Sleep Disorders

Sleep apnea

04/20/2004 03:35PM

Question:

My father has sleep apnea. His physician had him try using a CPAP mask over his nose but he was never able to get used to it. Are there some other alternatives we can look into for him?

Answer:

I am assuming your question pertains to Obstructive Sleep Apnea (OSA) only. As such, OSA is quite a common condition in modern society, affecting 2-4% of middle aged adults in America. This condition is due to the recurrent complete or partial closure of the airway during sleep. As a result of the breathing difficulty in sleep, individuals with OSA suffer from fragmented sleep and tend to feel unrefreshed upon awakening and sleepy and tired during the daytime. In addition, a poor sense of well-being, decreased ability to concentrate and reduced alertness may all come from untreated OSA. Increasing research also suggests that OSA may affect such important medical concerns as blood pressure control and risk for cardiovascular disease (such as heart attacks, heart failure and stroke).
The causes of OSA are numerous, though it most commonly results from obesity as the upper airway becomes narrowed with weight gain. Other factors that may predispose to the development of OSA include upper airway anatomic abnormalities, such as enlarged tonsils, a large tongue, a deviated nasal septum and an abnormal jaw structure. Determining why a particular individual develops OSA is extremely important, as this may affect the treatment options that are available to that particular person.
CPAP, or Continuous Positive Airway Pressure, is a device that delivers a positive pressure to the upper airway, preventing its collapse during sleep. This therapy can be extremely effective for managing OSA. In addition, it is safe and generally well-tolerated. However, some individuals may refuse to consider this as a treatment option while others who initially accept CPAP, have problems utilizing this therapy on a nightly basis. There are many potential reasons why an individual may have troubles adapting to or tolerating CPAP therapy. These range from problems with mask interface (how the CPAP device is worn by the patient) to nasal congestion to claustrophobia. Attempting to identify why a particular person is having trouble with CPAP is extremely important as many of these issues can be worked thru with simple adjustments and patience. As this therapy is generally so effective for the treatment of OSA, every attempt should be made to help the individual adapt to CPAP before giving up on this therapy.
Alternative therapies are available for the treatment of OSA, though these have their limitations as well. Determining which specific therapy a patient may best be suited for depends upon the individual's upper airway examination, the severity of their OSA and the individual's personal preference. The alternative therapies for OSA primarily involve the use of oral appliances or surgery.
Oral appliances are devices that fit in the mouth and are worn on night basis. They are generally manufactured by dentists and are intended to pull either the tongue or lower jaw forward when in place. This results in an increase in the airway space and hopefully improved breathing in sleep. In order to consider these types of devices, an individual should have mild to moderate OSA (not severe OSA) and good dentition. In addition, one should check with their insurance company regarding coverage as not all insurers cover these devices. The long term affects of this type of treatment on dentition, sleep apnea and compliance with treatment are not clearly known at this time.
Surgical interventions can also be offered to some individuals for the treatment of their OSA. These might include trimming the soft tissue in the back of the throat (uvulopalatoplasty or UPPP), tonsil removal, nasal surgery (such as repair of a deviated septum, reduction of enlarged turbinates), mandibular (lower jaw) advancement surgery and tracheostomy, among others. The effectiveness of each of these interventions is somewhat variable and depends in large part on an individual's airway anatomy and the severity of their OSA. All surgeries carry some potential risk, though for the less extensive surgeries this risk is often minimal. These surgeries are performed by Ear Nose and Throat specialist and Oral Surgeons.
Alternative "conservative" therapies may also be effective for some individuals with mild sleep apnea. These include weight loss (mild weight loss improves OSA while dramatic weight loss can cure OSA in some cases), positioning therapy (for example staying off your back in sleep or elevating the head of the bead), avoiding sedatives and avoiding alcohol and tobacco.
Given your father's trouble with CPAP therapy, I recommend your father consult a Sleep Specialist to discuss his case. Obtaining more specific information regarding your fathers case, as well as a clinical examination and review of his sleep study, should help the Sleep Physician determine what treatment options might be best for your father. With perseverance, patience and knowledge, your father should find a treatment that is acceptable to him as well as effective in treating his condition.
If you would like further information regarding sleep apnea or other sleep disorders, I recommend you consider visiting 2 websites. The first is the website for the American Academy of Sleep Medicine at www.aasmnet.org. This website contains information of sleep disorders as well as lists Sleep Centers around the country and hopefully one near where you live. The second website is that of the American Sleep Apnea Association at www.sleepapnea.org. This association was created by and for individuals with OSA and has plenty of useful information. Good luck!

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Response by:

Likith V Reddy, MD, DDS, FACS
Assistant Professor
Division of Oral and Maxillofacial Surgery
Department of Surgery
College of Medicine
University of Cincinnati

Dennis Auckley, MD
Director, MetroHealth's Center for Sleep Medicine
Associate Professor
Division of Pulmonary, Critical Care and Sleep Medicine
MetroHealth Medical Center
School of Medicine
Case Western Reserve University