Treatment of Obstructive
Sleep Apnea (OSA)

CPAP

CPAP, or continuous positive airway pressure, is considered the treatment of choice for moderate to severe obstructive sleep apnea.  Patients with mild sleep apnea can also benefit from CPAP therapy.  A CPAP device consists of a blower-motor that pressurizes filtered air, directs this air through a humidifier, and delivers the humidified air through tubing to a nasal, or oronasal mask.  The air is directed through the mask to the throat area where it splints open the walls of the throat, enabling the airway to stay open for effective breathing.  An optimal pressure, that varies from one person to another, keeps the airway open in all sleep positions, and in all sleep stages.  This pressure is determined during a titration study in the sleep center laboratory.  The CPAP equipment is quiet when it is operating properly, so that it will not typically disturb your bed-partner.  Device size has progressively become smaller, and devices are very portable, so that patients can take the equipment with them when traveling.

Most patients will have a period of time during which they acclimate to the CPAP therapy.  The length of time that it takes to adjust to using CPAP varies between individuals, and cannot be predicted.  Typically, most patients will struggle initially with the therapy, but adjust to wearing CPAP within a few days to a few weeks. For some, the time period to adjust to wearing CPAP may be longer.  Persistence with the therapy is important in acclimating to CPAP, as most individuals notice that the therapy is less bothersome, and easier to tolerate the more they use it.

BIPAP

BIPAP (bilevel positive airway pressure therapy) treats sleep apnea similarly to CPAP, with flow of pressurized air delivered via the nose, or nose and mouth.  BIPAP differs from CPAP in that air pressure delivered varies during a breath,  During inspiration, a higher pressure is delivered to help splint the airway open.  During exhalation a lower pressure is delivered to make it easier to exhale against the airflow.  BIPAP is often useful when higher pressures are needed to splint the airway open, and in some patients who have difficulty exhaling against pressure.  BIPAP represents a more complex therapy, and devices are more expensive than CPAP.  Most insurers require a trial, and failure of CPAP therapy, before covering BIPAP therapy.

As with CPAP, most patients will experience a period of adjustment during which they may struggle some with the therapy as they learn how to breathe with the device.  With persistence, most patients are able to acclimate to the therapy, and experience improvement in sleep quality and symptoms.

Surgery

Surgical options for treatment of obstructive sleep apnea include removal of tonsilar and adenoidal tissue, uvulopalatopharyngoplasty (UPPP), placement of palatal pillars, and mandibular advancement.  Most of these procedures are performed by a physician specializing in surgery of the ears, nose and throat (ENT).  Surgical procedures have varying success rates, and while some procedures may effectively eliminate snoring, they may not completely eliminate apnea events.  The commonly accepted definition of success of a surgical procedure for obstructive sleep apnea is a reduction in the AHI by 50%.  With the exception of palatal pillars placement, these surgical procedures require general anesthesia.  If you are considering surgery as a treatment, it is important that you discuss your options with your physician, sleep specialist and an experienced surgeon.

The uvulopalatopharyngoplasty, or UPPP, is the most common surgical procedure for sleep apnea.  During this procedure the uvula is shortened or removed, the soft palate (posterior roof of the mouth) is trimmed, and these tissues tightened. If present, the tonsils and adenoids may be removed.  Increasing the size of the airway can reduce the frequency of airway obstructions, though because the throat can be obstructed at levels above, or below the palate, residual abnormal respiratory events is common.

Removing the tonsils, and adenoids can be very effective in improving the airway caliber in children, and is the initial treatment of choice in this age group.  This procedure, however, may not “cure” the tendency for sleep apnea, and careful follow-up of children with sleep apnea having a surgical procedure as treatment is important.

Somnoplasty refers to the use of radio-frequency heat to cause damage to the soft palate and uvula.  This tissue heals with a scar that shrinks, tightening, and reducing the volume of the remaining tissue, resulting in an increase in the airway space.  Its’ advantage as an alternative to the UPPP procedure, is less pain, and the ability to perform the procedure in an office setting.  The treatment limitations of somnoplasty are similar to that of the UPPP procedure.

Palatal pillars are small plastic splints that are placed into the soft palate to provide stiffening to the tissue.  These splints help the soft palate to retain its normal shape and position during sleep, a time when the tissue normally relaxes.  Palatal pillars have been shown to reduce the tendency for obstructive sleep apnea, though are not considered a primary treatment modality.  This procedure, usually performed in the physician’s office, is less painful, and requires less recuperative time than the more invasive surgical procedures.

Because residual obstructive sleep apnea is frequently present following treatment with surgery, follow-up, including sleep testing, is important to ensure adequate treatment of the disorder has occurred.

Oral Appliance

The use of an oral appliance (mouthpiece, or oral orthotic device) has been shown to be effective for treating snoring and milder forms of obstructive sleep apnea, though studies document the effectiveness of this mode of therapy to typically be less than CPAP.  These devices, resembling mouth guards used by athletes, are fitted by a dentist trained in the use of oral appliances.  An oral appliance, used during sleep, will fit over the top and bottom teeth, and can be fixed to advance the lower jaw to a specified position, or the device can be gradually advanced to a position that opens the posterior throat to facilitate more effective breathing during sleep.  The use of an oral appliance requires that an individual have their own healthy teeth and cannot be used with dentures.  A dentist experienced in the use of oral appliances for treatment of sleep apnea can evaluate a prospective patient’s teeth and make a determination regarding whether a mouthpiece is an appropriate treatment option.

Weight Loss

Weight gain is an important risk factor for obstructive sleep apnea. Added weight often includes deposition of fat around the throat area in the parapharygeal fat pads. This narrows the upper airway, and increases the tendency for airway obstruction during sleep, when the muscle tone of the mouth and throat is reduced. A 10% gain in body weight has been shown to increase the frequency of obstructed apneic events by up to 33%. Weight loss can reduce the tendency for obstructive sleep apnea, though is difficulty to achieve because of metabolic barriers (including leptin resistance, and insulin resistance) caused by the sleep apnea. In addition, fatigue, lack of energy, and sleepiness make it difficult to incorporate exercise into a weight loss program, and instead usually result in less physical activity and subsequent weight gain. Patients with mild sleep apnea, and excess weight can use weight loss as a treatment strategy, though most individuals find it easier to lose weight if their sleep apnea has been treated, ie. with CPAP, and then pursue weight reduction.

Positioning Therapy

Most individuals with obstructive sleep apnea will have more frequent apneas and hypopneas while positioned supine (on their back). This occurs because the tongue will fall back into the airway as it relaxes after sleep begins. Some patients have a prominent positional component to their sleep apnea, with the majority of observed apneas and hypopneas noted while supine, and few abnormal respiratory events noted while positioned on their side. Avoidance of supine positioning during sleep in these individuals may result in significant improvement in their sleep apnea, and symptoms. Practically, however, staying off one’s back while sleeping can be difficult, as position changes occur normally during sleep, and one may not be aware that they have moved into the supine position during sleep. Maneuvers to reduce supine sleep include sewing objects (ie. tennis balls) into the back of a shirt used during sleep, to make it uncomfortable to be positioned on one’s back. The use of body pillows to prevent turning on one’s back has also been proposed. Though most patients with significant sleep apnea will require one of the other forms of active treatment for this disorder, positioning therapy can be useful as an adjunct to surgery, or the use of an oral appliance, and even to the use of CPAP.

Other Therapies

Though there is great interest in the development of a medication that can effectively treat obstructive sleep apnea, such a medication is not currently available. There are conflicting results regarding the airway stabilizing effects of Remeron (mirtazepine), an antidepressant agent. The use of REM suppressing antidepressant agents has some theoretical basis in patients who have a REM predominant form of sleep apnea, though practically, is usually not adequately effective.

Oxygen can sometimes be used to treat desaturations (decreases in oxygen saturations) that accompany interruptions in breathing during sleep, however it does not treat the obstructive process. This therapy may be useful in patients for whom other obstructive sleep apnea treatments are not acceptable.

Arranging treatment of sleep apnea

My next step
Once you have received the results of your sleep study and a diagnosis, and have made a decision regarding the treatment you will be pursuing, you will either contact a durable medical equipment provider (DME) to arrange for CPAP/BIPAP, or you will arrange to be seen by an ear, nose, and throat (ENT) surgeon, or dentist.  Your primary care physician, or specialist who ordered the sleep study may help you arrange the treatment.  If follow-up has been arranged with Sleep Medicine Associates, P.C., either Dr. Cocanower, or Lindsay Lang, N.P. will help you decide on the best treatment option for you in the context of your medical history.  It is important that you have a thorough understanding of sleep apnea, its treatment options, and if choosing no treatment, the health risks of not being treated.

Who orders my treatment?
If your treatment for sleep apnea includes the use of CPAP, an order or prescription for the equipment will be written by your physician, or if seen in consultation, by Dr. Cocanower, or Lindsay Lang, N.P.  CPAP equipment is similar to other medical treatments and devices, and must be prescribed by a physician.  A durable medical equipment (DME) company will provide the equipment to you, just as a pharmacy would fill a medication prescription.  Dr. Cocanower, and his staff can help you choose a DME company, keeping in mind that your insurance coverage may affect your choices.  Choosing a DME company is very important, as you will be relying on them to support you in the use of your CPAP treatment.   The order for your CPAP equipment will be forwarded to the DME provider that you select.

The DME provider will work closely with you in providing you with the equipment that has been ordered for you.  The use and care of your CPAP equipment will be thoroughly explained by the DME provider.  They will also act as a resource if you should have any problems with your equipment or need any changes made to your equipment.  They will also work closely with your insurance carrier in obtaining payment for your CPAP equipment.

Novel Medical, LLC

Novel Medical, LLC is the treatment arm of Sleep Medicine Associates, P.C. and was established to provide the highest level of CPAP and BIPAP services to patients of the practice who have been diagnosed with obstructive sleep apnea, and who pursue treatment with positive airway pressure therapy.  Novel Medical is located within the main office building of the practice and can be contacted at 812-962-1540 Monday through Friday 8:30 - 4:30 CST.