by Rob Suter
CPAP is the gold standard for OSA therapy, yet many dentists doing sleep appliances have had very little training on the topic and consider it the “dark side of the moon.” I have worked on the CPAP “dark side”and now on the dental sleep side and found that both sides have much to learn about the other. I firmly believe more treatment algorithm infrastructure and education on both sides is needed in order to successfully treat more SDB patients. In this article, I would like to share some foundational knowledge, lingo and definitions of the CPAP side. Dentists trying to speak to MDs and DMEs in their town need to comprehend the lingo; this involves a better understanding of CPAP, DMEs, Sleep Labs, and compliance monitoring. When I listen to dental lectures, I sometimes hear things like, “Nobody ever wears CPAP” or “CPAP compliance is 40% on a good day.” Some brag about all the patients they have taken off CPAP, because “no one wants to wear a mask on their face.” Dentists, be careful about who you listen to: if that’s all you hear from dental conference training, or if every patient’s story is about their CPAP problems, your view of that therapy may be tainted. It’s like police officers who deal with thieves, liars, and crooks all day developing a cynical attitude towards human nature.
As the former Regional Manager for Resmed’s Dental Sleep team and now the VP of Sales for osauniversity.org, I have a unique view of the Sleep world because I met the best and brightest sleep minds: Sleep MDs, DDSs, Hybrids, DMEs, RRTs and sleep lab techs. Working for ResMed, the global leader in sleep therapy, I was impressed with the hundreds of engineers creating solutions for SDB, from specialized VPAP devices to the first CAD-CAM MAD, the Narval CC. With so many choices for helping OSA patients, why is it that less than 10% are ever offered a 2nd line OSA therapy? When someone scans other areas of medicine such as depression, CVD, and asthma, there are clear protocols in place for what happens if the patient doesn’t respond to 1st line therapy. Cardiologists have JNC7 that outlines treatment algorithms for hypertension. Neurologists have the DSM V for depression, and pulmonologists have the ATS guidelines for asthma and COPD. All these manuals clearly elucidate and automate 2nd and 3rd line therapy algorithms for health care professionals to follow. Specialists know where patients are going, and hence so do the patients. Sleep apnea specialists have minimal centralized treatment algorithms, and most importantly, typically only 1st line therapy is shown to the patient. Or if another modality is shown, its from 1978 and is meant to scare the patient into the device of choice. We as sleep professionals need to address this issue, so everyone involved can be clear that it’s not a matter of what device is used first, CPAP or MAD: it’s about adherence to one or both. When either first choice fails, the patient should go to 2nd line therapy like clockwork, not if the patient reads a jaded billboard, ‘Do you hate CPAP?’
I hear Sleep MDs boast that their CPAP compliance is 90%, so they have no need for VPAP rescue or referring to a dentist because all their patients are adherent. I helped write a wireless CPAP compliance study where we took a hard look at a strong DME that had terrific patient follow through (Sleep Diagnosis and Therapy Vol 6 No 4 June-July 2011). The ironic part of the study was that the Hybrid DME and MDs thought their compliance was 92%, and thought the study would validate their success. However, after closer analysis and using CMS compliance standards, their adherence rate fell to a more normal level – 62.5%. Many times when I dig in to compliance claims, I find MDs and DMEs measure compliance differently. Many do not track the patients who reject therapy or do not go back to see them. See no evil, hear no evil; those patients are simply not counted and fall off the grid. This is the most troubling trend I see in our SDB market, and it needs to stop. In my opinion, dentists need to delicately confront and provide their sleep solutions.
Think of Sleep Docs as proud new parents sitting in the audience at a school play: they only see how smart, pretty, and funny their kids are. The Sleep Docs only see the patients that are doing what they were told. Life is grand on the dark side of the moon for the Sleep Docs; it’s the DMEs who handle the tough calls on mask and humidifier issues. The patients that are enjoying CPAP show up for their appointments, the compliant ones who are trying to make CPAP work for them. The Sleep Doc says, “Looks like you used your device 45.5% of the last 45 days Mr. Jones. I want you to try to use it more Mr. Jones” and sends them on their way. Meanwhile, the non-compliant patients call the DMEs and try to get help or new supplies. They get really frustrated because they’ve paid a lot of money, they can’t get comfortable in the mask, and now they have CPAP-induced insomnia! They show up angry in a dental chair and rant and rave about how much they dislike CPAP. This galvanizes the dentist’s perception ainto an anti-PAP slant…nobody is wearing those masks they wrongly assume. Truth be told, companies like ResMed track adherence from a higher vantage point, gathering non-patient-identified data. Use of PAP therapy is higher than most dentists think and lower than most Sleep Docs want to admit. There is a reason that ResMed is a billion dollar company, and it’s not because of MAD therapy; millions of people successfully use PAP every night. It is the gold standard for a reason.
I would encourage you to review and get to know the following terms and definitions. They will help you know the lingo and potentially explore new medical relationships so that you treat more patients in your practice. Good luck in your conversations, and I would encourage you to try the questions at the bottom. They are My trusted and tried pearls of wisdom. Sleep well.
Bonus question: Tell me what organ in the body doesn’t need oxygen?
CPAP: stands for continuous positive airway pressure. CPAP is a medical device that blows humidified air into a patient’s airway at night. This mechanism is highly effective at treating OSA patients and typically has good patient compliance if the mask fits properly. Every year millions of patient accept and adhere to therapy, but almost 1,000,000 patients* refuse or quit CPAP in North America.
CPAP pressure: measured in cm of water pressure, CPAPs have a range of 4-20 cm and are prescribed by the sleep physician at a set pressure. Used with a humidifier that is an add-on medical device that attaches to the CPAP and holds water in a tub. Humidifiers are used on nearly all patients to reduce dryness and pressure side effects.
AutoPAP or Auto: Autos have a flow-based algorithm and a similar range to CPAP 4-20 cm, but its air pressure automatically adjusts itself based on a flow sensor that detects the status of the airway. If the airway is closing, the Auto increases pressure to prevent apneas from occurring; if the patient snores several times, the pressure will likewise increase. If the patient has positional OSA and rolls onto their side, the Auto will detect this and decrease pressure. Autos are sometimes used in lieu of a titration sleep study when a specific pressure is determined.
Bi-level or VPAP/BiPAP: these are the most complex and expensive PAP devices. They have an inhalation pressure (IPAP) and an exhalation pressure (EPAP) that is at least 4 cm lower. These devices can have various modes of therapy, special algorithms, various comfort features and generally provide more data to MDs. Bi-level is used for complex sleep apnea, severe OSA, higher pressures, central sleep apnea or patients that need ventilation assistance such as COPD and neuromuscular patients. VPAP Auto, like MRD, is used frequently for noncompliant CPAP patients. Typical VPAP Auto pressures range from 4-25 cm and a delta between the pressure is 4-5 cm (IPAP/EPAP).
Mask or Interface: a medical device that delivers the air pressure by creating a light seal on the face. There are three main types:
Full Face Masks or FFM: delivers pressure into nose and mouth at same time; largest and heaviest masks that are used for mouth breathers, higher pressure needs, and patients with poor nasal airflow.
Nasal Masks: delivers pressure into the nose; medium size.
Pillow Masks: delivers pressure into nares only; lightest and simplest masks but typically are not comfortable at higher pressures
CPAP Compliance, Payors, Data cards and Modems: compliance is measured by Medicare standards; currently 4 hours per night or more, 70% or more of a 30 day window, within the first 90 days. Hence a patient for most insurance companies must use their device >4 hrs for 21 days out of 30 days at least one time within the first 90 days of therapy. If they fail to reach this compliance %, the DME picks up the CPAP after 90th day because the patient is now considered noncompliant or NCOSA. Some payers or insurance companies won’t continue paying for NCOSA patients. This is measured by downloading a data card that comes with CPAP or a wireless modem that gives on-demand compliance data.
DME or Durable Medical Equipment: primary service provider that has trained respiratory therapists that ‘set up’ new patients on CPAP, APAP, or Bi-level. A typical set up will be around 1 hour and entails CPAP, mask, and humidifier instruction in the patient’s home or in the DME office. DME’s are the key to CPAP compliance and typically check in with new patients several times to ensure the patient is using their device properly/adequately, and that mask is fitting well. DME size is described by number of setups they do: 20+/month is a good size, 50+/month is considered big. Examples: Apria, Lincare
Sleep Lab: primary site where SDB patients get diagnosed. Patients have a CPAP titration study in the lab and the sleep technologist ramps the pressure to the level that stops their apnea or events. MD then reads the study and RX’s that CPAP pressure to a DME company. If patient only has a home sleep study, with no opportunity to apply treatment during the sleep study, they are often prescribed an Auto which can then determine successful pressures with the built-in algorithm.
DDS opportunities: Sleep MDs: ‘What are you doing with your pap refusers Dr. MD?’ DME’s: ‘What are you doing at day 91 with non-compliant CPAP patients?’ Labs: ‘What do you offer patients that can’t tolerate pressure and/or mask in their sleep study?’