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Treating sleep apnea
Chad Ruoff, MD, is board-certified in internal medicine, sleep medicine, and obesity medicine and serves as a clinical assistant professor at the Stanford Center for Sleep Sciences and Medicine. This center is the birthplace of sleep medicine and includes research, clinical, and educational programs that have advanced the field and improved patient care for decades.
BeWell spoke with Dr. Ruoff to learn more about sleep apnea and what developments, if any, are occurring in the diagnosis and treatment of this disorder.
What exactly is sleep apnea?
While sleep apnea takes several different forms, the most common is called obstructive sleep apnea (OSA). OSA occurs when the airway obstructs/collapses during sleep. OSA severity ranges from mild (i.e., 5-15 collapses per hour of sleep) to severe (i.e., ? 30 collapses of the airway per hour of sleep).
What would make me suspect I might have OSA? And why should I worry I might?
OSA symptoms may include excessive daytime sleepiness, witnessed snoring and apnea, gasping/choking during sleep, dry mouth, nocturnal sweating, and morning headaches. The more severe forms of OSA have been shown to increase the odds of developing stroke, heart attack, depression — and all cause mortality, ranging from 2-5-fold increased risk.
How can I be sure that I have OSA?
The gold standard in diagnosing OSA is the in-laboratory sleep study, which requires an individual to spend the night in a sleep center. A person arrives at the sleep center in the evening, bringing with them clothes to sleep in and perhaps a blanket or pillow to make the sleep bedroom feel a bit more like home. A technologist spends anywhere from 30 to 60 minutes applying a variety of electrodes on the skin surface to monitor eye movements, brain waves, heartbeat, leg movements, and oxygen levels in the blood.
A home sleep study is an alternative to the in-laboratory sleep study. A home sleep study might be a great option for a person who suffers from classic symptoms of OSA — such as snoring, witnessed apnea, and excessive daytime sleepiness. Furthermore, if a person has avoided undergoing a sleep test due to anxiety about the test, then a home sleep test might be a great option as well. A word of caution: most home sleep studies are not as sophisticated and sensitive as an in-laboratory sleep test; therefore, a negative home sleep study does not necessarily rule out OSA.
How can OSA be treated?
Once a diagnosis of OSA has been made, the next step is to develop a treatment plan for the patient.
- CPAP: Still the gold standard treatment
The gold standard treatment of OSA is the use of a PAP (positive airway pressure) device while sleeping. In addition, for those individuals with excess weight, we always encourage healthy weight loss. The PAP device administers pressurized room air (i.e., not oxygen) via a tube and a small mask. The most common type of PAP machine is a continuous positive airway pressure (CPAP) device. There are also more complicated types of PAP devices. If a patient is not able to tolerate a CPAP device, then they may benefit from a trial of a more complicated device — such as a bi-level device, which can sometimes make breathing more comfortable for patients compared to a CPAP machine (e.g., lessens the feeling of being smothered during exhalation).
Common side effects from CPAP include dry mouth, skin irritation, and aerophagia (gas, bloating, cramping, flatulence, belching due to air traveling down into the stomach). A patient should have frequent follow-up visits with the prescriber of the PAP device to ensure all side effects are minimized and device settings are optimal. The newer PAP devices are equipped with technology that allows your prescribing physician to view how the machine is operating and then make calculated changes to the device settings remotely.
- Oral appliances and positional therapy
PAP remains the gold standard treatment for treating OSA. However, there are other options to consider when developing a treatment plan, such as the use of an oral appliance (OA). An OA requires an individual to wear a lower and upper dental tray while sleeping. The upper tray is used as a fulcrum to protrude the lower jaw. Since the tongue inserts on the lower jaw, the device effectively pulls the tongue forward, preventing the tongue from falling back into the airway — thereby lessening the frequency and/or severity of airway collapse.
In general, sleep apnea is often more severe on the back because gravity works against the tongue and airway, increasing the likelihood of collapse. We find that some individuals have positional sleep apnea, which is characterized by significant sleep apnea when sleeping on the back, but minimal or less severe sleep apnea when not on the back. For these cases of positional sleep apnea, the option of positional therapy can be considered. Positional therapy discourages the individual from sleeping on his/her back, accomplished by sleeping with a device that prevents the individual from moving to his/her back (e.g., a tennis ball or foam object sewn into the back of a shirt). Another example of positional therapy is wearing a device that alerts the individual when he/she has moved onto the back, so the individual can then change positions.
- Surgery and other new therapies
There are also a variety of surgical options for treating sleep apnea. The most commonly performed surgeries for sleep apnea are tonsillectomy and adenoidectomy; however, there are other surgical options, such as maxillomandibular advancement (MMA).
Another surgical intervention, which the FDA recently approved, is hypoglossal nerve stimulation (HGNS). This treatment activates the nerve innervating the tongue, thereby preventing the tongue from obstructing the airway.
Another treatment option is oral pressure therapy (OPT), using a device that is FDA-approved as well. It essentially works by creating a negative pressure in the roof of the mouth, thereby pulling the soft palate and/or tongue forward.
Why is weight management important if you have sleep apnea?
Every patient with OSA and weight problems should be encouraged to lose weight. In general, a 10% reduction in weight leads to an approximate 25% reduction in SA severity. A 20% weight reduction correlates to an approximate 50% decrease in the severity of SA symptoms. Plus, the weight reduction can result in other health benefits. Therefore, a patient should consider a referral to a registered dietician to develop a healthier diet. In addition, a patient can seek a referral to a bariatric and/or obesity medicine physician to tackle the weight issues and contemplate the risks/benefits of weight loss medications and ultimately bariatric surgery.
… any final thoughts?
If a person has been told and/or worries that he/she may have sleep apnea, the first step is to undergo a sleep test. The person should talk with a doctor to weigh the pros and cons of in-laboratory vs. home sleep testing. The evaluation and management of OSA requires a multidisciplinary team comprised of sleep specialists, ENT surgeons, bariatric surgeons, dentists, allergists, orthodontists, and others. If it is determined that you do have obstructive sleep apnea (OSA), PAP, oral appliances, and surgery are still the primary treatment modalities. However, newer interventions are available for those unable to comply with more conventional treatment options.
By Deborah Balfanz and Lane McKenna