IMPORTANT New Apnea Study

Snoreking writes:

With all of the flaws pointed out in this thread, the study still seems to me to say, at a minimum, that if you have apnea and do nothing about it, it is very much akin to driving recklessly, to use your metaphor

You really didn't get my point or maybe I didn't get the point of the article. First off, I didn't feel this article was saying it was a matter of treating your OSA in order to avoid the strokes. I thought just the opposite. It didn't matter, I thought, according to this article whether you treat it or not; you are still at risk by more than two times the average person of dying from stroke, etc. So if treatment doesn't matter to affect those odds, do I give a rat's patooty? No.

Second, why should I care about an article that unnecessarily worries people who have OSA by giving them such grim news and tells them, "It doesn't matter if you are on therapy or not, you still have that increased chance of dying from A, B or C"? Sorry, but I won't spend my days worrying about the things I can't change. And I can't understand why ANYONE would. Do you live just to find depressing news so you can dwell on it? Not my style.

I don't know what you read in my response and were surprised over. I am still one of the most pro-active people you will ever meet when it comes to everything in my life: healthcare, family, job. You could say I am hyper to a fault over certain things. But don't expect me to sit around wringing my hands over something like this. It's not going to happen.

I thought I'd log in one more time since this is the kind of research reporting that drives me nuts. Things like this hit the general media and people start to accept as truth that "Pomegranetes prolong life" or "Hormone Replacement therapy is good for your heart...wait a minute, no, it's bad for your heart... no....it's bad for cancer risk, I dunno about your heart...." You get my point. Nothing, no single study is conclusive. The flaws pointed out by Neversleeps and reiterated by Rested Gal are examples of good consumerism. After reading these articles, my main conclusion is I should read more articles and we need more studies.

The flaws are considerable. I do see some credible evidence that CPAP is not necessarily the treatment of choice, or a sufficient treatment for central apnea. It does raise that question mark. To me, that's a "Duh" moment. No surprise there. I also see huge flaws regarding failure to control for compliance, an assumption that the Rx pressure was appropriate and effective, failure to control for all the comorbid conditions that could/would affect the results, and on and on. Big time limitations. I do commend the researchers for saying, straight out, that we need studies of the effectiveness of CPAP- hopefully, since this made the WSJ, NEJM, and some other newslines, this will be an incentive for more research. That, as a researcher, is probably the best outcome of this all, the indication that there finally is more interest in doing credible, quality research in this area.

As an interesting sideline, I used one of these articles for students to critique in class (graduate students). They thought it was interesting but ended up, after their critiques, with a big "so what?" The limitations were so obvious. But that's how all research works. We all have to be wise and astute consumers of the media to figure out what is best for us.

Beth,

Good post. "So what" is my critique, too. This means nothing to me, sorry. All I can say to the author of the article is, "Thanks for giving me something you inconclusively put out there, yet feel you want me to worry about, AND tell me there is virtually nothing I can do about it." If it doesn't help you to do anything but worry, what is the point? Oh, right. So I can stress myself out over the "fact" that I am more likely to die of a stroke being I have OSA, treated or untreated. No thanks.

OK so I'm a board newbie and only recently REALLY started using my CPAP in earnest... every night. (I had problems with headgear, mask, all kinds of stuff... I think I have a fairly good combination now)... anyways...

I've also been dead. Oh, not for days or anything... just for a while... heheh... but it certainly changes one's perspective. I look at this article and think to myself how incomplete the research appears to be. Same conclusion as many others. However it makes me think about my CPAP therapy. *IF* this article were the factual truth... period... why bother with CPAP?

Easy... I don't care what that article says (the "so what" concensus) because my daily LIFE and daily FUNCTION is improved by using my CPAP. My quality of interaction with my family is better.

Now, while I'm hopeful that using the CPAP will lessen my risk... I'd like to be around for a while... I am also very satisfied with what it does for me in the present.

Take it from someone who has been through a high-speed head-on crash (although I DID enjoy the helicopter ride... kinda weird, huh?)... there are some things we just simply do not control. However we CAN do whatever we feel is prudent to IMPROVE our condition... with "condition" being either our physical state or our state of mind.

I'll keep using my CPAP and enjoying waking up rested in the morning.



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CPAPopedia Keywords Contained In This Post (Click For Definition): newbie, CPAP

This has been an interesting discussion! If I can follow-up to Lori's post, looking at the bigger picture of CPAP and OSA, I do think there is some conclusive evidence (as conclusive as anything ever gets, which is quite a philosophical assumption that conclusions are possible) that OSA is very dangerous. There also is conclusive evidence (above disclaimer applies) that CPAP can help a lot of people enjoy a much better quality of life. Based on that, and adding my own subjective experience (which often means more to me than just about anything else), even if my life is cut short for whatever reason, with the CPAP I will at least be awake and alert enough to enjoy it. Beyond that, I don't know that I really care that much! The Quality of Life factor has to be figured into any research in this area, I think. And I do look forward to more research (so we can have a good time tearing that apart, too - isn't science fun! - LOL!) Gee, imagine those folks diagnosed 15 years ago when there really wasn't anything to go on.... At least we are seeing some research done, for better or worse. Take it all with a grain of salt. The more I do and read research, the more I become a skeptic. Or is it just the curmudgeon-ness of middle age?

Previous studies have suggested that the obstructive sleep apnea syndrome may be an important risk factor for stroke. It has not been determined, however, whether the syndrome is independently related to the risk of stroke or death from any cause after adjustment for other risk factors, including hypertension.

conclusions
The obstructive sleep apnea syndrome significantly increases the risk of stroke or death from any cause, and the increase is independent of other risk factors, including hypertension.

Lori, Sleepless, Folks,
I think you're getting slightly carried away.
The NEMJ had two studies reported, one about OSA and one about Central Sleep Apnea in poeple with cardiac heart failure.

The OSA study did not attempt to deal with therapy and its effects at all. It's background is a legitimate attempt to find out if OSA, as such may cause strokes. It is a first, rough survey of the ground, and isn't geared at measuring the effect of any kind of therapy. Any CPAP user who decides to stop using CPAP because of this study is not reading it the way it was meant to be read. The study is not about CPAP, and doesn't attempt to be about it.

It is not a disservice to CPAP users, it is a service to human knowledge, and there is no reason not to publish it in a scientific medical journal. The disservcie, if any, was done by popular reporting which alway looks for the practical and the dramatic. Science it not alway practical, not always dramatic - it is important.

So what?
Well, if you've got OSA, and you lost weight and your BP is normal, and your blood sugar is fine, you've never smoked, don't drink and you're generally fit as a fiddle even then, you're still at risk, and had better try to control that OSA . T

The study doesn't attempt to say which is a good or better therapy for OSA. That was not what the OSA study was about at all, and therapy is not mentioned in either the name, the background or the conclusions.


O.

What ozij said! Great post!

ozij wrote:It is not a disservice to CPAP users, it is a service to human knowledge, and there is no reason not to publish it in a scientific medical journal.

O,

That line said it all, thank you. I really am not getting carried away. My only point that I so inadequately tried to make was, I thought they were saying that no matter what you do, treat or not treat your OSA, you are still in this high risk category to die from stroke, etc. To me, that is useless information. Thanks for nothing, in essence. It will not change what I do or do not do. I never took it, as many others I think did, to say that you shouldn't bother using CPAP because it won't reduce your chances of dying from these ailments. I thought it was saying that using therapy won't help reduce your being in this risk category. And, like I stated in my first reply, I would think that those of us who have gotten help as far as energy levels, reduced BP, and alleviation/elimination of other problems that were related to having OSA will never think of stopping the therapy because this article said they were in that high risk group. Who would think of going backwards just because of this?

I'm done, thank you. I guess I may come across as more emotional in my posts than I really am, the hyper woman that I have always been. It's not so, though. It was a very thought-provoking and interesting thread, in any event. Definitely not the usual, "What mask works best for you?" NOT that's there anything wrong with that question ...

Ozij,

Direct quotes from the study:

Of the 88 incidences of strokes or death subsequently recorded, 72 occurred among the sleep-apnea patients. Many of these patients were undergoing various forms of treatment, including the pump-and-mask apparatus known as continuous positive airway pressure, or CPAP. But even with treatment, the group still had an elevated risk of stroke and death, according to the study, which was paid for by grants from the NIH, the Department of Veterans Affairs and Yale.

The present study was not designed or powered to address adherence with treatment or the effect of treatment on outcomes.

They should have stopped there, but they didn't.

Nonetheless, our study demonstrated an increased risk of stroke or death from any cause among patients with the obstructive sleep apnea syndrome despite the administration of various therapies.

They indicate cpap therapy is ineffective without any basis in scientific fact. Already there are posters here and on TAS who are saying, "Why am I using cpap if it doesn't do any good?"

That is the disservice. If even one person reads this study and stops therapy, they have done irreparable damage.

Jeez, didn't think it would get so complicated or convoluted. Having read the various article and research since my original post of this thread yesterday, my takeaway was/is kind of simple:

What the research DOES say: Apnea is a damn serious health threat (not just a sleepiness/grumpiness variable) and should be treated accordingly. The impact of various treatments is unmeasured/ unclear/unknown, and is beside the point of this particular reseaqrch study. (In scientific research jargon, that translates as "more research needed.")

What it DOES NOT say: That any particular treatment or all treatment is ineffective or a waste of time or futile or anything to be discouraged in any way EXCEPT to the extent that there is a HINT that it may be less effective or ineffective if the cause is central apnea, which has a different genises and is generally unaddressed by current treatment methods.

That's about it.

Osij,
Not to pick nits, but that which you offer as "direct quotes from the study" are actually quotes from the articles describing the study rather than the study themselves are they not? Your point about the possible disservice of the statements is well taken, but probably attributable to the press rather than the actual studies or observations by the researchers. An important distinction...Yes, No, Maybe?

My apologies Osij -- the quotes and attribution was posted by neversleeps.

snoreking wrote:Rested Gal -- a somewhat unrelated point, but I have noticed in this thread and several of your previous postings that you are more than just a tad cynical about a surgery solution. I had my UPPP twelve years ago. My Apnea readings were at that point in the upper seventies. (yup, 70's!) My surgeon told me that the BEST results I could expect would be about a 50% reduction, so I would still require lifelong cpap therapy. He was right on target. Post surgery sleep study was down from 70's to low 30's. Now, with an average pressure of 11 (apap range 7-14) I have an AHI that seldom exceeds 1.0. The surgery was a major pain in the neck, as it were, but in my instance, well worth it, I beleive, despite the fact that I will never know if I would have had the same results using cpap without the surgery.

Hi snoreking,

Yes, you're right about my being extremely cynical about the most common surgery (UPPP) when it's offered as being an alternative to cpap by surgeons less truthful than your surgeon was with you. Your doctor made sure you understood it was unlikely to be a complete apnea cure for you.

I'm glad you ended up with a reduction in your AHI. However, since AHI severity and pressure needed to keep the throat open don't have much relationship with each other, there's no way (as you rightly pointed out) for most people to know if the surgery will even result in needing a lower pressure with cpap.

You had a good surgeon and you were lucky to be able to continue to use cpap later. Some people report having even more difficulties using cpap after UPPP than they had with cpap before.

Actually, it's only UPPP that I get most cynical about.

Alternative treatments for sleep apnea such as Pillar Implants ALONG WITH a dental device like the TAP II are being reported as working very well as an actual cure (resulting in less than 5 AHI on subsequent PSG's) for several people who post to the talkaboutsleep dental sleep medicine board, at least one of whom was in the moderate/severe range before.

I realize that neither you, snoreking, nor your surgeon was holding up UPPP as a "cure". If it has helped you to use cpap at a lower pressure than you would have had to use without the surgery; and if you do not have side effects from the surgery that make things more difficult in other ways for you, then it was a good thing for you to choose.

UPPP is not a good thing for most people to choose, however...imho. You see, I'm also cynical about how many really competent surgeons there are out there, as well as dismayed at the way so many people jump at even the tiniest chance that they might not have to "be on a machine" after all...perhaps not really listening to their doctor's cautioning statistics.

You chose a good doctor. A lot of people aren't as fortunate in the luck of the draw. You and your surgeon were both realistic about what to expect in your case.

Two interesting articles -- pro/con:

Upper Airway Surgery Does Have a Major Role in the Treatment of Obstructive Sleep Apnea by Nelson Powell MD

Upper Airway Surgery Does Not Have a Major Role in the Treatment of Obstructive Sleep Apnea by Barbara Phillips MD

snoreking, while not thinking of these next ones as a cure, I do believe some kinds of surgery are helpful toward making cpap use easier and more effective...turbinate reduction and sinus roto-rootering, in particular...to make it easier to get cpap treatment air through the snout.

For many reasons (sometimes hopeful, sometimes skeptical ) I keep updating these discussion links:

LINKS to surgery, turbinates, Pillar, TAP experiences

Just to ensure we're all looking at the same thing, here is the link to the full pdf of the original article from The NEW ENGLAND JOURNAL of MEDICINE:

Link to New England Journal of Medicine paper on risk factors with OSA

snoreking,

I'm sorry. It was quite a bit earlier in this thread that I referenced the source. The quotes are from the article noted in the post directly above this one:

Link to New England Journal of Medicine paper on risk factors with OSA

It is authored by the actual researchers of the study, not the press.

Based on that paper, by the authors of the study, I simply want to emphasize (for the benefit of anyone out there who thinks this study proves cpap therapy is ineffective):

The continued use of CPAP therapy throughout the course of the study was never monitored or verified. The researchers fully admit this. Some (58%) of the participants were prescribed cpap therapy at the beginning of the study. They told the researchers they used it at least 4 hrs per night, 5 nights per week when the study began. (That, alone, sends up a red flag. Would you reach a conclusion regarding the efficacy of cpap therapy based on participants who only used it half of their sleeping hours? Would you reach a conclusion regarding the efficacy of cpap therapy based on what someone SAID they did? This compliance was not verified by machine/software data; they just went by what these people told them regarding hours of use AT THE BEGINNING OF THE STUDY.)

There was NO verification or even an attempt to verify or monitor continued CPAP use by any of these people throughout the 3.4 year study. How many kept using it? THEY DON'T KNOW. THEY NEVER CHECKED. If any of the participants kept up with the therapy for the duration of the study, how many of their sleeping hours did they use it? THEY DON'T KNOW. THEY NEVER CHECKED. Yet, stunningly, they wrote, "Nonetheless, our study demonstrated an increased risk of stroke or death from any cause among patients with the obstructive sleep apnea syndrome despite the administration of various therapies."

Their indication that their study demonstrated stroke risk was not reduced despite the administration of various therapies was misleading at best, negligent at worst.