Untreated SA may worsen . . . heart health & diabetes

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
D.H.
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Untreated SA may worsen . . . heart health & diabetes

Post by D.H. » Thu Jun 15, 2017 9:16 am

Certainly, this is not news to most of us.

Unfortunately, there had been a recent study suggesting otherwise. Many have correctly pointed out that it was probable that the results of that study were skewed due to non-compliance.

This study was more meticulous about compliance. It reached a very different conclusion.

Link ===> http://www.businessinsider.com/r-untrea ... tes-2017-6

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jnk...
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Re: Untreated SA may worsen . . . heart health & diabetes

Post by jnk... » Thu Jun 15, 2017 9:31 am

Thanks, D.H.

It is my belief that what saves lives and improves health the most is PAP use that is verified as optimally implemented and used all night every night.

And I believe that it is the lifestyle changes that the successful use of PAP allows that then take the positive effects on health to the next level.

Compliance verification is fine. But compliance that is without verification of truly optimized pressures and that is without verification that leak is within acceptable range can be as problematic as noncompliance. In fact, bad implementation of PAP can, in my opinion, damage sleep more than it helps it.

I do not believe many studies have been done that take those factors fully into consideration. And I believe taking those factors into consideration is mission-critical for useful evaluation of PAP effects on health. Assuming that "use" means "effective use" is an assumption that negates the value of most PAP "studies."

That is, in my opinion as some guy on the Internet.

My position is that until a study proves that breathing and sleep are not important for proper functioning of the human organism, fixing breathing and sleep is a no-brainer.

-jeff
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D.H.
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Re: Untreated SA may worsen . . . heart health & diabetes

Post by D.H. » Thu Jun 15, 2017 10:12 am

I think that there is a link between compliance and having an optimal (or at least nearly optimal) setting. Those who have have a poorly suited setting and/or a poorly fitting interface are much less likely to comply.

Also, I would not discontinue treatment in the absence of any long-term health benefit, as I just feel so much better!

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Re: Untreated SA may worsen . . . heart health & diabetes

Post by palerider » Thu Jun 15, 2017 10:56 am

jnk... wrote:Compliance verification is fine. But compliance that is without verification of truly optimized pressures and that is without verification that leak is within acceptable range can be as problematic as noncompliance. In fact, bad implementation of PAP can, in my opinion, damage sleep more than it helps it.
"compliance" is still a woefully inadequate amount of usage, and, of course, compliance has nothing at all to do with effectiveness.

the 'standards' should be much higher in studies.

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Re: Untreated SA may worsen . . . heart health & diabetes

Post by jnk... » Thu Jun 15, 2017 11:29 am

For PAP studies, those diagnosed with moderate-to-severe OSA should be categorized as follows:

(1) Untreated
(2) So-called "treated"
(3) Actually treated

When users are not given the knowledge, the training, or the proper tools needed to make their PAP use successful and comfortable, I believe that referring to such ones as "noncompliant" is a form of blaming the victims. It is unethical to hold people back in categories one and two and to prevent them reaching category three--which is the primary category of patients that needs to be studied in order for anyone to assess properly the overall-population efficacy of the treatment.

I am unaware of any such study. Most studies are performed comparing categories one and two only.

After all, PAP has a prescribed dosage: all night every night with acceptable leak and optimal pressure(s).

So why do the "scientists" keep studying the people who aren't taking the prescribed dosage when attempting to assess overall efficacy of the treatment?

They do the world a disservice every time they do that, in my opinion.

I also believe that studies should concentrate on the moderate-to-severe OSA population when attempting to verify the health benefits of PAP. That isn't cooking the books; it is just separating the population into a sort of pre and post, as is done with diabetes and the like.
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Re: Untreated SA may worsen . . . heart health & diabetes

Post by D.H. » Thu Jun 15, 2017 2:05 pm

CPAP, rather unique in medicine, can be metered for compliance. It's not possible to verify if an individual takes his (her) pills or sticks to his (her) diet, or does all the exercises. However, it's very simple to verify if CPAP is attached and turned on (but not if the patient is actually sleeping). It's also possible to check (at last to some degree), whether the Apnea is well controlled.

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Re: Untreated SA may worsen . . . heart health & diabetes

Post by Arlene1963 » Thu Jun 15, 2017 4:07 pm

jnk... wrote:For PAP studies, those diagnosed with moderate-to-severe OSA should be categorized as follows:

(1) Untreated
(2) So-called "treated"
(3) Actually treated

When users are not given the knowledge, the training, or the proper tools needed to make their PAP use successful and comfortable, I believe that referring to such ones as "noncompliant" is a form of blaming the victims. It is unethical to hold people back in categories one and two and to prevent them reaching category three--which is the primary category of patients that needs to be studied in order for anyone to assess properly the overall-population efficacy of the treatment.

I am unaware of any such study. Most studies are performed comparing categories one and two only.

After all, PAP has a prescribed dosage: all night every night with acceptable leak and optimal pressure(s).

So why do the "scientists" keep studying the people who aren't taking the prescribed dosage when attempting to assess overall efficacy of the treatment?

They do the world a disservice every time they do that, in my opinion.

I also believe that studies should concentrate on the moderate-to-severe OSA population when attempting to verify the health benefits of PAP. That isn't cooking the books; it is just separating the population into a sort of pre and post, as is done with diabetes and the like.
Excellent comments, JNK. I completely agree with your conclusions.

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Re: Untreated SA may worsen . . . heart health & diabetes

Post by sc0ttt » Thu Jun 15, 2017 5:03 pm

Thanks DH.

The patients were CPAP regulars and the study was done just like a sleep lab, and the findings were that not using the CPAP is bad.
Some people will complain about anything.

Patients:
Thirty-one patients with moderate-severe OSA acclimated to CPAP.

Intervention:
Patients underwent attended polysomnography while sleeping with therapeutic CPAP, or after CPAP withdrawal, in random order. Venous blood was sampled at ∼20 min intervals on both nights. In 11 patients, we assessed glucose kinetics with an infusion of 6,6-[2H2]glucose.

Results:
CPAP withdrawal caused recurrence of OSA associated with hypoxemia, sleep disruption, and heart rate elevation. CPAP withdrawal dynamically increased nocturnal FFA (p = 0.007), glucose (p = 0.028), and cortisol (p = 0.037), in proportion to respiratory event frequency, heart rate elevation, or sleep fragmentation. Diabetes predisposed to glucose elevation. CPAP withdrawal also increased systolic blood pressure (p = 0.017) and augmentation index (p = 0.008), but did not affect insulin, triglycerides, glucose production, oral glucose tolerance, cholesterol, or hsCRP.

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Re: Untreated SA may worsen . . . heart health & diabetes

Post by jnk... » Fri Jun 16, 2017 7:49 am

sc0ttt wrote: . . . Some people will complain about anything. . . .
I would like to take this opportunity to complain about that statement.
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Re: Untreated SA may worsen . . . heart health & diabetes

Post by Flyoverguy » Fri Jun 16, 2017 11:57 am

Compliance metrics are necessary even if misused or not useful in some cases.

I would hope people have a vested interest in their own health and the desire to take positive steps to improve it. Unfortunately we live in a culture where short term satisfaction is the goal so too often expectations are not realistic. I imagine the longtime members on this board are very aware of what CPAP has done for them. I have been using CPAP for 7 years and I know it has made a huge difference. Furthermore undoing the harm from before therapy takes a lot more work. I have no problem with this type of research.

This study makes sense to me.

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Re: Untreated SA may worsen . . . heart health & diabetes

Post by jnk... » Fri Jun 16, 2017 1:29 pm

Flyoverguy wrote:Compliance metrics are necessary even if misused or not useful in some cases.

I would hope people have a vested interest in their own health and the desire to take positive steps to improve it. Unfortunately we live in a culture where short term satisfaction is the goal so too often expectations are not realistic. I imagine the longtime members on this board are very aware of what CPAP has done for them. I have been using CPAP for 7 years and I know it has made a huge difference. Furthermore undoing the harm from before therapy takes a lot more work. I have no problem with this type of research.

This study makes sense to me.
It makes sense to me too, if the limitations are kept in mind. The study mentioned in this thread does not seem to be an especially bad one, comparatively speaking, for such a small study. My words were not directed at the study. My words were directed at the statements in the original post . . .
. . . Unfortunately, there had been a recent study suggesting otherwise. Many have correctly pointed out that it was probable that the results of that study were skewed due to non-compliance. This study was more meticulous about compliance. . . .
. . . which I read to be implying that the lack of the collection of, and the lack of factoring in, compliance data have been the primary limitations in previous studies on similar subjects.

I agree it is a limitation, but for me, it is not anywhere near being the primary one.

That can be illustrated by the way PAP-use problems are often addressed in this forum. When someone comes here with a question about whether he or she is getting full benefit from the therapy, he or she is generally asked to provide screenshots of the kind of data needed to troubleshoot PAP effectiveness before hours of usage is addressed. That is because it is only after it is established that all the therapy isn't leaking out the mouth and it is established that AHI is being controlled by the pressure settings that number of hours of use first becomes meaningful and pertinent in the discussion. I believe it is the same in the research setting and that the same principles could and should be applied there. It is a case of how clinical experience should inform research--or more specifically, in this case, how fellow-patient-help experiences could, and should, inform research methods.

I have great admiration for many of research-science docs pumping out studies and doing so for all the right reasons. I just believe that a number of them have a blind spot in their understanding in this aspect of PAP. They seem to believe that PAP use is PAP use and that it is all equal. I believe it only takes a few days of watching this forum to learn that the reality with this treatment is otherwise.

As for "compliance metrics," at present in the U.S. they are mostly collected only as a way to establish that payers should pay for the machine. That has tricked some researchers into thinking that such data must be medically significant on its own without the more pertinent efficacy data.

I am a diabetic with an enlarged heart myself, so the title of the thread pushes a lot of personal buttons for me. And as for "compliance," I believe that if I merely used my machine with the goal of meeting the minimum usage required for me to be considered a "compliant" user by docs, clinical or research, I would still be accelerating myself to an early death doing so.

My heart goes out to the patients misled by a compliance measurement that was only meant to be a line in the sand for whether a machine should be paid for, not as a measurement of whether full benefit is being obtained from the therapy. That matters because the lives matter.

End of soapbox rant.

For now.
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Re: Untreated SA may worsen . . . heart health & diabetes

Post by palerider » Fri Jun 16, 2017 3:09 pm

jnk... wrote:End of soapbox rant.

For now.
Your rant is so true, and correct on so many levels... being​ "compliant” and calling it good is like wearing the wrong glasses all day... "I'm compliant, I wear my glasses all day but I keep running into things!”

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Re: Untreated SA may worsen . . . heart health & diabetes

Post by Arlene1963 » Fri Jun 16, 2017 3:11 pm

This thread really resonates with me today.

I've just spent some time this afternoon with an acquaintance who was recently diagnosed with OSA in an overnight in-lab sleep study. She has hypertension and a significant history of heart disease and OSA in her family.

She contacted me this morning because she's concerned that her numbers are going up on CPAP.

Her AHI last night was over 10, so I downloaded her data into SH and it is bad, really bad. Obstructives occurring in clusters. She's been put on CPAP despite having an APAP capable machine, but apparently "doctor knows best"

The sleep specialist will only see her in a few months and in the meantime she is at the mercy of a 23 year old at the DME who tells her that all is just wonderful, that because she's using her CPAP for 8 hours per night or more not to worry about the numbers.

Sorry for the rant but it makes me so angry that we have this incredible technology and patients are simply not empowered to take care of their own treatment. No wonder so many fall by the wayside.
Last edited by Arlene1963 on Thu Oct 26, 2017 4:00 am, edited 2 times in total.

D.H.
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Re: Untreated SA may worsen . . . heart health & diabetes

Post by D.H. » Fri Jun 16, 2017 4:08 pm

To Arlene 1963:

Can you possibly talk her into raising the max on the APAP (perhaps all the way to the max) and leaving the min as is? Perhaps then she'll see that she needs more. They say 5 or lower is good, but I think 5 is not so good (that means one event every twelve minutes).

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Re: Untreated SA may worsen . . . heart health & diabetes

Post by Okie bipap » Fri Jun 16, 2017 4:15 pm

When my wife went in for her most recent check with the sleep specialist, they raised her pressure from 14 to 20 cm. Needless to say, she could not handle that much of a change. I brought it back down to 15 and am raising it slowly to 20. She had a rough night last night since I just took it from 16 up to 17. I will see how it goes tonight, and will bring it down to around 16.6 if I need to.

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