That misleading study rears its head again...

Can Patients with Obstructive Sleep Apnea Titrate Their
Own Continuous Positive Airway Pressure?

Published in : AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 167 2003

O.

Snoredog wrote:Forget all these stupid studies, there will be one next week which says the complete opposite sponsored by some other drug company. Take your 325mg daily aspirin if you want to lower your risk of stroke or MI and drink plenty of pure non-chlorinated water and if you have OSA use your cpap.

The kind of stuff you're quoting comes from popular media reporting on medical studies. If you read the actual published studies themselves (and I don't mean editorials, commentaries or layman's summaries) it is very rare to see categorical conclusions. There are usually all sort of caveats and limitations in the results that are ignored by the media. So yes, the newspaper may say "New Study Finds B-12 Prevents Constipation" today and then "Another Study Concludes that B-12 Causes Constipation" next week. But if you read the actual studies neither of them says that B-12 causes or cure constipation. That's not what happens every time but it's the usual.

We are told by our doctors you have hypertension and that it is a leading cause of strokes. I've had 2 to date. So far I have yet to find a single study that directly associates or links hypertension with stroke yet doctors tell everyone that is the case.

Define "directly". You can't randomize people and give half them hypertension and the other normotension and follow them to see how many strokes they have. You have to do epidemiologic (population) studies and control for as many other causes as possible statistically. At some point, you conclude that in fact higher blood pressure causes a greater risk of stroke. That is in fact the case, no matter what definition of "directly" you prefer.

So your doctor prescribes a medication to lower your hypertension which most likely is some form of a diuretic like lasix, it's purpose is to dehydrate you so you have less water in the blood in essence thickening your blood. Thick blood increases your risk of stroke (complete opposite of what you want). Other side effects of the medication is it takes water stored in your joints where arthritis is now free to attack the joints, oh we have a drug for that one too, think it's called Vioxx.

Actually, the effect of diuretics on blood pressure do not arise directly from dehydration. In fact, dehydration itself doesn't particularly lower your blood pressure. For reasons that are poorly understood, diuretics do cause most hypertensive people to have lower blood pressure but that effect works fine even if they take in extra liquid to maintain hydration.

As for thick blood causing strokes, I suppose it's plausible that thrombosis strokes (as opposed to hemmorage strokes) might be more frequent if you are dehydrated and/or taking diuretics. If so, that's not a contradiction it's a tradeoff. Every single medical treatment option involves some sort of tradeoff (and choosing not to be treated is itself a choice which involves tradeoffs). Regarding diuretics causes dehydration causing dry joints causing arthritis...well, that just sounds made up. I think arthritis is more likely caused by Z-rays from space aliens circling overhead in invisible spacecraft. By the way, Vioxx is no longer available because it is unsafe for certain people.

Oh you already had a stroke, not to worry, we have a drug for that one too, it's called Plavix. What do you mean a study out TODAY from Cleveland Clinic shows PLAVIC DON'T WORK any better than plain aspirin and in some cases actually increases your risk of stroke.

http://www.cbsnews.com/stories/2006/03/ ... 3091.shtml

Now FDA approved Plavix as being safe and effective. I always thought effective meant it worked? I have taken Plavix myself for stroke prevention, spending sometimes over $200 a month for that crap finally giving up on it due to high costs. My 86 year old mother is still doing the same. We need to fire all them quacks in the FDA and start over. FDA is simply a joke and a license to steal money from you.

I'm not familiar with the study you're quoting. If you can supply a link to the actual study I'll be glad to take a look at it. As for firing everyone in the FDA, were you under the impression that they are able to forsee every effect of every drug that is allowed to go on the market? They don't have a crystal ball. Studies were done that showed Plavix to be effective (enough tot be useful) and safe (compared to the alternatives). If future studies find circumstances under which it is unsafe it will probably the taken off the market quickly. If future studies show it to be ineffective it will probably go off the market because people switch to alternatives. If you really think the entire world is an enormous scheme to rip you off why don't you move to a cave somewhere with your money and close the door behind you?

Untreated OSA: It's sorta like the knee bone connected to the thigh bone thingee, with OSA you don't get any oxygen to the brain, brain tells the heart to beat faster as I need more oxygen, your airway is blocked it can't do that, brain again signals heart to beat faster again. It doesn't know you have OSA otherwise it would do its job and hold your tongue out of your throat

Most people's heart rate initially goes down when they aren't breathing. I don't know about your body but mine wakes me up and makes me breathe rather than just increasing my heart rate. I'm absolutely positive that my tongue never blocks my throat.

I use cpap to restore oxygen levels, if the treatment your using doesn't do that your wasting your time.

Actually, my oxygen levels don't go down much when I have apneas and hypopneas. It's the arousals that keep me from resting and make me feel bad.

_________________

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

Brent Hutto wrote: .....

I use cpap to restore oxygen levels, if the treatment your using doesn't do that your wasting your time.

Actually, my oxygen levels don't go down much when I have apneas and hypopneas. It's the arousals that keep me from resting and make me feel bad.

Some people, myself included, need supplemental oxygen to restore their levels. Fixing the apneas may restore oxygen for most people being treated with cpap, but there may be other factors contributing to lack of oxygen, such as weak lung function or more. For those people such as myself, the cpap may restore some of the oxygen deficit, but not all. Also, there is more going on than just oxygen restoration. Cpap relieves stress on the heart and other organs which are working overtime to arouse your apneas. There's a whole physiology happening throughout your body to essentially save your life at a time of the day where your organs should be resting. It's why people with untreated apnea are more likely to experience heart attacks during nightime sleeping hours than the statistical normal of early daylight hours for the general non-apneac population.

No, my cpap is not wasting my time. It's saving my life.

.....my two cents (ok, three)


Linda

Brent Hutto wrote:The portion of your proposed study dealing with APAP vs. CPAP efficacy and compliance has been done and published a couple of times. I don't have my notebook with me but the conclusions are that the APAP will very slightly undertreat the OSD but not enough to matter. At least one study found a little better compliance and the other found the same compliance between the two modes of treatment. IIRC, the patient satisfaction was higher with APAP.

Thank you, Brent. Those studies certainly go in the direction of what I was asking about.

quote=ozij wrote:Can Patients with Obstructive Sleep Apnea Titrate Their
Own Continuous Positive Airway Pressure?

Published in : AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 167 2003

Thank you, ozij. Your article goes the rest of the way to address what I was asking about.

Quoting from the abstract of the article referenced by ozij:
"Manual continuous positive airway pressure (CPAP) titration in a sleep laboratory is costly and limits access for diagnostic studies. Many factors affect CPAP compliance, but education and support, rather than in-laboratory CPAP titration, appear to be pivotal. Self-adjustment of CPAP at home will provide equal or superior efficacy in the treatment of obstructive sleep apnea (OSA) as compared with in-laboratory titration. A randomized, single-blind, two-period crossover trial of CPAP treatment at the in-laboratory-determined optimal pressure versus at-home self-adjustment of CPAP (starting pressure based on prediction equation) . . . were tested."

This is how I see the dots connecting:
The 2003 study proved that randomly selected patients could titrate themselves on CPAP as good as or better than a sleep lab could titrate them.
The studies referenced by Brent proved that APAP is as good as or better than titrated CPAP.

So, now I'm almost at a loss for words (but not quite). In combination, these studies say that current medical practice, and that of ASAA, have it exactly backwards from the truth. The studies say that patients are better off with APAP and self-titration rather than CPAP titrated in a sleep lab.

I'm sure that somebody will tell me what's wrong with this picture though.

Regards,
Bill

NightHawkeye wrote:So, now I'm almost at a loss for words (but not quite). In combination, these studies say that current medical practice, and that of ASAA, have it exactly backwards from the truth. The studies say that patients are better off with APAP and self-titration rather than CPAP titrated in a sleep lab.

I'm sure that somebody will tell me what's wrong with this picture though.

As we were discussing earlier in this thread, I'd need to read the actual text of the article. I'll track it down when I get a chance.

[EDIT]

OK, I've skimmed through the whole article. Yes, their findings conclude that many OSA patients could use a home APAP trial in lieu of PSG titration and produce almost identical outcomes.

The only caveat that comes to mind is that everyone in that study received a diagnostic PSG before being randomized. So this study doesn't address whether a presumptive OSA case could possibly be given an APAP and a diagnosis arrived at by home APAP use. But once the diagnosis is confirmed, the results of this study indicate that the second night of PSG for titration can often be eliminated.

Oh, and I have to give the usual quibble about potential self-selection bias. Six of the twenty-four people who agreed to be in the study did not complete the protocol so there's always the chance that the dropouts were different in some way from the completers and that if they had stayed in the results would have been different. Not a big deal IMO. I would like to know how many people were invited into the study in order to get the twenty-four participants. If more than 1/3 or so of those invited declined to participate it would raise doubts as to the representativeness of the study sample (for instance, less educated and less motivated patients might have opted not to particpate).

You can go the http://www.redmed.com page and under "Clinician" there is a link to a number of studies. Looking through the abstracts, they all seem to find about the same thing. Manual titration and APAP produce similar pressures, compliance and objective outcomes. In some cases, subjective patient satisfaction type measures favor APAP. The general run of the literature I've seen so far seems to find that results will be similar and there can be cost savings by avoiding followup PSG, at least for the mainstream of OSA patients.

Brent Hutto wrote:The only caveat that comes to mind is that everyone in that study received a diagnostic PSG before being randomized. So this study doesn't address whether a presumptive OSA case could possibly be given an APAP and a diagnosis arrived at by home APAP use.

Beyond what I was asking about, but a case worthy of addressing, as some here, for various reasons which on the surface seem reasonable, have bypassed the PSG route.

Brent Hutto wrote:Oh, and I have to give the usual quibble about potential self-selection bias. . . ., (for instance, less educated and less motivated patients might have opted not to particpate).

I know that is a big concern in some circles, but I have to wonder if it isn't counterproductive to restrict individuals who can improve their own situation with minimal assistance, just so that their lot won't be any better than others who aren't able to make improvements by themselves. I'll liken it to the law requiring parents to buy airline tickets for an infant rather than letting the kid sit in the parent's lap. That law struck me as exceptionally stupid, since the result was likely that more infants were then killed in car crashes because the parents couldn't afford the expense of an extra plane ticket.

Brent Hutto wrote:Manual titration and APAP produce similar pressures, compliance and objective outcomes. In some cases, subjective patient satisfaction type measures favor APAP. The general run of the literature I've seen so far seems to find that results will be similar and there can be cost savings by avoiding followup PSG, at least for the mainstream of OSA patients.

Thanks, Brent.

Regards,
Bill

Brent Hutto's comments are much appreciated.

It's easy to tell when a treatment is not working-proving that a treatment is effective in preventing stroke, heart disease or death is much more difficult. Researchers often/usually end up with more questions than answers. The statement that there is a need to "examine treatments" for OSA/CSA does not mean stopping treatment-it means they need to look for better treatments. That's how care for diabetes and heart disease has improved-and there is still a long way to go. While they are looking for a better treatment for OSA I'm still going to use that little CPAP when I go to sleep.

Brent Hutton wrote:

Regarding diuretics causes dehydration causing dry joints causing arthritis...well, that just sounds made up. I think arthritis is more likely caused by Z-rays from space aliens circling overhead in invisible spacecraft. By the way, Vioxx is no longer available because it is unsafe for certain people.

I was simply stating my opinions on studies in general. You obviously missed the whole point of my response. I don't know if your a doctor, a veterinarian or a robot, but I wasn't quoting ANY study, if I was I would have included a link to it. We already know the medical profession doesn't like to give straight answers to anything other than "we don't know...but take this once or twice a day for the rest of your life..."

Now I didn't say dehydration causes arthritis, I said diuretics generally dehydrate a person, if you study the pathology effects of dehydration on the human body you'll understand where I'm coming from.

But the last time I heard the FDA is still made up and run by of a board of medical doctors. My understanding is they look at premarket studies (paid for and provided by the drug company trying to get the drug approved) and determine if a drug/therapy is safe enough for human trials or consumption.

But the fact remains, the FDA once approved Vioxx as safe for public consumption and has now changed its mind, this was only after many years of patients suffering heart attacks from it did they act to remove it. Now I'm not discounting that aspect of their job, that is what the hell they should be doing. So they remove drugs from the market they themselves once approved as being safe.

But on that same note, they also don't do anything if a drug is found totally ineffective like Plavix was found today. There are millions of patients taking Plavix for heart attack and/or stroke prevention. How do patients get Plavix? They get it when prescribed by a licensed doctor for a particular FDA approved purpose.

But my point was this same FDA also approved Plavixx for human consumption and it was found today by the Cleveland Clinic to be no better at preventing MI or stroke than plain aspirin. You can get a year's supply of that for less than $10 bucks.

Like I said, I was once on Plavix for stroke, it can cost the avg. patient upwards of $225 per month without insurance coverage for a single month's supply. I know I left a full bottle sitting on the drug store counter as I walked out after they told me the price.

But many of the patients taking these totally ineffective drugs are our elderly and already on limited income. They were also led to believe (like I was) that Plavix was not only safe but effective at reducing heart attack and stroke, afterall it was approved by our FDA and prescribed by a licensed doctor.

So I stand by my opinion of the FDA, and I'll even add to it, the FDA is a joke and only there to protect the status quo of doctors and get padded by the lobbyists at the same time. Maybe this new Prescription Drug program the government recently introduced is a good thing, we are now finding out about these totally ineffective drugs that don't really work for their intended purpose (once the government has to start paying for them).

But to protect yourself from those Z-Rays; You might try taking an aluminum pie pan, poking some holes in the edge for a chin strap. I was going to suggest using 2 pie pans over the ears but then you'll look weird like that Princess from Star Wars

NightHawkeye wrote: I know that is a big concern in some circles, but I have to wonder if it isn't counterproductive to restrict individuals who can improve their own situation with minimal assistance, just so that their lot won't be any better than others who aren't able to make improvements by themselves. I'll liken it to the law requiring parents to buy airline tickets for an infant rather than letting the kid sit in the parent's lap. That law struck me as exceptionally stupid, since the result was likely that more infants were then killed in car crashes because the parents couldn't afford the expense of an extra plane ticket.

Beyond requiring a prescription for buying a xPAP machine, there is no restriction on how you receive treatment for OSA. Obviously a good many people are out there self-managing their treatment. I know you're making a political point about the ASAA support forum but that is not a restriction on how individuals choose their treatment, it is a restriction on what methods of treatment are to be discussed on that forum.

You've read a lot, talked to a lot of people, thought about it and decided that you're better off self-managing your OSA treatment. There are people who have thought and studied just as much about it and concluded that self-administered APAP is a bad idea. On this forum, telling someone not to self-administer APAP would be immediately shouted down. On that forum telling how to self-manage their treatment violates the conditions of use. Both forums exist, both are widely read and actively participated in. Both groups of people are acting according to their own best understanding of the situation. That's a good thing...no, it's a great thing.

In the interest of full disclosure, I'll point out that my own informed opinion is somewhere in between the those two positions but frankly I see more to agree with in the ASAA position. I think they could in theory do a better job of spliitting the difference but I also understand their motivtion for handling it like they do (though I'd do it differently myself).

Brent Hutto wrote:On this forum, telling someone not to self-administer APAP would be immediately shouted down.

I have to point out that that's not quite true, Brent. Just in the last few days, we effectively talked an individual out of administering their own therapy, but it was that individual's choice (and an informed one). No one was shouting it down at all.

Brent Hutto wrote:In the interest of full disclosure, I'll point out that my own informed opinion is somewhere in between the those two positions but frankly I see more to agree with in the ASAA position.

I, like others have expressed here in this thread, greatly appreciate your insights and the thoughtfulness you added to this discussion, Brent. I understood your position to be heartfelt and respect that. I think most here feel the same way.

But, by the same token, I fully understand the position expressed by Snoredog. While it may be hard for those within the medical community to accept, and perhaps even harder to understand, particularly because they are in that very occupation to help people, currently accepted medical practice serves many people poorly, or not at all.

Please understand that those of us who have formed conclusions at variance with standard medical practice have done so honestly, and often after brutally painful lessons. And that is perhaps the reason that this forum will collectively take someone to task, if that person displays disingenuousness or duplicity of purpose, as has happened here in recent days.

Brent, on a more personal note, how is your treatment going?

Regards,
Bill

But, by the same token, I fully understand the position expressed by Snoredog. While it may be hard for those within the medical community to accept, and perhaps even harder to understand, particularly because they are in that very occupation to help people, currently accepted medical practice serves many people poorly, or not at all.

There are certainly people who have experienced poor and/or unsuccessful medical care. As we've seen in this thread, sometimes they can lose sight of the difference between a) pointing out the limitations and failures of conventional practice and b) making up pure nonsense. Someone may have the experience of taking diuretics for high blood pressure and then later have arthritis and strokes. That experience does not prove that diuretics cause arthritis (or whatever the actual claim was).

Put another way, well-trained and well-intentioned medical professionals can make mistakes or fail to recognize problems. If that is true, doesn't it stand to reason that untrained (if equally well-intentioned) non-professionals may well make ever more mistakes and fail to recognize even more problems? That's the rub.

Brent, on a more personal note, how is your treatment going?

I'm leaving in a few minutes to see the sleep doc, see the results of my titration PSG and (presumably) get my prescription for CPAP. I'm supposed to have the machine by Thursday or Friday of this week. I hope these wheels grind fine because they grind exceeding slow. Thanks for asking.

Brent Hutto wrote:I'm leaving in a few minutes to see the sleep doc, see the results of my titration PSG and (presumably) get my prescription for CPAP. I'm supposed to have the machine by Thursday or Friday of this week. I hope these wheels grind fine because they grind exceeding slow.

I hope things went well, Brent. Please let us know how things are going.

Again, I appreciate your sincere responses and the thoughts you've shared.

Regards,
Bill

Mar 14, 2006 - Anyone subscribe to NEJM?

sleepydave wrote:
"Look at that compliance. That isn't too great by anybody's standards."

And that is what I find disturbing about the Mayo cardiologist speaking of people in the study as "already receiving treatment for obstructive sleep apnea." If a specialist at Mayo comes away from looking at that study and regards that kind of compliance to be CPAP "treatment"..... sad.

RG, when you first posted this, you said:

rested gal wrote:And now there it is... a statement by a cardiologist associated with the Mayo Clinic commenting that "most people in it were already receiving treatment for obstructive sleep apnea". A flat statement as if it were a given that the treated people were being effectively treated. Sheesh. THE RESEARCHERS WHO DID THAT STUDY DIDN'T EVEN KNOW IF THE "TREATED" PEOPLE WERE REALLY BEING TREATED, yet called them "treated".

So, RG . . ., how does this sort of blatant error get corrected? Do you know? I realize this may sound like a rhetorical question, but I mean it in all seriousness. In my line of work, many avenues exist to address such discrepancies, but I haven't a clue how one would even begin to address this within the medical community.

What sort of mechanisms does the medical community have in place, short of FDA intervention (which wouldn't apply in this case, I don't think), to correct this sort of error? We could continue to speculate (which, granted, has great entertainment value) or we could directly address the issue in some manner and, in some small measure, attempt to resolve this matter.

Regards,
Bill (perhaps overly naive, but if ya don't ask, ya don't get.)

From the perspective of an epidemiologist, if the "treatment" for a certain condition involves receiving a prescription and a CPAP machine, then everyone who has received a prescription and a CPAP machine has been "treated". So it's perfectly valid to look at a population of people and point out that some subset of them have received the usual standard of care for that condition.

Take a simpler example where compliance isn't the issue. Let's say you give a few hundred people the best available, maybe the only available chemotherapy for a certain cancer. Let's say that chemotherapy only works half the time. It's a true statement to conclude that "Half the people who get that cancer die from it even when everyone receives treatment". If you want to know whether people die even when the drug works that's one question. If you want to know if prescribing the drug works, that's a whole different question.

Lack of compliance is no different than lack of efficacy of a drug. If you want to know whether prescribing CPAP and giving them a machine works, that's the first question. If you want to know whether being fully compliant with CPAP treatment works, that's another. From a public health perspective the first question that matters is whether OSA is killing people. The second question that matter is whether the usual treatment reduces the number of people killed by OSA. How to get people to be compliant is purely a clinical matter and unfortunately it's a problem with no really effective answer.