Cartoons, Sarcasm, and IRE!…Oh, my!

By David E McCarty MD, FAASM (but you can call me Dave) 

As I was stumbling around the house in a grinning post-Thanksgiving stupor, I decided to post a teaching point cartoon from our Beautiful Blue Book to various groups on Facebook, as a sort of public service announcement, not realizing I was about to step into a thorny trap that would draw debate, sarcasm, and insults.

But as usual, I’m getting ahead of myself again.

~ ~ ~ ~ ~

Let me start over, and build a little suspense:

1.     The cartoon is based on a teaching point that (in my opinion) is tremendously important for all patients with Sleep Apnea to know, because…

2.     Not knowing this teaching point makes a lot of folks abandon CPAP prematurely.

For the ethereal interwebs record: I taught this to every. Single. Patient. I. Cared for. And if I didn’t, I should have.

Wanna know what it is?

Here you go: “You haven’t failed CPAP until you’ve failed it on a low pressure with a nasal mask.”

~ ~ ~ ~ ~

The reason that this little tidbit makes a big difference for individual patients will take a bit of word-jockeying to explain. So let’s get to it. 

I’ll start with the mechanics. Oronasal masks typically require higher pressures on the device, compared with nasal masks. Here’s why: a mask that fits over the mouth and nose always puts some back-pressure on the mandible. This pushes the whole mandibular package—which, of course, includes the tongue—further back, and can worsen mechanical crowding. More crowding means it’s gonna take more pressure to get it open. In addition, an oronasal mask tends to encourage the open-mouth breathing position, a jaw position which further mechanically crowds the back of the throat.

 Now I’ll pivot to the science. Increasing evidence supports the notion that nasal breathing is simply healthier, compared with mouth breathing. During growth and development, mouth breathing leads to high arched palates and mandibular underdevelopment—both of which are features that increase the risk for adult Sleep Apnea. Nasal breathing promotes the production of nitric oxide in the nasal airspace, a substance that improves our ability to extract oxygen from the air we breathe and kills microbes to help protect us from respiratory illness.

 Mouth-breathing, on the other hand, lacks these benefits, while simultaneously promoting larger volume breaths (i.e.: relative hyperventilation), which increases the propensity for central apnea physiology events during sleep.

 But wait: there’s still more! A person who chronically avoids breathing through their nose tends to develop worsening problems with chronic nasal stuffiness, a condition termed nasal disuse syndrome. In other words: the more you don’t use it, the more you lose it.

 Looking at it another way, though, that stuffy nose is not necessarily permanent! Evidence is emerging that one can relearn how to be a talented nasal breather. Need convincing? Read James Nestor’s bestseller, Breath. Or Patrick McKeown’s book The Breathing Cure. Or Anders Olsson’s Conscious Breathing. Or Kelley Richardson’s The Very Stuffy Nose. Or…or…or…

 …you get my point.

 In the long run, we Airway Health Providers must all recognize the functional importance of nasal breathing, and loudly recognize the worthy long-term goal to do what we can to help all our patients become more talented nasal breathers.

 Many of my clinic patients were folks who had previously abandoned positive airway pressure therapy. Many of them swore at our first visit they’d never try it again, their physical experience with it was that bad!

 The most common reason for the failure? Overpressurization, Life-Fans! Clinically, my observation is this: oronasal masks and overpressurization are common bedfellows.

 Here’s a fun flow chart that illustrates one common pathway leading patients to this common and regrettable endpoint!

(Cue Windows 2000 Startup Sound)

 START HERE!—>A New Patient initiates PAP using a nasal mask, with an autotitrating unit, set on a maximum exploratory range (4-20 cm H2O)—>

—>The machine misreads central apnea physiology and delivers more pressure than is needed, forcing air out the patient’s mouth—>

—>the patient is told they’re a mouth-breather, and the mask is switched out to an oronasal mask. This requires higher pressures to be effective, and therefore requires a tighter fit—>

—>the patient lives with the new core belief that they are a mouth-breather, and that they have a high pressure requirement, and a requirement for an uncomfortable tight mask—>

 —> this core belief is never ever revisited, by anyone, ever, ever again, and the patient abandons therapy, because it’s too obtrusive. END CHART.

 I must have seen hundreds—heck, maybe even thousands—of folks like this. Left behind, by a system that did things mechanically, each step of the way determining what happened next, resulting in the same dumb failure, over and over again, like a person falling down the stairs in slow motion.

 Happy news: in my clinic, many of my patients could be talked down off the ledge of PAP Abandonment, with the simple knowledge that it was possible to try again, with a kinder mask and gentler settings.

 You haven’t failed CPAP until you’ve failed it on a low pressure with a nasal mask.

 You can’t just say it to them, though. You have to explain why. That’s when they get it.

~ ~ ~ ~ ~

 Many individuals are gratified to discover that most of us can be managed with pressures in the single digits, often as low as 5 or 6 cm H2O. Most folks with chronic nasal congestion don’t realize that their congestion will most likely improve when they start using the nose to breathe again, of course, with CPAP’s help. Folks often find their nerve, just by knowing that.

 For me, none of the above should constitute anything other than valuable teaching points that can enhance an individual’s long-term experience with therapy. As I said: I believe that these are teaching points everybody should know.

 Which brings me to the part of the story where I tell you about the trap, and the sarcasm, and the ire.

 Before I get to that, here’s the cartoon, along with the Thanksgiving-Stupor public service announcement.  I posted this to a social media group of Sleep Techs, with 5,500 members.

 Here’s what the post looked like:

~ ~ ~ ~ ~

 This is a public service announcement :)

Happy Friday!

Love,

Dave

PS: Please remember to down-explore the pressure before switching to oronasal. In his original description of “nasal-CPAP”, Dr. Sullivan never went over 10 cm H2O!

PPS: Pass it on!

~ ~ ~ ~ ~

That’s it. That’s what I posted.

Now, for the interesting part.

What I expected, in terms of comments, following this post were things like: “Good teaching point!” and “Happy Thanksgiving!” and “Why don’t you learn to draw?”

 What I didn’t expect was the controversy. What I didn’t expect was the sarcasm. What I didn’t expect was…the ire!

One responder put it like this (extra helping of sarcasm included for the price of one conjunction!):

Or.

We could use whatever mask is clinically indicated for the patient, and not villainize one category of mask.

Another put it much more bluntly:

This post is such bs…I don’t even know where to begin…so I won’t 

Others seemed to be clicking their tongues in the other direction:

Research has shown better compliance with nasal masks for years. Some folks either don’t look up current methods/research, or don’t want to learn [shrug emogi]

Yet another had clearly seen this before, and was tired of the whole debacle:

Petition to require both insurance coverage of and participation in therapy to address pathological all-or-nothing thinking among sleep techs until this “debate” finally dies.

~ ~ ~ ~ ~

Wow! As far as teaching points go, this one struck a nerve that I didn’t even know existed! So what gives? What drives this ire, to the point of reckless sarcasm?

Snapshots, Life-Fans. Snapshots.

When we see a patient in clinic, in the lab, in the DME office, it’s a snapshot. It’s a singular moment in time. We may get very good at describing the image in that snapshot, but it’s still just that.

A snapshot. And a single snapshot, Life-Fans, is not the whole movie.

~ ~ ~ ~ ~

Life as an overnight sleep tech—it’s a challenging one. You’re surrounded by twitchy technology, and whenever something goes wrong, it’s always in the middle of the night.

Remember that show MacGyver, where the guy could make a tool to pick locks out of stuff he’d find inside a sandwich? That’s sort of what Sleep Techs have to be like. They have to solve clinical and technological problems simultaneously, in real time. They often have to figure things out completely by themselves, in the dark.

When you’re a sleep tech

it helps to have a little MacGuyver in you

To a sleep tech, when a patient is struggling to use a nasal mask due to nasal congestion, an oronasal mask may be the only real-time option. If this particular snapshot happens a lot, the advice to “use a nasal mask” might sound pretty stupid, and, of course, it would be.

However. As I said, it’s a movie, not a snapshot.

Which brings me, as usual, back to education.

I submit that this whole oronasal vs nasal mask issue is a false debate. What happens in the lab happens because of judgment and practical experience. A tech should never be ridiculed for the mask that was required in real-time to get the job done. I’d also submit that the clinicians ordering the studies would do well to work with their patients on nasal patency before sending them to take up a valuable night in the sleep lab. But that’s just me.

At the end of the day, all techs and all patients should be made aware of the fundamental differences between the two mask styles, and the long-term implications of that important choice.

Everyone should also know about the possibility that one’s abilities with nasal breathing can be improved, and also that it’s possible to use the device at a gentler setting, if a nasal mask is used.

Everyone should know that.

Even the sarcastic ones in the back. :)

Happy Monday, Life-Fans!

(This concludes this Public Service Announcement).