Classic SleepCast

Comments on the New AASM PAP Guidelines


Barry Krakow MD - October 27, 2017 - Expert Insight
The AASM recently published a draft for new guidelines on the use of PAP therapy in order to spell out in reasonable detail the evidence that should steer sleep professionals in their efforts to treat OSA patients who use PAP. Because the process of developing guidelines is typically constrained by the premise that only high level evidence can be included in such consensus-style documents, the ensuing recommendations always end up with a fairly conservative tone. As the best example of this process, STRONG recommendations mean the evidence is very solid, whereas CONDITIONAL recommendations are more tentative. Of the 12 recommendations summarized at the beginning of the 63-page paper, only 4 fit the strong category and the remaining 8 are conditional. Quoting from the paper: “A CONDITIONAL recommendation reflects a lower degree of certainty in the appropriateness of the patient-care strategy, requires that the clinician use their clinical knowledge and experience,... Read more

Totally CPAP by Dr. Steven Park: Part V


Barry Krakow MD - October 25, 2017 - Expert Insight
First, it is necessary to point out as a segue from the previous post, the theme of advanced PAP is not widely researched, supported or advocated by most sleep centers in the country and around the globe, thus Dr. Park’s ideas remain well-constructed, valid and useful, because of the vast majority of OSA/UARS patients who are prescribed and attempting CPAP. As you will see in this post and later ones, for many of the issues identified and addressed by Dr. Park, we believe switching patients to advanced PAP therapy sooner rather than later should be the wave of the future in sleep medicine. But, until the insurance carriers and most sleep centers begin to adopt this premise, we need to stay focused on how the CPAP response can be improved, while simultaneously accepting that for some patients a CPAP mode will never solve their problems. In this second half of... Read more

Totally CPAP by Dr. Steven Park: Part IV


Barry Krakow MD - October 10, 2017 - Expert Insight
In chapter 5, Dr. Park tackles a very difficult aspect of the CPAP process as he tries to walk the tightrope between what research alleges about the process versus what actual users say about their experiences. The chapter divides into two main parts, and in the first half Dr. Park and I see virtually eye to eye on so many dimensions of the poorly recognized difficulties in adapting to PAP therapy. Right from the start, he questions the high regard placed on the concepts of adherence or compliance, when the paradox is clear that someone could be using a PAP device for many hours and thereby gain insurance coverage and yet still be receiving a lousy response to treatment. Instead of these insurance-driven terms, he prefers the word “stickiness” to convey how attached someone becomes to their CPAP machine and CPAP experience. Obviously someone gaining great benefits with little to... Read more

Totally CPAP by Dr. Steven Park: Part III


Barry Krakow MD - October 04, 2017 - Expert Insight
In chapter 4, Dr. Park returns his discussion to one of my favorite topics in managing CPAP patients, and he sums it up quite nicely and in bold no less: It’s your mindset. For a book that’s only a little over 100 pages long, it is inspiring how often Dr. Park returns to this topic to help people realize they hold the power within themselves to determine whether or not they will succeed with PAP. So many other books, research papers, and lay articles incessantly talk about conventional wisdoms such as find a comfortable mask, be persistent, start with lower pressures, use a humidifier, and don’t give up. Now, all these suggestions are worthy, and Dr. Park addresses them as well, but Totally CPAP is different because it goes to the heart of the matter, which in a word is: YOU! And, ultimately the way you choose to think and... Read more

Totally CPAP by Dr. Steven Park: Part II


Barry Krakow MD - September 25, 2017 - Expert Insight
Dr. Park continues with a discussion on many of the complexities in dealing with the insurance carriers who usually cover costs associated with PAP therapy, including devices, masks, headgear, tubing and humidifiers as well as for resupply of this equipment. The book does a good job of laying out the various steps and encounters in the process of working with an insurer, and he notes these relationships are often an awkward tetrad involving “convoluted” interactions between patients, sleep centers, insurance carriers and durable medical equipment companies (DMEs). Any person familiar with efforts to acquire a wheelchair, a pair of crutches, or supplemental oxygen will immediately recognize how this relationship works…up to a point. The doctor sees the patient and writes a script for the equipment, let’s say a pair of crutches for someone with a badly sprained ankle. The prescription goes to the DME, who also receives the doctor’s notes... Read more

Totally CPAP by Dr. Steven Park: Part I


Barry Krakow MD - September 17, 2017 - Expert Insight
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... Read more

Second Opinions and the Rise of REPAP: Part V


Barry Krakow MD - May 11, 2017 - Expert Insight
The impetus to develop the REPAP protocol derives from the recognition CPAP failure often emerges because continuous pressurized air provokes expiratory pressure intolerance (EPI) when settings are raised to titrate out RERAs. In accordance with AASM standards, a sleep laboratory must attempt to titrate out RERAs, the most difficult to treat of the three main breathing events (apneas, hypopneas, RERAs). To solve this problem, we learned several years ago the sophisticated algorithms embedded within the auto-adjusting technology of ABPAP and ASV coupled with an assist through the manual override of the sleep technologist were sufficient meet AASM standards to eliminate RERAs without triggering EPI. Although we alluded to this phenomenon in our initial PAP-NAP paper1 published in 2008, it was not until four years later we provided more definitive data2 and commentary3 on the topic to explicitly point out the failure of the CPAP mode of air delivery. Since then and more recently... Read more