Researchers argue that PTSD patients with OSA should be introduced to ABPAP or ASV when failing CPAP.

Many obstructive sleep apnea (OSA) patients with posttraumatic stress disorder (PTSD) have a difficult time adhering to CPAP therapy because of expiratory pressure intolerance (EPI), according to a recent study that posits possible solutions.

“Unfortunately, many professionals in the field of sleep medicine do not seem to understand this specific principle: when a sleep apnea patient experiences the feeling of ‘drowning in air,’ it is a traumatizing stimulus,” says Barry Krakow, MD, and lead study author. “Compounding this problem, many sleep physicians and technologists may not understand PTSD; and in not understanding it, they don’t realize CPAP is traumatic for many patients.” The sensation of drowning in air is triggered by EPI and arises when a patient attempting CPAP has difficulty breathing out against the continuous incoming airflow supplied by the device. For classic sleep apnea patients, the distress is mild to nonexistent, but for PTSD patients the sensation is overwhelming and often leads to immediate rejection of therapy.

“If patients feel like the CPAP is suffocating them, they won’t even initiate this therapy option because they want to avoid the stimuli,” Krakow adds. He and his team at the Sleep and Human Health Institute have known and reported on this adverse effect for many years, and so in 2005 they stopped prescribing CPAP to these patients. During the last 8 years, they’ve only been prescribing advanced positive airway pressure modes—auto-bilevel PAP (ABPAP) and adaptive servo-ventilation (ASV)—to these patients, since the advanced devices can be precisely titrated by the sleep technologist in the lab to minimize the amount of pressurized air the patient exhales against.

For the recently published study, they gathered objective data downloads for 102 patients with PTSD and OSA who failed CPAP and placed them on either ABPAP or ASV. Of these patients, 58% were compliant, which the researchers noted is significantly higher than recent reports of adherence rates among PTSD patients on CPAP. Yet, rarely would most sleep centers consider switching these patients to advanced PAP modes.

Krakow says he doesn’t willingly use CPAP for any of his patients, unless directed to do so by third party payers—which often poses a problem for patients who are not adhering to CPAP even though they are currently at subthreshold compliance (otherwise known as partial users). Of the 19 subthreshold patients in this study, 17 were mere minutes of use or a small amount of nights away from meeting insurance criteria, which means the insurance companies might seek to retrieve the device despite patients reporting benefits.

“There’s another problem in our field, both from an insurance point of view as well as in sleep medicine itself—there is no standardized definition of CPAP failure,” Krakow says. “In the case of physicians, failure means patients are not getting symptomatic relief from CPAP.

“Regrettably, it appears many sleep physicians and insurer medical directors are only looking at CPAP compliance numbers, after which they urge patients to find a way to persevere on CPAP, rather than try to get them on a different device.” Krakow adds that this is like telling someone who’s beating his head against the wall to “keep beating it until it stops hurting.”

Regardless of whether the patient is not receiving any benefit from CPAP or not meeting insurance criteria, Krakow advises physicians to do everything they can to provide their patients with better options for therapy. “Doctors must consider their rights to dispute insurance policies. When the patients are failing or not adhering to CPAP, physicians should try to get their patient on a different PAP mode,” he says. “The majority of patients will notice the difference and wonder why they weren’t introduced to the new device sooner.”

Patients with PTSD and comorbid OSA face a catch-22: suffer through the traumatizing stimuli and potentially exacerbate their PTSD, or opt for no sleep therapy at all and suffer with untreated OSA. Insurance companies “want these patients to somehow get used to CPAP, but there’s actually a potential to make PTSD symptoms worse by pushing this older model of PAP therapy,” says Krakow. “Then, to top it all off, [insurance] wants to take away their machines because they’re taking too long to adhere to the therapy. This is the problem these patients face right now, but few organizations seem interested in considering advanced PAP devices.”

Dillon Stickle is associate editor of Sleep Review.