Replies to This Discussion

Permalink Reply by jfarr on October 13, 2010 at 11:29am

Mike;

I am writing this reply to officially apologize for comments that I made on this forum on October 11, 2010. My intent was NOT to suggest that you are a drunk or a bad lawyer by any means. My irrational comments came from FEAR for patient safety (and I was speaking with other sleep professionals who were just as concerned as I). In my 16+ years as a respiratory therapist and 10+ years as a sleep technologist, my primary focus has always been on patient safety, education and compliance with therapy. In the sleep center that I manage, we have a desensitization program and I will spare no expense at patient compliance, even going so far as to supplying the patient with up to 5 masks (whatever it takes).

I DO think that your intentions are noble, even your position on self-diagnosis. I DO think that forums such as this are necessary for sufferers of OSA to help them overcome some of the common, and not so common, obstacles. However, I STILL think that your position on self-diagnosis is irresponsible and dangerous and I hope that you would reconsider that position.

If and when you do reconsider your position, please consider the following:
1. Oxygen is considered a drug that is regulated by the FDA and requires a prescription. One of the reasons for this is that oxygen, like any other drug, has contraindications and adverse effects at high liter flows (i.e., COPD patients with CO2 retention can knock out their drive to breathe with high flows). Should we allow someone to walk into a WalMart to pick up a concentrator or a cylinder for a quick hit?...
2. How many sleep industry professionals hear people say that they can’t sleep, so they are taking over the counter medicines to help them “get some sleep”. Many of these OTC’s have side effects and counteractions with other medications (prescribed or not). Some of these counteractions can lead to a suppression of the person’s respiratory drive. Smart… I think not!
3. And so does CPAP therapy also have contraindications (such as pneumothorax, Blebs on the lung, etc.) which can best be determined by a physician prior to initiating any kind of pressure therapy. So, now you will have someone who hasn’t seen their physician in years, has no outward symptoms of a contraindication, and is going into a WalMart, picking up a CPAP machine, putting it on that night and blowing out their lungs?!?

We need to regulate healthcare to prevent abuse of OTC’s as well as any kind of medicinal and therapeutic modalities. I completely understand that you, as a patient, need to be involved in your care, but that should not include self-diagnosis.

As I said before, Mike, I do appreciate and applaud your efforts. I hope that in some way we could collaborate on some level and that I could share some of my professional insights with you and your fellow OSA sufferers.

To the rest of the bloggers on this forum, I apologize to you as well for not following the guidelines of communication on this forum. I hope that you would allow me the opportunity to share my knowledge with all of you as well.


Mike said:

The context of John's remarks is the keynote speech I gave last week at a Respiratory Therapist conference in Atlantic City. I used the platform to advocate for the deregulation of CPAP and Sleep Apnea (i.e., lifting of prescription requirements and making a doctor's participation in treatment and diagnosis of OSA optional instead of compulsory). Many RTs and industry insiders actually came up afterward and agreed with my views. One said he disagreed. Most said nothing. John, on the other hand, comes up with (i) an argument that veers off-topic from plain OSA, which is what my talk at the conference was about, and (ii) name calling -- a libelous personal attack on me (i.e., alleging that I'm a drunk and a bad lawyer). All of this toward the end of making his case for the erudition and professionalism of his industry!? C'mon John . . . you make the case better than I ever could for why we should at least have the option to bypass folks like you.

John Farraye said:

Mike;

I was at the Respiratory Conference in Atlantic City on Thursday, October 7. You must have had way too much to drink the night before; and every day before and since. You are way too narrow minded to be involved in sleep medicine and should be banned from the industry. You say that you were a corporate lawyer; you should go back to something that you were probably very bad at.

That off my chest, did you ever consider CO-MORBIDITIES in any of your thought processes? In your exemplified study, you do not mention arrythmias, PLMS, or any other sleep disorder that could be diagnosed by PSG. What about Narcolepsy? (Do you even know what that is?...) How is a physician that YOU SAY doesn't know much about sleep medicine supposed to know what the REM latency is in order to pre-determine Narcolepsy other than through a PSG? Also, what about pneumothorax or a bleb on the lung? These are severe contraindications to CPAP therapy at high pressures. Your doctor knows all of your health history and what is proper therapy for your INDIVIDUAL case. That is what they are trained for. We, as lay people, do not have a clue as to what is proper therapy. However, we have far too many people that are trying to porray themselves as "experts" like yourself.

Dude, you are doing your followers a severe disservice with your lack of responsible use of this medium. Your irresponsibility could lead to some deadly results. Can you SLEEP with THAT on your head?

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Permalink Reply by Banyon on October 13, 2010 at 1:17pm

John Farraye said, "And so does CPAP therapy also have contraindications (such as pneumothorax, Blebs on the lung, etc.) which can best be determined by a physician prior to initiating any kind of pressure therapy."&

I think this is digging deep to find a fear tactic. A fear tactic that will help to keep part of the control over patients' health away from the patient and in the hands of the medical and government partnership. Control that will make it more difficult and more expensive for a patient to manage his condition.

This old statement is found in CHEST 1997; 112:1441-43, "However, only two cases are reported in the literature as having an association of spontaneous CPAP with barotrauma such as pneumomediastinum and pneumothorax."

Can you refer us to some resources that back up this fear of yours and indicate it is more than an extremely rare occurence?

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Permalink Reply by jfarr on October 13, 2010 at 3:34pm

No luck in getting anything as of yet, but I would like to discuss the article that you had found. This article discusses the use of CPAP, in patients who suffer acute hypoxic respiratory failure, in order to prevent or delay intubation and mechanical ventilation. It speaks of acute use of CPAP as opposed to continuous use of CPAP...And with that, only 2 cases of barotrauma were reported which were adverse effects to CPAP.

This has nothing to do with what I am talking about, which is contraindications before CPAP is initiated. Contraindications are conditions that CPAP should not be used with. This is not a valid example for your argument.

Banyon said:

John Farraye said, "And so does CPAP therapy also have contraindications (such as pneumothorax, Blebs on the lung, etc.) which can best be determined by a physician prior to initiating any kind of pressure therapy."&

I think this is digging deep to find a fear tactic. A fear tactic that will help to keep part of the control over patients' health away from the patient and in the hands of the medical and government partnership. Control that will make it more difficult and more expensive for a patient to manage his condition.

This old statement is found in CHEST 1997; 112:1441-43, "However, only two cases are reported in the literature as having an association of spontaneous CPAP with barotrauma such as pneumomediastinum and pneumothorax."

Can you refer us to some resources that back up this fear of yours and indicate it is more than an extremely rare occurence?

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Permalink Reply by Banyon on October 13, 2010 at 10:27pm

I will be patient while waiting for any evidence that this is something more than a crude scare tactic.

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Permalink Reply by Judy on October 13, 2010 at 11:02pm

John, I have COPD. I've had a spontaneous pneumothorax back in 1980. Left side. Yet my accredited, pulmonologist, critical care, sleep doctor scripted a loaner APAP w/the range set 4 to 20 cms. I'm interested in your comment that a COPDer with CO2 retention can knock out their drive to breathe with high flows.

John Farraye said:

Mike;
<... 1. Oxygen is considered a drug that is regulated by the FDA and requires a prescription. One of the reasons for this is that oxygen, like any other drug, has contraindications and adverse effects at high liter flows (i.e., COPD patients with CO2 retention can knock out their drive to breathe with high flows)...

... 3. And so does CPAP therapy also have contraindications (such as pneumothorax, Blebs on the lung, etc.) which can best be determined by a physician prior to initiating any kind of pressure therapy. So, now you will have someone who hasn’t seen their physician in years, has no outward symptoms of a contraindication, and is going into a WalMart, picking up a CPAP machine, putting it on that night and blowing out their lungs?!?

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Permalink Reply by Rooster on October 14, 2010 at 7:49am

Judy said:

John, I have COPD. I've had a spontaneous pneumothorax back in 1980. Left side. Yet my accredited, pulmonologist, critical care, sleep doctor scripted a loaner APAP w/the range set 4 to 20 cms.

I was wondering about this as I have never been checked for those conditions or even asked about it when my sleep doctors prescribed CPAP and one prescription was for a pressure range of 18 to 24! So if it is so dangerous why does the wonderful sleep industry never check for it before prescribing CPAP???

John, You missed the point of Banyon's post - it wasn't about what was in the article, it was that is the only article he could find and as you pointed out it wasn't even about regular use of CPAP. I also did my own web search and could find no medical studies citing the dangers you claim.

Your claims do sound like a scare tactic to maintain control over what other free individuals want to do. I also will watch for the legitimate evidence you will post backing up your claim. Then when I see it I will wait for sleep docs to incorporate warnings and checks about the dangers! Ha Ha.

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Permalink Reply by Mary Z on October 14, 2010 at 9:13am

What I learned while working at a nurse at the VA was that with COPD patients on O2 could not just raise their O2 levels (delivered by cannister by nasal cannula) too much without knocking out their "hypoxic drive". This was mainly about nurses who didn't understand COPD and O2- to keep them from having a COPD patient with more shortness of breath, from cranking the O2 up to 10 in order to give them more O2. In long time COPD patients the high CO2 levels they usually carry from not being able to adequately empty their lungs of air, was their drive to breathe. Given enough O2 the respiratory centers of the brain would say "I have plenty of O2, I don't need to initiate a breath". As an actual COPD patient, Judy, you can tell us if htis still generally holds true with O2, not CPAP, that big changes in the amount of O2 delivered by a person who does not understand the disease may be harmful. This was in the '80's. Don't reemember that we ever killed anyone. COPD is a terrible disease.

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Permalink Reply by jfarr on October 14, 2010 at 10:40am

Hi Judy;

Let me give you a little respiratory 101 crash course.

The reason that we breathe is simply to take in oxygen and expel Carbon Dioxide (CO2). The drive to breathe in a person with normal, healthy lungs is an increase in CO2. The brain senses an increase in CO2 and sends a signal to the diaphragm to drop in order to expand the lungs and allow oxygen rich air to flow in. When that happens the oxygen crosses into the blood stream through the arteries and carries the oxygen to all of the muscles and organs in your body. At the same time, the byproduct of used up oxygen (CO2) enters the bloodstream through the veins and travels into the lungs where the diaphragm pushes up onto the lungs in order to expel the CO2. Now, in a person who has COPD and retains CO2 (not all COPDers retain CO2, but most do-and the only real way to determine that is via an arterial blood gas test called an ABG), the body is compensated for that increased CO2 level and that persons drive to breathe is a decreased level of oxygen (hypoxia). Thnis is called the Hypoxic Drive. So, when the brain senses a drop in oxygen level, it sends the signal to the diaphragm to drop and that cycle begins. If that person's oxygen level does not drop (i.e. because they are on too much supplemental oxygen) then the person has no "drive to breathe" because the brain sees a normal amount of CO2, for this person, AND a normal amount of oxygen, so it is satisfied, does not send the signal to the diaphragm to drop and no breathing takes place.

Now, oxygen is delivered in Liters Per Minute (LPM) and CPAP, APAP, BiLevel are all delivered in Centimeters of water PRESSURE (cmH20). What I discussed in my example was just that, an example of other therapies for which "self-diagnosis" is dangerous. My example cited "high flows" which is different than "pressure". So your APAP PRESSURE is not something that you should be concerned about. You should only be concerned if you are on oxygen at a high flow (anything over 3 LPM).

My next question to you is, When did the doctor prescribe APAP? Was it in the '80s when you had your pneumothorax? I should have prefaced my pneumothorax condition with "untreated". So what the contraindication is is "untreated pneumothorax". Your pneumothorax was back in the '80s, so it could have either resolved, or had you had a thoracentesis or some other procedure to alleviate the condition?.

Are you now or have you attended a pulmonary rehab program for your COPD? It is a terrible disease as Mary Z. had said. Good luck with your condition(s) (COPD and OSA).

I hope this made sense. Let me know if you have any other questions

Judy said:

John, I have COPD. I've had a spontaneous pneumothorax back in 1980. Left side. Yet my accredited, pulmonologist, critical care, sleep doctor scripted a loaner APAP w/the range set 4 to 20 cms. I'm interested in your comment that a COPDer with CO2 retention can knock out their drive to breathe with high flows.

John Farraye said:

Mike;
<... 1. Oxygen is considered a drug that is regulated by the FDA and requires a prescription. One of the reasons for this is that oxygen, like any other drug, has contraindications and adverse effects at high liter flows (i.e., COPD patients with CO2 retention can knock out their drive to breathe with high flows)...

... 3. And so does CPAP therapy also have contraindications (such as pneumothorax, Blebs on the lung, etc.) which can best be determined by a physician prior to initiating any kind of pressure therapy. So, now you will have someone who hasn’t seen their physician in years, has no outward symptoms of a contraindication, and is going into a WalMart, picking up a CPAP machine, putting it on that night and blowing out their lungs?!?

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Permalink Reply by Judy on October 14, 2010 at 11:28am

Thank you for the clarifying explanation, John. I'm afraid I'm quite guilty of not educating myself about COPD as I have Crohn's disease and CPAP.

When I encountered the spontaneous pneumothorax I thought it was "just" pleurisy. The pain was excruciating but it was just the one lung so I went to the dog show anyway - and collapsed on my second turn running around the ring. I was transported to the FILTHIEST hospital in the state of Michigan (since closed) that FORTUNATELY had some U of M doctors in ER.

I don't know what they call the "procedure" I had - they put a small incision between my ribs under my arm on the left side, inserted a tube and attached a pump. I was admitted for 3 days at which time I INSISTED that I be released. The nursing care was HORRIBLE and the dirt unbelievable. I was in a ward w/5 other ladies. One lady was in her 80s and had some sort of digestive obstruction. She vomited feces during the night, I called for the nurses REPEATEDLY until one finally showed up. Wiped the woman's face off, spread and rubbed a sheet on the floor to avoid having to step in the mess - and left her and us like that for another 4 hours!!!!! About an hour before the doctor's showed up they came in and cleaned the lady and the mess up. I was furious!!!! And the minute the doctors walked in the door I lit into them about the incident. After that I was afraid to stay in that hospital under the care of those nurses!!!! The doctors would have preferred I stay another day just to be sure but recognized my dread of staying under the care of those same nurses and they signed my release. Needless to say I didn't ask or learn much about the SP. I just wanted OUT OF THERE!

I do remember tho, that at that time, the U of M doctor's did say that blebs on the lung were not at all uncommon w/Crohn's disease. The timing was odd to me since my Crohn's symptoms had started in mid-1975, I was Dx'd in early 1976, had a resection in early 1978 and was in my second year of a 20 year remission of Crohn's disease activity at the time of the SP.

I wasn't Dx'd w/COPD until late 1996. I did attend PH in 1998 up until the year gas shot up to almost $4 a gallon in Michigan. Truthfully, my only interest was in the "exercise" and the equipment to use. I really didn't take full advantage of the educational aspects of the program that I could and should have.

I am scripted at 2-2.5 L/M of 02 during the day and 2 L/M w/VPAP at night. I'm trying to remember .... I had my first ABG in 1996. Then not another until 2007 (?). That one was interesting: 6 minute walk on room air and ABG draw w/in 20 seconds of stopping the walk. Yeah, right! I had dropped to 84% Sp02 and was still at 84% Sp02 at 27 seconds when we were able to do the draw (first walk and attempt we hit a vein, not an artery). We decided a draw at 27 seconds was good enough for the pulmonologist I was going to. *red faced smile* At the time of that second and last ABG my understanding was that I was still not a C02 retainer.

However, just this past month to 6 weeks or so I've had one heck of an exacerbation of the COPD accompanied by a new game: artrial fibrillation. They thought pneumonia but chest xrays say not. Am mid-prednisone/Cipro therapy right now, also coumadin and a calcium channel blocker for the A Fib. In the middle of this had to change from VPAP to BPAP and despite pressure settings the same a drastic change in leak rate and data w/no way of knowing if due to device change or lung changes.

Life is NEVER boring!!!!
John Farraye said:

Hi Judy;

Let me give you a little respiratory 101 crash course.

The reason that we breathe is simply to take in oxygen and expel Carbon Dioxide (CO2). The drive to breathe in a person with normal, healthy lungs is an increase in CO2. The brain senses an increase in CO2 and sends a signal to the diaphragm to drop in order to expand the lungs and allow oxygen rich air to flow in. When that happens the oxygen crosses into the blood stream through the arteries and carries the oxygen to all of the muscles and organs in your body. At the same time, the byproduct of used up oxygen (CO2) enters the bloodstream through the veins and travels into the lungs where the diaphragm pushes up onto the lungs in order to expel the CO2. Now, in a person who has COPD and retains CO2 (not all COPDers retain CO2, but most do-and the only real way to determine that is via an arterial blood gas test called an ABG), the body is compensated for that increased CO2 level and that persons drive to breathe is a decreased level of oxygen (hypoxia). Thnis is called the Hypoxic Drive. So, when the brain senses a drop in oxygen level, it sends the signal to the diaphragm to drop and that cycle begins. If that person's oxygen level does not drop (i.e. because they are on too much supplemental oxygen) then the person has no "drive to breathe" because the brain sees a normal amount of CO2, for this person, AND a normal amount of oxygen, so it is satisfied, does not send the signal to the diaphragm to drop and no breathing takes place.

Now, oxygen is delivered in Liters Per Minute (LPM) and CPAP, APAP, BiLevel are all delivered in Centimeters of water PRESSURE (cmH20). What I discussed in my example was just that, an example of other therapies for which "self-diagnosis" is dangerous. My example cited "high flows" which is different than "pressure". So your APAP PRESSURE is not something that you should be concerned about. You should only be concerned if you are on oxygen at a high flow (anything over 3 LPM).

My next question to you is, When did the doctor prescribe APAP? Was it in the '80s when you had your pneumothorax? I should have prefaced my pneumothorax condition with "untreated". So what the contraindication is is "untreated pneumothorax". Your pneumothorax was back in the '80s, so it could have either resolved, or had you had a thoracentesis or some other procedure to alleviate the condition?.

Are you now or have you attended a pulmonary rehab program for your COPD? It is a terrible disease as Mary Z. had said. Good luck with your condition(s) (COPD and OSA).

I hope this made sense. Let me know if you have any other questions

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