Has Anyone Ever Succunbed To Apnea?

[ChicagoGranny]

So the comment that CPAP inhibits a person's natural defense to an apnoea is as silly as saying that using CPAP will mean that if I hold my breath when I am awake I might drop dead because my triggers for breathing have been eliminated.
That drive to breath, whether wake or asleep, is phenomenally powerful.

You have concentrated on the "drive to breathe" and have overlooked elevated hematocrit and hemoglobin levels ( https://tinyurl.com/y97p4zvp ). This is one of the defenses the body builds up over time in response to untreated apnea.

You have also ignored "positional therapy". Many untreated apnea patients have developed habits of sleeping on their sides or stomach to moderate the effects of their condition. With successful CPAP usage, their habits change, and it becomes common to sleep on the back. This can be very dangerous to some users.

These are two of the defense mechanisms to sleep apnea that may no longer exist in patients successfully treated with CPAP. That's why it is commonly reported, "I feel much worse when skipping a night of CPAP than I did before I started CPAP."

[RobertS975]

I have performed thousands of diagnostic sleep studies over 15 years

Your experience lacks something. You have probably performed very few, if any, studies of people who have used CPAP effectively for a few years or longer. With successful CPAP use, the defenses to apnea the body has built up are lost. Now comes that one night without CPAP, and it's like suddenly introducing a severe case of sleep apnea. This is a very dangerous night. More dangerous than for someone with a similar case of apnea who has never been treated.

OK, as a physician and as a 4 year OSA patient, I would like to see where this assertion is documented. Not disputing, actually makes sense. But I have been counseling that a day or two of omitted therapy, either because of a power failure or forgotten machine, isn,t likely to be a problem as most of us had the condition for decades before being diagnosed.

If this is a scientific observation, then backup power sources should be something covered by insurance!

[chunkyfrog]

Sleep lab personnel--some great, some good, some?????
Google it.

[jnk...]

. . . I would like to see where this assertion is documented. . . .

If CG can't get that for you, I may be able to find some relevant sources for you when I have the time. I think I can see what CG is getting at, though I might not have worded it quite that way, myself.

Over the years, some researchers have noted the paradoxical cardioprotective nature of intermittent hypoxia that seems to exist in some of the very elderly. Some hypothesize that the organs employ adaptations to hypoxia that may provide some patients a better chance of survival during a catastrophic event with delayed intervention. Couple that with the theory that brains and nervous systems that were once on hair-trigger alert to jar someone awake may not have the same response in someone who hasn't had a long apnea in years, and there is a definite theoretical risk in taking someone from years of zero apneas to a night of constant severe OSA. Some of the normal protective adaptation to balancing sleep and breathing may possibly have been lost. In theory, the CV stress could be increased with sudden all-in-one-night onset of severe apneas from nowhere versus gradual every-night increased apneas. This is difficult to establish, though, especially in view of the supposed "residual effect" of PAP therapy, in which some patients appear to have positive leftover benefits from previous nights of PAP use. That is why some labs have patients with mild-to-moderate OSA go a night of two without PAP before a reevaluation PSG to ascertain whether there is a continuing need for PAP, such as after a significant weight loss.

Moving out of the theoretical and into the practical, based only on my personal opinions, now--Yes, I believe that someone with moderate-to-severe OSA and a heart condition with family history should, indeed, be provided power backup by insurance. However, what would be needed as research for the collection of the evidence to form a basis for making that the policy of payers would be problematic. So it is what it is.

[D.H.]

The answer to "what happens if I miss a night with CPAP?" is the same answer as "what if I miss a day of medication for a serious condition?" The answer is "I don't want to find out!"

[jnk...]

This may be related to some of what CG had in mind . . .

http://onlinelibrary.wiley.com/doi/10.1 ... 0754.x/pdf

And personally, although I do believe that one night without PAP can be life-threatening for a subset of patients, I do NOT believe that belief to have been demonstrated as true for ALL patients. As one study noted:

. . . There is no immediate adverse effect of CPAP therapy withdrawal on myocardial perfusion in patients with moderate to severe OSA, despite the recurrence of OSA and relevant increases in blood pressure. We concluded that OSA patients are unlikely to be at risk for acute myocardial ischemia during short periods of treatment interruption such as on vacation. This finding was an important message for both clinicians and patients with OSA, since “CPAP holidays” are common. . . . -- J Thorac Dis. 2018 Jan; 10(Suppl 1): S24–S32. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803046/

I don't endorse that conclusion, myself. I consider it to be an overapplication of their observation. But I quote it because I respect the researchers and because it is the belief of many in the mainstream at this point, I believe. And it shows that balance is needed to prevent overapplication of OSA/PAP principles across populations. This board contains users of PAP across the full spectrum of disease-severity and treatment-circumstance. That's why we have personal docs--to give opinions that are, ideally speaking, customized to our specific individual risks. Experienced sleep docs keeping up with the literature should be able to give us a rule of thumb we can use in our future decisions on skipping a night.

To me, the important thing to remember is that anything that disturbs sleep increases risk of fatal accidents, vehicle-related and otherwise. And that's how the majority of people get hurt or killed from failing to treat any condition that disrupts sleep. Compared to accident risks, the risk for immediate death from one severe apnea, or a series of severe apneas, during sleep on any given night, may be relatively low for those who aren't medicated or abusing drugs or otherwise compromised. But, I don't think that's the most important point. Possibilities, however remote, can't be ignored, since whenever the discussion is risk of death, even small increases in probability become very significant in a multifactorial universe.

[So Well]

OK, as a physician and as a 4 year OSA patient, I would like to see where this assertion is documented.

One of the late (and great) members here always had in his signature, "Someday science will catch up to what I'm saying."

I won't try to speak for others' cases, but I am 100% certain to be in greater chance of a heart attack or stroke if I skip just one night of CPAP. That increased risk will last until the end of the next night's good sleep with CPAP. My sleep doc once told me not to skip a night because it would put me in too great a danger of stroke.

But I have been counseling that a day or two of omitted therapy, either because of a power failure or forgotten machine, isn,t likely to be a problem as most of us had the condition for decades before being diagnosed.

You can counsel your patients any way you like, but I would tell them something like, "You are under a bigger chance of heart attack or stroke the night you skip CPAP and all day the next day. How much bigger chance? We don't know."

[jnk...]

. . . My sleep doc once told me not to skip a night because it would put me in too great a danger . . .

I was told something very similar by my sleep doc, years ago. I believe it to be true in my case. I can't prove it to be true in the majority of cases.

[Hang Fire]

But I have been counseling that a day or two of omitted therapy, either because of a power failure or forgotten machine, isn,t likely to be a problem as most of us had the condition for decades before being diagnosed.

Many of us had heart attacks before starting to use CPAP. Heart attacks which could have been avoided by using CPAP.

[jnk...]

I like the way the Canadians put it. Polite. But clear.

If your doctor says you need to use CPAP, you must use it every time you sleep. -- https://www.lung.ca/lung-health/lung-di ... apnea/cpap

[PST]

I review hundreds of medical malpractice files every year, and from time to time I see cases in which death or hypoxic brain injury is attributed by experts to obstructive sleep apnea. The common denominator is always that the patient is taking some kind of central nervous system depressant, usually opioid painkillers. These can suppress the arousal mechanism enough to suffocate the patient. These days hospitals are good about monitoring patients with diagnosed OSA to prevent this. The issue now arises mostly when a patient has enough signs and symptoms of OSA that his family's lawyers can argue that he should have been tested for the condition or treated as if it had been diagnosed.

[jnk...]

Thanks, PST. Your post, as always: golden.

It is my belief that a forgotten dose of a sedating allergy med, maybe combined with a couple of beers late in the evening, could easily 'accomplish' much the same thing for making an apnea potentially deadly.

In support of your point, it is interesting to me that the following registry was interested in unanticipated deaths and near misses occurring as many as 30 days after surgery:

https://www.apsf.org/newsletters/html/2 ... gistry.htm

[Pugsy]

It is my belief that a forgotten dose of a sedating allergy med, maybe combined with a couple of beers late in the evening, could easily 'accomplish' much the same thing for making an apnea potentially deadly.

Yep. Mixing stuff can be very bad for a person...with or without adding sleep apnea into the mix.
If the brain is too doped up to know that it needs to tell the body "breathe stupid"....well the results are pretty final.

[Arlene1963]

Interesting.

Back in 2014 I had my gallbladder removed and was prescribed an opioid painkiller to use for the first few days after the op.

I didn't know I had OSA back then and had never even heard of it, but had the strongest feeling that if I took the painkiller I would not wake up should I fall asleep. I remember wondering at the time what could make me have such a powerful conviction that if I took it things would not work out very well.

Maybe on some level my brain was aware of the danger?

Or maybe my guardian angel was paying attention!

[yaconsult]

Two close personal friends did not treat their sleep apnea and they both had major strokes. One died and the other will never get out of a nursing home.

These are the kinds of risks you run if you have sleep apnea and don't treat it every single night. People do not have to die by suffocation to be victims of sleep apnea. Heart problems and strokes have been shown to be a much bigger risk for people with sleep apnea. Apnea and lack of oxygen puts major stress on many of the body's systems. It might not kill you immediately, but you will pay the price sooner or later.