Sleep Apnea (cont.)
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.
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.
Auto-titrating continuous positive airway pressure
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.
Next: What are the surgical treatments for obstructive sleep apnea? »
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