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Treatment options for sleep apnea

 

Lifestyle modifications

You can take some actions to improved your sleep apnea, improve your sleep quality, and feel more rested. Among these are changes in your lifestyle that could improve your airway patency. Weight loss (reducing BMI to 25), sleeping on your side, elimination of alcohol and certain medications are shown to improve your breathing at night by reducing sleep apnea events. There are other measures that could help you compensating for poor sleep quality. Developing healthy sleep habits is a great place to start. It is important to keep a regular sleep schedule and give yourself an adequate amount of time for sleep each night. Make your bedroom a relaxing environment by keeping it quiet, cool and dark. It is also important to limit naps and avoid heavy or large meals at least a couple hours before bed. Dietary changes can also help you sleep better. You should limit alcohol and caffeine intake, especially in the evening before bed. Eating the right foods and avoiding the wrong ones will not only improve your sleep but will also make your heart healthier. Things to add more of to your diet are fruits, vegetables, whole grains, fat-free or low-fat dairy, protein-rich foods, as well as oils and foods high in monosaturated and polyunsaturated fats. Things to avoid or limit in your diet are foods and beverages high in sodium, added sugars, saturated fats, and trans fats. Other healthy lifestyle choices that are beneficial include spending time outside, getting regular physical activity, losing weight(if your BMI is above 25), and quitting smoking.

Breathing Devices, CPAP and BiPAP

There are many breathing devices available to help patients with sleep apnea. CPAP (Continuous Positive Airway Pressure) and BiPAP (BiLevel Positive Airway Pressure) devices are the most studied and work by blowing air through the nose or mouth to keep the throat open. Invented by Dr. Colin Sollivan in 1980, these devices have improved significantly over the years. They have become quieter, more tolerable and very effective. Around 60-80% of patients are able to tolerate them and, when tolerated, they are effective more than 90% of the time.

CPAP is the most commonly recommended treatment for sleep apnea, producing almost the same pressure for inhalation and exhalation. BiPAP is typically used if carbon dioxide is elevated, BMI is greater than 35-40 or if CPAP can’t be tolerated. It produces different pressures for inhalation and exhalation. BiPAP-ST and Servo Ventilation(ASV) are more complex machines that are infrequently prescribed. These devices work by detecting the absence of breathing due to central sleep apnea and forcing mandatory breaths.

Dental Appliances, or Mandibular Advancing Devices

Dental devices can be used to help patients with snoring and sleep apnea. Mandibular advancement devices cover the upper and lower teeth, pulling the lower jaw forward and holding it there to prevent it from blocking the upper airway while helping to keep your throat open. The success rate for this device is around 60% for mild sleep apnea and less than 30% for severe sleep apnea. Another type of mouthpiece that can be used is a tongue retaining device (TRD), which holds the tongue in a forward position to keep it from blocking the upper airway. Usually you will need to see a dentist or orthodontist to ensure that these devices are fitted properly to your mouth and jaw. TRD devices may be available over the counter.

Implants, nerve stimulators:

These are recent technologies for treatment of sleep apnea. The most common one is called Inspire hypoglossal nerve stimulator. The device is surgically implanted, under the skin below the clavicle with the wiring placed next to the hypoglossal nerve. It is indicated for moderate and severe sleep apnea when CPAP fails. It senses the initiation of each breath and stimulates the hypoglossal nerve that goes to the tongue to pull it forward and open the throat. the success rate is around 70%.

Implants, the Pillar procedure

The Pillar procedure involves very small implants inserted by an ENT surgeon in the soft palate.

Surgical Options

If you have severe obstructive sleep apnea that does not respond to breathing devices, there are several surgical options that can help. Tonsillectomy is a surgery to remove the tonsils, the glands at the back of your throat, which is performed under general anesthesia. This is done when the tonsils are large enough to obstruct the upper airway. Another similar but more involved surgery, known as UPPP, is performed to remove the tonsils, uvula and part of the soft palate, all of which can obstruct the upper airway. Maxillomandibular jaw advancement is a surgery that involves moving the upper jaw(maxilla) and lower jaw(mandible) forward to enlarge the upper airway. There is also a maxillomandibular jaw expansion surgery involving widening the upper and lower jaw, which enlarges the nasal and retropalatal airway while stiffening the soft palate, creating more intraoral space. Endoscopically-Assisted Surgical Expansion (EASE) is the most current approach to this type of surgery and was developed by Dr. Kasey Li through years of modifications to the original procedure. This surgery is performed under sedation or general anesthesia in under an hour, requiring no hospitalization. It is achieved in a minimally-invasive  way, causing less trauma, pain and swelling than the tradition procedure. In rare cases of severe sleep apnea, when no other treatments have been successful, tracheostomy can be performed. A small hole is made in the windpipe and a tube is inserted which air flows through to the lungs, bypassing the obstruction in the upper airways.

Myofunctional Therapy

Myofunctional therapy is a form of physical therapy for the muscles of the mouth and face. It helps improve tongue positioning and strengthen muscles that control the lips, tongue, soft palate, lateral pharyngeal wall and face. Studies in children and adults have shown some benefits in reducing intensity of sleep apnea.

iNAP by Somnics

The iNAP is a vacuum-based therapy for sleep apnea that is developed by Somnics, Inc. This device creates a vacuum within the oral cavity that holds the tongue inside the mouth and prevents it from falling backward. While it is more discrete than a CPAP or other breathing machines, the efficacy of the device is less than 50%. The vacuum function, which creates negative pressure, is delivered inside the mouth through a pacifier shaped device. It is also powered by a small, pocket-sized console instead of a bulky machine. The iNAP system is now approved in the United States and is available for purchase.

 

Device Snoring Upper Airway Resistance Syndrome (UARS) Obstructive Sleep apnea Central Sleep Apnea Insurance coverages (most insurances)
CPAP May be May be Highly recommended May work Yes
BiPAP No No Yes No Yes
BiPAP-ST No No No Yes Yes
Servo Ventilation machines (ASV, Aircurve SV) No No No Yes Yes
Dental appliance, Mandibular Advancement Device Yes Yes Yes No Depends on the insurance
Tongue Retaining Devices (TRD) Yes Yes Yes No Most insurance do not cover
Pillar procedure Yes maybe maybe No Depends on the insurance
Inspire surgery Not approved Not approved Yes No Yes
Tongue exercises Yes Yes Yes no N/A
iNAP by Somnics Yes May be Yes No No
Surgery, tonsillectomy Yes Yes Yes No Yes
Surgery, UPPP or laser surgery Yes Yes Yes No Yes
Surgery, jaw advancement surgery or Maxillomandibular Advancement surgery No May be Yes No Yes
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