Diabetes and Sleep Apnea - P2

After Max and I worked with three recent new members, Tim called and asked us to meet with him. When we arrived, there were the two that had been asking us questions before and five other members. Tim told us we had the floor for any questions they wanted to ask. Questions we received and Tim asked that they take turns.

I said that I should start with the experiences that I have been through as all seven would be 65 years of age in a few years. I said that Max and I had each been to separate doctors and thus our experiences are different. Both of us needed to use a sleep study lab for the first time we changed equipment under Medicare. I went to Mason City and Max went to New Hampton.

I said that even my first sleep study was a sleep study lab. A sleep study lab means that you will arrive about 7:00 PM and then you will be fitted with a harness of wires attached to sensors on your head, neck, and chest plus a few on your lower legs. Then you are expected to sleep while cameras watch you. Yes, you have covers over you. I actually had two sleep study labs for Wellmark. The first determines that you actually have sleep apnea and the second to determine the pressure settings. When I had the one for Medicare, I was set up like the first sleep lab and when I had satisfied the first requirement, I was changed over to the second part of being on a CPAP machine.

Max stated that his first was a home sleep study that determined he had sleep apnea and the second was a sleep study lab to determine what pressures would be best. Max then stated that the Medicare was the same as what I experienced, just at a different place.

Everyone wanted to know why the two times and Max said that the first is to determine the degree of sleep apnea and that you have sleep apnea. The second sleep study is to determine the upper and lower pressure settings as now most CPAP machines do operate in a range and this is important for you to get the best sleep.

Max stated that his lower pressure is set on 12 and the upper pressure is 18. When asked I said my lower is set at 10 and the upper is set at 15. My average during sleep is 12.4 and I have lows at 10.3 and upper at 14.8. Max said his average is about 14.4 with lows at 12.8 and upper level is at 17.

Several more questions followed asking if we had a favorite doctor. Max and I both agreed we liked our doctors, but I stated that this should be up to each of them. I said that three others could answer that question after they finished their in home tests. I said home tests are becoming more acceptable and are being used more than the sleep study labs.

I stated that my sleep doctor is from India, and for several years showed his heritage by ignoring women until he encountered my first wife. When she asked a question and when he did not answer, she got up in his face and asked him why he could not answer her question. She told him that in the U.S. women are considered equal to men and just because I was the one being treated, she felt her question was important and if she was to help me, she should receive an answer. I said since then he has always answered questions from my second wife and not hesitated.

Max said his doctor is from Tennessee and talks more to my wife than he does with me. She, like Bob's wife, does not like the noise from the CPAP machines and complained about the first two machines, but the last one is quiet. Also, some of the earlier CPAP machines had masks that expelled a lot of air and you had no control over where it was aimed, which makes the position you sleep in miserable for a spouse. The newer masks are somewhat better, but still can blow air on your spouse if you sleep in the wrong position. Max said this means that you will be the one adjusting to be kind to your spouse.

We talked for another hour and answered many questions, but everyone seems ready to be tested and asked for the phone numbers of our doctors. We said we would be available to answer future questions and would ask the other three if they would be willing to answer questions once they had their CPAP machines.

Max said he would send out an email showing some of the machines available and they needed to be aware that their insurance might only cover one or two machines. As is was all had the same insurance that Max and I had and so they would have at least four different CPAP machines available.

Are You Using Your CPAP?

I wish the people who title some of these articles could use the correct terms. I had to cringe when I read this - "Are You Wearing Your CPAP?" To begin with, it is impossible to wear a CPAP machine and that is the reason for my title. Yes, if you have obstructive sleep apnea, you should use a type of CPAP, but you will only wear the mask.

The article in Diabetes in Control is a good reminder of what can happen when people do not use the CPAP equipment. In addition to elevated blood glucose levels, the person's hypertension was also worse and he was gaining weight. The patient was complaining about exhaustion, but eating right and taking his medications.

The office did not make any medication changes, but encouraged the patient to resume using his CPAP at night, and monitor. They established remote patient monitoring, and in the following week saw the blood pressure and glucose levels return to his targets. In addition, the weight started to drop. When contacted at the end of the week, the patient declared that after using the CPAP for one night, his energy was better and he thanked the office.

What lessons can be learned from this? For the patient:

• Assess your sleep habits.
• Respect sleep apnea as an underlying cause of increased blood pressure, glucose, weight, and more.
• Have yourself screened for sleep apnea, and referred to sleep labs/sleep specialists if you suspect a sleep issue.

For the patient's provider:

• If you know your patient has sleep apnea, ask the simple question, "Are you using your CPAP machine?"
• If your patient is not using his/her CPAP, ask why. Sometimes the answer is simple, and a simple solution can turn things around. Sometimes it is because it is uncomfortable. If uncomfortable, encourage your patient to contact their sleep medicine team to help recommend a device that is more comfortable.
• Follow up with your patients to make sure they use the recommended treatment. If they aren't using the recommended treatment, find out why, and help problem solve.

I can say from experience that using my CPAP machine makes my diabetes and blood pressure (hypertension) easier to manage. While my weight loss is not as rapid as I would like, using my CPAP is helping me avoid weight gain.

Still Learning about Sleep Apnea

I thought I had learned a lot about sleep apnea, but the lessons keep coming. I am now on my third CPAP machine and I am happy that I still ask questions. It seems that sometimes I ask too many questions as I am still searching for the right combination of machine, mask, and supplies to give me a great night's sleep. A question I asked recently has resulted in more problems as I believe an incorrect adjustment was made instead of the one I asked for.

I have had to change from a nasal mask to a full-face mask because of problems of breathing through my mouth. This will require some getting used to for me. Another problem that will require adapting is from a machine with an easy fill humidifier to one that cannot be filled beyond a certain level. Overfill slightly and then the air hose from the machine to the mask needs to be removed and the water drained out of the air hose. Then, while the machine is off, the humidifier needs to be drained to the right level. Fun, fun, and more fun for me.

I am happy that this CPAP machine runs more quietly than the previous machines, but I do miss the large capacity water container of my first CPAP for humidity. The last two have had small containers that only last for a day.

I have received questions from other readers and friends that wonder how I can tolerate wearing a mask of any type and sleep. I can only say that with the rest I am receiving by wearing the mask and using my CPAP, I would not want to sleep without it. I can remember how tired and sleepy I was before the CPAP machine that as long as I need it, I will use it.

A friend of Allen and me, who also has diabetes, refuses to wear a mask because he is so claustrophobic. He has even refused to use an oral device. He will not shut the bathroom door when he is using it and refuses to have a curtain for his shower. To play a joke on him one day, as he was getting his coat out of the closet, Allen pushed him in and shut the door. Allen will not do that again as he now has removed the door and refuses to put it back. Other closet doors are now missing in his home. Allen recently said he had been shown the results of the last sleep study by our friend and the apneas were almost normal. Our friend is happy about this as he has lost weight and had also refused surgery and another treatment.

While my CPAP machine is a true BiPAP or as others call it, an AutoPAP, I do like it as it is set with two settings, one for the lowest pressure, and one for the highest pressure. Then the machine self adjusts as I sleep to keep me breathing and not having apneas. I used a different source for my machine than previously because I felt I was not obtaining reliable service or even caring service. The number of problems just kept multiplying.

Family Support May Be Beneficial For CPAP Users

Family support for CPAP use may help in using the equipment. I know that does not matter for me because without my CPAP equipment use, I would be overtired and difficult to be around. Other people depend on family support for doing anything that their doctor may prescribe or recommend. I have seen this first hand and when I ask friends why they won't take a medication or use their CPAP machine, I normally receive this answer – 'my spouse makes fun of using it' or 'my family thinks it is funny and make a comedy out my using it.”

I now have a widow of a friend that is regretting the fun she made of her husband using a CPAP machine and full-face mask. Last week he did not wake up after suffering an apnea and even CPR could not revive him. She is a nurse and should have known better than making fun of his CPAP and its use. The autopsy revealed that he had died from a heart attack. On several occasions, I had warned him that this could happen and that he needed to use the equipment every night. I had even introduced him to the mask liners which had stopped the air leaks and noises from the mask when the seal was broken.

Yes, he was about 40 pounds overweight and had been in a sleep lab for his diagnosis, but his wife was not sympathetic and constantly made fun of the equipment and his use of it. I attended his funeral, but avoided his wife, but afterward she wanted to talk to me. I told her there was nothing to talk about and I was there for him. I left without saying anything.

This study by the American Academy of Sleep Medicine, is very clear in stating that people with obstructive sleep apnea (OSA) who are single or have unsupportive family relationships may be less likely to adhere to continuous positive airway pressure therapy.

Results show that individuals who were married or living with a partner had better CPAP adherence after the first three months of treatment than individuals who were single. Higher ratings of family relationship quality also were associated with better adherence. Results of the study were adjusted for potential confounding factors including age, gender, and body mass index.

If you are a CPAP user, a spouse of a CPAP user, or a family member of a CPAP user, do them a favor and give them your support, please. Read the article in the link above and help them use the CPAP equipment; they just might live longer and be around when you need them.

“The American Academy of Sleep Medicine reports that obstructive sleep apnea is a common sleep illness affecting up to seven percent of men and five percent of women. It involves repetitive episodes of complete or partial upper airway obstruction occurring during sleep despite an ongoing effort to breathe. The most effective treatment option for OSA is CPAP therapy, which helps to keep the airway open by providing a stream of air through a mask that is worn during sleep.”

Using CPAP During a Cold

Okay, you are using a CPAP machine and waking up rested. You have overcome your resistance to using the machine on a daily basis and are happy using it. Now, you are coming down with a head cold and are wondering what to do and think you should possibly take a break from using it until you are over the cold.

It is okay to take a break from using CPAP, if you have a cold. You may find that you have a residual benefit from the treatment, even several days into the break. This is because the inflammation and swelling of the tissues in the upper airway will take time to become affected again. See my blog from yesterday for possible breathing help using a CPAP.

When you have an upper respiratory infection, such as the common cold may make it more difficult to use CPAP. Similar to what occurs with allergies, the nose may become congested and runny. A stuffy nose may make it hard to breathe with the machine. The discharge of mucus may dirty the CPAP mask, especially if you use nasal pillows. The flow of air may also cause irritation if you have a sore throat. Each time you cough, opening the mouth may make the pressure uncomfortable.

If you do decide to continue using your CPAP during your cold, you may find it helpful to use a medication to alleviate a stuffy nose. Over-the-counter saline spray is inexpensive and effective. It can be used as often as you need it and will moisten the lining of the nose. Afrin spray may also provide relief, but it should not be used long term due to the risk for rebound congestion of the nose.

Other prescription medications may relieve chronic congestion related to allergies, including topical nasal steroids sprays such as Flonase, Nasonex, Patanase, and Astelin. It may also be helpful to rinse the nasal sinuses with a neti pot. If you have diabetes, be careful and only use prescription medications under the direction of a doctor, as many can raise blood glucose more than you want.

Some people actually like to use CPAP during a cold, especially if there is not a lot of nasal discharge. The heated and humidified air may add comfort and relief. This pressurized air may also move mucus along the nasal passage and decrease congestion. My CPAP has a heated humidifier and does help during a cold.

During and after your cold, it is important to be diligent about cleaning the CPAP mask, tubing, and humidifier tank. Give everything a thorough rinse with a mild soap and water.

Even if you want to take a break from CPAP when you have a cold, you don’t have to. If you find that you can tolerate the treatment during illness, it will help you to sleep better and wake feeling more rested. Except for one particularly bad cold, I have been quite comfortable using my CPAP machine and it has actually helped lessen the symptoms of my colds. You may need to experiment to find if this works for you.

Innovative Approaches Help Sleep Apnea Sufferers

This may be a solution for some people with sleep apnea, but I can honestly say it does not work for me. I have to have my own limits and I prefer not to be coached or bothered by someone that does not understand sleep apnea. I will listen to my doctor and consider what he says, but beyond that, leave me alone and let me use my VPAP (variable positive airway pressure) when I sleep.

I did listen to my wife when she complained about the air blowing at her from my first machine – the air exit from the masks was to blame. It took me some time to adjust the hose and the direction of the air exhaust to prevent this from happening, but now with the new machine and different masks it is much easier to prevent air blowing on her. I also listened to her when she complained about the noise from my full-face mask.

This study is published in the current issue of Sleep Medicine Reviews. The opening statement leaves much to be desired. They claim that people with obstructive sleep apnea are more likely to use the equipment and prescribed treatment when a partner or parent is involved in their treatment.

In conversations (not scientific at all) with people with sleep apnea, I have found more people do not want to use the CPAP because it leaves red marks on their face and back of the neck. Most people do not realize that shortly after waking, and preparing for the day, these will disappear. The other problem is their lack of adjustment of the mask straps and having them too tight, which will cause strap marks on their skin. When straps are too tight, the marks can last for an hour and usually longer.

The most legitimate complaint is the problem of air leaks around the masks. Then add the problem of the mask creating nose bridge irritations and even sores and this does present problems for wanting to use the mask. Again, this is a problem because either the mask does not fit your face properly, or the straps have been over tightened. This is even a concern for me and I solved this by obtaining nasal mask liners from this company. Take time to watch the video under “how it works”. The mask liners do dramatically reduce the air leaks and allows the mask to be worn properly without over tightening the straps.

I have written a blog about the nasal mask liners and I enjoy using them. I do get more than one use out of each liner by following the steps I outlined in the blog. It does take some time to process them, but I will continue to make use of them as it has allowed me to loosen the straps. I can still have some marks on my face, but they do not last long after I take the mask off.

“One of the studies that the researchers reviewed showed that about half of newly diagnosed sleep apnea patients would not use CPAP if it made them feel claustrophobic.” This is one of the better statements to come out of this study and is accurate. I have talked to people that feel this way about wearing a mask and it terrifies them whether it is a full-face mask or a nasal mask.

Even though I say the study is of little value, the proposals they set forth may work for some people. If something does work for you, make use of it. I know my way works for me and I generally wear my nasal mask for more than eight hours average per 24 hour period.

A Follow-up on Children with OSA Benefit from CPAP

It is a good feeling when you are asked for information about something, in this case obstructive sleep apnea. I had written about this here. Since this happened, the family and I have exchanged several emails about the progress of their son and how he is doing with his VPAP machine. The parents are happy that no surgery was required and that I have been able to direct them to more web sites about sleep apnea.

In the three weeks their son has been using the VPAP, they have added the mask liners (the son has both the nasal mask and a full-face mask) and report that this has helped dramatically reduce the air leaks and he is using the VPAP every night now. The father reports that the entire family now exercises and the son has lost five pounds in the three weeks since starting. With the snow, they just add snowshoes and keep moving.

I was told that the number of apneas during the sleep study had varied from 76 to 92 apneas per hour. The doctor did find a way to work them in the next day because of the distance for travel. This has to be a doctor with much kindness in his heart. The mother reported that the doctor took his time to explain the two masks to them and the fitting of the masks. When asked about the mask liners, the doctor was unfamiliar with them, but took his time to go to the web site and after research, offered a prescription if they needed it.

Both parents have expressed their happiness that surgery is the last option the doctor wants to consider. They did obtain the VPAP machine and masks from a local supplier approved by their insurance. The doctor had also issued a prescription for a second disk for them to use and mail him the first disk to read the results for the first 30 days. Then he will mail it back to them for them to use when they mail the second disk for reading the next 30 days.

I told them this was normal and the doctor would be looking for the amount of time on a daily basis that the machine was being used and if there happened to be sleep problems. In addition, the insurance company would receive a report from the doctor about the results. If problems showed up, this could indicate a need to adjust the pressure and may require a second visit to the doctor. If the results show normal or near normal, the disk mailing might stop or happen at an infrequent interval, just to monitor the results.

The son even reported that his sister likes to tease him about looking like an alien with his mask on. He said he told her he does not care as he is getting a good night's sleep every night and feels so much better. He also said his grades are improving and he is more alert in school.

We do continue to communicate about questions they have and questions they should ask their doctor or equipment supplier. They are happily surprised about the support they have received from their medical insurance and this is a big plus. Their insurance had questioned both the nasal and full-face mask, but when the doctor explained his reasons, the insurance company did allow both.

This blog is the first of four blogs about sleep apnea this week.