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Sleep Disorders

Sleep apnea

10/15/2007

Question:

This is a fantastic website. I have Sleep apnea - RDI 28. I have an A-PAP - but am not sure it functions the way it is should. 1-1/2 to 2 hours per night s all I can count on. My question: If CPAP/APAP does not allow you to get sleep, is there any help in any other direction? i.e., anything new in dealing with it? Thanks.

Answer:

Based on your question, I assume you have obstructive sleep apnea (OSA) being treated with an autoadjusting CPAP (ACPAP) device. However, it sounds as though you are having trouble with the ACPAP and thus are considering other treatment options. Which treatment is best for a given individual depends on a number of factors, including the severity of the sleep apnea, the patient’s size and airway anatomy, the patient’s co-morbid conditions and the patient’s willingness to accept a given treatment.

OSA is a condition where the airway partially or completely collapses during sleep. This results in fragmentation of sleep and, in some individuals, low oxygen level during sleep. The consequences of this condition can be serious and range from a poor quality of life (morning headaches, disabling sleepiness, poor concentration, irritability, etc) to increasing problems with blood pressure control, heart disease and strokes.

The primary treatment for OSA is the use of CPAP, which is very effective at keeping the airway open during sleep. It does this by “pressurizing” the airway to prevent it from collapsing. In a large number of well-done studies, CPAP therapy has been shown to be very effective at improving a number of measures of quality of life, including daytime alertness, improved concentration and improved mood. Individuals with OSA who can successfully use CPAP generally feel better! In addition, growing data suggest that CPAP may reduce some of the medical consequences associated with sleep apnea.

The main problem with CPAP is that many individuals, such as you, have trouble sleeping with this type of device and, as such, alternative therapies must be considered. However, before you consider alternative treatments, you should discuss this with your Sleep Specialist. Oftentimes, there are specific issues that need to be addressed (such as the interface or nasal congestion) in order for an individual to be able to effectively use CPAP. In other cases, sometimes a change to one of the newer types of devices (such as bilevel pressure support or an expiratory relief CPAP) can help improve tolerance of positive pressure therapy. I would make sure all these issues have been addressed before giving up on CPAP (or ACPAP) therapy.

Alternative treatments for OSA really fall into 2 main categories: oral appliances and surgery. Oral appliances generally work to advance the lower jaw, hoping to open space in the back of the throat. They tend to work best in individuals with more mild to moderate OSA and in those who may have a small or more posterior positioned jaw. Individuals who use oral appliances during sleep often tolerate them, though they can have some annoying side effects (jaw achiness, pain with chewing in the morning, headaches, drooling). In addition, if there is a history of temporomandibular joint (TMJ) disease, these devices should be used with great caution as they put considerable stress on the TMJ and can worsen problems.

For some individuals, surgery is a reasonable option. Surgery tends to be most effective in those with clear anatomic problems that are amenable to surgery (such as large tonsils, deviated septum), more mild to moderate sleep apnea and who are not obese. There are a variety of surgeries that can be considered, though they are generally tailored based upon an individual’s anatomy. A tracheotomy (surgical tube placed in the neck) is usually curative for OSA, but because it is somewhat disfiguring, is reserved for severe cases that fail other treatments. Other treatments that have been mentioned in the literature included weight loss for those who are overweight (in some cases, this can be curative), positional therapy (avoiding sleep on your back) and medications.

Unfortunately, aside from treatment to help alleviate nasal congestion, almost all medications hoped to significantly impact OSA have failed when well-studied. Primary medication treatment for OSA is not recommended at this time. There is extensive research looking into better and more effective ways to treat OSA. However, at present, none have been proven to be superior or better tolerated to those mentioned above.

To learn more about sleep apnea, sleepiness, or other sleep disorders, please visit the American Academy of Sleep Medicine website. In addition to information, the website contains a list of Sleep Centers across the country so that you may locate one near you. The website Sleep Education.com also contains plenty of consumer friendly information about sleep and sleep apnea. Good luck and here's to better sleep!

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Response by:

Dennis   Auckley, MD Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University