Continuing our video series, Dr. Jerome Hester explains “Treatment Options for Obstructive Sleep Apnea”.
I’d like to talk about the treatment options for obstructive sleep apnea. Obstructive sleep apnea occurs when the airway from approximately the level of the nose to the back part of the tongue collapses during sleep due to the lack of tone in the musculature. Obstruction can occur at any of the levels in this space or all of the levels and therefore, any treatment needs to be aimed at correcting the levels of obstruction. Failure to correct all the levels of obstruction will lead to failure of the treatment.
The first treatment I’d like to discuss is CPAP, which stands for Continuous Positive Airway Pressure. This treatment at this time is considered the gold standard for how to treat the disease as its success rate is very high. The mechanism of action is that through wearing a mask or small device covering the nose, positive pressure air is forced into the airway, therefore, stenting the airway open during sleep preventing it from collapse. It essentially can be effective in only almost any patient by basically titrating the amount of pressure that is delivered. The other advantage besides the high rate of success is the fact that there is no true risk associated with this treatment.
Finally, there really is no reason why this burns any bridges to try a future treatment if this is not successful. However, the downside of CPAP is compliance. Depending on the study one looks at, compliance rates at six months were as low as 40% but generally are believed to be somewhere in the 60 to 70% range. The reason for not being able to tolerate such a treatment are really myriad. There are several reasons from comfort levels to having to get up in the middle of night and having it back on. It can dry the lining of the sinuses or the nose during treatment basically leading to an inability to get a good night’s sleep.
Overall, I believe it is the first-line treatment to try in this process. However, if it is not successful or the patient chooses not to wear it, there are other options. These other options include dental appliances or what are commonly known as mandibular repositioning devices. They look much like a child’s retainer although a little more elaborate and they work by wearing it every night and pulling the lower jaw forward as one sleeps. The advantage here is obviously, that once again, this is not surgical in nature.
However, there are some disadvantages also. First of all, this is not adequate for every patient. It specifically widens the airway in the area behind the base of the tongue and if that is not the predominant area of obstruction, this may lower the success rate itself. In addition, it is very important that these devices are made by someone well-trained in manufacturing such a device. Because they are pulling the lower jaw forward during the night, problems with both the jaw joint and even how the teeth fit together can arise. It is also important, if this device is used as a treatment, that once it establishes itself as being a reasonable choice by the patient, that a sleep study is obtained with the devices in place to determine whether the devices certainly solved the problem or simply improved it slightly.
The next thing I’d like to touch on at least briefly is weight loss. Now, weight loss can certainly contribute to sleep apnea. However, it is rarely the cause of sleep apnea and so therefore, simply proceeding with a weight loss program as treatment is usually not adequate. It has also been shown that once someone has sleep apnea, it is more difficult to lose weight. The suggestion most of the time would be to take on another treatment form such as CPAP, attempt to lose weight while one is wearing the CPAP and then if the weight is lost, a sleep study can be performed to see if the weight loss in fact made a significant difference but otherwise, which is very common for us to see patients going on year after year with untreated sleep apnea with the hope that someday they’ll be able to lose weight to change this scenario.
The final treatment option is a surgical treatment option. As I alluded to at the beginning of the talk, obstruction can occur at any level between the nose and the back of the tongue. It is very important that the individual treating a patient with sleep apnea has the ability to do a comprehensive evaluation of the airway, determining to the best of their ability where the obstruction is. Surgical treatment then needs to be aimed at those levels. A common cause of failure of surgical treatment is inadequate treatment of all the levels of obstruction, therefore leading to only a partial clearance of the airway. Surgery itself can be very simple and it can be very complicated depending on the patient’s anatomy and severity of disease. However, studies have shown that the overall surgical success rate is very high when applied in a comprehensive manner.