Advice from a Sleep Doctor With Sleep Apnea

My name is Dr. Amie Stringfellow, and I'm a board-certified physician in Sleep Medicine, Internal Medicine, and Pediatrics. I operate a practice called Milepost Medical which provides provides affordable direct primary care and sleep medicine services outside of insurance. Like many of you, I have Sleep Apnea, and in this article, I'll share the story of my treatment journey in the hope that you may learn from some of the experiences I've had.

I was actually 15 when I was diagnosed with Sleep Apnea. I was starting to snore at night, got really tired and cranky during the day, and was struggling to stay awake in school. My parents took me to my ENT (Ear, Nose and Throat) doctor. Initially, they tried to do an at-home oxygen test, to monitor my oxygen levels at night while I was sleeping. These tests actually came back normal, so the ENT told me I was fine. I was still tired and snoring though, so my parents said - "no, this isn't normal". I ended up having a full in-lab sleep study done. While my oxygen level was fairly normal, we didn't catch the apneas until I had the in-lab sleep study and not just the oxygen reading. From there, my doctor ordered me a CPAP.

Initially, the struggle with Sleep Apnea was just simply getting the diagnosis. That took... months. I was really having a hard time being tired and struggling at school - this had not happened before.

When I got the CPAP machine, I did pretty well with it. Right away, I noticed that when I wore it, I felt better during the day. I felt a difference very quickly.

This isn't to say it was all roses. I struggled to fall asleep with the CPAP on. I did it every night - I knew I would feel better for it, but it was tough. I remember putting on the equipment and being very conscious of my breathing and trying to regulate it. The CPAP makes you very aware of how you're breathing, so I would just lay in bed thinking about breathing in and out. I had to find ways to distract myself so it wouldn't bother me. I really had to consciously not think about my breathing. Which is hard. If someone tells you not to think about a cat. What do you do? You think about a cat.

Once I fell asleep, I was totally fine. But it probably took me a whole year to put the mask on without thinking of my breathing. It got progressively better over that time, but it wasn't easy.

I was highly motivated to get it right for the rest. And I did.

You must have realistic expectations with CPAP therapy. If you think, I am going to hate it, you will. If you think, this is going to be immediately awesome - you will likely be disappointed. Everyone has an adjustment period when they first start using their CPAP. Some people adjust quickly and others take months. Just realizing that it is a process is helpful. When that process becomes tedious, I find working with someone who is knowledgeable about sleep apnea treatment is helpful.

When I started using CPAP, there weren't nearly as many mask options out there, but I am pretty sure I tried every mask that was available at that time before I was able to find one that worked. No idea how many. I tried a lot. It was over several different days of course. I'd try one at home, it wouldn't work, and I'd go back and try more.

It takes time. It takes being diligent and working through problems. You have to stick with it. Eventually, you will find the right combination of things that will work for you.

Currently, I use a Respironics DreamStation APAP, and it is what I usually recommend to my patients. There are other machines like BiPAPs and ASVs - but strictly for CPAP - I like this Respironics machine. Respironics makes a good machine and their data reporting is really helpful. As a physician, it gives me a lot of good insight. I can look at the data and make recommendations. I can have a meaningful visit with my patients, say, "I am seeing this, so we should try this other thing". Many other machines don't have the same advanced data, and so I am less helpful because I only get half the story.

A little more on the machine type: An APAP is just a fancy CPAP that can adjust pressure itself. I like the flexibility of an APAP. There is flexibility if patients gain or lose weight or if they don't feel as good. I can open the pressure range up and let them re-titrate at home. That's very useful and more helpful at managing the patient's Sleep Apnea over the long term.

Now, having said that, APAPs are a little more expensive. The CPAP is also a good option and I do also like the DreamStation CPAP. ResMed is the other big player here - the AirSense line. They also make a really good machine. I just happen to like the data from Respironics a bit more. But if a patient comes to me on a ResMed machine, that's good as well.

Now for masks... they are the marker of if a patient will be successful or not. I get asked a lot: "What is the best mask?" It's like being asked what color is the best? It's a personal preference. One person might like green, one person might like red. Masks are the same - some like nasal masks, some like full faces.

I personally use a nasal pillow, the Respironics DreamWear nasal pillow. I like it very much, but will it work for everyone? Absolutely not. It's really an individual choice.

In general, the less surface area that a mask needs to seal, then the less likely it is to leak and to stay in place. Nasal pillows have a very small surface area.

The nasal mask also has a relatively small surface area, but definitely more than nasal pillows.

Then there are full face masks, which tend to be the most likely to leak, but if you can't comfortably breathe through your nose, or sleep with your mouth open - you will need this. It just all depends on the person!

Lastly, I don't usually recommend CPAP accessories right off the bat. I like to let patients try their therapy, see how they do, then based on what problems they may encounter - seek out solutions. A few products I recommend for each problem:

For rain out the SnuggleHose is great

For face marks or pressure from mask headgear the Pad-a-Cheek strap wraps are good

Also good for skin irritation or leaks are the mask liners

Again, there's no one thing I recommend all the time, it really depends on the individual. I really like to address the problems only as they present themselves.

I'm not afraid to talk about my personal medical experience with patients, so I think it helps patients relate to me and what I am educating them on. It allows me to be more thorough and hopefully be seen as more reliable. Me saying "Go do this and good luck" isn't as helpful as saying "I know this can be annoying, but you can work through it." I get to strike a good balance between commiserating with them and helping them do what it takes to realize the benefit of treating their sleep apnea. Being able to say "been there, done that" helps the patients better fight through whatever complications they are trying to solve.

And, I want to emphasize, I don't necessarily think everyone with Sleep Apnea needs to see a sleep doctor. Whether it's a pulmonologist, neurologist or even a primary care doctor with a lot of sleep education - you can likely get the help you need. However, if you're having a hard time adjusting to CPAP therapy, it's important to find someone who is knowledgeable about all the options available, to help you walk through those rough patches, and help you troubleshoot any issues.

Here in the office, we've seen quite a few patients who were diagnosed with sleep apnea, say 10 years ago, and never liked the CPAP. They never used it regularly and are now just completely miserable and want to know what to do. So realistically if they had someone work with them 10 years ago to understand their options - well they might have been better off ten years ago. Don't wait until you're desperate - find someone who has the knowledge and can work with you to find a solution that works for you.