before the objective data shows marked increases in total sleep hours.

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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