Dr. Nabili received his undergraduate degree from the University of California, San Diego (UCSD), majoring in chemistry and biochemistry. He then completed his graduate degree at the University of California, Los Angeles (UCLA). His graduate training included a specialized fellowship in public health where his research focused on environmental health and health-care delivery and management.
Doctor Verneuil grew up in Orange County and played high school water polo. He attended UCLA for his undergraduate degree in Kinesiology. Doctor Verneuil graduated from Mayo Medical School. He completed six years of Internship and Residency training in head and neck surgery at UCLA. He is Board Certified with the American Board of Otolaryngology.
Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
What are the non-surgical treatments for obstructive sleep apnea?
The non-surgical treatments for obstructive sleep apnea are similar to the non-surgical
treatments for snoring with a few differences. Treatments include:
behavioral changes,
dental appliances,
CPAP (continuous positive airway pressure), and
medication.
Behavioral changes
Behavioral changes are the simplest treatments for mild obstructive sleep
apnea, but often the
hardest to make. Occasionally, apneas occur only in some positions (most
commonly lying flat on the back). A person can change his or her sleeping position,
reduce apneas, and improve their sleep.
Obesity is a known contributing factor to obstructive sleep apnea.
It is estimated that a 10% weight gain will worsen the apnea-hypopnea index by 30%, and a 10%
weight loss will
decrease the apnea-hypopnea index by 25%. Therefore, a healthy lifestyle and
diet that encourages weight loss will improve obstructive sleep apnea.
Unfortunately, most people with obstructive sleep apnea are tired and do not have much energy for exercise. This is
a difficult behavioral spiral since the more tired a person is -- the less they
exercise -- the more weight they gain -- the worse the obstructive sleep apnea becomes
-- and the more
tired they become. Frequently, after obstructive sleep apnea is treated by other methods people are
able to lose weight and the obstructive sleep apnea may improve.
Sleep hygiene and other behavioral modifications known to improve the overall
quality of sleep are also recommended. Below are some common practices that can
induce sleep and enhance its quality:
reduce lighting and noise in the bedroom;
avoid reading or watching TV in bed;
avoid eating or exercising prior to sleep;
use the bedroom only for sleeping;
keep work related activities outside of the bedroom; and
try a period of physical and mental relaxation before going to bed.
Medication
Many medications have been studied for obstructive sleep apnea; however,
because obstructive sleep apnea is due to an anatomic airway narrowing it has been difficult to find a medication that
helps.
In people
with nasal airway obstruction causing obstructive sleep apnea, nasal steroid sprays
have been shown to be effective. In one study, the respiratory disturbance index
(RDI) decreased from 20 to 11
with nasal sprays.
Topical nasal decongestants such as oxymetazoline and neosynephrine, also can temporarily improve nasal swelling.
The problem is that they cannot be used for more than 3-5 days without decreased
effectiveness and withdrawal symptoms.
People who have obstructive sleep apnea due to
hypothyroidism (low thyroid hormone production) improve with thyroid
replacement therapy. However, people with normal thyroid function, will not improve with
this therapy.
People who have obstructive sleep apnea due to obesity may improve with diet
medications if they are effective in assisting with weight loss.
Other
medications have been studied, including
medroxyprogesterone (Provera,
Cycrin, Amen), acetazolamide (Diamox) ,
theophylline (Theo-Dur,
Respbid, Slo-Bid, Theo-24, Theolair, Uniphyl, Slo-Phyllin),
tricyclic antidepressants, and selective serotonin reuptake inhibitors (SSRIs). In these
studies, they were shown to have little or no effect. There are also new
medications to help increase alertness. They may be temporarily successful in
increasing attention; however, they do not treat the
sleep deprivation or the cause of obstructive sleep apnea.
In cases where sleep apnea may be caused by another underlying condition, appropriate treatment of such conditions is recommended and may be beneficial. For example, treating underlying heart failure may improve sleep apnea if it is a contributing factor. In people with
sinusitis and
nasal congestion, the swelling and inflammation of the upper airway passages can cause snoring and sleep apnea. Therefore, medications to treat underlying sinusitis and congestion can potentially improve sleep apnea in these individuals.
Medications are also available that could increase daytime wakefulness in people who suffer from
sleep apnea. These medications stimulate the brain through an unknown mechanism of action. The prototypical drug in this class is called modafinil (Provigil). Studies have revealed greater resolution of daytime sleepiness when using modafinil in patients with sleep apnea. A similar, newer drug in this class, called
armodafinil (Nuvigil), has a longer half-life and is also approved by the FDA for the treatment of excessive daytime sleepiness in people with sleep apnea. Armodafinil has shown similar clinical results in significantly improving daytime quality of life and functioning. It is important to note that the primary treatment for obstructive sleep apnea (OSA) remains CPAP (described below). Stimulants, such as
modafinil (Provigil) and armodafinil, are recommended for those who have excessive daytime sleepiness despite proper CPAP use at night. They are not meant to replace CPAP use, but rather, as an adjunctive therapy to CPAP in those who have daytime symptoms even with CPAP use. Approximately one third of people who use CPAP at night for sleep apnea may continue to have somnolence during the day. This is the population that could benefit from using modafinil
(Provigil) or armodafinil (Nuvigil).
Dental appliances
A dental appliance holds the jaw and tongue forward and
the palate up, thus preventing closure of the airway. This small increase
in airway size often is enough to control the apneas.
Dental appliances are an
excellent treatment for mild to moderate obstructive sleep apnea. It is reported
to be about 75% effective for these groups. A dental appliance does not require
surgery; it is small, portable, and
does not require a machine. However, there are some disadvantages to the dental
appliance. It can cause or worsen temporomandibular joint (TMJ) dysfunction. If the jaw is pulled too far forward, it can cause pain
in the joint when eating.
For this reason, it is best to have a dentist or oral surgeon fit and adjust the
appliance. A dental appliance requires natural teeth to fit properly, it must be
worn every night, and the cost is variable, as is insurance coverage.
Continuous positive airway pressure (CPAP)
Continuous positive airway pressure (CPAP) is probably the best, non-surgical
treatment for any level of obstructive sleep apnea. In finding a treatment for
obstructive sleep apnea, the primary goal
is to hold the airway open so it does not collapse during sleep. The dental
appliances and surgeries (described later) focus on moving the tissues of the
airway. CPAP uses air pressure to hold the tissues open during sleep.
CPAP was
first used in Australia by Dr. Colin Sullivan in 1981 for obstructive sleep
apnea. It delivers the
air through a nasal or face-mask under pressure. As a person breathes, the
gentle pressure holds the nose, palate, and throat tissues open. It feels
similar to holding your head outside the window of a moving car. You can feel the pressure,
but you can also breathe easily.
The CPAP machine blows heated, humidified air
through a short tube to a mask. The mask must be worn snugly to prevent the
leakage of air. There are many different masks, including nasal pillows, nasal
masks, and full-face masks. The CPAP machine is a little larger than a toaster.
It is portable and can be taken on trips.
Determining CPAP pressure: With CPAP it is important to use the lowest
possible pressure that will keep the airway open during sleep. This pressure is
determined by "titration." Titration frequently is performed with the help of
polysomnography. It can be performed during the same night as the initial
polysomnography or on a separate night. In the sleep laboratory an adjustable
CPAP machine is used. A mask is fit to the person and he or she is allowed to
fall back asleep.
During baseline sleep the apneas and hypopneas occur, and the the
technician then slowly increases the CPAP pressure until the apneas and
hypopneas stop or decrease to a normal level. A different pressure may be needed
for different positions or levels of sleep. Typically, laying on the back and
REM sleep promote the worst obstructive sleep apnea. The lowest pressure that controls
obstructive sleep apnea in all
positions and sleep levels is prescribed.
Effectiveness of CPAP: CPAP has been shown to be effective in improving
subjective and objective measures of obstructive sleep apnea.
It decreases apneas and hypopneas.
It decreases sleepiness as measured by surveys and
objective tests.
It improves cognitive
functioning on tests.
It improves driving on driving
simulation tests and decreases the number of accidents in the real world.
When adjusted properly and tolerated, it is nearly 100% effective in
eliminating or reducing obstructive sleep apnea.
An important clinical outcome of CPAP use is in the area of prevention of the potential complications of obstructive sleep apnea. Studies have shown that the proper use of CPAP reduces hospitalization for cardiac and pulmonary causes in people with obstructive sleep apnea. More generally, treating obstructive sleep apnea with CPAP can reduce the risks of conditions related to
obstructive sleep apnea, such as, ischemic heart disease, abnormal heart rhythms, stroke, hypertension, and insulin dependence.
Problems with CPAP: The first 2-4 weeks is the crucial time to
become a successful CPAP user. During this time, it is important to try to sleep
as many hours a night as possible with the mask on. If the mask does not fit
properly or the machine is not working it is important to have it fixed
immediately. It is also helpful to remember all of the increased risks of
untreated obstructive sleep apnea (decreased productivity, heart attacks, strokes, car accidents,
and sudden death) as an incentive to continue using CPAP.
People with severe obstructive sleep apnea,
never get a normal night of sleep. They often put on the CPAP mask and think it
is the best thing ever. They quickly get used to it because it allows them to
sleep. They take it on vacations because without it they have no energy and are
always sleepy.
However, CPAP is not always easy to use. People with only mild to moderate
sleep apnea often have a harder time using CPAP. About 60% of people with CPAP
machines report that they use them, but only 45% of them actually use them more
than four
hours per night when the actual use time is measured. Between 25% and 50% of people
who start using CPAP, stop using it.
It is not easy to sleep with a mask that is blowing air into your nose. Some people are claustrophobic and have difficulty getting used to any mask. If a patient has nasal congestion or a septal deviation; it is important to have these evaluated since they can be treated (as discussed later). Some people do not like the inconvenience of sleeping with the mask or traveling with the machine. Others do not like the image of having to sleep with a mask. The noise of the machine blowing air can also be bothersome to some people using the CPAP or their bed partners.
Bi-level positive airway pressure (BiPAP)
Bi-level positive airway pressure (BiPAP) was designed for people who do not
tolerate the higher pressures of CPAP. It is similar to CPAP in that a machine
delivers a positive pressure to a mask during sleep. However, the BiPAP machine
delivers a higher pressure during inspiration, and a lower pressure during
expiration, which allows the person not to feel like they are breathing out against
such a high pressure, which can be bothersome. It is most helpful for people who
require a higher pressure to keep their airway open. BiPAP was designed to
improve CPAP compliance; however it is difficult to measure an increase in
compliance when compared to standard CPAP. BiPAP is often only approved by
insurance companies after documentation that a patient cannot tolerate CPAP.
The auto-titrating CPAP
machine is a "smart" CPAP machine that makes pressure adjustments throughout the
night. As discussed above, different pressures are needed for different levels
of sleep and positions. The goal of auto-titrating CPAP is to have the lowest
possible pressure for each position or sleep level. At a given pressure, if a
person starts to have an apnea or hypopnea, the machine adjusts the pressure
higher until the episodes are controlled. If a person is in a sleep level or
position that doesn't need a higher pressure, the pressure is reduced. The
benefit is when a lower pressure is all that is required, the machine is not
stuck at the highest pressure needed. The down side is, if the machine does not
adjust, a person can be stuck at a lower pressure having episodes of sleep apnea.
With auto-titrating CPAP, the mean pressure throughout the night is lower
and 2/3 of the night is spent below the set CPAP pressure. The machine also can
adjust for the changes in pressure that are needed to overcome the effects of
weight gain and alcohol or sedative use. It may also improve compliance;
however, this has not been measured. The disadvantages of auto-titrating CPAP
are that leaks may underestimate pressure or airflow. Each company has a
different algorithm for adjusting the pressure and adjusting for leaks. It is
unclear which company has the best algorithm, but studies are on-going.
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. A poor blood supply resulting from congestive heart failure may cause the body's organ systems to fail, leading to a weakened heart muscle and fluid accumulation in the lungs and body tissue. There are many diseases that can impair pumping efficiency and symptoms of congestive heart failure including fatigue, diminished exercise capacity, shortness of breath, and swelling. Treatments include lifestyle modifications, medications, heart transplant, and therapy.
High blood pressure, also known as hypertension, is a repeatedly
elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above
140 with a diastolic pressure above 90. There are two causes of high blood pressure, primary and secondary. Primary high blood pressure is much more common that secondary and its basic causes or underlying defects are not always known. It is known that a diet high in salt increases the risk for high blood pressure, as well as high cholesterol. Genetic factors are also a primary cause. Secondary high blood pressure is generally caused by another condition such as renal hypertension, tumors, and other conditions. Treatment for high blood pressure is generally lifestyle changes and if necessary, diet.
Sinus infection (sinusitis) signs and symptoms include headache, fever, and facial tenderness, pressure, or pain. Treatments of sinus infections are generally with antibiotics and at times, home remedies.
Hypothyroidism is any state in which thyroid hormone production is below normal. Normally, the
rate of thyroid hormone production is controlled by the brain at the pituitary.
Hypothyroidism is a very common condition and the symptoms of hypothyroidism are
often subtle.
A stroke results from impaired oxygen delivery to brain cells via the bloodstream. A stroke is also referred to as a CVA, or cerebrovascular incident. Symptoms of stroke include: sudden numbness or weakness of the face, arm or leg. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing in one or both eyes, sudden trouble walking, dizziness, or loss of balance, and/or sudden severe headache with no known cause. A TIA, or transient ischemic attack is a short-lived temporary impairment of the brain caused by loss of blood supply. Stroke is a medical emergency.
Heart attack happens when a blood clot completely obstructs a coronary
artery supplying blood to the heart muscle. A heart attack can cause chest pain, heart failure, and electrical
instability of the heart.
Temporomandibular joint disorder, or TMJ, is a disorder of the temporomandibular joint(s) that causes signs and symptoms including ear pain, bite problems, headaches, dizziness, clicking sounds in the jaw, tinnitus and/or locked jaws. Behaviors or conditions that can lead to TMJ include teeth grinding or clenching, fingernail biting, habitual gum chewing, trauma to the jaw, stress, and occupational hazards. Treatment for TMJ may include heat, ice, a soft diet, antiinflammatory medications, physical therapy, stress management, occlusal therapy, correction of bite abnormalities, and surgery.
Polycythemia (elevated red blood cell count) causes are either primary (aquired or genetic mutations) or secondary (diseases, conditions, high altitude). Treatment of polycythemia depends on the cause.
Insulin resistance is the diminished ability of cells to respond to the action of insulin in transporting glucose (sugar) from the bloodstream into muscle and other tissues. Causes of insulin can include conditions such as stress, obesity, metabolic syndrome, and steroid use. Some of the risk factors for insulin resistance include fatty liver, heart disease, strokes, peripheral vascular disease, high cholesterol, and smoking. Treatment for insulin resistance are lifestyle changes and if necessary, medication.
It is thought that the tonsils and adenoids assist the body in fighting incoming bacteria and viruses by helping the body form antibodies. This is thought to be important only during the first year of life. Acute tonsillitis, strep throat, mononucleosis (mono), chronic tonsillitis, peritonsillar abscess, and hypertrophic tonsils and adenoids are all common problems involving the tonsils and adenoids. Treatment of tonsillitis and adenoids include antibiotics and other medications depending on the cause. In some cases, a tonsillectomy or adenoidectomy (the removal of the tonsils or adenoids) may be necessary.
Marfan syndrome is hereditary condition affecting connective tissue. A person with Marfan syndrome may exhibit the following symptoms and characteristics: dislocation of one or both lenses of the eye; a protruding or indented breastbone; scoliosis; flat feet; aortic dilatation; dural ectasia; stretch marks; hernia; and lung collapse. Though there is no cure for Marfan syndrome, there are treatments that can minimize and sometimes prevent some complications.
Heart rhythm disorders vary from minor palpitations, premature atrial contractions (PACs), premature ventricular contractions (PVCs), sinus tachycardia, and sinus brachycardia, to abnormal heart rhythms such as tachycardia, ventricular fibrillation, ventricular flutter, atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), Wolf-White-Parkinson syndrome, brachycardia, or heart blocks. Treatment is dependant upon the type of heart rhythm disorder.
Heart disease (coronary artery disease) is caused by a buildup of cholesterol deposits in the coronary arteries. Risk factors for heart disease include smoking, high blood pressure, heredity, diabetes, peripheral artery disease, and obesity. Symptoms include chest pain and shortness of breath. There are a variety of tests used to diagnose coronary artery disease. Treatment includes life-style changes, medications, procedures, or surgery.
Pulmonary hypertension is an abnormal elevation of the pressure in the pulmonary circulation caused by the constriction of the blood vessels that supply blood to the lungs. Shortness of breath and dizziness are symptoms of pulmonary hypertension. Treatment involves diuretics, blood thinners, calcium channel blockers, and using supplemental oxygen to increase blood oxygen levels.
Snoring, like all other sounds, is caused by vibrations that cause particles in the air to form sound waves. While we are asleep, turbulent air flow can cause the tissues of the nose and throat to vibrate and give rise to snoring. Any person can snore. Snoring is believed to occur in anywhere from 30% of women to over 45% of men. People who snore can have any body type. In general, as people get older and as they gain weight, snoring will worsen. Snoring can be caused by a number of things, including the sleep position, alcohol, medication, anatomical structure of the mouth and throat, stage of sleep, and mouth breathing.
Obesity is the state of being well above one's normal weight. A person has traditionally been
considered to be obese if they are more than 20 percent over their ideal weight.
That ideal weight must take into account the person's height, age, sex, and
build.
High blood pressure (hypertension) means high pressure (tension) in the arteries. Treatment for high blood pressure include lifestyle modifications (alcohol, smoking, coffee, salt, diet, exercise), drugs and medications such as ACE inhibitors, angiotensin receptor blockers, beta blockers, diuretics, calcium channel blockers (CCBs), alpha blockers, clonidine, minoxidil, and Exforge.
Insomnia is the perception or complaint of inadequate or poor-quality sleep because of difficulty falling asleep; waking up frequently during the night with difficulty returning to sleep; waking up too early in the morning; or unrefreshing sleep. Secondary insomnia is the most common type of insomnia. Treatment for insomnia include lifestyle changes, cognitive behavioral therapy, and medication.
Fatigue can be described in various ways. Sometimes fatigue is described as feeling a lack of energy and motivation (both mental and physical). The causes of fatigue are generally related to a variety of conditions or diseases for example, anemia, mono, medications, sleep problems, cancer, anxiety, heart disease, drug abuse, and more. Treatment of fatigue is generally directed toward the condition or disease that is causing the fatigue.
Sudden cardiac arrest is an unexpected, sudden death caused by sudden cardiac arrest (loss of heart function). Causes and risk factors of sudden cardiac arrest include (not inclusive): abnormal heart rhythms (arrhythmias), previous heart attack, coronary artery disease, smoking, high cholesterol, Wolff-Parkinson-White Syndrome, ventricular tachycardia or ventricular fibrillation after a heart attack, congenital heart defects, history of fainting, and heart failure, obesity, diabetes, and drug abuse. Treatment of sudden cardiac arrest is an emergency, and action must be taken immediately.
Narcolepsy, a chronic disease of the central nervous system causes have not been fully determined. Some theories include abnormalities in hypocretin neurons in the brain or an autoimmune disorder. Symptoms of narcolepsy include excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, sleep paralysis, disturbed nocturnal sleep, and automatic behavior. Diagnosis of narcolepsy is based on a clinical evaluation, specific questionnaires, sleep logs or diaries, and the results of sleep laboratory tests. Treatments of narcolepsy symptoms include medication and lifestyle changes.
Seizures are divided into two categories: generalized and partial. Generalized seizures are produced by electrical impulses from throughout the brain, while partial seizures are produced by electrical impulses in a small part of the brain. Seizure symptoms include unconsciousness, convulsions, and muscle rigidity.
Sleepwalking is a condition in which an individual walks or does other activities while asleep. Factors associated with sleepwalking include genetic, environmental, and physiological. Episodes of sleepwalking may include quiet walking to agitated running. Conditions that may have similar symptoms of sleepwalking, but are not include night terrors, confusional arousals, and nocturnal seizures. Treatment of sleepwalking generally include preventative measures. Medication may be prescribed if necessary.
A deviate septum is a condition in which the bone and cartilage that divide the nasal cavity of the nose in half (nasal septum) is significantly off center or crooked. The causes of a deviated septum can be congenital, or develop after a trauma or injury to the nose. Symptoms of a deviated septum include nasal congestion, recurrent sinus infections, nosebleeds, headache, facial pain, postnasal drip, snoring, and loud breathing. A deviated septum can be relieved with medications, and if necessary surgery, called a septoplasty.
Heart failure is caused by many conditions including coronary artery disease, heart attack, cardiomyopathy, and conditions that overwork the heart. Symptoms of heart failure include congested lungs, fluid and water retention, dizziness, fatigue and weakness, and rapid or irregular heartbeats.
Urinary incontinence in children (enuresis) is twice as common in boys as in girls and may occur during the daytime or nighttime. Nighttime urinary incontinence is also called bedwetting and sleepwetting. The cause of nighttime incontinence in children is unknown. Daytime incontinence in children may be caused by an overactive bladder. Though many children overcome urinary incontinence naturally, it may be necessary to treat incontinence with medications, bladder training and moisture alarms, which wake the child when he or she begins to urinate.
Hypersomnia is a condition where a person has excessive daytime sleepiness and trouble staying awake during the day. Treatment for hypersomnia includes medication, CPAP machines, and lifestyle changes.
When sleepiness interferes with daily routines and activities, or reduces the ability to function, it is called "problem sleepiness." A person can have problem sleepiness without realizing it. Symptoms of problem sleepiness include: consistently don't get enough sleep, or poor quality sleep, fall asleep while driving, struggle to stay awake when inactive (like watching TV or reading), have difficulty paying attention or concentrating at work, school, or home, have poor performance problems at work or school, have difficulty remembering things, have slowed responses, have difficulty controlling your emotions, and/or if you have to take naps on most days.
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