Rochelle Goldberg, MD, FAASM, FCCP

Diplomat, American Board of Sleep Medicine

Director Sleep Medicine Services

Main Line Health Systems

Lankenau Medical Center and Paoli Hospital

So PAP Doesn’t Work

Disclosures

• Speaker: Teva, UCB, Purdue

• Advisory Board: Welltrinsic Sleep Network

• Consultant: Vapotherm, Inc.

• National Interpretor: Novasom

The Translation

• What they say... “It doesn’t work!”

• What they may mean… – I hate it and don’t want to use it.

– I have problems with it (mask, air, etc)

– I’m still snoring, choking, etc.

– I still can’t fall asleep.

– I still don’t sleep well.

– I am still sleepy.

Translation 101a

“I hate it and don’t want to use it!”

• Is it an education issue?

– Do they understand sleep apnea?

• Relate their specific symptoms to the diagnosis.

• Are they aware of the risks of untreated apnea?

– Are test results clear?

• Severity, oxygen and sleep effects; PAP findings

– Are they aware of other treatment options?

Translation 101b

“I have problems using it.”

• Is it a technical or compliance issue?

– Do they understand PAP treatment?

– Are they using equipment properly?

– Are side effects of PAP interfering with sleep?

– Are there environmental or family issues?

Translation 101c

“I’m still snoring, choking, sleepy, not

sleeping well.”

• What were the original symptoms?

– Is there any symptom resolution?

– Are these consistent with treatment problems

or limited compliance?

– Are symptoms unrelated to sleep apnea and

PAP?

PAP Compliance and Sleepiness

Weaver TE, Grunstein RR. Proc Am Thorac Soc

2008 Feb 15: 5(2): 173-178.

Excessive Sleepiness

Bixler E O et al. JCEM 2005;90:4510-4515

Excessive Sleepiness

Bixler E O et al. JCEM 2005;90:4510-4515

Sleep in Translation

• Are there other sleep problems?

–“It ain’t all apnea, and even when it

is-it ain’t all PAP!” R Goldberg-famous sleep philosopher

Question 1 Joe Stevens has been using CPAP for 3 months. He is not

snoring, but continues to have dry mouth (using a nasal

mask). He returns with complaints of continued daytime

sleepiness? Which of the following would be most helpful

to evaluate his ongoing concerns?

A. compliance report

B. urine drug screen

C. medication review

D. Epworth sleepiness scale

“It’s not working” (…but it

should)

• Consider timing of the problem:

– Early: learning curve, settings (pressure,

ramp, humidity), training, mask fit, side effects

– Later: equipment wear, patient changes

(weight, allergies, other medical), new side

effects

Early Equipment Issues

• Mask vs. machine

• Fit, leaks, the “180”have patient put mask on; training, refitting;

• Pressure, ramping, humidity review test, adjust ramp or heater

• Patient specifics • Sleep position review sleep test details, consider pressure

• Allergies / nasal complaints heater, filter, cleaning, RX

• Family dynamics, cultural implications

• Environmental changes • Altitude, humidity adjust settings, patient education

• Swimming with PAP or the dog ate my…

Later Equipment Issues

• Mask vs machine – Worn supplies, equipment cleaning patient education

• Patient specifics – Weight change consider pressure adjust and / or mask re-fit

– Other medical, allergies

• Environmental changes – Travel implications and adjustments humidifier, altitude

It is working…

but symptoms persist

• “I still can’t fall asleep.”

• “I still don’t sleep well.”

• “I am still sleepy.”

“I still can’t fall asleep”

– Insomnia

– Inadequate sleep hygiene

– Circadian rhythm disturbance

– Restless legs syndrome

– Medications

– Other medical or psychiatric conditions

“I still don’t sleep well.”

• Insomnia

• Inadequate sleep hygiene

• Parasomnias

• Medications

• Other medical or psychiatric conditions

Question 2 Susan Waakup is a 53 yo woman with OSA. She has been using

CPAP regularly for the past 6 months. She reports good PAP

compliance and is pleased that she is not snoring. She is still having

problems sleeping. These include trouble falling asleep, frequent

waking and “discomfort”. Her medical history includes hypertension,

hyperlipidemia, depression. She is perimenopausal. She is married

with twins who recently started college in another state. Of the

following choices, which is the best next step?

A. obtain actigraphy and order a ferritin level.

B. download PAP compliance report and start sleep logs.

C. repeat PAP titration and review medication list.

D. start auto PAP unit and refer back to her psychiatrist.

“I am still sleepy.”

• Insufficient sleep (sleep deprivation)

• Circadian rhythm disorders

• Narcolepsy and other hypersomnias

• Medications

• Other medical or psychiatric conditions

Medications and Poor Sleep • Cold and allergy remedies

• Antihypertensives (beta antagonists)

• Cardiac treatments (digoxin)

• Lipid-lowering drugs

• Thyroid supplements

• Birth control medications

• Asthma therapy

• Pain medications

• Antidepressants (especially SSRIs)

Medications and Sleepiness • Codeine (pain medications and cough suppressants)

• Morphine (and other pain medications)

• Antihypertensives (alpha 2 agonists)

• Antiarrhythmic agents (fatigue)

• Dopamine agonists (pramipexole, ropinirole)

• Antiepileptics

• Sleep aids (including benzos, non-benzos, OTC remedies)

• Anxiolytics

• Antihistamines (prescription and OTC)

• Antidepressants (older TX-TCAs, MAOIs)

Medical Conditions and Sleep

• Medical conditions commonly associated with sleep

problems: – Pregnancy

– Menopause

– Headaches

– Cardiac disease

– Pulmonary diseases

– GERD

– Rheumatologic conditions

– Chronic pain conditions (including fibromyalgia)

– Degenerative neurologic disease

– Stroke

– Substance abuse (alcohol, drugs active and withdrawal)

Psychiatric Conditions and Sleep • Depression

– Insomnia or sleepiness

– Insomnia as a risk factor for depression

• Bipolar disorder – Sleep complaints vary with cycling

• Generalized anxiety – Sleep initiation problems, or extended wake time

• Panic disorder – May be isolated nocturnal

• Schizophrenia – “In schizophrenia, sleep is habitually disturbed.”-Bleuler 1950

Insomnia(s) • Characterized by difficulty initiating sleep, disturbed sleep during the

night (or non-restorative sleep complaint).

• Considered a hyperarousal phenomenon.

• May be primary; secondary to other sleep, medical or psychiatric

conditions.

• Prevalence 5-48% in general population.

– Varies broadly by definition applied.

• Increased risk: female, older, lower socioeconomic status

• “Growth industry”!

– Role of pharmacology??

• Treatment generally includes behavioral measures.

– Cognitive therapy, stimulus control.

Inadequate Sleep Hygiene

• Behavioral condition (lifestyle).

• Routines that interfere with proper sleep

timing and stability.

• Frequent component to insomnia and

sleepiness complaints.

Good sleep hygiene

1. Keep a regular schedule for bedtime and wake time.

2. Avoid mentally or physically stimulating activities, and emotional stress close to bed. Relax prior to getting into bed.

3. The bedroom should be cool, dark and quiet.

4. No TV in the bedroom. Turn clock away-DO NOT CLOCK WATCH.

5. The bedroom is reserved for sleep (and sex).

6. Avoid naps.

7. Maintain regular daily activites. Avoid exercise close to bedtime.

8. If hungry, have a light snack at bedtime.

9. Avoid alcohol late in the evening.

10. Limit caffeine later in the day.

11. Avoid sleeping medications (prescription and OTC).

Circadian rhythm disorders

• Common theme is misalignment of body

clock and environment.

• Supported by temperature disregulation

and melatonin.

• Delayed sleep phase, advanced sleep

phase, shift work disorder, jet lag.

Question 3 Jay Night is a 22 year old man who complains of significant

daytime sleepiness. This has been a problem for 4 years.

He may nap on weekends but does not find naps

refreshing. The Epworth score is 15. Statistically, the most

likely explanation for his sleepiness is:

A. Sleep apnea

B. Narcolepsy

C. Insufficient sleep

D. Restless legs syndrome

Insufficient Sleep

• Behavioral condition.

• Limited time in bed, does not meet sleep needs.

– Sleep itself is not impaired.

• Daytime sleepiness results.

• Extended sleep hours improve symptoms.

• An epidemic!

Good Sleep Care Recipe

• Take a thorough sleep history

– Order sleep testing (if needed)

• Apply education

• Provide support

• Combine gently

• Repeat as needed

Conclusion • It ain’t all apnea!

• Even when it is apnea, patients may have

other sleep problems!

• It is our job as sleep clinicians and

educators to spread this word…

– to patients, other clinicians (and those who

determine treatment authorizations)