APAP or Positional Therapy

Hello,

I was diagnosed with moderate sleep apnea 6 years ago, and I am happily using my CPAP even since. The reason I am writing this post is my father, who is 71 years old and recently diagnosed with severe sleep apnea.

My father was actually diagnosed with sleep apnea years ago, and had a surgery in 1998, however the surgery was not very successful. He had a sleep study last month, and here is the summary:

"Total 102 obstructive apnea, 23 mixed apnea, 5 central apnea; total 130 apnea events. Apnea Index is 17.6. Total 114 hypopnea events. Apnea-Hypopnea Index (AHI) is 33.1.

Sleep time percentage in supine position: 37.4%. Supine AHI: 67.2.

REM AHI: 11.9. Non-REM AHI: 35.9. Oxygen saturation is minimum 77% and in average 90%. The sleep duration during which oxygen saturation is 80-89% is 298.8 minutes (67.6% of total sleep duration). ODI: 40.0. Snoring: 0.3 minutes (0.1% of sleep time). Arousal index: 14.3/hr. TST: 40.5"

After the second sleep study (titration), my father was prescribed with APAP device (6-13 cm water pressure).

My father is 71 years old, and as far as I know him, I think that it will not be easy for him to get used to sleeping with a mask.

My question is: since AHI is 33.1, supine AHI is 67.2 and percentage of sleep time spent in supine position is 37.4%, by doing some basic math, I calculated that his non-supine AHI is only 12.7.

Would it not be much better for him to first try positional therapy, before investing in a APAP device?

Thank you in advance for your comments and recommendations...

My opinion is that your average 71-yr-old would find optimized PAP much less annoying, and much more effective, than positional therapy. Your mileage may vary.

After 71 years of life I am sure your father has had to overcome difficulties and been successful doing so.

Let's look at the probabilities. IF he can stay off of his back, it may help. On the other hand using APAP will keep the airway open regardless of his sleep position. I think using APAP wins out.

Keep in mind the goal. The goal is to enjoy restful and restorative sleep. Having oxygen levels drop and frequent arousals disrupts sleeps and robs you of the benefits of restful and restorative sleep.

Your dad has possibly 30 - 40 years left. Figuring out how to endure a mask on his face will pay off in big dividends over the long run. Go with the APAP and look into sleep positions as additional help.

You could use APAP that works, or you could fool around with Positional that might help a little, maybe not killing you a little or just slower, Jim

Like your father, I, too, had surgery years ago in an attempt to control my sleep apnea. I started treatment with a bi-level machine when I was 72 years old, and continue to use it three years later. My wife started using a bi-level machine when she was 71 years old. It is not easy, but older people can adapt to using a machine and sleeping with that alien thing on our face just the same as anybody else. Your father can make it work if he makes up his mind to do so, but that is a decision only he can make.

Go with APAP.
Even if positional therapy worked, he still needs PAP.

Hi - you have a PM.

I'm a handful of years younger than your dad and also realized that, were I able to stay on my side, my apnea issues would essentially disappear. Problem is, staying in one place. I tried propping up firm "My Pillows" next to me (because who can sleep on those things??) to prevent me from rolling onto my back, but my sleeping self is a clever lad and prone to defeat any such strategies, even when I leave myself zero room on the edge of the bed. He could try sleeping with a backpack loaded with a blanket, a wedge pillow "companion," or sew a bunch of tennis balls into the back of his PJs, but I'm guessing he'd still end up on his back one way or another.

Why not try both? Figure out ways for increasing the amount of time on his side and PAP it as well, as just in case?

Cheers,

MC

Hi Herman77,
Your father will probably decide for himself what is the best course for him. xPAP therapy is not well tolerated by many people. I think it is about 50% of people diagnosed with sleep apnea do not use their machine long term.
I think it is great that you are thinking outside of the box. There are other alternatives.
Positional therapy is one of them, although an AHI of 17 still is a problem. Getting his AHI down several points would help a lot.
General exercise (cardio) has been shown to reduce AHI by an average of 35%.
Tongue/throat exercises have been shown to reduce AHI by up to 40%.
And if he has any weight to lose, of course that will help a lot.
If he uses any of these alternatives, plus positional therapy I think he could do well.
Of course, as I said further up, it will be up to him to decide the best course of action. I can remember trying to influence my dad, it didn't go my way very often.
Good luck.

When doing the math there are some things that can change how you view the numbers. For instance, consider overlap. If his REM sleep is problematic for apneas, but in the study part of his supine time was spent in REM. How can you know if maybe those numbers should have been counted in the side sleeping category if they were due to being in REM rather than being supine? I understand you're just trying to get a general idea if the consideration of positional sleeping is reasonable. Without some sort of testing it will be hard to know for sure. Maybe using one of the currently popular sleep monitors along with a recording oximenter could give you enough information to settle it in your mind if this is a viable option.

Since his oxygen level is of concern, will the duration of any remaining events be acceptable in that respect, even if the reduced count is more tolerable? Something for him to consider if he goes forward with treatment, he'll want to be in tune to if his APAP treatment is actually therapeutic. Complex sleep apnea and centrals may not respond the same to treatment as obstructive events. Not sure if his provider will be monitoring his data remotely or not, but this discussion needs to accompany treatment with an eye on his machine data, particularly until treatment stabilizes and becomes routine.

I think Dr. Downey and friends recently said it best with commendable clarity in a Medscape article that also mentioned positional therapy:

"People with mild apnea have a wider variety of options, while people with moderate-to-severe apnea should be treated with nasal continuous positive airway pressure (CPAP)." -- https://emedicine.medscape.com/article/295807-treatment

Thank you very much for all your helpful comments! We already ordered the APAP machine and I hope my father will adhere to it and say goodbye to waking up tired

herman77 wrote: ↑

Wed May 09, 2018 7:12 am

Thank you very much for all your helpful comments! We already ordered the APAP machine and I hope my father will adhere to it and say goodbye to waking up tired

You are doing the right thing!

herman77 wrote: ↑

Mon May 07, 2018 2:39 pm

I calculated that his non-supine AHI is only 12.7.

This can be very misleading. During the non-supine periods, he may have spent little to no time in REM sleep. For many people, obstructive sleep apnea is much worse in REM sleep.

Julie wrote: ↑

Mon May 07, 2018 8:15 pm

Hi - you have a PM.

This pops up from time to time. Julie is hiding her advice from the rest of the forum members. She is known to give bad advice which is often contradicted by more knowledgeable members. It's best anything she says be peer-reviewed in the thread. In fact, it's best that all of us provide our advice out in the open giving others a chance to add to it or amend it.

When the positional nature of OSA is documented as VERY positional and the OSA is mild, positional therapy can be of great help for some, or at least a few, who won't or can't use PAP. But when we factor in that the whole purpose of treating the OSA for those with mild OSA is to prevent the disruption of sleep, it really doesn't make much sense to do something whose whole purpose is to disrupt sleep every time someone tries to sleep on his back.

Unless someone is using a reliable device to ascertain and record his own sleep position all night every night, he has no idea whether he might still be ending up partially on his back now and then. It is counter-intuitive how often people with entire backpacks of gear can still end up partially on their backs when recorded at night and then won't believe it happened until they see the recording of it for themselves.

The larger problem is that when something is done that is only partially successful but considered 'successful enough,' that makes it much less likely that it will be noticed when apnea gets bad enough to need treatment beyond the positional--a risk that should not be taken lightly.

Add to that the facts that few well-done studies have examined the approach and that what studies have been done find that long-term compliance leaves much to be desired, positional therapy is worthy of full cynicism at this point in the history of sleep medicine, although it does seem to show some potential for future improved versions of it one day.

As one non-industry-funded examination pointed out in 2015, in a nutshell:

Compliance with PT [positional therapy] using the tennis ball technique could, for example, be limited as a result of the bulkiness of the device resulting in back pain and discomfort, which could lead to disruption of sleep and low sleep quality. -- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4298770/

I will be glad to repost this any time a PM is sent to anyone about PT.