The Sleep Quality Conundrum
I am often asked by patients who are treated for OSA/UARS, “how do I know whether I am getting a good enough response?” The two common scenarios for this question are those using oral appliance therapy or OAT and those using CPAP. Most using OAT received a mandibular advancement device that inserts into the mouth and anchors to the teeth (the device fitting is based on impressions made from upper and lower dental arches). CPAP users nowadays are usually on auto-CPAP that adjusts pressures during the night.
Many people obtain fantastic responses to OAT and to CPAP or auto-CPAP, but even among this group you will find individuals with lingering questions about their response.
Unfortunately, in the field of sleep medicine rarely do we see a push to optimize treatment to gain outstanding responses. A big part of the problem is no one seems to know what an “outstanding” response would look like. Making matters worse, the CPAP world places far too much emphasis on number of hours of device use, a policy strictly enforced by insurance coverage guidelines. I say unfortunate because many sleep professionals are now slanted towards pushing patients to use CPAP more hours instead of stepping back and looking at the big picture to clarify precisely how well the individual is responding to this treatment. To far too many sleep doctors, it appears that using a device for a sufficient number of hours is enough information to declare the response, “good enough.”
Making things more problematic, many sleep professionals as well as patients become obsessed with variables they can download from the device, the two most common are leak and apnea-hypopnea index (AHI). It certainly makes sense to keep the leak as low as possible if not zero and the same for the AHI numbers, but you could use a CPAP device for 7 straight hours, show no leak or breathing events and still feel like crap in the morning and the rest of the day. In other words, it’s not at all clear who is asking, “how well are you sleeping with CPAP?”
And, further complicating things, if patients report persistent sleepiness after regular use of CPAP, then sleep professionals are being guided by the pharmaceutical industry to prescribe stimulants or newer wake-promoting agents to relieve this residual symptom.
When you consider all the above, I implore you to realize sleep quality is NOT being measured or addressed on most of these patients. It probably sounds surprising, but the truth remains most people who think about sleep including professionals and patients tend to think in terms of number of hours of sleep. Since 1995, we’ve been pushing the sleep quality angle as the much more relevant guidepost.
The failure of so many to ignore sleep quality is one of the reasons I started this newsletter and a primary reason for writing my new book, hopefully coming out early next year.
FYI, the next Discussion Q & A will occur in January