The Southern Sleep Society 2018 (Part II) - Dr. Krakow's lectures on PTSD and CPAP compliance gain attention among top sleep professionals.

During my last blog post on the Classic SleepCast for Classic SleepCare, I discussed how I was invited to deliver two talks on sleep at the Southern Sleep Society’s 40th annual meeting. I will also be doing the same lectures during the September Sleep 2018 meeting as well. My talks delved into the “PTSD Sleep Clinic and Nightmare Triad Syndrome” and “Advanced PAP Therapy to Increase Compliance and Decrease Insomnia.” Both talks were received very well and sparked a number of discussions afterwards with several of my colleagues and other attendees. Several key points were offered in my talks, and my last post used a bullet point summary to make you aware of the most relevant.

In that post, I also discussed how an atypical presentation of OSA/UARS in an insomniac often leads to the use of advanced PAP devices at our sleep center in New Mexico. Now, I want to delve into this same issue but we will be looking at the point of view where someone is prevented from obtaining an advanced PAP mode. And, this barrier to the use of advanced PAP almost always relates to the current confusion about the core concept of CPAP failure, something we have discussed in this blog previously.

A recurring theme from attendees who approached me after each of the talks were the difficulties, hassles, and obstinacy encountered when dealing with insurers to clarify the notion of CPAP failure as well as to gain approval for advanced PAP devices. Some of these sleep professionals clearly perceived their insurers as the major obstacle as they pointed out the near impossibility of even obtaining a simple bilevel device for their patients failing CPAP. So, let’s summarize this vicious circle with a few bullet points before we dig deeper into the details:

  • An astronomically high number of patients do not like CPAP; we know this reaction to be true because as much as one-half of all 'CPAP attempters' quit - so there must have been something about CPAP that made them quit.
  • Sleep doctors and sleep technologists observe this de facto CPAP failure all the time in clinics or in the labs or in communication with DME companies.
  • Yet, when sleep center staff approach insurance companies to rectify the situation by promoting the implementation of a more advanced device, even something as simple as bilevel, these insurers will often balk by using twisted rules to prevent any efforts in helping the patient.
  • The sleep doctors, techs, and staff attempt to explain to the insurers how the patient is failing CPAP.
  • But the insurers keep bringing up various factors, which according to their rule book, must be addressed before someone can get a 2nd or 3rd or 4th chance at a different device.
  • These rules seem straightforward. If the leak has not resolved, get a new mask; if dry mouth remains an issue, prescribe a chinstrap; if leg jerks are a problem, treat them with medications. And, all these steps are usually attempted but they do not always yield stellar results. My favorite rule is the one where the patient cannot reach standard compliance numbers of 4 hours per night for 5 nights per week, and then the insurer’s medical director informs me the patient “needs to try harder.” This set of rules is how an insurer often prevents patients from ever seeing the light of day in a sleep lab, where individuals could try bilevel, discover greater benefits, and then expect to receive a prescription for a BPAP device.
  • With some insurers, you can eventually get them to agree with in-lab sleep testing, which is the best chance a sleep center gets to demonstrate the value of advanced PAP in a struggling individual.
  • However, it is very clear some insurers absolutely never want their beneficiaries (don’t you love that word) to ever get into the lab, not only because of the expense, but also because the insurer knows the patient might be exposed to an advanced PAP mode (insurer’s read that as ‘a more expensive PAP mode’) regardless of whether this patient might appreciate a noticeably better response.
  • Finally, if a center is fortunate enough to build the case for the patient to return to the sleep lab, then the definition of CPAP failure enters into the equation in ways that many sleep professionals do not appear to know how work through to move beyond standard CPAP therapy.

Let’s continue with this discussion of CPAP failure. As we have discussed numerous times in the past, a sleep tech and the supervising sleep doctor must be able to recognize expiratory pressure intolerance as it emerges while that patient’s fixed CPAP pressures are increased to attempt to eliminate RERAs. These two concepts should prove to be the chief variables in defining CPAP failure in the overwhelming majority of cases when such a problem needs to be documented in the sleep lab.

But therein lies part of the problem. Since so much imprecise information has been written on the topic of CPAP failure, no one really knows for sure what it means. In the olden days, back in the 1980s and part of the 1990s, there was a belief that the only way you could fail CPAP was to take it home and try to use it. When you returned and showed non-compliant data you were said to have failed the device. Keep in mind that one of the major scenarios in play back occurred when a patient wanted surgery or maybe a dental device, so they needed to “fail” CPAP to gain insurance coverage for these other treatment options. Many of these patients simply brought their CPAP devices home and found a very comfortable and stable resting place for the machines in their closets. Three months later, they returned to the sleep center to gain the “CPAP failure designation” and then proceed with surgery or OAT.

To my knowledge, there may be some insurers who still insist the patient must try CPAP at home in order to achieve failure status. However, over the past 15 years we have observed and routinely implemented a different approach based on what occurs upon exposure to CPAP in the sleep lab. As mentioned in prior posts, our sleep center in New Mexico specializes in mental health patients with sleep disorders, which often included some degree of anxious feelings (e.g. claustrophobia, panic, anxiety attacks) related to sleep problems in general or sleep apnea/PAP in particular. Thus, we got to know first-hand 15 years ago many of these patients were struggling with and hating CPAP and very much needed an alternative form of PAP.

Their rejection of CPAP in the sleep lab was then designated CPAP failure, because in so many of the cases patients were either freaking out while attempting fixed pressure or reporting a great deal of discomfort akin to the “drowning in air” metaphor. Either of these scenarios can be deemed CPAP failure, and we have used them successfully to punch the patient’s ticket for a night in the lab.

In my discussions with the sleep professionals at the Southern Sleep Society conference, it was very clear that many doctors or techs were just not clear how they could push the envelope in this fashion for the benefit of their patients. I spent a fair amount of time discussing this phenomenon and showing graphics to demonstrate how efforts to raise pressures to resolve RERAs would result in EPI, and that EPI is almost universally the core factor in patient discomfort that leads to outright CPAP rejection or sufficient CPAP discomfort to consider it as a failure case.

However, most sleep technologists are not trained to be looking at the expiratory limb of the airflow curve once apneas have been eliminated. Instead, the focus turns toward the inspiratory limb to eliminate hypopneas. At some sleep centers, this progression continues in an attempt to eliminate RERAs, but as the pressures increase toward this objective, the expiratory limb starts to change and frequently shows irregularities - suggesting the patient is fighting with the pressurized air. The simplest explanation for this struggle is the unnatural feeling of trying to breathe out against incoming air. The sensation is probably most analogous to sticking your head out the window of car driving 60 mph and then expecting to have an easy time breathing against the strong wind created by moving vehicle. Even inspiration can feel odd with this much air blowing inwards, but with certainty we can tell you that expiration for most of these patients feels very odd indeed.

These experiences appear to be occurring among many CPAP users, but at varying degrees of intensity, such that some patients eventually adapt to CPAP at home whereas others give up on CPAP from the word “go.” Because there is no clear-cut definition for CPAP failure a lot of sleep professionals are at a loss on how to proceed. Few recommend retitrations. Some ask their patients to take a break and start again. Others recommend trying to use new masks, chinstraps, nasal pads, mask liners and so on, yet only a very small proportion directly address the problem of higher pressures needing to treat RERAs, which then aggravates expiratory pressure intolerance. Moreover, there seems to be little discussion within the sleep community on how the auto-adjusting mode of something like an ABPAP device can facilitate the treatment of RERAs without triggering EPI. Ultimately, because there also remains a lack of clarity on the true components of normal sleep breathing, all these barriers converge to prevent providers from even considering advanced PAP devices for most of their CPAP failure cases.








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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