My friend and colleague, Dr. Steven Park, has recently published a new work, Totally CPAP, available wherever books are sold. You may not know it, but Dr. Park is one of the few surgeons, an ear, nose and throat specialist (otolaryngologist) who is also board-certified in sleep medicine. As you would expect, he is not simply working from a surgical perspective, and based on the content and accurate insights from the book, we can assume Dr. Park is seeing tons of patients who never go under the knife.
Two things are most evident from the outset of the book. First and foremost, Steven is clearly seeking to motivate his readers. He speaks with authority, passion, and commitment to help people learn to succeed with CPAP. Second, and aligned with his desire to motivate you, he spends a great deal of time gently and diplomatically reminding the reader that ultimately success only emerges for those willing to put forth the effort.
We know these goals are sincerely presented by Dr. Park from the outset, because his Preface and Introduction spell out the large disconnect that continues to plague the field of sleep medicine wherein patients seeking to use CPAP are often working with sleep medicine professionals who either are not appreciating or perhaps are misunderstanding how to help their patients solve the inevitable obstacles that must be overcome for someone to gain the most from a CPAP experience. Dr. Park sees this “gap in communication” as a major reason for so many CPAP patients falling through the cracks in whatever healthcare systems they may find themselves. And, he astutely recognizes that among those individuals who have already failed CPAP once or suffered through an unproductive experience in attempting to use CPAP, their chances for success are diminished by these past negative experiences. As he accurately points out, “…many people are given CPAP haphazardly, with little education, support, or follow-up,” which reminds me of an old saying from a golf instructor, “practice makes permanent.” You see, if you keep trying to use CPAP the wrong way and continually experience poor results, there’s a very good chance you will permanently reject CPAP.
Dr. Park’s book is written in such a way not only to motivate you, but in some ways more importantly to help you understand the right steps and the right tools to use so you are using CPAP the right way. Sad as it is to say, the current healthcare system in general and clinical sleep medicine in particular has failed many patients for innumerable reasons, and Dr. Park’s book addresses many of these issues in a convincing manner likely to help someone receive the education that perhaps was not provided by their original sleep center or even more likely by the durable medical equipment company that was providing the CPAP device and related equipment.
Along these lines, I very much appreciate Steven’s candid style as he notes, “…I hold nothing back.” His final paragraph of the Introduction is especially refreshing, because he provides something I frankly could not recall having seen previously in any book: he offers a disclaimer to the traditional medical disclaimer. And, he lays it out so well, I will quote the key points here, “I will include relevant medical research when needed, but I’ve found that even with respected medical studies, you must take the advice with a grain of salt. You have to use common sense and decide for yourself whether or not you want to try one or more of my recommendations. By all means, please consult with multiple physicians about the problems, or about my proposed solutions. I guarantee that you’ll get conflicting opinions.”
As you can see by his choice of words, he does not want to discount the standard advice to discuss various treatment steps with your current doctors, but he is much more interested in empowering you to take the “bull by the horns,” because he recognizes the pivotal role you the patient will play in determining the final outcome, namely using PAP therapy and achieving great benefits or not. However, instead of foisting this patient-centric model of care onto your shoulders as if to shame you into accepting the responsibility, it is obvious he wants to coach and motivate you toward success. For these reasons, I strongly recommend for readers of Totally CPAP to avoid the customary habit of turning to Chapter 1. Reading the Preface and Introduction are crucial components for understanding Dr. Park’s perspective about the realities of clinical sleep medicine, and his framework I believe is accurate, precise, and courageous.
My blog posts for the next few weeks will continue with a discussion on many of the key components of Dr. Park’s book, and we’ll begin here with some thoughts about Chapters 1 and 2 where he discussed the basics of CPAP and the critical importance of mask type and fit.
In Chapter 1 about basics, we learn how CPAP is used to stabilize a collapsible airway, a physiological state measured by the apnea-hypopnea index or AHI. Unfortunately, the concept of the respiratory effort-related arousal or RERA that I discuss so frequently in my posts, shows up a little later when the author turns his attention to how auto-CPAP (APAP) works to potentially titrate out these more subtle breathing events. A reader might be confused at first, because there is no mention of standard CPAP being used to eliminate RERAs, which is in fact the standard of care regarding titrations. Nonetheless, one of the most important pearls in this chapter, one often not seen in other works attempting to educate CPAP users, is to dispel the idea that PAP equals oxygen therapy. It is remarkable how many people believe CPAP means delivering more oxygen to the user. Dr. Park lets us know very quickly PAP is about air pressure delivery and how delivering oxygen therapy to an obstructive airway is “not a good idea.”
In his discussion of patient preferences regarding CPAP vs APAP vs BPAP, he makes a salient point on why we need to be careful in interpreting scientific evidence. First, he reports there are no studies showing clear subjective or objective differences in the different modes of PAP, but then reiterates the caveat: “Just like any scientific studies, they reported overall averages, but didn’t take into account individual variations.” With this backdrop, he offers the percentage breakdown of patient preferences as 1/3 for each of the three primary modes listed above. However, he also points out how this issue poses a practical challenge, because for someone to discover which mode he or she likes best, they would need to find a way to try out the mode, a process that may be inhibited by insurance requirements steering patients only towards initial CPAP or APAP use.
The most obvious place to try out these devices would be the sleep laboratory, but as you know from previous posts on this site, many sleep centers do not even consider offering their patients a chance to test-drive any mode of therapy other than CPAP. While some centers are beginning to test out APAP devices on their patients in the sleep lab environment, very few as far as we can tell use the technique we recommend involving manual titration of auto-adjusting dual pressure technology, which means using auto-bilevel (ABPAP) or adaptive servo-ventilation (ASV). When patients are exposed to these advanced forms of PAP, there is a greater than 90% chance they will select these modes over CPAP, APAP or even fixed BPAP if for no other reason than comfort. Moreover, in our clinical research, we find their results are objectively better than with traditional PAP modes. As Dr. Park points out, modes such as BPAP or ASV may be better options for some patients, but unfortunately you may have no choice in the matter depending on your particular insurance or other circumstances related to the sleep professionals in your locale.
In the ensuing paragraphs, he covers a wide range of comfort-related topics including the use of ramp features, expiratory pressure relief systems, arousal triggering devices that drop the pressure with awakenings, and then concludes the chapter with a very thorough discussion on the essentials of heated humidification, the types of water to be used in these systems, and cleaning schedule steps for your equipment. He also explains the problem of humidification rain-out when the temperature differential between the room you’re sleeping in and the setting on your humidifier causes water to condense in your tube.
The only point of contention in Chapter 1 regarding our approach to care would be our distinctive takes on the issue of comfort. Dr. Park points out that some of the technology related comfort enhancements may prove useful based on patient preferences, but he recommends focusing first on the basics of CPAP initially so you clearly understand what you are trying to accomplish. Our approach places comfort issues at the head of line so to speak, because we see too many patients whose discomfort has already stopped them from using CPAP or has yielded poor outcomes. In other words, the comfort issue itself, most often the inability to breathe out against constant air pressure, discourages so many patients in the initial phases they no longer wish to continue using PAP. And, it is crucial to appreciate that at any given point in time and space when using CPAP or APAP, the pressure is always constant for each breath. For these reasons, we almost always test out BPAP and ABPAP in the sleep lab to assess comfort issues very early in our care model.
In Chapter 2, Dr. Park delves into mask types and mask fitting where he provides a broad and helpful overview on various types. There were a couple of minor wording issues in this chapter to mention. Dr. Park states that nasal pillows rest under the patient’s nostrils, but omitted they also may fit inside the nostrils. He mentions nasal pillows are a great choice and often a favorite first choice for many individuals, but this simple mask type may prove intolerable at higher pressures. Technically, he is correct as it would refer to CPAP use, but in patients on BPAP or ABPAP or ASV, the higher pressures may be more tolerable, because the air delivered will be much lower on exhalation where most pressure discomfort occurs. Last, he mentions that full face masks may cause claustrophobia. Again, technically, he is correct if we are referring to a new patient trying out a full face mask for the first time. However, full face masks often turn out to be the most effective treatment for “mask claustrophobia” in the long run, because it relieves the patient’s anxiety about being able to draw in a breath through the mouth. As claustrophobia is almost invariably based on the false assumption a person cannot catch a breath, it naturally triggers an anxiety attack. When the patient switches to the full face mask, it relieves this anxiety because the patient immediately recognizes he or she will never be prevented from opening the mouth to breath.
That said, Dr. Park is spot on when he declares in a bold subtitle, “The Best CPAP Mask is the One That Works.” And, he further notes that while many people might do well with the first mask they try, others often must go through three to five different masks before finding a good fit. Astutely, he also notes the importance of having a backup mask in case the one you like best becomes damaged and cannot be quickly replaced. Finally, one of the most important suggestions he makes is that “the squeaky wheel gets the grease,” and this point cannot be stressed enough when attempting to maneuver through the intricate systems of durable medical equipment companies and their relationships to your insurance carrier.
In the last part of this chapter, he highlights the importance of using various mask liners including the Pad-a-Cheek product. I would add to that list the REMZzzs liners. Next up, Dr. Park tackles the frequently vexing interactions with insurance carriers.