Opening Lines of Communication

Addressing the respiratory conditions of bariatric patients takes more than just a CPAP.

More than 18 million Americans suffer from obstructive sleep apnea according to the National Sleep Foundation, and the prevalence of the sleep disorder increases as waist lines get bigger.

In fact, men who have a neck circumference of more than 19 inches have a 95-percent chance of having the disorder. Nearly two thirds of the morbidly obese population in the United States — people who weigh in excess of 350 pounds — has OSA, and co-morbidities such as diabetes and heart disease usually go hand in hand with the disorder. When choosing a CPAP for their bariatric patients, providers must consider physical factors that are not found in non-obese OSA clients.

“The bariatric patient has a lot of belly fat, and they’re going to have a difficult time ventilating; not just getting the air in but actually having the gas exchange at a cellular level,” says Kelly Riley, CRT, the director of the MED Group’s National Respiratory Network. Riley has more than 25 years of experience in the respiratory arena.

However, physical weight is only one hurdle providers will face in trying to help bariatric patients with their OSA treatment. Before anything, they must establish a bond of trust with the patient. That isn’t necessarily easy. Because obesity is still heavily stigmatized, bariatric patients might feel ashamed to go to a provider to address OSA needs.

“At an airport, you’ll see people who look at person A walking down the aisle who is not morbidly obese, and then you’ll see person B [who is morbidly obese] walking down the aisle, and you’ll see that many people will just give an open look of disgust,” Riley says, explaining that regularly experiencing that level of prejudice can greatly influence how bariatric patients interact with a provider.

If bariatric patients feel any type of judgment from the provider, they will hesitate to share important information that the provider needs in order to ensure patients get the right type of respiratory device.


Start With a Shoulder to Lean On

Bariatric patients might first come to a provider because of a referral from a sleep clinic, but in order to give them the best type of respiratory therapy, a provider must gain the patient’s trust. An excellent way to create a firm foundation of trust, Riley explains, is to establish a support group for such patients, and become invested in the issues facing morbidly obese clients.

“There are all kinds of people you can draw upon to provide a speaking piece or education piece [for the support group], and you’re providing a safe haven for people to come and network,” she says, emphasizing that not only is creating such a group easy to implement but cost effective, as well. Once patients feel more comfortable in a provider’s store, they will be more inclined to inquire about products that will help improve their quality of life.

“They’re going to see things that have to do with promotion of safety and independent living,” she says, explaining that even if they do not buy an additional product the first time, they will at least be aware of the importance of certain products.


The Right Staff

Having a support group is a moot point if a provider doesn’t employ staff that can address bariatric respiratory needs. Clinical expertise on how excess weight gain affects the respiratory system is clear, but equally important, providers need staff who can deliver compassionate and non-judgmental service. “You certainly do not want to come off as judgmental, but at the same time, it is important to be clear and concise in your communication, and educate as much as possible,” Riley says.

Staff who have gone through similar experiences might also notice fluctuations in a bariatric patient’s weight, which would not be noticeable to the average assessor and could change the pressure requirements of the CPAP or bi-level device that has been prescribed. They also have to consider the effects of a patient’s weight on the diaphragm and lungs when they are sleeping. Bariatric patients will typically hypoventilate because they are lying down and may not oxygenate as well at night.

“So often in our oxygen orders, we see O2 at 2 liters,” says Riley. “Well, that may be great for the oxygen patient who is moving around throughout the daytime, but you put that patient to bed at night, and especially with a bariatric patient, there may not be enough to adequately oxygenate that patient.”

Providing patients with an ongoing as-needed assessment tool, such as nocturnal oximetry, will help improve compliance.

Because of the frequent weight changes found among bariatric patients and because of the differences in pressure needed during the day and night, Riley recommends putting them on an auto-titrating device, “so that if there are fluctuations in weight, providers have some assurance that those [oxygen] needs are going to be addressed on a day-to-day basis.”

An example of one of the latest auto-titrating devices is Fisher & Paykel’s SleepStyle 200 Auto CPAP, which continuously monitors patients’ breathing patters, sensing when they were awake or asleep (see Product Solutions, page 29, to read more about the SleepStyle 200 and other CPAP products). The SleepStyle’s 200 SensAwake technology reduces airway pressure when it senses that a patient has awaken.

Bi-level devices, which help patients exhale as well as inhale, are another viable option. Riley explains that it depends on the types of co-morbidities the patient has because “anytime you have a bariatric patient, it’ll be very rare to have one pure issue to deal with.” ResMed’s VPAP Auto, for example, synchronizes with a user’s normal respiration, so that breathing feels more natural and comfortable.


Thinking Beyond the Box

Providing an assessment beyond respiratory therapy will help promote safety and ambulation among bariatric patients. For instance, positioning pillows help shift a person’s weight off of bones, joints and the chest, making the patient more comfortable and improving compliance. In fact, patients with morbid obesity typically can’t sleep and breathe well unless their head is elevated, and a CPAP pillow can improve patient comfort and compliance. An example would be Contour Products’ C-PAP Multi-Mask Sleep Aid, which helps make sleeping with a CPAP mask more comfortable. The cutouts on either side of the pillow relieve pressure and prevent leaks.

The patient might be coming in for a CPAP, but providers can also recommend cash sale products that improve their safety at home.

“When I talk to the bariatric population, there are a number of patients that are 400, 600, 700 pounds,” Riley says, adding that they are often hesitant to move because it’s painful and they’re at risk for falling injuries. Suggesting bath safety items such as handrails, and transfer benches helps keep them safe. “Once they’re safe, they’ll move more, and that will help promote better disease outcomes,” she adds.


Coping with Policy Revisions

Helping bariatric patients with their respiratory needs represents a shifting environment in terms of public policy. CMS’s policy revisions last October might have made it harder to treat bariatric patients. “We know it’s better to put these patients on autoPAP therapy,” Riley says. “There’s not a separate code for autoPAP versus CPAP, and so it seems like at every turn there is an obstacle.”

Also, while payment for bariatric surgery and bandings has increased, Riley worries about those who fall through the cracks. “What about the patient who isn’t a candidate for those surgeries? They’re just kind of left out there and abandoned and that’s just wrong.”

Riley says she wishes there was a mechanism to help teach disease management in relation to nutrition, but until then, the best thing providers can do is to promote safety and independent living. “It’s cash sales for the provider and it also establishes the provider as someone who cares,” Riley says. “And that’s what they need more than anything else.”


This article originally appeared in the April 2009 issue of HME Business.

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