My Sleep Apnea: CPAP

In previous entries, I've talked about my initial adventure with sleep apnea and my subsequent sleep study. The gist of those entries is that I was diagnosed with "severe" obstructive sleep apnea, with an AHI (Apnea-Hypopnea Index) of 48. This number means I had an average of 48 sleep interruption "events" per hour -- these events range from blood-oxygen desaturation to a complete closure of the airway. There are lots of people out there with worse cases than mine (including readers of this blog!), so I took some comfort that my case seemed pretty typical -- there was every indication that I could be treated.

In my daily life, particularly in the last few years, I've been a very sleepy person. I've generally existed in a sort of brain fog, muddling my way through each day until I could collapse for a longish night's sleep (10+ hours) that, sadly, didn't seem to refresh me. Of course, now I realize that during all that sleep, I was having these constant breathing interruptions, which caused my blood pressure to increase, and severely impaired my ability to experience the restorative effects of sleep. It's strange to think that sleeping doesn't lead to restfulness, but it certainly explained why I just seemed to feel worse as the months dragged on. After going through a sleep study, my doctor reviewed the results, told me about my AHI and various other fascinating acronyms, and finally prescribed a CPAP machine -- a device that blows air up my nose, effectively stenting open my airway with air pressure. The idea is to prevent the airway from closing, and thus get that AHI number down -- so the patient has uninterrupted sleep.

Getting the CPAP machine was an adventure. My prescription was sent to a medical device sales company in my area. That company called me one night and set up an appointment for me to come over (they're "down by the airport") and get fitted for my new sleep gear. My appointment was set for 5pm on a Thursday, and I'd be part of a "class" of people all getting their machines at the same time.

REMstar Auto M SeriesI was the youngest person in my class by about twenty-five years (I'm 30; the oldest person there was pushing 80). Everyone was given a CPAP machine, though they differed quite a bit based on prescription. Mine was a REMstar® Auto M Series, with a heated humidifier attachment. (Pretty sweet, huh?) Without going into all the specifics, the CPAP machine is programmed with various information from my prescription (specific air pressure ranges), and it does some amazing things -- for example, it is able to detect apnea/hypopnea events and records them internally. It also records the specific air pressure used at all times, and builds an internal log of the entire therapy process. This information goes on a smart card which is later sent back to the medical services company, who work with doctors to analyze it, graph it on a computer, and make sure everything's copacetic. In addition to the machine itself, I was given (okay, sold) a six-foot length of air tubing (about 1" in diameter) and a mask that attached to my nose to actually deliver the air into my respiratory system.

ResMed Swift LTThe mask is a whole story of its own. While the CPAP machine's usage is pretty straightforward for the patient -- you press one button and it starts blowing -- there's all kinds of stuff you can do with different mask styles. Masks need to be fitted, adjusted, and regularly cleaned, and there are many opinions about which masks are best for various situations (though the global advice is just to get something that "works for you"). My doctor had recommended a "nasal pillow" mask for me based on my dislike of the over-the-nose cup used in my sleep study. I didn't like the cup because the straps to keep it on were super tight, the cup irritated the bridge of my nose, and it leaked a lot of air, blowing continuous blasts of air into my eyes all night. In contrast, the nasal pillows are sort of like little nose plugs -- they stick directly into your nostrils, and deliver air through a big hole in the middle of the "pillows." The amount of headgear touching skin with this mask is far less than with a cup style mask, and I liked that idea. I ended up with a ResMed™ Swift LT mask (better pictures here). It's much less invasive than the nose cup, but my doctor had warned me that nasal pillows freaked some people out -- the issue being that using this mask involves closing your mouth, sticking something very like nose plugs up your nose, and then trying to go to sleep. Your brain isn't used to this situation (mouth and nose both covered), and rebels, thinking that you're being suffocated despite the tons of air pumping through the system. Also, the nasal pillows concentrate the air flow into nostril-sized holes, so the pressure feels higher than when using a nose cup or other large-area mask. It took a conscious effort for me to relax past the suffocation panic and let the system work, but I liked the idea of the nasal pillows since I'm a side-sleeper, and I felt that less headgear was better.

So I had the gear: CPAP machine, air hose, and mask. The class instructor told us various stuff about how to use it, particularly recommending the "ramp" feature on the machine, which starts off blowing air at a low pressure, then ramps up to full pressure over the course of a half hour. My machine happens to have a "flex" function which automatically decreases the air pressure when I exhale, which increases comfort. The instructor also recommended that we disassemble everything -- mask, hoses, humidifier attchment, air filter -- and clean it every day. This isn't a ton of work, but it's far more infrastructure than most people are used to just to go to sleep and wake up in the morning. But I dutifully listened, and even bought a gallon of distilled water for the humidifier on my trip home. (You have to use the distilled stuff, or minerals build up in the machine. Given the expense of the machine, I listened.)

I set up all the equipment, put on the mask, and started the flow. Within thirty seconds I ripped off the mask and was gasping for breath. My brain was screaming -- suffocation! -- and somehow it seemed much worse at home lying in bed than in the class. I chilled out for a while and tried again, but still the sensation was too intense. I switched to the nose cup mask I had disliked in my sleep study (they gave it to me to hang onto), and that was a lot easier to handle. So on my first night, I slept with the nose cup (plus an Ambien) and it was...tolerable. Except for the rain-out.

Rain-out is a phenomenon where water condenses inside the mask and air tubing, because the air in there is warmer and moister than the air in the room. This was certainly true in my room, which was probably at 60 degrees F, and I was using a heated humidifier on the CPAP machine. The result was water condensing in the mask and literally raining on my nose (and sometimes up my nose). No fun. There are many potential solutions to this problem, but so far what I've done is simply warm up the room and reduce the heat on the humidifier -- there's still a little condensation, but not enough to bother me. Aside from the rain-out, the other problem is just getting used to having something strapped to your head all night. This is genuinely weird, and takes some getting used to. A final issue is the restricted range of motion you have when you're attached to a mask and air hose -- rolling over in bed requires a little planning, and I had to reconfigure my pillow setup. (But frankly, as a geek, this was kind of fun.)

In subsequent nights, I switched back to the nasal pillow mask. Although it was hard to get past the suffocation reflex, I just kinda powered through it. Now that problem is mostly gone, and I'm able to get past the freakout sensation with a minute or two of calm breathing. I like the nasal pillow mask far better than the nose cup -- it's more comfortable, it's smaller, and overall it just feels like a better fit. So I'm happy. I must say that getting used to CPAP is genuinely challenging -- I can see why some people give up. There's a lot of gear and maintenance involved, and you have to change your sleep routine permanently. But in my case, the daytime sleepiness had just gotten too bad -- there was no way I was not going to use CPAP. I needed a change, and CPAP was going to give it to me, if I put in the work.

So what's my progress? In my first two weeks on CPAP, my AHI has gone from 48 to 0.7. So I'm still having the occasional sleep-interrupting event, but vastly fewer than before. I'm also routinely sleeping through the night, whereas before I would wake up repeatedly (up to ten times a night), and often got up to visit the bathroom. This is just gone -- my body no longer seems to feel the need to dump liquids at night. I no longer wake up thirsty; there's no real need anymore for a glass of water by the bed, which is a big change. My blood pressure has gone down. I'm losing weight. I'm also dreaming much more, and the dreams are intense and memorable. I'm still sleeping 10+ hours a night, which seems like a lot, but maybe I'm paying down a sleep debt? I'll have to ask my sleep doctor. The best part is I'm more wakeful during the day. The wakefulness isn't perfect -- there's no miracle here -- but it's clearly a lot better than before, and the fog is clearing. I'll see my doctor next week, and we'll review the machine setup and the data, to see how things are going.

So my overall experience with my sleep apnea diagnosis has been positive. It's frankly a lot of work to go to a sleep doctor, fill out forms, go get a sleep study, figure out how to sleep during it, go back for more review and testing, get the machine and mask, set it all up, maintain it, and use it -- but the upside is enormous. And the potential downside (leaving it untreated and never being properly rested) is horrible. So I'm sticking with it. For those who haven't yet been diagnosed, I encourage you to be persistent -- you have to be your own advocate within the medical system. But there are many people who have gone before, and have shared their experiences online.

Please share your experiences in the comments. I've already heard from many readers with sleep apnea, and I've been very encouraged by your stories! Thank you. Also, I found the forums at cpaptalk.com encouraging and enlightening -- many of those folks have Gone Pro with their sleep apnea, buying special software and hardware to monitor their CPAP data. It's inspiring -- and this CPAP machine gives me a new thing to geek out on! The community over there has answers for pretty much any question, and it's a great resource.

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How Your Sleeping Position Can Help (or Harm) Your Health
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iStock

Getting a good night's sleep is key to your health, but what's the best position for maximizing those benefits? According to SciShow, the answer depends on who you are and what your body is presently doing. Do you have acid reflux? You might want to avoid sleeping on your right side, since studies have shown that can aggravate heartburn (though scientists still aren't quite sure why). Are you pregnant? Aim for the left side, since it helps blood and nutrients flow to the placenta, among other benefits. Do you snore? Maybe avoid sleeping on your back, and roll over on your side instead. The video below goes over the whole menu of possible sleeping positions, and explains which ones will help you get the most out of your 40 winks.

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Harris and Ewing, Library of Congress
14 Facts About Margaret Sanger
Harris and Ewing, Library of Congress
Harris and Ewing, Library of Congress

Born in 1879, activist Margaret Sanger sparked both revolution and controversy when she began pushing for legalized access to birth control and founded the Planned Parenthood Federation of America. Sanger remains a controversial figure even today, more than 50 years after her death.

1. SHE BLAMED HER FATHER FOR HER MOTHER'S DEATH.

Sanger was born Margaret Louise Higgins, the sixth of 11 children. Her mother, Anne Purcell Higgins, also had seven miscarriages, for a grand total of 18 pregnancies within 22 years. She suffered from poor health for much of that time, and when Anne died of tuberculosis at age 50, Margaret was just 19 years old. According to TIME Magazine, Margaret confronted her father at her mother's coffin and said, "You caused this. Mother is dead from having too many children."

2. SHE WANTED TO BE A DOCTOR.

Margaret Sanger sitting at a table.
Harris and Ewing, Library of Congress

Sadly, medical school was too expensive, so instead she entered a probationary nursing program in 1900. In early 1902, she met architect William Sanger. The two got married later that year and moved to Hastings-on-Hudson, New York, a suburb about 20 miles away from New York City. They had three children.

3. HER HOUSE CAUGHT FIRE, LEADING HER TO MOVE TO THE CITY.

After the Sangers' house in Hastings-on-Hudson caught fire, Sanger stopped enjoying life in the suburbs. By 1911 the couple had decided to start a new life in Greenwich Village, where Sanger joined the Women's Committee of the New York Socialist Party. There, she met fellow radicals and reformers—like novelist Upton Sinclair, anarchist Emma Goldman, art patron Mabel Dodge Luhan, and intellectual Max Eastman—who supported her ambitions to help working women.

In New York City, Sanger decided to jump back into her career by working as a visiting nurse in the Lower East Side tenements. She often treated women who attempted to give themselves abortions because they didn't have the money to care for another child. Dismayed by the poor health and poverty she saw among immigrants there, she developed opinions that would later lead to her advocacy for birth control.

4. SHE BELIEVED BIRTH CONTROL WAS A FREE SPEECH ISSUE.

Soon after arriving in Greenwich Village, Sanger began writing sex education columns for the New York Call, a socialist newspaper. Her frank discussion of women's sexuality and reproduction offended some readers. In 1913, politician and post office official Anthony Comstock censored her column because he considered her usage of words like syphilis and gonorrhea too vulgar.

A year after her column in the New York Call was banned, Sanger launched The Woman Rebel, an eight-page monthly newsletter advocating contraceptive use. Operating under the slogan "No gods, no masters," Sanger used the newsletter to openly defy Comstock's eponymous 1873 laws. (The Comstock laws made it illegal to use the United States Postal Service to send anything containing information about contraceptives or anything else deemed obscene.) She was indicted in August 1914, but she fled to Europe to avoid arrest. She would eventually return to the United States to face trial, but in February 1916 the prosecution dropped the charges.

5. SHE WAS AGAINST ABORTION.

Despite her advocacy for family limitation, Sanger disliked the idea of abortion. She believed proper education and legalized contraceptives would reduce the need for the procedure. In her 1938 autobiography, Sanger described her experience treating Sadie Sachs, one of the women in the East Side tenements. In 1912, Sachs's husband called for Sanger's help after he found Sachs unconscious from a self-induced abortion. After three weeks of treatment from both Sanger and a local doctor, the only advice the doctor could offer Sachs was to avoid "any more such capers" and have her husband sleep on the roof.

Three months later, Sachs became comatose from another self-induced abortion, and Sachs's husband again reached out to Sanger for help. The woman died within 10 minutes of Sanger's arrival. Frustrated by the lack of resources and information available to lower-class women, Sanger resolved to make changes. From that time forward, she wrote, she wanted to "do something to change the destiny of mothers whose miseries were as vast as the skies."

6. SHE POPULARIZED THE TERM BIRTH CONTROL.

Sanger is often credited for coining the term, but that honor actually goes to Robert Parker, a friend of hers who helped create The Woman Rebel. In her 1979 biography on Sanger, author Madeline Gray described Parker as a polio victim who studied yoga with the hopes of gaining more control over his partly paralyzed hand. Gray wrote:

"It occurred to him that control might apply to birth as well. 'Birth control,' he mused. 'Birth control … I think I like it.' They all liked it. As they put on their hats and left, they agreed that birth control was the best name for the movement."

Otto Bobsien, another of Sanger's colleagues, was the first to use the term to proclaim the start of the Birth Control League of America, a new organization he later said "never had more than a nominal existence." In 1915, when Sanger was away in Europe, Bobsien joined the National Birth Control League and offered the fledgling organization use of the movement's new name. When Sanger returned from Europe later that year, she helped popularize the term, considering it more straightforward than phrases like "family limitation."

7. SHE OPENED THE FIRST BIRTH CONTROL CLINIC IN THE U.S.

Historical image of Margaret Sanger standing on a street in New York City
Sanger outside of her trial on January 30, 1917.
Bain News Service, Library of Congress

In October 1916, Margaret Sanger opened a birth control clinic in Brooklyn with the help of her sister, Ethel Byrne, and interpreter Fania Mindell. It was the first of its kind in the U.S., and she modeled it after a Dutch clinic she had visited while evading American police. In the Netherlands, Sanger had learned about pessaries and diaphragms and became convinced they were more effective than the suppositories and douches she promoted in the United States. Sanger brought that new knowledge to her Brooklyn clinic, which served more than 100 women on its first day. For a cover charge of 10 cents, Sanger gave every woman a pamphlet of her New York Call column on "What Every Girl Should Know," a lecture on the female reproductive system, and instructions on several types of contraceptive use. The clinic closed just nine days later when Sanger was once again arrested for violating the Comstock laws. Sanger immediately attempted to reopen the clinic after being released on bail, but, as she wrote, she was promptly re-arrested and charged as a public nuisance.

8. SHE ONCE TOLD A JUDGE SHE COULDN'T RESPECT EXISTING LAWS.

Sanger and Byrne's court trials began in January 1917. Sanger's sister was tried first and sentenced to 30 days in a workhouse, but she immediately went on a hunger strike; Byrne fasted for a week before being force-fed by prison staff. When Sanger went to trial on January 29, she was supported in court by several Greenwich Village socialites and about 50 of the women she'd treated in the Brooklyn clinic. Presiding Justice John J. Freschi offered her a lenient sentence if she promised to obey the law, but Sanger responded by saying, "I cannot respect the law as it exists today." Sanger was found guilty and Freschi also sentenced her to 30 days in a prison workhouse.

In 1918, Sanger appealed the court decision and won a victory for the birth control movement. Although the court upheld Sanger's conviction and she still had to serve her 30 day sentence, Judge Frederick E. Crane of the New York Court of Appeals also ruled that doctors could prescribe contraceptives and disseminate information about birth control under certain conditions. Sanger ran with the new loophole in 1923, when she established a new clinic staffed largely by female doctors. The new clinic operated alongside the American Birth Control League. Almost two decades later, in 1939, the league and the clinic merged, forming the Birth Control Federation of America, and in 1942 this new organization officially became known as the Planned Parenthood Federation of America.

9. THE ROCKEFELLERS ANONYMOUSLY SUPPORTED HER CAUSE.

In the mid-1920s, John D. Rockefeller Jr. anonymously donated $10,000 to the American Birth Control League to fund research into contraceptives. Rockefeller's son, John D. Rockefeller III, continued his father's early support of Sanger's work, albeit more publicly. The Rockefeller Brothers Fund donated money to Planned Parenthood until 1981, when it decided to start funding agricultural research—which was decidedly less controversial—instead.

10. LIKE MANY WELL-KNOWN INTELLECTUALS OF HER DAY, SANGER SUPPORTED EUGENICS.

Many historians believe Sanger's support of eugenics was part strategic and part ideological. Sir Francis Galton, a cousin of Charles Darwin's, initiated the Western eugenics movement by suggesting that traits like "talent and character" could be passed down to children through intentional breeding. Several British and American academics latched onto the idea, including figures like Theodore Roosevelt, John D. Rockefeller Jr., and Alexander Graham Bell. Sanger's support for sterilizing the diseased and "feebleminded" legitimized the birth control movement by aligning her ideas with those of contemporary intellectuals.

Sanger's belief in eugenics was a little different from other intellectuals', though. Eugenicists, she said, believed a woman's first duty should be to the state, and that all "fit" women should bear children. Sanger, on the other hand, thought a woman's first duty should be to herself. She contended the primary reason for birth control was to prevent pregnancies among women who couldn't support a child financially. Sanger believed her ideal of economic eugenics was morally superior to the views posed by traditional eugenicists.

The modern-day Planned Parenthood doesn’t hide Sanger's controversial support of the eugenics movement, but it doesn't endorse it, either. In a document published in 2016 [PDF], the organization said, "We believe that [those ideas] are wrong. Furthermore, we hope that this acknowledgement fosters an open conversation on racism and ableism—both inside and out of our organization."

11. HER BOOKS WERE AMONG THE FIRST BURNED BY NAZIS.

In May 1933, Nazis sanctioned the burning of more than 25,000 books deemed "un-German." Sanger had published at least nine books by that point, and they were all among that number, as were titles by Jack London, Ernest Hemingway, Sigmund Freud, Albert Einstein, and dozens of others. Sanger's books, which advocated for women's choice in everything from childbirth to politics, directly contradicted everything the Third Reich believed. Adolf Hitler supported traditional gender roles and wanted to maintain high birth rates, ideas Sanger decried in her books.

12. HER NIECE WAS PART OF THE INSPIRATION FOR WONDER WOMAN.

A panel of a Wonder Woman comic from 1978.
Tom Simpson, Flickr // CC BY-NC-ND 2.0

Olive Byrne, Sanger's niece, was involved in a polyamorous relationship with Wonder Woman creator William Moulton Marston and his wife, Elizabeth Holloway Marston. Marston credited both Olive and Elizabeth as his muses, according to historian Jill Lepore. In her 2014 book The Secret History of Wonder Woman, Lepore wrote that Marston based part of Wonder Woman's costume on the silver bracelets Olive often wore. Lepore also suggested Sanger herself may have been an influence on the popular comic book character. Feminist movements in the early 1900s often symbolized female oppression with chains, and Sanger was quick to adopt such symbolism with books like Motherhood in Bondage. Wonder Woman's use of chains and ropes as weapons echoed Sanger's vision for female liberation.

13. SHE WAS NOMINATED FOR THE NOBEL PEACE PRIZE 31 TIMES.

Margaret Sanger received 31 nominations for the Nobel Peace Prize between 1953 and 1963. In 1960 alone, she received 20 nominations from 16 university professors and four members of India's parliament (Sanger took several trips to India, where she worked with people like Gandhi to discuss birth control).

14. SHE LIVED JUST LONG ENOUGH TO SEE HER LIFE'S WORK COME TO FRUITION.

Planned Parenthood's publicity director looks over a poster in 1967.
H. William Tetlow, Fox Photos/Getty Images

Two important legal milestones happened after Sanger founded the American Birth Control League in 1921. In December 1936, the 2nd U.S. Circuit Court of Appeals effectively overturned all federal restrictions on birth control, making it legal for doctors throughout the United States to provide access to contraception. On the state level, contraception was legal in some form or another everywhere except Connecticut, Mississippi, and Massachusetts. In 1965, Griswold v. Connecticut overturned the state laws preventing married women from accessing birth control. Griswold v. Connecticut later served as precedent for cases like Eisenstadt v. Baird (1972), which gave unmarried couples unrestricted access to contraception; Roe v. Wade (1973), which legalized abortion; and Carey v. Population Services International (1977), which made it legal for doctors and pharmacists to distribute contraceptives to minors.

Sanger died on September 6, 1966, about a year after the Supreme Court decided on Griswold v. Connecticut. The next day, Alaska Senator Ernest Gruening spoke about Sanger in Congress. In an address to the president, Gruening said Sanger was "a great woman, a courageous and indomitable person who lived to see one of the most remarkable revolutions of modern times—a revolution which her torch kindled."

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