Apnea said not to increase risk of death??

[Posey]

If this was already hashed over then ignore but my daughter sent it to me along with the suggestion to "just lose weight'.

http://www.npr.org/blogs/health/2013/09 ... utm_medium

If you click on guidelines, it sends you to there.

[khauser]

If this was already hashed over then ignore but my daughter sent it to me along with the suggestion to "just lose weight'.

http://www.npr.org/blogs/health/2013/09 ... utm_medium

If you click on guidelines, it sends you to there.

Medicine makes me laugh so hard sometimes that I get sick from it.

I don't have time to hunt them down, but I am pretty sure that other "researchers" have indeed documented the link between OSA/CSA and premature death, BUT let's pretend that's not the case for a second.

There *IS* a strong correlation between lack of sleep and weight gain. If one is not able to sleep right, how are they supposed to lose weight without treating the underlying sleep issue? I would suggest they got it wrong: Treat the OSA with this very simple treatment that for 99% has no risk whatsoever, and then when that's good concentrate on losing weight. Maybe the OSA will get better, maybe not ... but ignoring it and trying to lose weight will probably be an exercise in frustration. I know that was a huge factor in my ability to lose weight.

[robysue]

In my humble opinion, the NPR story oversimplifies the study they are reporting on.

The study itself can be found at http://annals.org/article.aspx?articleid=1740756 . It is published in the Annals of Internal Medicine. The study itself is statistical analysis of other previously published papers which involved comparing various treatments (or proposed treatments) for OSA. The point of the studies in the previously published papers were to investigate the effects of one (or more) ways of treating OSA and its (their) short-term effects on a variety of clinical outcomes. By short-term effects, I mean that all of the studies looked at in this article took no more than two years to complete, and most of them took less than 6 months to complete.

The major points of the article (as I see them on a rather quick perusal) include:

Main summary of the article

Clinicians should target evaluation and treatment of OSA to patients with unexplained daytime sleepiness. Assessment of effectiveness is based primarily on improvement of daytime sleepiness; however, the effect on other clinical outcomes, including hypertension, cardiovascular events, and death, is uncertain. Adherence to therapies, especially CPAP, is important for effective OSA treatment. Clinicians should keep patient preferences and adherence, specific reasons for nonadherence, and costs in mind before initiating CPAP. They should encourage weight loss in obese patients because obesity is associated with increased risk for OSA, and weight loss may reduce OSA symptoms and has many other health benefits. Pharmacologic therapy is not currently supported by evidence and should not be prescribed for OSA treatment. Surgical treatments are associated with risks and serious adverse effects. Current evidence evaluating surgery was limited and insufficient to show the benefits of surgery as treatment of OSA and thus should not be used as initial treatment.

Saying that the effect of treating OSA on "other clinical outcomes" (including death) is "uncertain" means the data is NOT there.. It is NOT the same as saying there is no increase risked of death (or any of the other "clinical outcomes") if you don't treat the OSA. No data just means no data. And in this case, part of "no data" is the lack of high quality studies attempting to measure the effect of treatment of OSA on many of these "clinical outcomes" and part of the "no data" is that the data from different studies is conflicting at times.

Case in point: The article in the Annals says not once, but twice:

No randomized, controlled trial (RCT) on OSA treatment with regard to mortality outcomes was identified.

and

The literature review identified no RCTs evaluating the effect of CPAP on mortality rates. The ACP's supplemental search also identified no long-term RCT of CPAP in the general OSA population

If nobody's explicitly studied the problem, then there won't be any data. And seriously: How would anybody actually do a genuinely long term RCT on CPAP vs no treatment: Would any happy PAPer volunteer for a study where they might be randomly assigned to go without their PAP for several years???? Would it even be ethical to design a study where half the population was randomly assigned to go without the "gold standard" therapy for several years just to see what kinds of potential differences in mortality risks there are between treating or not treating OSA?

The surprising thing (and it IS surprising) is that in the OSA co-morbidities that have been studied, there's no clear evidence that shows a positive correlation between use of CPAP and improvement of the co-morbidities---except for daytime sleepiness. That doesn't mean there is no correlation; it doesn't even mean that no study has found such a correlation. It does mean that there's conflicting evidence from different studies on some co-morbidities and that there's weak or no evidence on others. It's also rather remarkable how few high quality studies were found and how many low quality studies were found in the literature search.

It's also important to keep in mind that NONE of the studies analyzed in this paper are genuinely long term studies in the sense of looking at what happens to folks who use CPAP for years or decades. I believe the longest study that caught my eyes was in the neighborhood of 24 months (2 years). Most of the studies were only 1-6 months long and almost all were for periods of less than one year. Hence it could very well be that the positive correlations between treating OSA and reducing the risks associated with OSA-related co-morbidities simply take longer than a few months to a few years to kick in.

And since there was no long-term RCT comparing (long term compliant) CPAPers with the general OSA population (including subpopulations of untreated OSA patients, OSA patients who use oral appliances long term, and the long-term affects of surgery for OSA), there's no data available compares the relative benefits of long-term therapy when it comes to reducing the risk for any perceived risk of untreated OSA---including death.

[torontoCPAPguy]

Hi guys. I'mmmmmm baaaaack!

OSA vs. The Grim Reaper

I absolutely GUARANTEE you that untreated or improperly treated OSA is associated with the premature meeting of your maker (assuming you have lead a clean life of course.... otherwise bring the suntan lotion).

It is simple really. OSA creates in most situations a significant drop in blood oxygen level. When this happens your heart goes into overdrive to try and keep your internal organs and brain cells alive. When THIS happens your blood pressure SKYROCKETS. So, unless you are so totally fit that there is no chance that you may have plaque or clots hiding out anywhere (your heart is a popular place for clots to form). BINGO. Clot comes loose or is forced out of your left atrial appendage... or wherever.... reaches your brain, your lungs, your coronary arteries, whatever... and BLOTTO. Massive stroke.

The headlines, however, will read (just in case you are concerned) "He/she died peacefully in his sleep at age 52".

Asides from the chance of a massive stroke you need to be aware of the damage that low blood oxygen will do to your vital organs. You may survive 20 or even 40 years, but in the end your vital organs will not be able to sustain themselves in a critical situation and will do what they do when faced with this. Shut down. Either way, you are going to meet your maker.

I simply REFUSE to sleep anywhere, anytime without my APAP gear. In fact, in order to maintain my blood oxygen above 90% I need to infuse oxygen into my APAP line to raise the air oxygen content being presented from 21% to about 38%.

I check regularly, and also use a hospital grade automatic BP meter that prints and a recording pulse oximeter. One can very clearly discern "events" on the data from the APAP, against the data from the recording pulse oximeter and the BP meter. Now that all is in synch, no more issues with high BP, low blood oxygen, racing pulse, etc.

Losing weight will likely help but I would keep an eye on things even at ideal body weight. I have three friends that visit the gym daily and are fit as a fiddle and of ideal body weight. They all suffer from OSA and use the gear.

[kteague]

I'm guessing there's more supporting evidence to this article's claim that I just haven't seen? This doesn't say there is no increased risk, just that the definitive research isn't there. We could just as easily say sleep apnea DOES cause an increased risk because there's no evidence it doesn't.

"...The big surprise here is that the doctors didn't find any evidence that sleep apnea boosts a person's risk of death. That's been commonly assumed to be true. But the guideline committee didn't find any research that measured risk of death, heart disease or stroke in people with sleep apnea." (emphasis mine)

I just searched a little bit over on PubMed's site. Plenty of clinical data there to support that sleep apnea is a factor in several processes that make one high risk for a lot of ugly stuff that can lead to death. As far as waiting till one loses weight - that's just illogical. If your blood pressure put you in danger, would you defer treatment and try weight loss first? No. You'd treat the problem while working on weight loss then re-evaluate the needs after the weight is gone. If you are diagnosed with diabetes would you leave it untreated for the whole length of time it might take to lose weight just in case the weight loss would bring your sugar down? No. You'd treat the issue then re-evaluate after weight loss, because in the interim adverse health effects continue to ravage the body.

I don't need a clinical study (although they're out there) to tell me that untreated sleep issues initiate a self-perpetuating spiral of physical deterioration - including weight gain. I've lived it. Any suggestion that a person not treat their sleep apnea is not based on knowledge. The article referenced above is not a "real" medicle article. It's fluff stuff written to fill space and to give an appearance of giving the reader new information. In my opinion the writer of this article is irresponsible to even suggest that evaluation for sleep apnea come after the weight loss. They totally lost credibility with me so I can't hear anything else they have to say. At the end they affirm their position of needing to treat sleep apnea, but have just said it's ok to go for months or years without treating it. Good grief!

EDIT: Just read Robysue's post. Thanks for doing the work!

[torontoCPAPguy]

Definitely DO NOT wait. As I stated in my post, weight loss did nothing for my friends and I have three that are fit and slim that all have OSA or STILL HAVE OSA.

You are driving on bald tires. Don't take chances.

[jnk]

The point is, bad breathing and bad sleep can increase the risk of having a life that can seem like a fate WORSE than death.

Until a study is able to prove that hypoxia and sleep deprivation improve and prolong life, I'm not sure I understand the question the researchers are asking. Any of them. It ain't rocket science.

All the researchers have to do is to stop sleeping themselves and start suffocating themselves eight hours a day and then see how they feel and how long they live.

In fact, I volunteer to participate as a paid sleep-depriver/suffocator of those researchers if anyone wants to arrange that kind of study.

My understanding is that the studies on combining water-boarding with sleep deprivation have already been well-documented by the CIA, but those studies can't be released to the public until Snowden says so.

[BlackSpinner]

The point is, bad breathing and bad sleep can increase the risk of having a life that can seem like a fate WORSE than death.

THIS TOTALLY!! I do not want to go back to being the depressed nasty zombie I was before cpap.

[Iowamv]

Science is messy. The progress is not linear. It just takes a long time to sort through various results, especially given the differences between studies. And media reporting on science often leaves something to be desired. One of their major points is that many people who SEEM to have apnea probably don't, and their symptoms can/should be treated by losing weight. That's great, except that is NOT the same thing as saying that people who have been diagnosed with apnea using PSG should be treated first by encouraging weight loss. My BMI is 25; I'm in the healthy column. I don't think losing weight is going to help my AHI. So they are discussing different things here: treatment of secondary signs of apnea via weight loss, and treatment of clinically confirmed apnea.

Nonetheless, that study had three major recommendations. One of them is this:

Recommendation 2: ACP recommends continuous positive airway pressure treatment as initial therapy for patients diagnosed with OSA. (Grade: strong recommendation; moderate-quality evidence)

I assume the Wisconsin Sleep Cohort Study, published in 2009, is still considered to be solid science. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699290/ Among their findings:

Longitudinal analyses with the WSCS data support the hypothesis that SDB has a role in increasing significant cardiovascular morbidity, depression, and mortality. After accounting for confounding factors, persons with SDB, particularly severe, untreated SDB, had 3–5 times greater incidence of the leading causes of poor health and well being, and mortality. Corroboration from other population studies is needed, but our findings suggest that the burden of SDB is large, due to a high prevalence of untreated SDB and potentially high attributable risk for significant adverse health and well-being outcomes.

SDB is likely to contribute to increased cases of hypertension, cardiovascular disease, stroke, depression, and mortality. Adjusted relative risks and hazard ratios indicate moderate to large effect size (e.g., Table 1, point estimates of risk of significant health outcomes with severe SDB range from 2.5–5)

Modification of the total burden by diagnosis and treatment with CPAP holds the greatest hope for reduction of the SDB burden.

[robysue]

The point is, bad breathing and bad sleep can increase the risk of having a life that can seem like a fate WORSE than death.

THIS TOTALLY!! I do not want to go back to being the depressed nasty zombie I was before cpap.

BlackSpinner and jnk's remarks are examples of the one clinical outcome the Annals article says is positively correlated with treating OSA (particularly with PAP) vs. not treating OSA: Quality of life in terms of resolving issues with Excessive Daytime Sleepiness..

That's the one thing that multiple RCT studies were able to show. So that's the one clinical result this paper in the Annals says has strong, medium to high-quality data to support it. According to this particular paper in the Annals: For untreated OSA patients with significant problems with Excessive Daytime Sleepiness, CPAP is more effective at resolving those problems than any other method of treating OSA and it far beats not treating the OSA at all. And the studies with a strong positive correlation between consistent CPAP use and significant improvement in terms of Excessive Daytime Sleepiness symptoms range in length from 1 month studies to 1 year studies if I recall the table correctly.

Folks: This article in the Annals is NOT anti-CPAP. It endorses the idea that CPAP should be tried for treating OSA patients---particularly those OSA patients coming in with EDS problems, but it acknowledges that "Adherence to therapies, especially CPAP, is important for effective OSA treatment." And then it points out a rather obvious fact: Clinicians who are prescribing CPAP ought to make an effort to figure out whether the person is likely to have problems with nonadherence or have problems dealing with the on-going cost of PAP therapy before writing the prescription, giving it to the patient, and telling them "See you next year."

The real questions the article raises in my mind, but does not answer are these:

1) If an OSA patient has NO existing problems with Excessive Daytime Sleepiness and the OSA is mild or moderate, is there really a need to treat it with PAP? is there really a need to treat it at all?
The data are NOT clear on this issue. The article does not say there is no need to treat, but the article does point out that there is no consistent, solid data from randomized control trials that indicate there is a strong statistical correlation between (short-term) use of CPAP (or oral appliances) and positive clinical results for the whole long list of suspect co-morbidities with OSA. For example, this paper is making the argument that a doc should NOT be telling a newly diagnosed OSA patient who also suffers from high blood pressure, but who does NOT have Excessive Daytime Sleepiness, that CPAP will help or fix the high blood pressure problem. We all know folks here who have found that PAPing has helped; but the overall statistical data between PAPing and reducing high blood pressure is just not clear.

2) It is known that CPAP can improve the Quality of Life of OSA patients who suffer from Excessive Daytime Sleepiness problems. But are there any other long term health benefits to using PAP?
The paper says that in the studies found in the literature search, there is remarkably little reliable data that show long term benefits beyond resolving the Excessive Daytime Sleepiness problems. Part of the reason is the paucity of long term studies: Hence long term data is simply hard to come by. And hence better quality studies and longer-term studies may be needed.

3) Patient adherence to both CPAP and oral appliance therapies is a problem. But many things that are commonly assumed to have a positive affect on increasing PAP compliance in particular are not backed up by data from reliable studies. So what kinds of interventions would make a big difference in getting people to give PAP a genuinely fair trial?
The data from studies comparing APAP to CPAP and use of heated humidified air seem to show no statistically significant difference in the rate of adherence during the first several months of PAPing. The data that supports things like use of bilevel machines, exhalation pressure relief systems, and rather basic kinds of "patient education efforts" are often insufficient to draw meaningful conclusions for large populations. In other words, any one of these things may hold the key to helping an individual become a Happy PAPer, but it is NOT reasonable to expect that the percentage "compliant" patients for of a given doc's OSA patient pool will dramatically increase just because the doc starts prescribing APAPs instead of CPAPs for example. Overall, the real thrust of the paper concerning this question is: Not enough is known about what really affects patients' willingness to comply with therapy---beyond a short-term improvement in Excessive Daytime Sleepiness.

4) Since resolution of Excessive Daytime Sleepiness symptoms is the one clinical outcome that is positively correlated to CPAP use in a statistically significant way across many studies, are patients without preexisting EDS problems at much higher risk of non-compliance?
It seems like common sense: If you're not feeling very sleepy in the daytime to begin with, will PAP really make any positive difference in the perceived day-to-day quality of your life? And if PAP is not making a positive difference, then why bother with all the crap that you have to go through each and every night just to use the damn machine? As near as I can tell, none of the studies looked at that issue at all. I personally think its an issue that sleep docs don't really care about because they tend to assume that anybody with untreated moderate to severe OSA will automatically be a zombie, and hence they should start feeling better shortly after starting therapy if only they'd be a nice, compliant patient. But what if there's a large subset of OSA sufferers who don't actually have severe problems with EDS before their diagnosis? What if the ranks of the 50% of noncompliant OSA suffers have a large number of folks who were simply not feeling all that bad before starting PAP?

[robysue]

Science is messy. The progress is not linear. It just takes a long time to sort through various results, especially given the differences between studies. And media reporting on science often leaves something to be desired. One of their major points is that many people who SEEM to have apnea probably don't, and their symptoms can/should be treated by losing weight. That's great, except that is NOT the same thing as saying that people who have been diagnosed with apnea using PSG should be treated first by encouraging weight loss. My BMI is 25; I'm in the healthy column. I don't think losing weight is going to help my AHI. So they are discussing different things here: treatment of secondary signs of apnea via weight loss, and treatment of clinically confirmed apnea.

I agree 100% here.

I too am not overweight (5'1'' and 110 lbs) and I have clinically confirmed moderate apnea. Losing weight won't fix my problem.

The problem with the NPR article as opposed to the article in the Annals is (very) sloppy reporting. The NPR article makes it sound as though the recommendations for how to treat OSA have suddenly changed to downplay CPAP in favor of recommending weight loss. And that's just not borne out by actually reading the article in the Annals.

[SleepingUgly]

4) Since resolution of Excessive Daytime Sleepiness symptoms is the one clinical outcome that is positively correlated to CPAP use in a statistically significant way across many studies, are patients without preexisting EDS problems at much higher risk of non-compliance?

Yes. I read that those without daytime symptoms are at most risk for noncompliance (but don't ask me where I read it...it's been years).

SDB is likely to contribute to increased cases of hypertension, cardiovascular disease, stroke, depression, and mortality

Have there been studies of WHO with SDB is at risk for these, with an attempt to ferret out whether its SDB or its correlates that increase the risk? For example, obese people are at risk for hypertension, cardiovascular disease, etc., so in someone who is obese and has SDB, how do we know it's the SDB that puts them at risk? (a study of obese vs. nonobese would help address that.)

Another question I have is whether those without oxygen desaturations are at risk for any health problems (other than the crappy quality of life syndrome, which is probably also related to things like depression)?

So, I agree, in someone with NO EDS, and particularly if they have mostly hypopneas with arousals and not desaturations, is there any evidence that PAP will improve anything remotely important? And if they do use PAP and they develop EDS or insomnia, are they at greater risk of mortality (and crappy quality of life) now than they were when they were untreated?!

If I were a patient with no EDS and no desaturations, I would demand to see evidence that this was going to in one way or another improve my life, or you better believe I would be "noncompliant".

[Iowamv]

Another question I have is whether those without oxygen desaturations are at risk for any health problems (other than the crappy quality of life syndrome, which is probably also related to things like depression)?

Is it common that someone has an AHI over 5 without desaturation? I just assumed they went together, at least for moderate and severe SA. You'd think I'd learn to stop making assumptions, wouldn't you?

[SleepingUgly]

Is it common that someone has an AHI over 5 without desaturation? I just assumed they went together, at least for moderate and severe SA. You'd think I'd learn to stop making assumptions, wouldn't you?

Hypopneas can be scored if they are associated with arousals OR desaturations, depending on which AASM criteria the lab adopts. It not only makes a big difference to AHI, it makes a difference as to whether someone is diagnosed with OSA in the first place. See:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2635578/

Kinda makes you wonder about the whole categorization of OSA as mild, moderate, and severe, doesn't it?!

[chunkyfrog]

You can't believe everything you read.
Yep!