Barbara Phillips: MD, MPH, FCCP: Dosing Strategies for Sleep Apnea

Choosing the right treatment plan for a new sleep apnea patient can be challenging, but doing so based off of observational data can make the task all the more daunting.

In an exclusive interview at this year’s CHEST meeting in San Antonio, TX, Barbara Phillips MD, MPH, FCCP, sat down with MD Magazine^® and explained why choosing the appropriate dose strength and treatment strategy for a new sleep apnea patient can be difficult. While continuous positive airway pressure (CPAP) has been noted to be a beneficial treatment for patients with sleep apnea, Phillips noted the positive results are largely based off of observational and cross-sectional data.

MD Mag: What is the relationship between pulmonary arterial hypertension and sleep apnea?

Phillips: The relationship between pulmonary arterial hypertension and obstructive sleep apnea is not as well described as you would think. To sum it up briefly, it tends to be mild.

Pulmonary hypertension pressure is 30 millimeters or so in the pulmonary arteries. It [pulmonary arterial hypertension] tends to be completely ignored while the clinician managing the patients goes after much sexier and more expensive treatments. It [also] tends to be present in the sickest people—people who have low blood oxygen, [and] not just at night when they’re sleeping, but also when they are awake. That’s a small group [of patients].

MD Mag: What is the dosing strength and regimen strategy for treating a new sleep apnea patient?

Phillips: That is a really good question because of a couple of things. Those 2 things are, as I mentioned before—we can’t promise a patient, on the basis of well-done randomized controlled trials, that using CPAP is going to prevent any terrible thing.

We have a lot of observational data, we have a lot of cross-sectional data, and that data tends to show that people who use CPAP are less likely to die, have a car crash, have a stroke, so forth, and so on. The problem with that kind of observational, cross-sectional data is the people who use CPAP are more likely to quit smoking, take their medicines, exercise, lose weight, and do other things that are going to improve their prognosis. That’s the problem with an observational trial.

Let me give you an example of an observational conclusion. If you went to my YMCA [Young Men's Christian Association], almost any morning, and you were trying to swim laps there, you would find half the pool is filled with people who are doing water aerobics.

If you looked at these people over time—and perhaps you’re a little resentful because you couldn’t get into a lap lane because of them, and you were drawing malignant conclusions—you might think, ‘Gosh, water aerobics must make you really fat,’ because that’s who’s in there doing water aerobics.

Now, do water aerobics really make you fat? I don’t think so. I think there are characteristics about the people who choose to do that that is really associated with the obesity, and I think it’s possible that the good outcomes that we see in observational trials of CPAP treatment are because people who actually use their treatment do more healthy lifestyles.

I don’t think that’s likely. I actually do think CPAP can make a difference. After a third of a century of taking care of patients and hearing what they tell me and seeing how many of them have responded, but I can’t prove it the way we need to prove things in this country in order to get things funded, to convince insurance companies, to even convince patients and some other clinicians, ‘This is what we need to do.’

Let me come back to the question you asked, which was ‘If somebody has pulmonary arterial hypertension, are you more likely to treat them early on?’

Again, I think this depends on the clinician. I have tended to be a collaborative clinician, so I would have this discussion. ‘You have pulmonary arterial hypertension, you have sleep apnea. CPAP might improve your pulmonary arterial hypertension. It’s pretty safe, it’s pretty easy, and we don’t have to continue it, but I would recommend that we try it. Oh, by the way, it might also help your sleepiness, your systemic hypertension, your diabetic control, your quality of life, and so forth.’

But at the end of the day, patients are going to do what they’re going to do, right?

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