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It can cause depression, fatigue and irritability. It can even be fatal. Yet many people who have sleep apnea do not know the warning signs and the severity of this sleep disorder. Home medical equipment providers and the manufacturers of sleep therapy products play a critical role in educating consumers on sleep apnea and the most effective treatment options on the market.

Currently more than 12 million Americans suffer from sleep apnea and it is conservatively estimated that an additional 10 million remain undiagnosed, according to the American Sleep Apnea Association (ASAA). Sleep apnea is a common sleeping disorder and continuous positive airway pressure (CPAP) devices are the most common and effective method of treatment.

"Left untreated, sleep apnea is potentially life-threatening; the consequences include high blood pressure and other cardiovascular complications."

The typical sleep apnea patient is overweight, male and over the age of 40, but sleep apnea can affect both males and females of all ages and weights.

Left untreated, sleep apnea is potentially life threatening; the consequences include high blood pressure and other cardiovascular complications. Sometimes patients do not even know they have sleep apnea until they have already had a stroke.

Central sleep apnea syndrome is characterized by a cessation or decrease of ventilatory effort during sleep and is usually associated with oxygen desaturation.

According to the American Sleep Disorder Association, the hemodynamic complications of central sleep apnea include the development of cardiac arrhythmias, pulmonary hypertension and cardiac failure. Difficulties with memory and other cognitive functions may result from excessive sleepiness, and headaches can occur upon awakening.

Obstructive sleep apnea, the most common form, is characterized by repetitive episodes of upper airway obstruction. During sleep, the muscles which control the tongue and soft palate hold the upper airway open. If these muscles relax the airway becomes narrower, often causing snoring and sometimes breathing difficulties. If the upper airway muscles relax too much, the airway can become blocked.

This blockage can cause sleep apnea patients to stop breathing as often as 100 times a night, according to ASAA. There can be sudden awakenings following the obstructive events and complaints of chest discomfort, choking or suffocation.

The obstruction to breathing prevents sufferers of sleep apnea from reaching deeper stages of sleep which leads to irritability during the day and an increased risk for traffic accidents. Depression and anxiety also are associated with obstructive sleep apnea.

By pushing air through the airway at a pressure high enough to keep the airway open during sleep, the CPAP machine can be the solution that sleep apnea patients need to regain a peaceful night's sleep and to eliminate the risks associated with sleep apnea.

To meet this critical need for sleep apnea patients, manufacturers of CPAP devices make continuous changes in technology to improve comfort, ease of use and overall compliance. In addition, HME providers have the difficult task of reaching the large number of patients who are not aware that they have sleep apnea.

ResMed Corp., Poway, Calif., manufactures products for the diagnoses, treatment and management of sleep disordered breathing. ResMed offers a varied product line of flow generators, masks, humidifiers, clinical diagnostic systems and accessories.

Typically there are three types of CPAP devices, although they are not all called CPAPs. There is a static device which provides continuous airflow, a bi-level device which alternates between higher air pressure during inhale and lower during exhale; and a smart CPAP device which alters pressure on demand. This CPAP device is the most advanced on the market: algorithims in the device assess air flow and increase or decrease it based on the particular individual demand.

ResMed's AutoSet T, which uses this advanced technology, is an automatic positive airway system for the treatment of obstructive sleep apnea. Using patented AutoSet technology, the delivered pressure is automatically adjusted on a breath-by-breath basis to suit patient needs as they vary throughout the night.

This feature is more comfortable for patients than traditional CPAPs since the minimum pressure effective for adequate treatment is always administered.

Nidek Medical Inc., Birmingham, Ala., offers the Silenzio Delta, which has all the features of a bi-level device, but also features a back-up breath rate. The Silenzio Delta operates in a choice of modes. The spontaneous mode senses patient breathing patterns and delivers the right pressure and the spontaneous timed mode respiratory transition is triggered by the patients breathing cycle and supported by an adjustable back-up breath rate.

ResMed has also introduced the exclusive patient management software, AutoScan 3.0. "Autoscan 3.0 is the only software available to meet true patient efficacy, not just compliance as other products on the market offer," said Curt Kenyon, senior vice president of sales and marketing for ResMed.

"After all, a clinician wants to know if the patient is being effectively treated, not only if the patient is using the device," Kenyon said.

Compliance can be a problem for sleep apnea patients if they are not comfortable with the equipment they are using, if they are having difficulty using the equipment or if they do not understand the importance of being compliant.

Choosing the correct fit and type of face mask is important for patient comfort as well as compliance.

ResMed offers the Ultra Mirage and Mirage mask systems for comfort and ease of use.

The Ultra Mirage mask's lightweight cushion is covered by a soft silicone membrane specially designed to eliminate pressure on the sensitive nose bridge. Air flowing through the mask inflates the membrane and gently positions it against the face, so that it forms a secure seal without having to tighten the headgear straps. This unique design reduces the possibility of pressure sores, according to ResMed. Four points of attachment between the mask frame and the headgear enhance the mask's stability.

ResMed's Mirage mask is an extremely lightweight, comfortable mask with an excellent seal from leaks, Kenyon said.

To add to patient comfort, many manufacturers offer humidification products to relieve the drying side effects of CPAP treatment. Almost half of CPAP users find that the dry air causes nasal congestion and a dry nose and throat. The humidification adds moisture to the air, making the patient more comfortable and improving adherence to treatment.

These added features and new technologies of CPAPs are intended to minimize or possibly eliminate the side effects of treatment such as nasal congestion and drying; facial skin irritation, abdominal bloating, mask leaks, sore eyes and headaches. The less intrusive the products, the more likely a patient will continue to use the product.

Patient Education Leads to Compliance

Not only is it critical for people who have sleep apnea to realize they have this sleep disorder, but it is also of equal importance for current sleep apnea patients to use their CPAPs every time they sleep. If they have any concerns or problems with the equipment they may stop using it, so it is important for HME providers to follow up with a patient's treatment.

Houston-based CPAP-Direct, an independent distributor of CPAP devices for major manufacturers primarily through the Internet, provides support and coaching for their consumers.

"Sleep apnea is a very pressing problem, but we do have effective treatment that works and that is CPAPs," said Thomas K. Speer, PhD, president and CEO of CPAP-Direct and a board certified sleep therapy specialist. "CPAP's are 90 percent effective for treatment and the most effective treatment option available," Speer said.

Following up with a patient to find out if the mask is comfortable, if the pressure is optimal and if the patient is sleeping enough is essential, Speer said.

Kenyon agreed that patient education is critical. "The patient, and equally important the spouse, must not only understand how to use the device, but also how they are benefiting from treatment and the implication of not being compliant," Kenyon said.

Kenyon said that non-compliance increases the chances of heart disease, stroke, high blood pressure and traffic accidents.

Another important aspect of compliance is for the patient to be able to tolerate the pressure at therapeutic levels. ResMed's AutoSet technology is able to deliver pressure in a manner which actually increases patient compliance and effectiveness of treatment over conventional CPAP devices, by responding to the individual needs of a patient.

"It is important for the provider to document compliance, but what the referring clinician and insurance carrier ultimately want to know is whether the device is effectively treating the patient, or the efficacy of the treatment," Kenyon said.

Speer said that physicians or providers of CPAP devices need to offer support to patients and ask them questions after they begin their treatment. "You have to follow through and ask patients how they feel, if they are comfortable and if they have positive sleep behaviors. You can't just hand them the equipment and pat them on the back."

Patients should have a goal and physicians should let patients know how they should expect to feel, Speer said.

Currently the national average for compliance is 60 percent but Speer said CPAP-Direct - through follow-up and educational efforts - has increased compliance to 80 percent for its consumers.

Reimbursement

Patients typically rely on their physicians or DME providers to recommend a device mask system. Some devices are rented and others are purchased depending on what the insurance company specifies for coverage. Some patients rent and convert to a purchase over time.

Speer said that Medicare often dictates what company or companies a patient can buy a device from and this limits the choices. If Medicare only reimburses for the lowest priced, standard CPAP, many patients cannot benefit from the advanced technology smart CPAPs offer.

Although patients need a prescription for a CPAP device from their physician, the Internet is making patients and their families seek out information regarding products on their own. If customers have the option to make a choice for a device on their own, they take the suggestions of their physicians and augment this information with an Internet search. Most consumers look for CPAP devices that are quiet, easy to operate, dependable and portable.

Getting the Word Out

Speer said there should be more public service announcements and more literature to educate the public on the severity of sleep apnea. Speer suggested targeting those who would be at high risk: ages 40-60, overweight, a history of snoring and sleepiness during the day.

It is also important for women to be aware that they can have sleep apnea even if they are of ideal weight, according to Speer. Often women who snore and have sleepiness or headaches during the day may take a sleeping pill, which only serves to mask their symptoms and prevents them from identifying that they have sleep apnea. People who begin to fall asleep while driving may also be at risk.

"A clinician wants to know if the patient is being effectively treated, not only if the patient is using the device."

Educating the public also falls into the hands of physicians. "The medical community and private physicians have to do a better job of diagnosing sleep apnea. They need to catch it sooner," Speer said.

With the variety of CPAP devices and appliances available to treat sleep apnea, the outlook for treatment is positive; however, more effort is necessary to reach those who remain undiagnosed.

SleepNotes

In order to educate consumers and the general public, CPAP-Direct.com offers SleepNotes, a Website page designed to educate patients on CPAP devices.

The following are tips on how to choose a CPAP machine from CPAP-Direct:

· The operation of the machine should be quiet so as not to disturb sleep or the sleep of your partner. Most machines today are extremely quiet so it is important to consider mask options to ensure that the sounds at night are not disruptive.

· The machine should be easy to operate and easy to clean. Most machines are in need of very little, if any, maintenance. The key here is the manufacturer's warranty.

· The machine's size and weight is important for portability. If you travel or camp, make sure the CPAP is durable. If necessary, adjust for changes in altitude.

· Look for advanced features that add to better usage - automatic stop and start features, delay timers that let you lower the pressure at points of awakenings to allow for you to drift to sleep at lower pressures. Customized timers or a range in choices is helpful.

· Consider the design of the device in relation to where you intend to place it -- on a headboard or a night stand.

· The quality of the product and reliability of the manufacturer will go a long way in ensuring long-term usage. Choose a system from a reputable manufacturer for uninterrupted treatment.

· Dependable service is important if and when you need service. Most manufacturers do their own service in a central location. A company with a strong worldwide network of providers will help speed up the time to get your device back.

· Most CPAP machines today deliver pressure with very little drift in pressure, therefore the advanced features may make a significant difference in comfort as well as nightly use. Get the mask or mask systems that work well with your machine and consider humidification as an integral part of your therapy.

This article appeared in the September 2000 issue of Home Health Products, Vol. 8, No. 8.

This article originally appeared in the September 2000 issue of HME Business.

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