Michael J. Hutz, MD
Michael J. Hutz, MD, head and neck surgeon double board-certified in sleep medicine and ENT-otolaryngology specializing in the surgical management of obstructive sleep apnea at Rush University Medical Center, Chicago. Rush.edu
Obstructive sleep apnea (OSA) is a serious medical condition that can endanger your overall health. The risks from untreated apnea include high blood pressure, worsening diabetes, heart attack, stroke and other cardiovascular risks, as well as a significantly higher risk for car accidents because your motor skills and reaction time are decreased when your sleep quality is poor.
Until recently, using a continuous positive airway pressure (CPAP) machine at night was your only choice to treat sleep apnea. Problem: More than half of CPAP users don’t tolerate it long term because the mask is uncomfortable…the tubing gets tangled…and/or the skin around the mouth becomes irritated.
Good news: Innovations in diagnosis and treatment can help, says sleep surgery specialist Michael J. Hutz, MD. Even if you’ve tried unsuccessfully to address your sleep apnea before, it may be time to consider a new treatment. Here are the good—and the bad—options now…
CPAP machines: The gold standard in sleep apnea treatment is still a CPAP machine. It provides a continuous column of air pressure that prevents your airway from collapsing. If you wear it every night, it’s more than 90% effective at preventing the collapse and, in turn, stopping snoring and reducing the risks from sleep apnea.
What’s new: “Smart” machines that deliver air pressure may be easier to tolerate…
Automated positive airway pressure (APAP) machines make adjustments when you need more or less pressure to keep your airway open. This can be helpful for people whose sleep is disturbed by the continually high level of pressure from a conventional CPAP machine.
Bilevel positive airway pressure (BPAP) machines deliver higher pressure when you breathe in and lower pressure when you breathe out. This can make CPAP use more comfortable, again because of the lower amount of pressure.
What may not help: A newer category of devices marketed as micro-CPAP machines deliver expiratory positive airway pressure (EPAP). The device, small enough to fit in your hand, has a tiny fan that delivers pressure through nose buds that you place in your nostrils. CPAP pressure is measured in terms of water pressure. Because a micro-CPAP delivers only one or two centimeters (cm) of water pressure versus the 4 cm to 20 cm or more that a CPAP machine delivers, it may be helpful for patients who snore with mild sleep apnea, meaning between five and 15 apnea episodes per hour. Moderate sleep apnea is 15 to 30 episodes per hour, and severe is 30 or more episodes.
You will need a doctor’s prescription based on a diagnosis of sleep apnea to obtain an FDA-approved CPAP machine. Devices sold online without a prescription may or may not be FDA-approved. Currently, no micro-CPAP machines have FDA approval.
Oral appliances: When made by a dentist trained in dental sleep medicine, a custom-fitted oral appliance can effectively treat mild or moderate sleep apnea by repositioning the jaw and tongue to reduce airway blockage. Some insurers now require that you try one of these devices before they’ll cover any surgical intervention (see below). Your molars and other teeth must be in good condition to use one of these, so they are not an option for people who wear dentures or have poor teeth.
What’s new: The Excite OSA tongue stimulator is a small oral training device that you place in your mouth for just 20 minutes a day every day for six weeks while you are awake. After that, you use the device for 20 minutes a day twice a week. It emits slight electrical currents that help to build up the tongue’s muscle tone, making it less likely to collapse and narrow your airway while you’re sleeping. This device works best for people with snoring or mild obstructive sleep apnea.
What may not help: Generic mouthguards advertised for sleep apnea—referred to as “boil-and-bite” because you heat the guard and bite down to mold it to your mouth—may help some people with snoring and mild sleep apnea. But a concern about a mouthpiece that isn’t custom-made is that it can cause temporomandibular joint (TMJ) disorders or changes in the jaw joint or teeth. Also: Tongue-“retaining” devices designed to hold down your tongue typically are not well tolerated or very effective in the long run, although they can be an option for patients who snore or have very mild sleep apnea.
Surgical approaches: Snoring and sleep apnea often are linked to mouth-breathing. Surgery to open the nasal passages and reduce mouth-breathing may improve snoring or make other treatments such as an oral appliance or a CPAP machine more effective.
Soft tissue surgery includes removing the tonsils if they are large and causing a blockage of the airway or removing the lingual tonsils (tonsil tissue on the back of the tongue that sometimes is swollen). Pharyngoplasty is another common surgery that is essentially a “facelift” for the back of the throat that involves removing the tonsils and tightening the soft palate so that it’s less likely to collapse.
Skeletal surgery. Palate expansion is an option for younger patients who have a narrow, high-arched palate. By expanding the upper jaw, nasal breathing and the overall airway can be improved. Maxillomandibular advancement surgery, for people whose small, underdeveloped jaw causes their sleep apnea, moves the upper and lower jaws forward to permanently increase the size of the airway. This is the most effective surgical option but also the most invasive.
Neurostimulation implant. The FDA-approved device Inspire targets physiology, not anatomy. A stimulator is placed through two small incisions, under the chin and near your collarbone. It is connected to the hypoglossal nerve, the nerve in the neck that controls the tongue, and it acts like a pacemaker for the tongue while you sleep. You use a remote control to start the device each night so that it turns on once you fall asleep. When you take a breath, Inspire stimulates the tongue muscle to move forward and open up the airway behind it. Inspire has been beneficial for many patients because as we get older, loss of muscle tone can cause the airway to start to collapse. Inspire improves muscle tone without changes in your anatomy. About 60,000 patients in the US use Inspire, and it is about 70% effective in the right patients. The outpatient surgery typically is well-tolerated. Risks include swelling or infection at the incision site. Some people report being aware of the device, but this can be corrected when your doctor adjusts its settings.
Lose weight. A 10% increase in body weight can lead to a 30% or more increase in sleep apnea severity. A 10% loss in body weight can decrease sleep apnea by about 25%.
Positional therapy. If you experience apnea only when sleeping on your back, train yourself to sleep on your side—positional devices, even a tennis ball sewn to the back of a sleep shirt, can help. Or you can elevate the head of your bed by about 30°.
The first step in diagnosing sleep apnea is participating in a sleep study at a hospital, a sleep center or even at home. Advanced diagnostic techniques can pinpoint the source and degree of the problem. For those who can’t tolerate CPAP, treatment will target the cause of your sleep apnea—specifically, the structures that are collapsing in your airway. Diagnosis is done with a drug-induced sleep endoscopy (DISE). You’ll be given the anesthetic sedative propofol through an IV to make you sleepy enough to start snoring and have apnea. This allows your doctor to see exactly what part of the airway is collapsing. Examples: If the problem is due to the tonsils or soft palate, pharyngoplasty may be beneficial. If the tongue is falling back, Inspire could be effective. And if the whole airway is collapsible, jaw surgery may be most effective.
Important: DISE is required by the FDA before Inspire surgery. Some surgeons do DISE on every patient. A few medical centers, including Rush University Medical Center, perform DISE-PAP, that involves using a CPAP machine during DISE to gauge the severity of the airway collapse.
