Treatments for Obstructive Sleep Apnea
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| Who should be treated?
The decision to treat OSA should be made with your doctor. If you suffer from the classic symptoms of sleep apnea with daytime sleepiness and alterations in your mental function or personality, then treatment will be of great importance to you. But some people with sleep apnea are surprisingly unaware or free of symptoms. Do these people need treatment? Even asymptomatic patients may be at risk for the cardiovascular complications of OSA. You may be at risk of developing hypertension or other medical complications, even if you do not have severe apnea or marked drops in oxygen levels at night. The decision should therefore be based on both symptoms and signs of sleep apnea after review with your physician.
Continuous Positive Airway Pressure (CPAP)
CPAP involves the delivery of air (not oxygen) under pressure to the upper airway. This air pressure acts as a splint, holding the airway open and preventing the partial or complete collapse that is the main event in OSA. Usually this is delivered through a mask that fits over the nose only. In almost all cases this eliminates the signs and symptoms of OSA as well as the snoring. Most patients get relief quickly, some the first night they use it. In others it may take up to several weeks to adapt to the sensation of using the machine. CPAP was first used in Australia in 1981. Almost 30 years later PAP devices are far more advanced. There are some units which adjust the amount of pressure as needed throughout the night. For some people this is more comfortable. Another choice for difficult cases, particularly for those with more severe OSA, is BPAP or bi-level PAP where the pressure during inspiration can be different than during expiration. This too can be more comfortable for some, especially when high pressures are needed.
Oral Appliances
In the last several years, many devices, which can be worn inside the mouth, have been tried for sleep apnea. The goal is generally to hold the mandible (lower jaw bone) in its normal position or to pull it slightly forward. This prevents the jaw and tongue from falling backward during sleep and causing obstruction. The devices are generally well tolerated if the patient has no major tooth or jaw problems to begin with. They seem most helpful in mild to moderate cases but some success has occurred in more severe cases as well. This offers an alternative to those who cannot use CPAP and may not be candidates for surgery.
Body Position
Sometimes relatively simple measures can help sleep apnea. Some patients may only have apnea when sleeping on their backs. If they can stay on their side apnea may be reduced or eliminated. Unfortunately this is more difficult to achieve than it would seem. One suggestion has been to sew something such as a tennis ball into the back of the pajama top. In addition to the lateral position, elevation of the head of the bed by about 30° will also substantially decrease apnea in some patients.
Weight Loss
For many the severity of obstructive sleep apnea is also related to their weight. Even modest weight loss may significantly decrease apnea.
Alcohol Avoidance
Most agents that cause sedation will worsen OSA. Alcohol in particular results in a decrease in upper airway tone and often leads to marked worsening of OSA. Avoidance or at least decreasing the amount of alcohol, especially close to bedtime, is of great importance in managing sleep apnea medically.
Nose and Throat Surgery
For some CPAP is not an acceptable choice. This may be because of their inability to tolerate it. Many of these patients are candidates for surgery.Surgery for sleep apnea focuses on correcting the obstruction of the upper airway. Obstruction of the upper airway can occur at several levels including the palate, the base of the tongue or both. Surgery is aimed at correcting whichever obstruction is present. Nasal obstruction may also be present and contribute to the tendency for the airway to collapse, even though it is rarely the sole cause of OSA. When present along with other areas of obstruction, it may be important to correct this problem as well. This may be the first surgical procedure tried. In some cases, correction of a nasal problem will then ease the use of CPAP so that no further surgery is needed.If examination reveals that the soft palate is contributing to obstruction then removal of some of the palate, the uvula and any remaining tonsillar tissue may be of help. The surgery is not complicated or dangerous, but is quite painful. Alternatives to this include creating a flap of tissue rather than complete removal. Lasers have also been used but are generally less successful. Another surgery involves tightening the tongue so it does not fall backward against the throat during sleep, something that is common in OSA. In some patients an additional procedure in which a small bone called the hyoid is pulled forward, creating more space at the base of the tongue.In the remaining patients, further surgery on the jawbones themselves may be necessary to create a larger airway. This is more aggressive but the results have a greater success rate.
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