Empowered Sleep Apnea
Some podcasts give you INFORMATION. Empowered Sleep Apnea gives you knowledge. Join Sleep Medicine master-clinician Dr. David McCarty and Sleep Neuroscientist Dr. Ellen Stothard as they do a deep conversational dive into one of the most complex, common, and misunderstood disorders on the planet: Sleep Apnea. Using a combination of humor, fictional elements, and--yes--even CARTOONS, Empowered Sleep Apnea takes you where no other Podcast has gone before!
Empowered Sleep Apnea
Season 2: STORIES FROM THE FIELD Episode 11: PRESSURE TOXICITY (Three tales of TERROR!) (Special HALLOWEEN edition)
All content (c) 2024 Empowered Sleep Apnea, LLC unless otherwise noted
A PDF transcript of this episode (includes cartoon! HUZZAH!) is within your grasp by clicking HERE.
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HAPPY HALLOWEEN, Life Fans! For this extra-delibulous palindromic 11th episode of our second season, Dave reads from the Beautiful Blue Book three tales of a SCARY thing we see here on the ISLE of SLEEP APNEA, something called "CPAP Pressure Toxicity".
What's CPAP Pressure Toxicity? It’s any CPAP setting that’s TOO HIGH FOR YOU? What does that look like? Well, listen to our three stories...SCARY STORIES for HALLOWEEN…and find out for yourself! Don’t worry, Life Fans! We wouldn’t leave you IN THE DARK! All three of our TALES OF TERROR happily resolve into joyful EMPOWERMENT!
The cartoon for today's episode is a teaching point that's worth REMEMBERING...the type of mask we use for CPAP really MATTERS...our cartoon character CLAUDIO helps us take a look at the functional differences between nasal masks and oronasal masks.
To fully grasp this episode's cartoon, just click HERE!
Our Website: https://www.empoweredsleepapnea.com
Official Blog: "Dave's Notes" : https://www.empoweredsleepapnea.com/daves-notes
To go to the BookBaby bookstore and view the BOOK, click HERE!
Empowered Sleep Apnea: THE PODCAST
Season 2: STORIES FROM THE FIELD
Episode 11: PRESSURE TOXICITY!! Three tales of TERROR! (special HALLOWEEN edition!)
All copy ©2024 Empowered Sleep Apnea, LLC
www.EmpoweredSleepApnea.com
A PDF of this transcript (includes cartoon! HUZZAH!) can be grabbed by clicking HERE :)
00:00 Change the Channel
COMMERCIAL KIDS: Honeycomb’s big, yeah yeah yeah! It’s not small! No, no no!
Kids in the hall: Change the channel!
Smoothie Singer: … don’t have to hang around…
Kids in the hall: Change the channel!
Popstar Earworm: And you know and you know that you don’t know… And you know and you know that you don’t know… And you know and you know that you don’t know… And you know…
Kids in the hall: Change the channel!
[DING!]
Everyone: HUZZAH!!
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00:22 Disclaimer
Dave: Empowered Sleep Apnea is an educational podcast, which is a bit different from a medical advice show. Clinical problem-solving in Sleep Medicine can be complex and even empowered patients need a partner. So…play it smart, and make sure you discuss it with your qualified healthcare provider before making any changes to your medical treatment plan.
And now…on with the show!
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00:48 Opening Titles
DISEMBODIED VOICE:
Empowered Sleep Apnea: THE PODCAST
Season 2: STORIES FROM THE FIELD
Episode 11: PRESSURE TOXICITY!! Three tales of TERROR!
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01:22 Prologue Redux
Dave: This is Dr. Dave McCarty. You might remember…way back in the first episode in this season—PROLOGUE—I promised that some of the stories we’d hear in this series would be fiction.
And, because it’s fun to tell stories on Halloween—especially SCARY stories!!—I wanted to tell you some stories about a scary topic that we at the ISLE of SLEEP APNEA call “Pressure Toxicity”.
PRESSURE TOXICITY???!!
Like—Like—it’s some sort of poison, or something?
No! No! No! No!
It’s not that kind of toxicity! We’re talking about the bad things that can happen when the pressure on the CPAP machine goes too high for YOU!
Continuous positive airway pressure, or “CPAP” is a proven therapy for “Sleep Apnea”, on this point, everyone agrees.
CPAP puts air under pressure into YOU through a mask of some type, and, as we’ll see in the three tales I’m gonna tell you next, the mask type DOES matter. The pressure DOES matter.
I want to tell you that three stories I’m going to tell you today are excerpts from our book Empowered Sleep Apnea: A Handbook for Patients and the People Who Care About Them. You can find out more about our “Beautiful Blue Book” on our website Empowered Sleep Apnea.com, and you can try to figure out why the Journal of Clinical Sleep Medicine, a flagship journal of the American Academy of Sleep Medicine, called it “an invaluable resource for healthcare professionals starting their journey in sleep medicine.”
I mean…look at it like this…if it’s an “invaluable resource for a healthcare professional”…and it was written so that anyone with a high-school reading level can understand it…maybe there’s something to this idea that collaboration cures!
So, anyway…I wanna welcome to this very special Halloween edition of Empowered Sleep Apnea: THE PODCAST…and please…don’t worry… here on the ISLE, even SCARY stories end up with EMPOWERMENT.
As always, make sure you tune in ‘til the end.
No tricks, only treats: we’ll get to this episode’s CARTOON, and you gotta have your Dad Joke fix!
So Happy Halloween, Life Fans! As I light the candle in my Empowered Sleep Apnea Jack-O-Lantern, I’m opening up my copy of The Beautiful Blue Book, where I’ll be reading to you some chapters from it…pretty much verbatim, though as the storyteller, I might add a few words here and there…just for fun…
So here we go, with a collection I’m calling:
PRESSURE TOXICITY…three tales of TERROR!
I hope you enjoy it!
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(The following four chapters are excerpted—with minor editorial storyteller differences--from: McCarty DE, Stothard E. Empowered Sleep Apnea: A Handbook for Patients and the People Who Care About Them. Chapters 82-85. BookBaby Press, NJ, 2022).
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04:19 What is Pressure Toxicity?
CPAP or “continuous positive airway pressure” therapy is a physical treatment strategy.
A knee brace for your airway. Because of its physical character, there will always be potential problems with it. Let’s talk about one of the most common of these problems, a concept we’ll call pressure toxicity.
Let’s start with the understanding that CPAP therapy works like a pneumatic splint for the upper airway. The ideal amount of pressure is “just enough” to overcome the obstructive pathology, but not so much that you notice it. If the pressure goes too high, it can feel downright uncomfortable!
Though everybody agrees that conceptually, PAP at too-high-for-you pressure is a bad thing, there is no universal definition for what, exactly, defines Pressure Toxicity. It happens that there’s a lot of overlap between symptoms of Pressure Toxicity and symptoms driven by other sources.
This is where we’re gonna get to our THREE TALES OF TERROR, Life-Fans!
So let’s join in with some of our fellow ISLAND ADVENTURERS and see what this looks like…
The first of these TALES OF TERROR I’m calling: “Gail and the Annoying, Non-Resolving, Really-Aggravating Chronic Cough”
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05:50 Gail and the Annoying, Non-Resolving, Really-Aggravating Chronic Cough
Gail was doing reasonably well on her CPAP for the last two years.
Reasonably.
Her original AHI (under Medicare rules—with the 4% desaturation criterion) was 18 per hour, and her original sleep-wake complaints included loud and disruptive snoring, difficulty initiating and maintaining sleep, and a tendency to doze off during afternoon meetings.
About two years ago, Gail was prescribed “AUTO-PAP” 5-15 cm H2O through a nasal interface, and she’d been using it successfully ever since.
“AUTO-PAP” means that the machine’s allowed to go anywhere between 5 and 15 cm H2O based on an internal algorithm driven by its ELECTRONIC BRAIN…
At follow- up visits, she’s noted improvements to sleep continuity and depth, a complete elimination of snoring, and an improvement in excessive daytime sleepiness.
Overall, a successful strategy, if anybody asks!
Data from her device showed excellent adherence, an excellent average AHI of 3.7/hr .
Now, the 30-day range…showed a range of 1.3 to 6.1… and a 95th percentile leak of 18 L/min. That means that 95% of the time, the machine is reading the leak as being less than 18L/min.
(That’s a lot!)
Detailed data showed that higher leak rates were seen whenever the device accessed pressures higher than 8 cm H2O.
INTERESTING!
Breakthrough events were seen during timeframes of high pressures and high leaks.
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07:42 Enter the Cough
Over the past two years, Gail had been having increasing difficulty with a nagging cough.
Multiple times per day, she reported fits where she “couldn’t stop coughing.”
Now, this caused problems in her job as a cosmetics counter clerk at Macy’s. The odors were triggers for the cough. She was having to excuse herself to go to the restroom several times a day.
It was enough of a problem that she sought a complete lung evaluation at a nationally-recognized Pulmonary Disease Hospital, though she wasn’t making much progress in terms of recovery.
Gail hadn’t thought about it before, but she admitted that her problems with chronic cough began sometime after she started using CPAP! She admitted that she often felt that her mouth was really dry in the morning, and that the device woke her up by blowing air out her mouth from time to time.
With the hypothesis that Gail’s chronic cough was a result of airway desiccation and irritation due to Pressure Toxicity, Gail and her provider decided to down-explore her pressure range.
After several pressure adjustments, Gail’s final pressure was fixed CPAP at 6 cm H2O. Her average AHI was lower at 1.7/hr, with a lot less variability day-by-day.
Best, yet: her 95th percentile leak was much improved at only 3 L/min, and her perception of waking of with air puffing out her mouth VANISHED, as did her dry mouth!
And…psst…get this: the chronic, annoying, non-resolving, really-aggravating chronic cough…WENT AWAY….
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09:49 Let’s Talk About Gail
So…EMPOWERMENT brough a pretty satisfying outcome for Gail…lowering the pressure so that it’s just enough, but not so much that it wants to blow air out the mouth and cause irritation…
Sometimes, folks can’t withstand the TERROR of pressure toxicity right up front…and it causes a chain reaction leading to…well…other sources of TERROR!
Let’s take a closer look, as I tell you the second story for tonight…a tale I call… The Story About Sam and The Big Dumb Clunky Oronasal Interface
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10:38 The Story About Sam and The Big Dumb Clunky Oronasal Interface
Sam started CPAP therapy with high hopes.
He started his journey with a no-bones-about-it Big Bad Apnea, with a Medicare-criterion AHI of 49/hr, nearly 100% obstructive apneas.
He snored like a freight train, waking up every 2 hours to urinate, always sleepy in the daytime.
This was BIG. BAD. APNEA, follks!
Sam was set up with a CPAP device…it was set to AUTO-PAP 5-20 cm H2O…
…with the idea that the pressure was going to be adjusted, based upon his response after a couple of weeks of use.
In other words, PAP was started, using AutoPAP 5-20…and they were gonna choose the 90th percentile pressure…
OK… Here we go!!
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11:40 Sam’s Woe
Sam didn’t think he would even make it through the weekend, let alone two weeks.
On the very first night, Sam knew it was no use. He put the nasal mask on, just like the technician told him. And at first, the machine felt all right, and he was able to drift off to sleep.
But then, out of nowhere, the machine woke him up, feeling like it was forcing air into him.
Oppressive … claustrophobic…It’s like I’m connected to a Jet Engine! he later told his wife.
After only two nights of having the air blowing forcefully out of his mouth, waking him up in a panic, feeling like he is suffocating, Sam was ready to hang it up. He brought the machine back to the equipment supplier, all wrapped up in its duffle bag.
"This,” Sam proclaimed, as he set the toaster-oven-sized duffle bag down on the countertop with a resounding THUD, “is never going to work.”
After some cajoling, the technician talked him into trying again with a larger mask, one that goes over the mouth and nose.
Sam reluctantly agreed.
13:00 Sam’s New Mask
It turns out that Sam had a bit more success with this. He was still not very happy with the larger mask. His AHI result was nicely suppressed, though, averaging at 3.9/hr. His snoring was under control, and he admitted that he was, in fact, sleeping better.
Reluctantly, he allowed that “it is what it is,” but he was genuinely not very happy about the big red mask straps that came with the larger interface. And he had read somewhere that Mouth Breathing Is Bad For You.
Then Sam found his Empowerment.
Empowered Sam decided he would like another try with a nasal interface, this time, at a more restricted pressure range. Oral air-venting--orair being forced out the mouth when a nasal interface is used--is a common product of Pressure Toxicity. An overly-aggressive starting pressure is a common reason for this problem, which leads to early switching to a more obtrusive, higher-pressure-requiring oronasal mask.
For Sam with his new nasal interface, after several steps of down-exploration of pressure, the final setting was a much less burdensome AUTO-PAP 5-7 cm H2O.
His follow-up average AHI showed excellent control over events at 1.9/hr.
The best part…the best part…THE BEST PART…was that Sam had absolutely no difficulty with oral air venting. On the more restricted pressure range, he was able to keep his mouth closed, and the quality of his sleep was enhanced.
Overall, Sam was much happier with the smaller, less-obtrusive nasal interface.
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14:58 Let’s Talk About Sam
I’m happy how this story turned out for ol’ Sam, that he found his EMPOWERMENT, and learned that maybe the reason for his initial “failure” on CPAP therapy was simply that the machine was set too aggressively for him at the beginning…and that oral air venting can be controlled by DOWN-EXPLORING the pressure.
Calls to mind one of the ol’ sayings we have here on the ISLE OF SLEEP APNEA…you haven’t failed CPAP until you’ve tried lower pressures through a nasal interface!
In our third and final tale, we’ll see another chilling way that CPAP can wreak havoc when the pressure is set too high…that it doesn’t just force air out the mouth…air can come out of…OTHER PLACES, too!
Buckle up tight, Life Fans, and have another Reese’s Peanut Butter Cup… brace yourselves for our final TALE OF TERROR…a little story entitled: Gramma Suzanne’s Eyes, Gramma Suzanne’s Legs.
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16:10 Gramma Suzanne’s Eyes, Gramma Suzanne’s Legs
Gramma Suzanne is a fiery first-generation Italian-American, 81 years old, and 98 pounds, soaking wet and full of spaghetti and meatballs.
When her husband Mateo passed away suddenly—inexplicably—Suzanne’s usual high-energy slipped away on the slopes of grief into depression.
That was when she began sleeping for fourteen hours per day.
Her adult grand-daughter Leslie, a pediatric oncologist, pressed her to get an evaluation.
Sure enough, polysomnography revealed the presence of Sleep Apnea, with an AHI of 26 per hour, a score made of nearly all hypopneas of an undisclosed mechanism.
Her physician impressed upon her how important it was that she go on treatment, in the name of RISK management.
It’s worth mentioning that Suzanne was terrified of the possibility of a stroke, having cared for her own mother for twelve years, following a catastrophic left hemispheric stroke that felled her like an oak, leaving that vibrant force of nature crippled.
The indignity of it was painful enough. The fact that her mother’s stroke occurred within the context of a colorful social form of self-abuse called chainsmoking and alcoholism made it all the more tragic.
Saying Suzanne never cared for the CPAP machine is an understatement. She detested it. Yet, out of duty, she bore the burden.
See, she wouldn’t burden her child, the way her selfish, beautiful, impossible, uncontrollable mother burdened hers.
She would use this machine, night after night, in spite of the fact that it was literally pushing air out of her eyes…
You ever notice that, when you cry, it seems to suddenly make your nose start running? That’s because there is a convenient little drainage duct on the inside corner of your eye, which funnels your tears down into your nose, so you can snivel and snort properly, when you ugly-cry.
That convenient little aquaduct is called the lacrimal duct.
It turns out that if you apply air under pressure to the nasal airspace, it’s possible to pump air backwards through that duct.
Air. Coming out, through the eyes.
That’s why Suzanne hated her machine so much.
Wearing it made air come out of her eyes!
Suzanne did her best to use the machine, but the data showed limited use. She felt like a failure. She stopped coming to follow up appointments.
This was when her Sleep Medicine provider decided to review her original sleep study. Not the report, but the actual study data. The raw waveforms that can show patterns beyond the numbers.
It turned out that the vast majority of her hypopneas appeared to be central apnea physiology-driven. Though she did have some upper airway resistance features, like faint snoring, some fluttering of the airflow trace contour…most of the variability of the breathing appeared primarily related to effort oscillation.
Wow!
Let’s say it again, and savor the importance: the primary pattern seen on this study was one of recurring central hypopneas.
Of importance to future management, the central hypopneas occurred in cadence with frequent periodic limb movements of sleep!
Now, Life Fans, we haven’t been introduced to periodic limb movements of sleep yet. That’s OK, we’ll get there. For now, just scratch your chin and say this: Hmmmm. That’s interesting. The leg movements seem to be driving the arousals from sleep!
Let’s just flash back to the time that Suzanne was tested: she had been clinically depressed, had not been eating well. During that time, she had quietly developed iron deficiency. In addition, she had also been taking Sertraline, prescribed for treatment of depression complicating bereavement.
As we mentioned above, at this point in our journey, we haven’t yet explored the moving parts for developing clinical restless legs syndrome—the academic eggheads are now calling this Willis Ekbom Disease. We’re going to ask you to put a pin in this, OK?
We’ll get there.
Just know for now: the leg movements might be treatable.
The leg movements might go away.
Also for now, it’s important enough to know that the leg movements on the sleep study seemed to be a driver for arousals from sleep.
Holy Smokes!
The arousals from sleep were a major moving part in the breathing instability, the central apnea physiology.
HOLY SMOKES!
The leg movements could be the primary problem!
In this section, though, we’re talking about pressure toxicity, right?! We’re talking about air coming out the eyes! Aren’t we?
Given the revelation about the central apnea physiology on the diagnostic study, Suzanne decided to re-group at the [FIVE REASONS MONUMENT &] Coffee Hut.
After a few cups of coffee and a nice slice of lingonberry pie, she decided that RISK might not be looming as large as she had originally thought.
At that point, her provider did several things.
First, she proclaimed Suzanne’s PAP therapy “optional.”
Second, she treated the iron deficiency, which was clearly contributing to the periodic limb movements of sleep and the restless legs symptoms.
Third, she communicated with Suzanne’s primary care physician, in order to switch Sertraline to Buproprion, which doesn’t tend to provoke the “restless legs” type physiology.
We’ll learn more about the why of these changes were important when we explore the wilderness that we call the Willis Ekbom Wilderness…that place where Restless Legs Syndrome interacts with Sleep Apnea.
For now, just know that she and her provider took a swing at some of the treatable components that can contribute to the restless legs syndrome and the periodic leg movements of sleep, OK?
Over the course of the next four months, Suzanne walked through the valley of her grief. Gradually, she began to re-engage in elements of her life that had brought her joy.
She began cooking again.
Somewhere along that timeline, she stopped using her CPAP machine, completely. She just quit.
Also: somewhere along that timeline, the quality of her sleep improved, and her restless legs symptoms resolved.
Also: somewhere along that timeline, she began sleeping 8 hours a night again.
Now, the thought that crosses your mind: perhaps the requirement for sleep can change over the course of a person’s journey through life? Perhaps grief itself can increase the drive for sleep? Perhaps Sleep Apnea can change over time? Well, these thoughts come from a place of wisdom, Life Fans!
You are correct.
You are absolutely correct.
23:30 Suzanne’s Transformation
It was about the time that Suzanne started sleeping normally again that she came back for her follow up sleep study.
Because of the central sleep apnea physiology concerns, her provider requested the study to happen in the Sleep Lab.
When the results came back, it appeared that a miracle must have occurred! The new test showed a much milder flavor of Sleep Apnea, with a Medicare criteria AHI of only 3/hr and an 3%/arousal scored AHI of 11/hr.
Of interest, the periodic leg movements had resolved. Central apnea physiology had also nearly completely resolved.
At that point, Suzanne realized she was in a very different part of her journey. The primary concern—that the Sleep Apnea would punish her noncompliance by giving her a stroke—was gone!
She was thrilled, to be emancipated in this way, from her captor.
With the stressor of RISK off the table, Suzanne felt more comfortable exploring what was actually wrong. She realized that she did sometimes sleep poorly as a result of her breathing, mostly when her allergies are acting up. When her nose was stuffy.
On nights like that, she thinks that using her CPAP actually helps. She knows she sleeps more soundly with it (again, sometimes, when her nose is acting up), but she likes the way it makes her nose feel clearer in the morning when she uses it.
The device? Well, that was down-explored on the pressure to CPAP 5 cm H2O, which suits Suzanne just fine.
She uses it sometimes, and it helps, and she’s happy with that.
Her favorite part: She no longer has air coming out of her eyes.
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25:36 Pressure Toxicity: Summing Up
Let’s talk about these three different stories for a minute.
Common to all of them was an unnecessary degree of suffering, induced by the treatment itself.
A complication of therapy, in other words.
Our friends were suffering because the pressure on the device was too high for them. That’s the concept we are calling pressure toxicity.
In the first example, chronic oral air venting was perceived by the patient only as paroxysmal awakenings with dry mouth. She didn’t make the connection that the chronic irritation was an ongoing trigger for her chronic cough.
In the second story, dramatic oral air venting and perceived pressure discomfort drove an early decision to switch to a more obtrusive oronasal interface, vaguely lowering the patient’s sense of sleep satisfaction.
In the third example, Gramma Suzanne felt compelled to use CPAP therapy, even though the therapy was abusing her in a unique and disquieting way (air coming out her eyes? REALLY?).
She did this, out of fear for the consequences of stopping. Fear, that, as it turns out, was placed on an improper understanding of the notion of RISK, as pertinent to her case.
In each of these three cases, a reduction in the pressure improved the patient’s overall experience and improved the quality of life.
Three different stories of suffering, due to the physical aspect of treatment. The narratives are distinct, individual, like a fingerprint. The unifying characteristic across these stories is that excessive air pressure was needlessly causing harm.
So, how should Pressure Toxicity be defined? Ultimately, is it like that famous-yet-useless definition of Pornography (I know it when I see it)?
Tsk. Tsk. We Empowerees can do better than that! In light of the fact that too-high pressures can affect people poorly in all kinds of ways, we would like to offer the following cryptic definition for Pressure Toxicity, until something better comes along…
Pressure Toxicity: A Definition that is Not a Haiku
What is Pressure Toxicity?
It’s anything uncomfortable, intolerable, or abusive
That improves, when you lower it.
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28:10 Cue Majestic Theme Song/Closing Credits/Cartoon
This is Dr. Dave McCarty.
Empowered Sleep Apnea: THE PODCAST is an educational production of Empowered Sleep Apnea, LLC. Today’s show was performed by me, David E. McCarty MD FAASM, taken from material from the Beautiful Blue Book, which was written by me and Ellen Stothard, PhD.
The cartoon for today’s episode was found taped to the mirror in an abandoned train station bathroom, underneath a single word written in red lipstick with four-inch capital letters…the word was…
“REMEMBER”…
…it’s a little two-panel comparison strip that shows the difference between a nasal mask and an oronasal mask…turns out they are not the same…nasal masks tend to require lower pressures to do the same job compared to oronasal masks, and…remember that bit about MOUTH BREATHING IS BAD FOR YOU?...
Yeah. Me too.
So, anyway…thanks for tuning in to this extra special Halloween edition of Empowered Sleep Apnea: THE PODCAST, where TERROR is simply the opposite of EMPOWERMENT, and, as we all know…EMPOWERMENT SAVES.
Stay tuned next…for your Sleep Medicine Dad Joke.
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29:46 Sleep Medicine Dad Joke
Neighborhood kids: TRICK OR TREAT!!
Dad: Ok…I got one…this joke is great for Trick or Treating!
Not-Dad: Dad….
Dad: No really…what did-- what did the zombie say when he was unable to sleep because his CPAP machine was set too high?
Not-Dad: …I don’t know, what did the zombie say?
Dad: You ready? BRAINS! Ha ha! Get it?
Not-Dad: No…why would he say “brains”?
Dad: Because that’s what they say for everything! BRAINS! Ha! That’s why it’s funny!
Not-Dad: Dad! That’s not even funny at all! That’s the most unfunny thing you’ve ever said!
Dad: …and that’s why it’s funny!
30:43 End Program
