ADVENTing: Getting the Most Out of Your CPAP

Sleep apnea diagnosis has the potential for mistreatment. On this episode of ADVENTing, we discuss setting you up for success when it comes to sleep apnea.
Reviewed by
Published on
November 20, 2019
Updated on
December 9, 2019

We don't want to give you a CPAP but if it is the best solution for you ADVENT knows how to make sure you get the most out of your CPAP.

So looking at sleep apnea in particular I would say out of all the areas we treat and that's a big one that's an area where there's the most misunderstanding, misdiagnosis,

Non-diagnosis, under treatment, poor treatment, over treatment in some regards.

It's just a certain kind of show that's not a good show kind of a thing. I mean it's just and it has never been since the dawn, sleep apnea's been around since the dawn of humankind, but the diagnosis of sleep apnea came about in the 80's so it's not that long ago. It existed before then, but we didn't have any way to measure it and the deal with sleep apnea is that in order to measure what's happening, to test what's happening you have to test and do a sleep study. Back in the old days the only way to do a sleep study was in a sleep lab and the sleep labs were run by pulmonologists who also then decided upon the treatment, which was a CPAP machine. So somebody has to just break it down. If somebody has sleep apnea they have a throat issue about 100% of the time. Obstructive sleep apnea is not 95%, 90%--

It's obstructive.

Obstructive sleep apnea by definition means you're obstructing your upper airway period.


So if you had a throat issue 100% of the time about one to 2% of those folks who have a throat issue are actually treated by throat specialists like us.

Right, which is crazy.

Which is crazy, now to flip that and somebody says, if somebody were to say, "Well buddy I don't believe you, "you know I don't think that can be that there's nothing "in the world that's a 100%" The proof to that reality is if you have obstructive sleep apnea and we do a trache, so a trache means we're gonna put a breathing tube in your neck below our upper airway, we will cure your sleep apnea or your obstructive sleep apnea 100% of the time. It's a cure.


So by, again I'm not usually one about like a 100% of this and that, but it's a throat issue, like I don't know that there's much of, I have not, I welcome, I would welcome somebody to step up to that challenge and say otherwise.

And to clarify there is something called central sleep apnea


And that's different and that's a brain issue. It's a signaling.

So central sleep apnea is your brain tells your lungs to breathe. Your lungs decide to expand and your upper airway shuts down.


The back of your throat shuts down. That's obstructive sleep apnea. That's what that is. So that's what we're talking about. Central sleep apnea which happens, it's very rare, but it does happen. Central sleep apnea is when the brain forgets to tell your lungs to breathe to begin with and that's a whole different issue.


That's a brain issue. Now the reality is this is not 100%, but I'd say, but almost everyone who has central sleep apnea has obstructive sleep apnea. It's very rare for those things for central sleep apnea to exist without obstructive sleep apnea.


If you have mixed sleep apnea, which means central sleep apnea and obstructive sleep apnea, the first line of treatment is you treat the obstructive component. Treat the throat issue and many times the central component will become better.


So even there so not to confuse the issue at all, I'd say yes, central sleep apnea is not a throat issue period. Though many folks who have central sleep apnea actually do have a throat issue, because they have obstructive sleep apnea as well, but then back to obstructive sleep apnea. If you have a throat issue, the challenge is the gold standard for treatment is a CPAP machine, which is a machine that you put on your nose, on your nose and your mouth and it pushed air to the back of your throat. It's basically just blowing constant, so continuous positive airway pressure, CPAP. That's what that stands for. So it's blowing and by blowing it's tenting that open. It's not delivering oxygen, it's just pushing air in to hold a tube that's collapsing to hold it open. That's what that is.

So why is that the gold standard?

Why is that the gold standard? You tell me.

Yeah so this is where this just doesn't sit well with me. Like we said okay so ENT doctor, throat issue, we should be treating that issue. The reason why a CPAP machine in my opinion is the gold standard is because well, how was sleep apnea diagnosed? Usually sleep medicine doctors, pulmonary doctors and so they use something that can be effective and work well for patients, but that is the only thing that they can give a patient.


You know so for them, all the studies, all the treatment studies everything else was based on a technology that again can be effective for some people, hard to wear we can get into that, but looking at a sleep doctor prescribing a CPAP machine you know because you couldn't do anything else.

Yeah because they can't, so their only option, if you're a sleep medicine, a pulmonologist or a neurologist that does sleep, your only option that you can actively deliver to somebody is the CPAP machine.


Which is okay when it works, but the reality is that more often than not it doesn't work. So if 100% of folks who have sleep apnea have a throat issue about 80 to 90% of those same folks also have nasal obstruction and they may not know about it. So these areas are interrelated. So your nose and your throat, they kind of play in tandem and if your throat is tight by definition if you have sleep apnea your throat is tight and then by definition, so that's one of the holes you can breathe through and then the other two which are your two nostrils are likely to be compromised. So those things go hand in hand. And so if you're a lung doctor with a CPAP machine treating a patient with a throat issue and a nose issue your machine that you're gonna use isn't gonna work properly.

Well because especially is the nose is tight you're pushing it through a tiny straw versus a big tunnel. And so why do most patients end up getting full face masks? Well because maybe they start with that nasal mask and they can't tolerate it because their nose is so tight. Then they get a full face mask slapped on them and then it's really hard to tolerate that machine you know, and then compliance rate. This is the other thing that really vexes me is that you know compliance from a insurance, "Hey this patient is using this or not" is based on four hours of sleep five nights a week, right and there's not a single person out there that tells me that they will feel rested. Let's say they didn't have sleep apnea and they were sleeping four hours a day or night five days a week like that person isn't rested and they don't have sleep apnea.

So that, follow the ball there four hours of sleep five nights a week is, that's the bar we're setting.


Which is a crappy like that's a low.

That's a horrible bar.

That bar which is starting, you're starting out like, "Hey guy," if you're let's say you're doing baseball and you're, you're basically saying, "Oh my bar is I need to be a 100 hitter to be successful." Now the bar is so low the likelihood they're gonna hit that bar is about 30% like you started out your bar is ridiculously low and you're not even gonna hit that and then you're gonna accept that as, "We're all good" you know kind of a thing, which just doesn't make any sense.

Or the thought that a doc would tell the patient, "Hey you're compliant. "You're using this and it's working for you."


When a patient is like, "No this isn't working for me," but no, no, no you're compliant, so it says that you are.

Right, correct. Yeah it doesn't make any sense, but it's just how it is. There are a lot of things in medicine, so I think again, I think a lot of people come to our profession with an expectation that everything's been sorted out like an ENTs is an ENT, a sleep study is a sleep study, a CPAP is a CPAP. Everything you know is the same, this is the same and it's a, no. In my opinion, there are a lot of things, I mean we certainly benefit from all the hard work that has been done up until now with all the docs and various specialties that have done that work wonderful, but the understanding and the treatment, especially for the issues that we deal with are still pretty rudimentary compared to, I mean things have not moved forward as much as they should and part of that. I guess and you said it before, I'm gonna sort of bear the cross on this is that, whose fault is it that lung doctors, and brain doctors, and psychiatrists are treating a throat issue? Whose fault is that?

It's the ENT's fault.

It's our fault, it's my fault and it's your fault. That's you know, we absolutely bear the price for the sins of our fathers and mothers you know that's on us. That doesn't mean you have to be sort of cursed forever, it says, "Well we can own up to that." The reality is, if you have sleep apnea what you deserve is to be treated by somebody who can offer all the treatment options that are available. That's my opinion. I don't think that's not sticking my neck out really far.


That's just saying you gotta throat issue, maybe you oughta see somebody who can do a CPAP if that's appropriate, do an appliance if that's appropriate, do surgery if that's appropriate. Now we as surgeons rarely do throat surgery for sleep apnea. That would be if you guys are looking at doing throat procedures for folks who have sleep apnea. There are certainly people who are good candidates for throat surgery for sleep apnea, but most people aren't.

Well I mean certainly you wouldn't necessarily do throat surgery if their nose was completely shut down too, first right? So throat surgery tends to be you know longer recovery, more painful you have to be on pain meds things like that. So we use it wisely, in the sense of when we decide to move forward with a patient on that it's, have we checked some other boxes and made sure that we've addressed some other issues that are easy to address first? And then is this what makes sense moving forward?

Right, and another way to say that a little differently is that kind of what we were talking about before about medications and those sorts of things. My personal opinion is if I have sleep apnea I could rid myself of that issue without having to use a CPAP machine that's how I would choose to do it. Doesn't mean that's right for everybody else it's fine. The reality is in the typical system, this medical system as it exists, if you go into any sleep center, the only treatment option is gonna be CPAP, so that game is by definition rigged. It's rigged against you. It is a shake down, and it's not a shake down that was set up with ill will I don't think. It was a shake down that was set up because that's the only tool we have man, like I am a throat doctor but if I wasn't a throat doctor and I'm seeing this problem which is significant I mean there's millions of millions of people in this country who have sleep apnea who aren't getting treated.

And it's grossly under-diagnosed

Because it's rigged.


Because everybody knows that thing's rigged against you, I'm gonna go in I'm gonna get the study. I'm gonna get a CPAP machine. And CPAP we prescribe a lot of CPAP, we do. And because it's an appropriate treatment when used appropriately, unfortunately is that machine that can help a lot of people is misused so you know it hurts at both ways, like you're misusing it when you can use it properly and it just doesn't pass at all.

But we prescribe a lot of CPAP having a full transparent conversation around hey, with patients, these are your options. They choose to do a CPAP machine.

Because we've looked at all the options.


There are times, if somebody has severe sleep apnea, meaning the throat is super tight and we, of course we're gonna get their nose working before we do any of these treatments because it's necessary and if CPAP's the right option for you, you're gonna hear that and you don't have to. We're not gonna stutter. You don't have to read between the lines here. It's gonna be really the right option for you to use CPAP. Now that's some folks, most folks have options. Most folks who have sleep apnea machine, if somebody has sleep apnea that needs to be treated, then the CPAP machine is going to be a potential treatment option, but there are gonna be other options, and so an oral appliance is a different way to go about it. It's basically like retainer. You wear it when you sleep at night. It sits in your mouth and it's just helping open up your airway by using your teeth to open that airway up. Most folks who are candidates for CPAP are candidates for an oral appliance. Most folks who are put in or forced into a CPAP or told to buy a CPAP never hear about an oral appliance. And then again there are some folks who would be good surgical candidates from a throat standpoint. Those mainly would be folks who have big tonsils or issues that we can get in there, get out of your way and maybe you don't need a machine to push air at ya and maybe, it literally open an avenue. So if, if, if we are suggesting that somebody starts with a CPAP machine, that is here. We are either approving your nose and how it exists or we're gonna make it better. We're gonna make sure your nose is a good pathway for you to breathe because it's the start of your airway, so that's gonna be, that's right behind.

And the nose is the primary, the nose is the airway you should breathe through.

Absolutely, no question, but then if we are saying CPAP that means, that's really a good option for you. You're gonna know that we've considered all the other options. We're gonna talk through all those other options anyway, so it's not like you have to have any guessing games.

Well how many patients have you had come in here that maybe are on a CPAP machine, how many of them have ever been told about any other options for the most part?

I put that out to the world and say, if you're in a CPAP what other options were discussed with you?


And I, knowing, we see so many patients from so many different you know sort of broken systems that come in to see us that they just don't and part of that is, part of it is because they don't have the capability to do anything other than the machine, so if you cannot put somebody in an appliance you're not gonna talk about an appliance. If you can't do a procedure on their throat you're not gonna talk about that, if you can't even look at somebodies nose or look into the nose or fix that nose you're not gonna talk about that. You're gonna talk about this is the option so you know, and you just don't wanna talk about whatever you can't do or say or control, it doesn't exist.


Which is not, I'm not okay with that I mean I'm okay with you know I'm okay with everyone bringing their best if we're on the playing field we'll bring our best game, and everybody else brings their best game and we'll see you know, whose victorious on the field and that's fine I don't have any problem and full disclosure here's how it is. But some of the shell games that happen in the sleep world, in the CPAP world, it's not just sort of, it's actively hurtful, it's actively making a decision for somebody else that you have no business making the decision for. That's not, my job and your job is as you know physicians and surgeons isn't to take control of somebody and say this is what we're gonna do you know without any you know kind of conversation about it. it's a education. It's a discussion. It's a let's kind of work together on this sort of thing. That's just not how it's done elsewhere. Because they do that, they can't do that because it only works to have that railroad mentality.

Yeah, I mean one of the things that you always say that stands out to me is that you know, what's one of the greatest sins you know, if you have if you know of other options that are on the table and you don't present 75% of them because you can only do one versus hey maybe if you're unaware of other options and you're presenting what you truly believe are the best options, fine. You're doing the right thing and I think you're presenting as best you can and if you don't know you don't know you know, now go learn about more things. But if you have lots of options on the table and you again, don't tell patients about seventy-five percent of them because you don't have those ability to give that to that patient that's not right

That's not okay, and that's an opinion I mean maybe there's a counterargument maybe there's somebody in the world would think the opposite um and that's cool I guess that's fine for them that's just not like it's not at all and I guess I'd say our mindset. Maybe it's the patients who come to see us. Maybe it's because folks are seeking out like minded mindsets and attitudes maybe it's the prevailing attitude around us is that I don't I am not, I can not recall sitting down with somebody talking about sleep apnea talking about the options where um you know where it hasn't been received with, you do not have to be thrilled with me telling you

You have sleep apnea.

You have sleep apnea and this is what we need to do. You don't need to be like sort of singing songs about it, but I think walking out of here with a thorough understanding about what's going on, why it's going on and what the rational options to treat that those issues are like that doesn't get old as a construct.

Right, yeah.

Like that's what we do. You know that's what we're here for. And know and each person gets to sort of make an informed decision based off the information. That's it.

Yeah, and I feel like you know to the best of our extent, we are presenting every option that we know of and that we can deliver on.

Sure, absolutely yeah.

That's a wrap.

First published by ADVENT on
November 20, 2019
Table of contents
ADVENTing: Getting the Most Out of Your CPAP