Obstructive Sleep Apnea

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Treatment

Several treatment options exist for dealing with OSA. These include weight reduction, oral appliances, positional therapy, positive pressure therapy, and surgical options.

Weight gain is a significant risk factor for the development of OSA. While sleep apnea usually can be corrected by weight loss, other factors involved in the pathophysiology of OSA, such as anatomic abnormalities, may cause the condition to persist. However, the vast majority of OSA cases can be improved, if not eliminated, with significant weight loss. The amount of weight a patient needs to lose to achieve these benefits varies. Some may need only a modest reduction in weight to gain improvement, while others require significant weight loss. It is not necessary to slim down to "ideal body weight" to achieve these benefits.

Oral Appliances

Oral appliances used for the treatment of OSA generally come in two categories: mandibular advance devices and tongue-retaining devices. A variety of both types exists. Oral appliances may be used to treat mild to moderate OSA.

Mandibular advance devices essentially consist of a plastic (or other material) mold of the teeth. They resemble the athletic mouth guards commonly used in boxing, football, and other contact sports. The mold for the lower teeth is advanced further forward than the mold for the upper teeth. Advancement of the lower teeth moves the jawbone forward and opens the airway, preventing its collapse during sleep. These devices can be particularly effective in treating positional OSA.

Tongue-retaining devices, which also resemble athletic mouth guards, are suction devices that are placed between the upper and lower teeth. The tongue sits in the suction device and is pulled forward during the night. Positioning the tongue forward may eliminate any obstruction caused by the base of the tongue.

Oral appliances are best fitted by a dentist experienced in their use. Patient compliance is essential in order for these devices to be effective. Complications associated with oral appliances include temporal mandibular joint pain and excessive salivation.

Positional therapy can be used to treat patients whose OSA is related to body positioning during sleep. Most people with sleep apnea have worse symptoms if they lie flat on their back during sleep. Indeed, most bed partners know this from experience and often try to make their partner move onto their side during the night to stop their snoring. There are several strategies which can help patients who have mild apnea only when lying on their back. One is to sew or attach a sock filled with tennis balls, length-wise down the back of their pajama top or nightshirt. This makes it uncomfortable for the sleeper to lie on their back, and they usually will move onto their side. Another technique is to use positional pillows to assist in sleeping on the side. Positional therapy has its limits, but it has been tried with success in some patients.

Positive Pressure Therapy
Positive airway pressure is a very effective therapy for obstructive sleep apnea. It has three forms: continuous positive airway pressure (CPAP), autotitration, and bi-level positive airway pressure.

Regardless of the mechanism used it is desirable to use the lowest possible pressure to eradicate the sleep apnea. In most cases, positive airway pressure is easier to tolerate at lower pressures. Every patient requires a different pressure. To determine precisely the individual patient's optimum airway pressure, it is necessary to titrate the pressure to each individual patient during a polysomnogram. A polysomnogram will show not only when the respiratory events have ceased, but also when the arousals from the respiratory events occur.

CPAP, the more common of the three therapy modes, usually is administered at bedtime through a nasal or facial mask held in place by Velcro straps around the patient's head. The mask is connected by a tube to a small air compressor about the size of a shoe box. The CPAP machine sends air under pressure through the tube into the mask, where it imparts positive pressure to the upper airways. This essentially "splints" the upper airway open and keeps it from collapsing.

Approximately 55% of patients who use CPAP do so on a nightly basis for more than 4 hours. It is the most commonly prescribed treatment for OSA. The advantages of CPAP are that it is very safe and completely reversible. Generally, it is quite well tolerated. The main disadvantage is that it requires active participation every night; that is, patient compliance is necessary for it to work.

Mask fitting is an essential element of a patient's success with positive airway pressure therapy since it affects compliance and effectiveness of treatment. Higher pressures can result in air leak and patient discomfort. Demands on mask stability increase as pressure increases. Higher pressures may also require tighter head gear to maintain an adequate seal contributing to the discomfort. When selecting a CPAP mask the following factors should be considered:

• Comfort
• Quality of air seal
• Conveninence
• Quietness
• Airventing

Side effects of CPAP include contact dermatitis, skin breakdown, mouth leaks, nasal congestion, runny nose (rhinorrhea), dry eyes, nose bleeds (rare), tympanic membrane rupture (very rare), chest pain, difficulty exhaling, pneumothorax (very rare), smothering sensation, and excessive swallowing of air (aerophagia).

Nasal congestion often can be reduced or eliminated with nasal steroid sprays and humidification placed into the machine. Rhinorrhea can be eliminated with nasal steroid sprays or ipratroprium bromide nasal sprays. Epistaxis is usually due to dry mucosa and can be combatted with humidification. Dry eyes are usually caused by mask leaks and can be eliminated by changing to a better fitting mask.

Autotitration devices are designed to provide the minimum necessary pressure at any given time and change that pressure as the needs of the patient change. Autotitration devices respond to different parameters and rely on different algorithm so they do not all operate the same.

The AutoSet® by ResMed acts by monitoring the patient's inspiratory flow-time curve. A flattening of the inspiratory flow-time curve typically precedes an upper airway obstruction, which causes apnea, hypopnea, or snoring. Monitoring and responding to the flow-time curve, reduces the number of respiratory events and arousals improving sleep quality.

Bi-level positive airway pressure is a variation of CPAP. Most of the problems patients experience with CPAP are caused by having to exhale against a high airway pressure. Because the air pressure required to prevent respiratory obstruction is typically less on expiration than on inspiration, bi-level positive airway pressure machines are designed to sense when the patient is inhaling and exhaling and to reduce the pressure to a preset level on exhalation. Bi-level positive airway pressure machines usually are used when the patient does not tolerate CPAP or when the patient has more than one respiratory disorder.

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