Obstructive sleep apnea is a common breathing disorder, in which the airway in the throat and neck collapses during sleep. It’s very important to diagnose and treat this problem properly, not only because treating it can make you feel much more awake and alert during the day and stop your terrible snoring at night, but also because untreated sleep apnea increases the risk for substantial medical problems, including hypertension, heart failure, cardiac rhythm abnormalities, and early heart attack and stroke.
Problem is, it’s estimated that out of the millions of people in the U.S. with sleep apnea, about 85% of them have not yet been diagnosed. Why is that? There are probably several reasons. First, symptoms can be insidious. You’re not awake to hear your own snoring or witness your own pauses in breathing; if you’ve felt tired for years, the fatigue can just feel “normal,” to the point in which falling asleep while driving or during conversations at parties becomes your “normal.” Secondly, medical care in general is expensive, particularly with the increased deductibles many now have to pay, and in today’s economy some people elect to put off non-emergency medical care. Thirdly, and importantly, there are a lot of presumptions regarding testing for and treatment of sleep apnea which are inaccurate or simply untrue.
When I see someone in my clinic for the first time for possible sleep apnea, I make it a point to discuss thoroughly the nature of the disorder, the procedure of diagnostic testing, and all standard accepted treatment options. A primary and common form of treatment for sleep apnea is continuous positive airway pressure (CPAP), a device that takes room air, pressurizes it at a pressure prescribed by the physician, and delivers it via a small mask into the nose and into the airway. CPAP is not designed to push or force air into the lungs. The air from the device acts as a splint for the upper airway, keeping it patent (open) all night and thus allowing air to travel into the lungs, where it’s supposed to go. This then dramatically deepens sleep, because the brain no longer arouses constantly due to low oxygen levels, thereby making the patient much more awake and alert during the day. The success rates in resolving the sleep apnea with CPAP are incredibly high, provided that 1) the device is utilized properly, and 2) the patient is willing to utilize the device.
Most of my patients come to me very open-minded regarding how to fix their breathing problems during sleep. There are times, however, in which my first mentioning of CPAP in clinic is met with reluctance, or a flat-out refusal. In some ways, it’s perfectly natural to have initial reservations. We are designed biologically always to protect our airways, so it seems counterintuitive to cover your nose or nostrils with something that it meant to make you breathe better. This can be a source of an initial sensation of claustrophobia for some. In addition, there is not only a mask involved, which may seem daunting to the uninitiated, but also a change in night-time habits, and we, the humans that we are, are naturally inclined to hate lifestyle changes thrust upon us by someone else. But I’m struck by the responses I get when I ask why there is such immediate pushback to the consideration for CPAP use, when the patient hasn’t even seen or touched the device. Among the most common of these is, . . . “I don’t want to look like Darth Vader.”
Come on. Really? I’ve heard this, or the equivalent (“Oh yeah, that Darth Vader thing,” or “That’s the Darth Vader mask, isn’t it?,” or some other such statement), so many times, I wonder who are these people out there telling everybody they’ve become Sith lords after starting CPAP and inviting others to join the Dark Side by getting treated too.
Lookit. I was a disciple of Star Wars growing up. I was ten years old when the first Star Wars movie (now known as Episode IV: A New Hope) was released in 1977. In terms of pure love and sheer personal impact, I rank it right behind The Godfather on my list of all-time favorite films. As a kid I studied it religiously, including its philosophies and characters. I memorized the presentation, clothing, and mannerisms of all the characters through scrutiny of books, magazines, and my precious trading cards. So trust me when I say, there are no CPAP masks that are remotely similar to Darth Vader’s mask.
Vader’s mask isn’t even really just a mask. It’s a full-on helmet, covering the entirety of the head, designed and utilized not only for protection but also as a contained respiratory support system required due to massive injuries sustained following Anakin Skywalker’s unfortunate battle with Obi-Wan Kenobi on Mustafar. Take a look:
Uh, the typical CPAP user is not using CPAP for these reasons. All the CPAP device does is simply allow air to pass freely through the upper airway so oxygen can get to where it needs to go: into the lungs and thus into the bloodstream so you can, you know, live. In most cases all that’s needed is a small nasal mask that just covers the nose, with headgear to secure it in place:
Or small “nasal pillows,” soft prongs which are placed gently in the entrance of the nostrils:
OK. So you don’t look glamorous with these things on, and it can take a little while to get used to; that’s the reality of it. However, your bed partner or spouse isn’t going to care much how you look while asleep; he or she presumably will care more about your health and longevity than how you appear while you’re sleeping, and will appreciate that your heroic snoring is now completely gone. My patients generally become accustomed to CPAP use quickly, and these mask interfaces are more comfortable and tolerable than one may think. With proper support from the sleep physician, the sleep center, the durable medical equipment service providing you with the materials, and your family, nightly use of this device can be a complete game-changer, dramatically improving the way you feel (and thus, the quality of life) and the way you sleep.
Another reason why people may relate CPAP use to Darth Vader is the presumption that the device is noisy, with some loud, pervasive inhale/exhale sound that keeps everybody awake all night. Since the CPAP machine is at its core essentially a blower, there is some noise, but the devices now are incredibly quiet, in many cases virtually imperceptible, and the tonal differences between inhalation and exhalation can be adjusted with the new technologies built in to modern devices.
Ultimately, my sense is that some people have heard from someone–Uncle Frank, or Bill down the street–in the distant past about some negative experience with CPAP, and the resulting conjured images just get stuck. As we all know, once an image is lodged in your brain it’s hard to unstick it. And it’s true that ten years ago CPAP machines were loud and bulky, with limited choices of available masks. But think of how technology in general has changed and improved over the past decade. Look at our cell phones now, our desktop and laptop computers, our TVs. Of course everything is better and smaller (well, the TVs are bigger, but thinner and lighter). Same goes for CPAP use. The devices are now very small and whisper quiet, with lots of built-in bells and whistles to make them more comfortable and easier to use. There are dozens and dozens of different masks available now, all in different sizes, so it’s very rare now for my patients to have difficulties finding a mask that fits well. I’d also ask that you look at this from a different perspective: the companies that produce these machines and accessories are all competing in a race to make the best, most comfortable, most popular products. As such, new products come out all the time. You, the consumer, therefore have an advantage, with an ever-expanding circle of choices for products to use to optimize your treatment experience. Ahh, capitalism at its finest!
Having said all of this, there are plenty ways for CPAP use to go sideways (literally and figuratively), limiting one’s abilities to tolerate and use the device. Virtually all of these potential problems are fixable, however, and I will discuss these issues in future posts.
Some think that full face masks must be used when using CPAP (these masks cover both the nose and the mouth). Though these masks are available and may be necessary or desired in some very specific circumstances (a topic for another blog entry), the substantial majority of CPAP users just need a simple small nasal mask or nasal pillows. Full face mask or not, you will not end up looking like Bane from the Batman series:
. . . or another of my favorite bad guys, Hannibal Lector:
I also sometimes hear, “Won’t I suffocate with the mask on?” My reply to that is, “No, quite the opposite. You’re suffocating every night without the mask on.”
You know what would be cool? Since George Lucas recently sold the Star Wars franchise to Disney, maybe I should approach someone at Disney about creating and marketing an actual Darth Vader CPAP full face mask. You know, paint it black, have it play John Williams’ ominous Darth Vader theme music when you put it on. Then all of these references to Darth Vader could actually become true! I’ll look into it. Wish me luck on that one.
So here’s my take-home point for today: don’t deny yourself the diagnosis and treatment of an important medical problem because of what you think the treatment might be like. Explore, speak with your doctor, keep your mind open to trying something that can actually change your life. Insurance companies rent the CPAP device on your behalf for the first several months of use, because they don’t want to pay for a CPAP machine you don’t end up using. If you really hate the machine no matter what is done to try to make things better, you can return it. In other words, you have very little to lose and a lot to gain by at least trying it, if it’s recommended by your sleep doctor. You’ll never know how much it can help you unless you try.
“You’re disoriented. You just woke up. You’re in the future. You’ve been asleep for eight hours.” — Jarod Kintz