PAP Eliminates Apnea. Why Doesn’t It Eliminate OSAS?
It’s finals week here at Cal State Long Beach, and we’re in the process of adopting a new mascot. I voted for the giraffe, a regal and noble animal with attractive coloring and a long tongue, but it came in dead last behind the pelican. The pelican? Seriously? The one with the big bag for carrying fish in its beak? The overwhelming winner was the shark; we have a world-famous shark research program here. But shark mascots are everywhere, and they all look like the “Saturday Night Live” land shark from years ago. And they have so many teeth. But I digress.
One of the questions I posed to my Sleep and Dreams class on their final examination was to consider that, in most cases, PAP therapy will substantially reduce or eliminate apnea. And yet, as a recent meta-analysis of double-blind, placebo-controlled studies1 has shown, treatment does not result in a statistically significant reduction in morbidity or mortality. In short, eliminating apneas does not always eliminate obstructive sleep apnea syndrome (OSAS). Sure, patients may have a slight reduction in blood pressure and some improvement in quality of life. But reductions in morbidity and mortality are not as great as we might hope, given the logic of removing the symptom-defining apnea events. How does this happen?
I think, at least in part, this arises from the biomedical model. This has served health care well, especially in terms of surgical interventions, reduction of bacterial infections and control of viral illnesses (or at least until recently). But the model fails to include a variety of other factors that contribute to illnesses. But it relies on mind-body dualism. The physician treats the body, and the mind is something separate and unique, communicating with the body only through the pineal gland (according to Rene Descartes). The mind is a “ghost in the machine” of the body.
I teach in a psychology department, and my students know that the mind is hugely influenced by the body. If you exercise, you are more likely to feel alert. If you are in pain, you are more likely to feel depressed. But the body is also influenced by the mind. Pleasant hospital environments are associated with quicker recovery and better health outcomes. Making healthy food choices results in higher energy levels. Most people think of psychology as only beneficial for mental illnesses, if that. But there’s a whole lot more to psychology in the health care field.
The bio-psycho-social (BPS) model was introduced by George Engel, an internist, in 19772. It builds on the medical model and includes changing people’s perception of their health problems (the “psycho” part) and providing a positive environment that encourages well-being (the “social” part). Since its description it has been enthusiastically incorporated into the American health care system and has resulted in enormous improvements in our healthcare system. I’m kidding, of course. Although the BPS model is part of the Affordable Care Act, it is rarely included in physician education and woefully underfunded as a treatment option.
Let’s circle back to the treatment of OSAS. Sleep medicine has been focused on eliminating apnea. That’s the job of a sleep technologist. Crank the pressure up until the apneas go away. And attack hypopneas, RERAs and snoring while you are at it. Psychological and social factors have been largely ignored. One possible exception is the recommendation that patients are compliant with their treatment, using motivational enhancement. Another possible exception is the recommendation that OSAS patients lose weight. But analysis of the APPLES study found that PAP use actually resulted in a statistically significant weight increase, especially in patients who were compliant with therapy3.
I think this reflects the problem with treating OSAS (the syndrome) as if it is OSA (the apnea). The patient is led to believe that wearing a PAP mask will “cure” OSAS, and they don’t need to do anything more. Wash down those French fries with a milkshake? No problem, I’ll wear my PAP tonight and I’ll be fine. Exercise a half hour a day? Who needs that when you have a PAP mask? But the syndrome is more than the events.
Treatment of insomnia has moved away from the biomedical and more in the BPS direction for many years. Rampant hypnotic use (purely biomedical) is falling out of favor. Cognitive behavioral therapy? That’s the BPS model in action. When we apply this model to OSAS we’ll be working with patients to encourage weight loss, a healthy diet and exercise, but we’ll also address other factors that may be contributing to continued morbidity and mortality even with adequate PAP use. De-stress with yoga. Use a blue light reducing app when binge-watching “Game of Thrones.” Exercise with a buddy. (I recommend a dog; they are ready to go when you are, and they don’t expect you to discuss politics while you walk). Develop a growth mindset. We don’t know how effective these interventions are … yet. But sometime soon we may be able to support these interventions with data (and that’s a growth mindset).
If any physicians are reading this, they are probably thinking that there is no way they can add this to their eight minutes with the patient. That’s where sleep technologists come in. Implementation of the BPS model will require buy-in from a broad range of health care professionals. Start by checking out this article on the BPS model4. It may turn out that being a coach and cheerleader is just as important a getting the right mask and pressure settings.
- Yu J, Zhou Z, McEvoy RD, et al. Association of positive airway pressure with cardiovascular events and death in adults with sleep apnea: A systematic review and meta-analysis. 2017;318(2):156–166. doi:10.1001/jama.2017.7967
- Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136. doi:10.1126/science.847460
- Quan SF; Budhiraja R; Clarke DP; Goodwin JL; Gottlieb DJ; Nichols DA; Simon RD; Smith TW; Walsh JK; Kushida CA. Impact of treatment with continuous positive airway pressure (CPAP) on weight in obstructive sleep apnea. J Clin Sleep Med 2013;9(10):989-993.
- Adler RH. Engel’s biopsychosocial model is still relevant today. J Psychosomatic Res 2009;67:607-611