“I am not going to use one of those machines to breathe with,” my patient says making a smothering gesture over his face. I know he is talking about CPAP, continuous positive airway pressure, the most effective form of treatment for obstructive sleep apnea. In my practice most people tolerate CPAP very well. It is also true that many people have negative ideas about CPAP before they try it. As their physician I step them through the process of diagnosing their problem, educating them about the condition, and presenting their treatment alternatives.
Obstructive sleep apnea is diagnosed by a sleep study called a polysomnogram. “Poly” means many, “somno” means sleep, and “gram” means recording. If those three are put together it means that we are recording many physiologic parameters of sleep overnight. In more practical terms a patient sleeps in a normal bed (a queen-sized Sleep Number bed in my sleep facility) with some wires attached with adhesive so we can monitor brain activity and sleep stages, breathing, heart rhythm, movements, oxygen levels, etc. We record all of that data and analyze it. If the patient stops breathing frequently during the night we can detect it, measure its severity and frequency, and stratify the degree of sleep apnea into mild, moderate or severe.
It is important to stratify the severity of obstructive sleep apnea, because severity of sleep apnea correlates with degree of cardiac risk. Once obstructive sleep apnea has been diagnosed, the patient needs to be treated.
The most commonly used treatment is CPAP which stands for Continuous Positive Airway Pressure. Since Obstructive sleep apnea is a condition of soft tissues of the throat such as the tongue and soft palate collapsing and closing the airway the treatment needs to prevent that process from happening. CPAP uses a tube and mask to deliver a specified setting of air pressure to inflate the airway and make an open conduit for breathing. CPAP consists of a small, quiet machine, a mask and a tube, as well as a humidifier to make the air comfortable. In the past the success rate was approximately 50%, not because of treatment failures but because patients simply found the devices too uncomfortable for daily use over the long term. Newer CPAP units are much smaller and quieter with better humidifiers and airflow features that allow breathing to feel more normal and natural. Masks are lighter, more comfortable and easier to use. Some just fit at the nostrils. Success rates are now 80-90% with CPAP.
Another common treatment is a Mandibular Advancement Device. This is an oral device that is somewhat like the mouth guard a dentist makes for people who grind their teeth except it is more sophisticated. This device has a piece for top and bottom teeth and keeps the jaws held together when the person is sleeping to prevent the bottom jaw from sinking down and back which is a natural position for the bottom jaw in sleep. Since the tongue and muscle under the tongue are attached to the bottom jaw, those structures are also held forward and they are less likely to collapse the airway. The advantages of this treatment are night time convenience and travel size. The treatment is not always as successful as CPAP in every individual.
Surgery is a treatment that has had a role in sleep apnea therapy since sleep apnea was first identified. In fact, the first treatment for obstructive sleep apnea was a surgical tracheostomy to bypass the obstructed upper airway. There were no other effective treatments to directly manage sleep apnea. Today there are surgical methods to correct a deviated nasal septum and improve nasal airway obstruction to allow better airflow. Procedures are performed to reduce the size of the soft palate as well as the base of the tongue to decrease the obstruction. There are also procedures to tether the hyoid bone of the neck to help keep the airway from closing during sleep. In children with sleep apnea tonsils and adenoid tissue are often removed to successfully treat sleep apnea. There are even occasional adult cases benefiting from this procedure. Surgery is usually considered a second-line treatment for adults with sleep apnea because surgery is actually less successful than CPAP and there can be a small possibility of surgical side effects.
Weight loss can have a remarkable effect on the upper airway and sleep apnea. As a person loses excess weight, fat tissue is reduced in and around the neck opening the diameter of the upper airway and decreasing the obstruction of sleep apnea. In some cases sleep apnea can be improved from severe sleep apnea to mild or even to the point where other treatment is no longer necessary. It is often very hard to lose weight with untreated sleep apnea because of excessive fatigue, associated changes in eating behaviors, and metabolic changes caused by sleep apnea. However, when a person has treated sleep apnea and then embarks on a weight loss regimen, we often see dramatic improvements in the degree of sleep apnea.
A relatively new advance in the treatment of obstructive apnea is ProventTM. It is a deceptively simple little device that looks a lot like a small oval band-aid. In the center of the adhesive there is a small plastic valve. One valve goes into each nostril and the adhesive holds it on the nose making an airtight seal. Provent’s valves treat sleep apnea by taking advantage of the physiology of the upper airway by producing partial resistance to the exhale part of the respiratory cycle. This resistance to flow increases the pressure in the airway and inflates it somewhat like CPAP does. When the next inhale cycle occurs the valves have no resistance and the airway starts somewhat inflated and much less likely to collapse. ProventTM does not work for every sleep apnea patient, but can be effective and convenient for some patients.
Long scoffed at by many sleep professionals, positional therapy is starting to take a role in serious sleep apnea management. The principle is deceptively simple. It does not take a full polysomnographic study lab to determine what bed partners will freely report: a large percentage of sleep apnea sufferers exhibit some degree of worsening of their sleep apnea and snoring when they are on their backs. When studied we can determine that some patients will manifest sleep apnea nearly exclusively on their backs. Gravity is clearly having an effect on the airway structures on the front of their airways (the tongue, soft palate, uvula) and pulling them back to close the airway. If we could simply prevent gravity from causing those structures to close the airway we would solve the sleep apnea. In order to prevent the effects of gravity we could send every sleep apnea patient with this type of positional component to the International Space Station. Unfortunately, there are millions with sleep apnea, so overcrowding would be a problem. We could instruct all of the patients to get a t-shirt, sew a long pocket down the center of the back and tell them to put half a dozen tennis balls down the pocket. Then that shirt is their new pajama shirt. The idea is that the patient needs to sleep on his or her side. Rolling onto the back will be very uncomfortable and cause the person to wake up and roll onto a side once again. Since the tennis ball t-shirt was quite seriously the mainstay of physician directed positional therapy for sleep apnea, positional therapy was not considered a serious modality for years. Many did not want sleep with a bizarre shirt. Others found the discomfort of the tennis ball shirt unpleasant and annoying. Surprisingly, some would sleep so deeply they would roll onto the tennis balls, stay asleep and wake with a backache. A number of years ago one of my patients even fashioned a positional device out of an empty 2 liter soda bottle filled with sand strapped to his back with seatbelt straps so he would be physically unable to roll over onto his back. The space station might have been less inconvenient. Today there are specific devices which can be worn comfortably and gently but firmly resist rolling from side to back. One is called the ZzomaTM which attaches around the torso and has a specially shaped foam block on the back.
Treatments for obstructive sleep apnea continue to improve and exciting new advancements are in trials. One promising development is an implantable device which electrically stimulates the hypoglossal nerve which is the nerve under the tongue that controls tongue muscle tone. This pacemaker-type device is switched on at sleep time and stimulates the hypoglossal nerve which triggers a neuromuscular response to open the airway. So far published trials have shown successful deployment of the devices and significant reduction in sleep apnea, even in severe cases. As studies continue to go forward we are optimistic about this novel treatment.
Obstructive sleep apnea affects a significant percentage of the population and there is not a single treatment that is appropriate for every individual. Fortunately, there are multiple ways to manage sleep apnea and with the support of a multidisciplinary sleep center a patient can explore options to resolve obstructive sleep apnea, its symptoms and its health risks.
