Written by: W. Joseph Newman, MD
With the explosion of telemedicine (TM), a new way of patient care in the form of remote patient montioring (RPM) is transforming the medical industry. I have found that monitoring is the negleted aspect of OSA for CKD.
In a previous blog, I described the ABCD’s of OSA and are as listed:
A: Awareness of symptoms suggestive of OSA
B: Be tested if such symptoms exist
C: Comply with treatment, if diagnosed with OSA
D: Direct your own health care
In that blog I stated that of the four aspects of OSA care in CKD, “A”, awareness, was most important as without it, “B”, and “C” would never exist. However, after more investigation into the effects of OSA on CKD, I feel I must add a fifth aspect, “E”: Efficacy of treatment of OSA. In fact, after the diagnosis has been made, and treatment option selected, “E”, or monitoring, assumes primal importance.
There are many options for treatment of OSA, all of which have variable success rates, and bring their own set of problems. CPAP, the “gold standard”, has been shown to reduce the apnea/hypopnea index (AHI) to less than 10 in 75% of compliant patients. However, compliance is the death knell to CPAP as it carries a 40% compliance rate, meaning 60% of such OSA patients are not being treated. Oral appliance therapy (OAT), usually reserved for mild OSA, 5-15 AHI’s per hour, has been shown to reduce AHI’s to less than 10 by 50%. Studies show that at 2 years of OAT less than 60% of such patients are compliant.
Oral surgical/reconstruction intervention reduces AHI’s to less than 10 by only 30% and is a complicated process requiring significant healing time. Hypoglossal nerve stimulators, such as Inspire Sleep (INSP) carries the best AHI reduction rate at 80% and compliance rate of 95%. But to get the INSP device, a more expensive therapy, a patient must first be declared a CPAP mask failure.
All tallied, 80% of OSA patients are treated with the dreaded CPAP mask. The reasons for poor compliance include the obvious claustrophobic sensation of wearing a mask, either too much air pressure setting, leading to air leaks and nasal and eye irritation, or too little air pressure leading to a smothering sensation.
But the main reason patients don’t comply with CPAP therapy may well relate to “E”: efficacy of treatment, i.e., monitoring of OSA therapy. Current monitoring of
CPAP patients currently consists of a chip download or a remote app download from a CPAP machine to the patients DME store. Such data includes hours of usage per night, recommended to be at least 6 hours, and a summary of their AHI’s, which if less that 10, and approaching 5, then all is assumed to be well for the patient.
My experience with established OSA/CPAP/CKD patients shows that although a patient’s nightly AHI score is deemed to be good, i.e., near 5, many of them still feel tired and have ongoing daytime somnolence, suffer from low energy, and quit using the CPAP mask as the benefit gained does not seem worth the effort to comply. The reason for their continued persistent symptoms is now being illuminated by remote patient monitoring, RPM, an outgrowth of Covid 19, and telemedicine, TM.
I am currently employing SleepVigil (SV), an RPM app, in OSA/CKD patients. SV details oxygen saturation (02sats) during sleep which is the most important aspect of CPAP monitoring, and is not otherwise currently available through DME downloads. Through SV, by measuring 02sats, I am discovering that many compliant CPAP patients, who are persistently tired and fatigued, and with good AHI’s, spend 30-40% of their nights with 02sats less than 90%, which means they are significantly hypoxic, and depriving bodily organs of sufficient amounts of oxygen.
Regardless of method of OSA treatment, such significant hypoxia means CKD progression, despite compliance, refer to my blog: The Perfect Storm Your Ticket to Dialysis. For the majority of OSA/CKD patients, those being treated with CPAP, it is now possible to combine CPAP machine kinetics available from the DME downloads of their particular CPAP device with SV, to titrate their device as to decrease hypoxia and thereby diminish their symptoms and boosting compliance.
CPAP machine titration through such monitoring would be expected to improve patient symptoms, compliance and decease progression of CKD, which is the ultimate goal. I have found that with just several months of 02 monitoring and titration of CPAP machine settings, an improvement of 02 sats >90% most the night with a subsequent increase in eGFR, decrease proteinuria and reduced need for blood pressure medications.
If your interested in being monitoring for your OSA, CPAP optimization and be apart of this cutting edge intervention to slow progression of CKD, please contact us here.