Encouraging CPAP Use Among Patients With Sleep Apnea
by Lynn Hetzler
Doctors have diagnosed more than 20 million people in the United States with sleep apnea and frequently prescribe the use of a CPAP mask to help these patients breathe better. Unfortunately, less than half of those prescribed a CPAP mask actually use it. A sleep expert at National Jewish Health has devised an approach he hopes will increase compliance with CPAP masks – by showing patients videos of themselves struggling to breathe while they sleep.
Sleep apnea is a common disorder that interrupts breathing during sleep. Someone with untreated sleep apnea may stop breathing 30 or more times each hour, according to the National Institutes of Health (NIH). Pauses in breathing may last for seconds or minutes before normal breathing begins again, sometimes with a loud choking sound or snort. Sleep apnea may also cause shallow breathing or snoring sounds.
Paused or shallow breathing causes an individual to move out of restful deep sleep into less restful light sleep, which often results in daytime sleepiness and fatigue. In fact, the NIH names sleep apnea as a leading cause of excessive daytime sleepiness.
Because it happens while they sleep, many with sleep apnea do not realize they have the condition until someone else points out the paused breathing or snoring sounds.
Sleep specialists determine the severity of a patient’s sleep apnea by measuring oxygen desaturation levels and determining the Apnea Hypopnea Index (AHI), which reflects the number of apneic episodes in which the patient stops breathing during an hour of sleep. The Division of Sleep Medicine at Harvard Medical School uses AHI to classify the severity of sleep apnea:
- None/Minimal: AHI < 5 per hour
- Mild: AHI ≥ 5, but < 15 per hour
- Moderate: AHI ≥ 15, but < 30 per hour
- Severe: AHI ≥ 30 per hour
Paused breathing reduces the amount of oxygen in the blood. Normal blood saturation is usually 96 to 97 percent at sea level. Oxygen saturation can dip to 80 to 89 percent in patients with moderate-severity sleep apnea and can drop below 80 percent in those with severe sleep apnea.
Left untreated, sleep apnea can increase the risk for hypertension, heart attack, stroke, diabetes and obesity. It can also increase the risk of heart failure or worsen the condition and increase the risk of arrhythmias. Daytime sleepiness associated with sleep apnea increases the risk of work-related or driving accidents.
The three main types of sleep apnea are:
Obstructive sleep apnea – occurs when muscles in the throat relax
Central sleep apnea – occurs when the brain fails to send proper signals to the muscles that control breathing
Complex sleep apnea syndrome – occurs when someone has both central sleep apnea and obstructive sleep apnea
Obstructive sleep apnea is the most common type. Relaxation of the throat muscles causes collapse or obstruction of the windpipe. Air squeezing past the blockage causes loud snoring.
CPAP, an acronym for “continuous positive airway pressure,” is a therapy that helps people with sleep apnea breathe better while they sleep. The CPAP machine delivers air pressure through a mask placed over the patient’s nose. The air pressure delivered by CPAP is at a higher pressure than the outside air, and this extra pressure holds the upper airway open as the patient sleeps.
While CPAP is effective and reliable, many people find it cumbersome or uncomfortable, so they stop wearing the machine after just a few weeks. Others stop wearing their CPAP because they do not realize how much they struggle to breathe while sleeping. Mark Aloia, Ph.D., may have found a way to increase compliance with CPAP – by showing patients videos of themselves gasping for air and struggling to breathe as they sleep.
The results were dramatic.
Personalized Snoring Video Boosts CPAP Compliance
The first results, an ongoing clinical trial presented at the annual meeting of the Associated Professional Sleep Societies, suggest that patients who watch videos of themselves having apneic episodes were significantly more likely to wear their CPAP.
The researchers enrolled 24 participants diagnosed with sleep apnea into the study and randomly assigned the subjects to one of three treatment groups. Participants in all three groups received sleep apnea and CPAP education. One group also watched videos of a stranger having apneic events during sleep. Another group watched videos of themselves snoring and gasping for air as they slept.
In the preliminary results, the participants who had watched videos of themselves used their CPAP treatment for a mean of 6.5 hours each night across the 99-day study period. Those who had watched a video of a stranger wore their CPAP units for a mean of only 4.1 hours a night, while participants who had received standard CPAP instructions only used their devices a mere 3.5 mean hours per night.
Even after adjusting for age, education level and the severity of sleep apnea, participants who watched videos of themselves gasping for air used their devices more than two hours longer than did participants in the other two groups.
Participants in both video-intervention groups watched 30 minutes of sleep footage once before starting CPAP therapy. The research team downloaded data from the PAP devices over the first 90 days of use to determine CPAP adherence.
The average age of participants in the study was 50 years. Participants had moderate to severe sleep apnea, with apnea hypopnea indices ranging from 26.5 to 33.3. Most study subjects were obese, with body mass indexes over 30.
Seeing themselves struggling to breathe seemed to have a profound effect on the participants. John Brugger was one such patient. “It was a powerful moment in my life,” said Brugger. “It made me cry watching it, and to see myself basically drowning in my sleep made me very determined to fix that.”
Since seeing the video, Brugger now wears his CPAP mask every night.
“Many times, we think that if our patient just knew what we know, he or she would use CPAP more, but there is evidence that doctors don’t take their medications any more than patients do, so it is not just a matter of education; it is a little bit deeper than that, and it has to be personalized,” said Dr. Aloia, a psychologist at National Jewish Health in Denver.
“The use of a personalized video is promising… we hope to present more data next year.”