In times past, people never received information about diseases or explanations about treatment modalities.  We went to the doctor with a backache, received a prescription, and just went home and took the pills. We always trusted our doctor and most of the time never posed the question: why?

Now, we know that treatments are much better accepted when the patient has the chance to learn about the disease process and how therapy works.  Hopefully, education for sleep apnea begins way before the sleep test occurs.  It should start with an initial visit with the doctor, continue through evaluation, pre-testing, all the way to post-testing and beyond. 

Since obstructive sleep apnea has not yet been classified as a chronic disease, it still requires education for a lifetime. Sharing information can also be an integral part of education and acceptance.  Support groups offer this opportunity to gather information and tips on use of PAP therapy.  A more than through support system from doctor, therapists, and family ensure comfort and acceptance for therapy.

White noise machines and other similar products are recommended by doctors for baby sleep problems, by mothers for their children, by professional people for their offices, and by restless sleepers. We are less likely to wake up if we have some soft white noise in the background.

Some people enjoy sleeping to nature sounds, surf, waterfalls or others like birds or crickets. I have found that I preferred sleeping to the sound of rain, I even liked hearing the sound of thunder associated with a storm.

Most of the time (365 days a year), I sleep with a box fan on in my room. This was something I started when I worked nights and was often woke up, when the garbage man came through or the neighbor's dog barked 24/7. 

After 14 years of nights, it has become a habit now that I can't break. I have to have some noise in order to sleep. I'm not sure if there is a White Noise Anonymous group I can join, but I am open to suggestions. If you've found something that has helped, send your remedy my way so I can share it with everyone...

Mask interfaces are constantly changing. Some of the latest are beginning to take shapes that answer the demands of users.

But for many years, being a PAP user and a woman has not been a good combination. Questions are asked by PAP users and non-PAP users about the telltale marks that masks leave on the faces of nightly users.

Masks that use headgear that comes from the chin are not user-friendly for side to side sleepers.  Some of the covers on the market can help with this nuisance. 

I also have seen some wild solutions to this problem. One lady told me she used hair curlers to combat mask marks. I could not quite grasp how she used her curlers but it was clear after she sent me a picture. She cut the foam curlers she used for her hair and placed the foam side down to keep the mask from leaving marks on the side of her face. I found this solution comical at first and then I was convinced that this was the answer to her problem.

What is your solution? If you have any good pictures or suggestions, please let me know!

New research studies show that our sleep dispositions are related to our formative years as adolescents and young adults.  If a person has a tendency to sleep for only short periods and keeps a late night schedule, it may well carry over to our adult years.

We are just beginning to gain a good understanding of the biology of circadian rhythms -- the cyclic, clock-like expression of genes in the body.

The newest theory is we all have a "Clock Gene."  Research teams using a combination of genomic, biochemical, and behavioral approaches, recently revealed a "new genetic component of the mammalian clock -- a protein known as ‘Rora.'"

This discovery may someday help people with jet lag, shift workers who feel wiped out after working a night shift, and people with more serious sleep disorders, many of which are related to circadian rhythms.

You could be the next Idol in your bed partner's book! That means that using your PAP device is a win-win situation.

Although when educating patients and their families, I still hear PAP users saying, "the mask is not very sexy".  Of course my next response is what is more beneficial, using the mask and machine, or having your bed partner sleeping in another room.  Most people say they would rather have the bed partner in the same room.

This is much better than the alternative, which could be waking up next someone who is  DEAD.  I know that sounds harsh, but this kind of straight talk sometimes brings people to realize that PAP, "ain't all that bad".

Most bed partners are definitely the support system.  They remind PAP users to put their masks on when they sleep and often assist with adjustments when air leaks are present.

There are still scenarios that prove our brain disconnects us from our environment when sleeping.  Patients try out their skills as comedians when they say, they aren't sure if they snore, since they don't stay awake long enough to find out.  But again the bed partner speaks up to say there aren't words to describe the snoring.

So be the next Idol at your house, put on the PAP....

Most CPAP users know that checking that expensive machine is not a good idea. It's bad enough when you are going one way and you find out your luggage has gone another.  I learned this lesson the hard way.  After watching the baggage handlers tossing luggage and missing the loading ramp, my priorities definitely changed.

While the Department of Transportation has limited carry-on luggage to one piece plus a personal bag such as a purse or briefcase, it has noted that the new "limit of one carry-on bag and one personal bag (e.g., purse or briefcase) for each traveler does not apply to medical supplies and/or assistive devices."

This information is available for reference and printing at the American Sleep Apnea Association website.

CPAP users should also take into consideration lighter machines, lighter masks, and light weight tubing.  All make it a lot easier to travel light with CPAP devices.

Who's the biggest loser? Would it be the PAP user or the medical equipment supplier? With restrictions tightening the belts of compliance guidelines, how can we continue to ensure that what we are doing is actually in the best interest of the PAP user?

My philosophy has always been some PAP therapy is better than nothing. When questioning users about compliance, many respond with, "it's too much air." At the VA, our physician will allow 2 cm of pressure up or down without additional testing. These policies vary by sleep centers.

When compliance downloads reveal that the person is not using the machine regularly, we contact our veterans with a letter. Sometimes non-compliance can be related to illness, colds or sinus infections. If we run into non-compliance on the next follow up, we make a personal phone call to investigate. Solutions can sometimes be as simple as adjusting the mask or humidity levels.

How does your sleep center handle these issues?

When educating sleep professionals, it is vital to explore all of the options available. If your company is required to have patients return their equipment when it is not being used, everyone tries to exhaust efforts to bring compliance to an exceptional level. Even some of the best follow-up policies don't always keep your patients from becoming the biggest loser.

Gastric Bypass surgery for obesity--specifically, Roux-En-Y Gastric Bypass--is the most common gastric bypass procedure today.  RNY Gastric Bypass is an operation to create a small food "pouch" at the upper end of your stomach with a capacity of less than two ounces (<50 ml). 

It's a drastic lifestyle change. But, it has given many people their lives back. Like me, they can look forward to being able to breathe again, to sleep at night apnea-free and finally off PAP machines.

Most patients with obstructive sleep apnea (OSA) who required nighttime treatment with positive airway pressure, no longer needed PAP by 1 month after gastric bypass surgery. (That does vary with your own set of circumstances.)

Patients who have undergone a bariatric procedure maintain a stable weight. When weight loss is achieved, the likelihood is excellent that sleep apnea will greatly diminish or completely resolve, which provides for an enhanced quality of life.

Bariatric surgery is one means of allowing substantial and long-term weight loss for morbidly obese patients. However, it is not cheap and does come with risk.

My procedure cost around $33,000 dollars.  My doctor also wanted to do an EGD, esophagogastroduodenoscopy. I had one of the worst reactions to the procedure ever. Some doctors require other testing prior to the gastric bypass, depending on your insurance and health factors.

For many people this is literally a life-saving operation!  But make no mistake: it is not a cure for obesity, nor is it something to be taken lightly.

Snoring is no laughing matter. It comes in all shapes and sizes, has no age barriers, and affects children and adults, males and females, even pets!!

When I tell people that we are predisposed for snoring by our gene pool, they look at me in disbelief.  If Granddad snored, chances are you will too.

In my family, everyone, including my baby brother who passed away at the age of 41, uses PAP.  That includes my dad, sister, brother-in-law, and husband.  Our mother snores but we have yet to get her to submit to sleep testing. 

A couple of years ago, we were in Panama City Beach, Florida on vacation and the air conditioning went out. We had to open the window of the room. We all knew we would be safe because if anyone broke into our room, they would think the aliens had landed, seeing all of us on our CPAP machines.

While working at Children's Hospital, I saw kids in for overnight testing, a lot of them just snoring the night away. We had parents sleeping in the room with them for the overnight study and found they were also snoring like a "big dawg."

Everyone doesn't always fit our preconceived notions about who will snore. By reviewing listings of patient's medications at times you can almost predict if your 90-pound female will be a snorer. 

Thyroid meds and hormone replacement therapy are unknown markers for snoring.  I have had patients who, when questioned about their medications, say they have been snoring for years and their physicians never told them that some medications are responsible for snoring.

So remember: snoring is no laughing matter and can be a symptom for potentially life-threatening medical conditions.

Some patients are just searching for answers they will never find, or an alternative to use of PAP devices. I tell people everyday that what you have is somewhat a result of your gene pool. When a person has very mild sleep apnea some suggestions may be successful. Some non-medical interventions include:

• Weight loss - as little as 10 pounds may be enough to make a difference.
• Change of sleeping position - Because you tend to snore more when sleeping on your back, sleeping on your side may be helpful.
• Avoid alcohol, caffeine and heavy meals - especially within two hours of bedtime.
• Avoid sedatives - which can relax your throat muscles and increase the tendency for airway obstruction related to snoring.

Some other alternatives do include risky and painful procedures that at times don't give the desired results, read on.....

Radio Frequency of the Soft Palate uses radio waves to shrink the tissue in the throat or tongue, thereby increasing the space in the throat and making airway obstruction less likely. Over the course of several treatments the inner tissue shrinks while the outer tissue remains unharmed. Several treatments may be required, but the long-term success of this procedure has not as yet been determined. This is still used in some parts of the world and mostly done in the office of a physician, under light sedation.

Laser-Assisted Uvuloplasty is a surgical procedure that removes the uvula and surrounding tissue to open the airway behind the palate. This procedure is generally used to relieve snoring and can be performed in the Oral and Maxillofacial Surgeon's office with local or general anesthesia. I still say there is not enough ice cream in the world that will convince me as an adult to have this procedure done!! But it has made for a great party trick, when you can spew carbonated beverages out of your nose.

Hyoid Suspension - If collapse occurs at the tongue base, a hyoid suspension may be indicated. The hyoid bone is a U-shaped bone in the neck located above the level of the thyroid cartilage (Adam's apple) that has attachments to the muscles of the tongue as well as other muscles and soft tissues around the throat. The procedure secures the hyoid bone to the thyroid cartilage and helps to stabilize this region of the airway. We had a patient a few years ago that was convinced he was not going to use the PAP device and chose this type of surgery. He was in his early 40's and had a stroke during the procedure that left him paralyzed on his left side.  It really does pay to consider all of the risks associated with surgery.

Genioglossus Advancement was developed specifically to treat obstructive sleep apnea, and is designed to open the upper breathing passage. The procedure tightens the front tongue tendon and reduces the degree of tongue displacement into the throat. This operation is often performed usually along with at least one other procedure such as the UPPP or hyoid suspension. Not for the faint of heart!

Maxillomandibular Advancement is a procedure that surgically moves the upper and lower jaws forward. As the bones are surgically advanced, the soft tissues of the tongue and palate are also moved forward, again opening the upper airway. For some individuals, the MMA is the only technique that can create the necessary air passageway to resolve their OSA condition, but PAP suddenly doesn't seem so bad.

Again, most of these procedures are considered serious surgery, but when you have people who are looking for an alternative to PAP therapy, there are no easy answers.

Most dental devices are acrylic and fit inside your mouth, much like an athletic mouth guard or orthodontic appliance. Others fit around your head and chin to adjust the position of the lower jaw. The mandibular repositioning device and the tongue retaining device open your airway by bringing the lower jaw or tongue forward during sleep.

I used an oral device for about seven months. My biggest problem with it was lip and tongue biting. Your lower jaw is in the extended position for 6-7 hours, so when the device is removed, you have a tendency to bite the inside of your lower lip and side of your tongue. Most dentists that prescribe the device recommend a bite exercise after the device is removed. It is important to get evaluated and fitted by a dentist that specializes in sleep apnea and to see the dentist on a regular basis for any problems that may occur.

While oral devices are less cumbersome than PAP and relatively simple to use, they are only effective for some patients with sleep apnea. As with any treatment option, many factors may determine its effectiveness, including the severity of the sleep-disordered breathing and the patient's preference. The important thing to remember is that alternatives exist, and it sometimes takes different therapies for successful treatment of sleep apnea.

All of these become an especially big problem for Southern PAP users when the winter season is over and spring begins. We have had a lot of calls to the VA from users saying, "I can't use my machine, it suddenly makes my mouth so dry."

From my own personal experience, sometimes turning up the heat is not the first choice. But it is one of the first questions I ask when I hear this complaint.  I remind patients that sometimes increasing the heat can dry your mouth more. Consider the equation that heat is a natural drying agent. If we have some really cold weather, for instance, in the teens, for an extended period of time, I say, increasing the heat to 1 is a good idea. This idea remains a big debate in the sleep field.

Medications can be the culprit too. If this is the case, chances for dry mouth with PAP use increases three fold. Some of the leading causes of dry mouth include:

• Over-the-counter medications
• certain health conditions
• diabetes
• medical treatments such as chemotherapy or radiation therapy
• alcohol
• and caffeinated beverages.

My personal experience with dry mouth began essentially before I started PAP therapy.  Medications that I took at bedtime had side effects which included dry mouth. 

I started using some over the counter mouth rinse that helped lock in moisture and keep me from waking up with my tongue stuck in the roof of my mouth.  I suggest this to Veterans who are on multiple medications and have complaints about dry mouth.

Helping people use their PAP devices everyday is the main goal but sometimes there are barriers that can be overcome with a few simple suggestions.

Before coming to the Birmingham VA, I didn't have an opportunity to do as much follow up with patients as I do now. Many of them come in our office and tell me, "Well, I stopped using my CPAP machine for a while, but now I want to start using it again." Then they proceed to give me all of the reasons they couldn't succeed. I see this scenario play out more often than you would think.

Not many people are accustomed to sleeping with an air hose blowing up their nose. If PAP patients can overcome resistance and fear of the machine, many of them will have success.

In order to help patients succeed, you need to have the right attitude. The initial approach is a big part of the process, data has proven that most patients either will use the machine or won't within a month of beginning therapy. Sleep technicians have to realize that they are in the driver's seat when it comes to introduction of PAP interfaces and devices. Using the firm but gentle approach is best, being well informed, educated and persistent when necessary.

When we are getting patients set up at night, time becomes an issue. As a technician can we find the time to actually give our patients a real understanding of PAP masks and machines, in a short time?

We give a required class now to patients before they come in for testing. During this class we give education about sleep disorders, what to expect during testing, including pictures!

I thought how often I would have appreciated this information prior to some of the medical tests I have had in the past, (what was really going to happen when the doctor asked me to drink that little bottle of citrus magnesium!) But, giving this information to potential PAP users is critical to the beginning of a life time journey.

When the patient does get home after testing and receives their equipment, it suddenly becomes a realization. Most become aware that their bed partners are not giving in when it comes to sleeping. We are all too familiar with issues such as mask leaking, pressure sores, insomnia, bloating, (gas), dry mouth, condensation in mask and tubing.

All obstacles that would stumble even the most well trained athlete At the VA my personal philosophy has been, education does not stop with diagnosis. The road will be bumpy, there will be set-backs, so if at first you don't succeed, try, try again.... and again.....and again.

When I first entered the respiratory field that was the way most of the therapists learned.  Someone who was training would demonstrate how a specific procedure was done and then you would follow their lead and also attempt to do the same.

Instead of monkey see, it was called see one, do one.  How many of you learned using this process?

I still see this as a successful way to teach patients how to use their masks and machines. 

Sometimes demonstrating how interfaces work can be the key to increased compliance. Allowing patients to handle different masks, giving them choices of different styles, versus, or just putting on any mask style helps decrease mask anxiety.

By putting on a mask myself, I can show technique and the simplicity of how the mask delivers air pressure. When you have a patient who can identify with you, it makes acceptance easier.  By demonstrating, for example, how they take their masks apart and then put them back together, we know that they truly understand. By giving the patient a choice it also gives them back some autonomy of making decisions in their care.

As technicians at night we are sometimes pressed for time to get patients in bed, but if we know in advance that this person has claustrophobia or anxiety just spending a few extra minutes with them can mean the difference of whether they will or won't use the machine after they leave the sleep center.

So, monkey see, monkey do. Or, see one, do one. By whatever name you use, demonstrating and allowing patients to observe and demonstrate is a winning strategy. 

It's really not necessary to tie up your tongue but successful PAP use does involve the mechanics of the tongue. Proper tongue placement seals up the airway, allowing the patient to breathe through their nose.

Patients need to know how important proper tongue placement is so they can be comfortable using PAP interfaces. Airway mechanics and how different parts of the airway work together are subjects we could all use lessons in. Without this knowledge, our job skills are sadly lacking.

When a patient says the air pressure is too high or "I feel like I can't breathe," most of the time they don't have the tongue in the correct position in the roof of the mouth.

In order to successfully teach new PAP users how to use PAP devices, I often use this trick:

Before placing a mask on a patient, I have the patient sip water through a straw and swallow. Then I ask him about where the position of his tongue is when he swallowed. This makes him realize that yes, the airway can be sealed and that breathing through the nose is a natural thing, just like we were all designed to do as infants.

Breathing through the nose is a natural thing if the airway is sealed and the tongue is in the roof of the mouth. You can encourage patients to maintain this airtight seal by reminding them that if they wake up with air blowing out the mouth, they can just take a swallow, seal the airway, and take some breaths through the nose.

This trick has eased the anxiety of many of my patients and can work to help you with your patients too. So don't be tongue tied, know how important the tongue can be to your patients and their success with PAP therapy.