Sleep Apnea & Snoring Treatment FAQs

Who should be screened for sleep apnea?

Ideally, everyone.  Sleep apnea affects men, women, and children of all sizes.  At minimum, patients suffering from disorders co-morbid with sleep apnea should be screened.

Common co-morbidities include:

  • Hypertension
  • Obesity
  • Diabetes
  • Congestive Heart Failure
  • Atrial Fibrillation
  • Coronary Artery Disease
  • Angina

What are common indicators of sleep apnea?

  • Loud Snoring
  • Witnessed Apneas
  • Excessive Daytime Sleepiness
  • Obesity
  • Neck size >17″ male >16″ female
  • Morning Headaches
  • Nocturia

Selected Studies & Conclusions:

Studies:

Studies from 1999 & Earlier

RESEARCH SUMMARY

The following presentation is a review of pertinent literature, from a variety of sources, on the subject of snoring and sleep apnea.  It is intended to summarize the papers for the benefit of the reader. Most of the text of this presentation are direct quotes from the articles, however in the interests of brevity some editing has been done.  There has been no change in the assumptions or conclusions of the authors.

PART I – GENERAL INFORMATION ON SLEEP APNEA AND SNORING

Ref. 1:

USA Department of Health and Human Services

NIH Publication September 1995

Sleep Apnea is a serious, potentially life threatening condition that is far more common than generally understood.  First described in 1965, sleep apnea is a breathing disorder characterized by brief interruptions of breathing during sleep.  It owes its name to a Greek word, apnea, meaning “want of breath”.

Ref. 2:

Snoring: Not Funny, not hopeless

Patient Info AA0-HNS – Inc.1997

Forty five percent of normal adults snore at least occasionally, and 25 percent are habitual snorers.  Problem snoring is more frequent in males and overweight persons and it usually grows worse with age.

Ref.3:

Respiratory Care Clinics of North America

The term sleep disordered breathing has been  used synonymously with the term obstructive sleep apnea syndrome (OSAS).  In a broader sense, the disorders of breathing during sleep exist along a spectrum of severity.  The mildest form of sleep related breathing disorder is intermittent snoring, which is primarily a nuisance without significant health sequellae.

The most severe form of disordered breathing is the obesity-hypoventilation syndrome, which associated with severe morbidity and very high mortality.  In between these two extremes are disorders of gradually increasing impact on morbidity and mortality: persistent snoring, upper airway resistance syndrome, and OSAS.

Ref. 4:

Sleep Research Online 2 (1):11-14, 1999

Snoring in the Singapore Population

Snoring is a common finding in any population.  It is possible that a person can progress from asymptomatic snoring to a full-blown obstructive sleep apnea syndrome (Lugbarse it al, 1983).  Asymptomatic snoring itself should be considered a potential medical problem because it is a risk factor for developing hypertension, ischemic heart disease and stroke.  (Koskenmuo et al, 1987).

Ref. 5:

The evolution of sleep apnea syndrome in sleep snorers.

Am Journal of Respiratory and Critical Care Medicine 1999 Jun: 159(6):2024-7

We conclude that, among this group of individuals who were selected for original polysomnographic study and follow-up because they were thought to have symptoms of sleep apnea, sleep disordered breathing became significantly worse over time.

Ref. 6:

DECISION MAKING IN OBSTRUCTIVE SLEEP DISORDERED BREATHING

Clinics in Chest Medicine – Vol 19 NO 1 March 1998

Obstructive sleep disordered breathing (OSDB) is a relatively common medical problem.  It consists of a spectrum ranging from apnea to hypopnea to the upper airway resistance syndrome (UARS).  Obstructive apnea refers to the temporary cessation of airflow during sleep for 10 seconds or more despite continuing ventilatory effort, whereas hypopnea means reduction of 30% to 50% in airflow for 10 seconds or more.  The two findings often overlap each other in the same patient.  On the other hand, UARS is characterized by frequent arousals in response to increased respiratory effort as a result of upper airway narrowing, without overt apnea or hypopnea.  Patients with UARS are usually heavy snorers.

Ref. 7:

Prevalence of sleep disordered breathing (SDB) and sleep apnea syndrome (SAS) in a population of 50 to 70 years.

Division of Respiratory Medicine, Hospital General de Galicia, Santiago de Compostela, Spain.

n  The prevalence of SDB (apnea/hypopnea index of greater than 5) was 28.9%.  There was no difference between males and females.

n  The prevalence of SAS was 6.8%, there was no difference between males and females.

n  Subjects in the SDB group had higher systolic blood pressure than in the non-SDB group.

Ref. 8:

The Occurrence of sleep disordered breathing among middle aged adults (30-60).

New England Journal of Medicine – April 29, 1993-Vol.328, No 17

Conclusions: The prevalence of undiagnosed sleep-disordered breathing is high among men and is much higher than previously suspected among women.  Undiagnosed sleep-disordered breathing is associated with daytime hyper-somnolence.

n  There is a wide spectrum of undiagnosed SDB among adults ranging from a few episodes of apnea or hypopnea during sleep to 89 abnormal breathing events per hour of sleep.

n  24% of men and 9% of women show a prevalence for undiagnosed SDB, as indicated by five or more episodes of apnea or hypopnea per hour of sleep.

n  4% of men and 2% of women in the middle-aged work force are likely to meet minimal diagnostic criteria for SAS

Ref. 9:

Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women.

Young T – Sleep -1997 Sep:20(9):705-6

n  93% of women and 82% of men with moderate to severe SAS have not been clinically diagnosed.

The proportion of sleep apnea syndrome (SAS) in the general adult population that goes undiagnosed was estimated from a sample of 4,925 employed adults.  Questionnaire data on doctor-diagnosed sleep apnea were followed up to ascertain the prevalence of undiagnosed sleep apnea.  In-laboratory polysomnography on a subset of 1,090 participants was used to estimate screen-detected sleep apnea.  In this population, without obvious barriers to health care for sleep disorders, we estimate that 93% of women and 82% of men with moderate to severe SAS have not been clinically diagnosed.  These findings provide a baseline for assessing health care resource needs for sleep apnea.

Ref. 10:

Obstructive sleep apnea patients have increased relative risk of co-morbidity prior to apnea diagnosis.

APSS Abstracts – 1997

n  OSAS patients had greatly increased risk of having been diagnosed with mental, cardiovascular, neurologic and respiratory diseases in the five years before apnea diagnosis.

n  “Symptoms, signs and ill-defined conditions” was 23 times more common for OSAS patients than controls.

Ref. 11:
Obstructive sleep apnea patients use more health care resources ten years prior to diagnosis.

Krieger et al – Sleep research on line 1(1):71-74, 1998

n  Sleep apnea patients use health care resources at approximately twice the rate of controls as far back as 10 years before their diagnosis.

n  This study likely underestimates the cost differences because it does not take into account costs associated with medications, home care, out patient visits, most hospital laboratory tests or sessional fees covered under global hospital budgets.

n  OSAS remains under diagnosed and under treated, patients continue to be both ill and financially burdensome on governments and health care providers.

n  One possible reason that sleep apnea is under-diagnosed (Ohayon et al, 1997) is that the amount of time allotted to teaching in medical schools about sleep disorders is minimal and so most practitioners have had little or no training in this area.

Ref. 12:

Population statistics:  USA Department of Commerce – Census Canada

n  USA Department of Commerce 1994:

  • Age 30 – 60           104,642,748
  • Age over 30          147,882,751
  • Male                        70,983,720
  • Female                     76,899,070

n  Census Canada 1996:

  • Age over 30          17,717,000
  • Male                         8,681,330
  • Female                      9,035,670

n  Domestic market USA and Canada:

  • Total market          165,599,750
  • Male                      79,665,050
  • Female                   85,934,700

Ref. 13:

Coronary artery disease associated with sleep apnea syndrome.

APSS Abstracts – 1997

n  44% of patients with Coronary Artery disease also exhibited sleep apnea syndrome.

n  The study suggests that sleep apnea and nocturnal breathing disorders may influence the progression of coronary artery disease.

Ref. 14:

Cardiovascular Implications of Sleep Apnea

Journal of Respiratory Care Practitioner (60RT Feb/March 1999)

University of Cincinnati

n  Over 50% of the Congestive Heart Failure population of the United States (4 million) have sleep disordered Breathing.

n  Patients with congestive heart failure spend 20% of their total sleep time (TST) with oxygen saturation below 90%, as compared to non-apneic patients who spend less than 1% of the TST below 90%

n  These respiratory events result in increased morbidity and perhaps mortality for congestive heart failure patients.

n  The more severe the congestive heart failure the more likely the patient is to develop sleep apnea

n  The conditions of sleep apnea and congestive heart failure are interdependent:

n  If you have sleep apnea the congestive heart failure risk is up

n  If you have congestive heart failure unrelated to a pre-existing sleep apnea condition the patient is doubly at risk to develop sleep apnea in addition to congestive heart failure.

Conclusion:

n  All congestive heart failure patients need to be in treatment for sleep apnea.

n  The more severe the congestive heart failure the more likely the patient is to develop sleep apnea

n  These conclusions hold true for both congestive heart failure and atrial fibrillation patients.

Ref. 15:

Otolaryngology for the Internist:
Medical Clinics of North America Vol 83 – No 1 January 1999

Snoring is a common condition affecting up to 60% of the adult population with significant physical and social consequences.  Nearly all patients with obstructive sleep apnea (OSA) snore, and a significant number of patients who snore may suffer from OSA.

n  The prevalence of OSA syndrome in commercial truck drivers has been reported to be as high as 46%

n  The National commission of Sleep disorders Research estimated that 18 million Americans suffer from OSAS syndrome

n  OSA syndrome is now considered to be a major public health concern.

n  In patients with an apnea index greater than 20, the cumulative 8-year mortality of untreated OSA was 37% compared to 4% for those with an index at or below 20.

n  OSA may be responsible for 38,000 cardiovascular deaths per year and the cost of OSA is approximately $42 Million annually from hospitalizations alone.

n  95% of OSA patients may be undiagnosed.

Ref. 16:

Spousal arousal syndrome: the response of sleep partners to treatment of SAS.
APSS Abstracts – 1997

CPAP treatment of the sleep partner had the following effects on the Arousal Index (ARI) of the partner:

n  Prior to treatment of the sleep partner ARI = 28.

n  After treatment ARI = 14

n  Sleep efficiency in the bed partner increased from 72 to 85

n  A reduction in the frequency of nocturnal arousals and increased sleep efficiency would have substantial benefit for the bed partners of snorers with OSA.

Ref. 17:

Snoring and sleep apnea in the Singapore population.

Sleep Research Online 2(1):11-14, 1999

n  Snoring is to be taken as a serious public health hazard.  Its greater morbidity is through its associations with OSA.

n  24.09% of the Singapore people suffer from loud habitual snoring affecting men and women.

n  In a survey of married couples, 86% of husbands and 57% of wives were habitual snorers.

n  87.5% of loud habitual snorers have an Apnea index of greater than 5

n  72% complained of excess daytime sleepiness.

n  Most published data on OSA is from the Caucasian population.  The prevalence is higher in African Americans and in Hispanics and minorities living in the United States.

n  The Singapore study indicates are higher degree of prevalence in the Chinese population.  This population needs further study of the anthropomorphic variables such as body mass index, waist and neck circumference and cephalometrics.

Ref. 18:

Why apnea should be diagnoses and treated:
Clinics in Chest Medicine Vol 19- No. 1- March 1998 – Meyer Kryger MD

n  OSA is associated with and can aggravate many medical illnesses, it is associated with :

  • Systemic hypertension
  • pulmonary hypertension
  • cardiac arrhythmia
  • ischemic heart disease
  • stroke
  • OSA patients with an apnea index of more than 20 have increased mortality.

Ref.19:

A 10 year follow up of snoring in men. (Sweden)

Chest Vol. 114 – No-4-Ocotber 1998

n  Only 30 years ago snoring was still regarded as a social nuisance that was harmless to the sleeper.

n  The recognition of obstructive sleep apnea syndrome (OSAS) during the 1970’s markedly increased interest in snoring as the most frequent complaint in patients with OSAS.

n  Even in the absence of apneas, snoring has been found to be highly associated with excessive daytime sleepiness, subjective work performance problems and morning headache.

n  The treatment of non apneic snorers by surgery has been reported to result in a significant decrease in daytime sleepiness

n  Snoring cannot be regarded as merely a nuisance.

n  Snoring is more pronounced during slow wave sleep, while apneas prevail during light sleep stages and rapid eye movement sleep.  The proportion of nocturnal sleep spent in slow wave sleep decreases with age, this might contribute to the decline in snoring prevalence seen at higher ages.

Ref. 20:

Evolution of sleep apnea syndrome in sleepy snorers:

American  Journal of  Respiratory and Critical  Care Medicine 1999 Jun: 159(6):2024-7

We conclude that, among this small group of individuals who were selected for original polysomnographic study and follow-up because they were thought to have symptoms of sleep apnea, sleep disordered breathing became significantly worse over time.

PART II – THERAPY – COMPARATIVE RESEARCH SUMMARY:

Treatment options for sleep apnea and snoring range from general health and home remedies such as weight loss, use of pillows, nasal sprays, nasal strips (BreathRite), to electronic detectors worn on the wrist to provoke arousal of the snorer when the snoring noise is picked up by the sensors.  The great interest in finding a solution to snoring has spawned a proliferation of such remedies.

The medical answers to these problems has been focused in primarily three areas:

1.                  Continuous Positive Air Pressure (CPAP), is the most common effective treatment for sleep apnea.  In this procedure, the patient wears a mask over the nose during sleep, and pressure from an air blower forces air through the nasal passages.  The air pressure is adjusted (titrated) so that it is just enough to prevent the throat from collapsing during sleep  The pressure is constant and continuous.

2.                  Surgery:  treatment aimed at surgically altering the size of airway or removal of the soft palate and uvula to eliminate the noisemakers.

n  The earliest surgical approach was a conventional scalpel surgery to remove the tissues in a hospital procedure known as the Uvulopalatopharygeoplasty (UPPP).

n  With the development of the use of lasers for surgery, this procedure when done with a laser became an outpatient procedure and known as a Laser Assisted Uvulopalatoplasty (LAUP). is a surgical procedure that involves partial resection of the uvula and soft palate using a laser.  This is done to eliminate snoring but has not been shown to be effective in treating sleep apnea.

3.         Dental Appliance Therapy: treatment conducted using intra oral dental devices to reposition the lower jaw or move the tongue forward and out of the airway.

The following research articles address the procedures themselves and also compare the efficacy and compliance of the medical treatment alternatives.

1.  CONTINUOUS POSITIVE AIR PRESSURE (CPAP)

Ref. 21:

Reversal of obstructive sleep apnea by continuous positive airway pressure applied through the nares

Sullivan CE – :Lancet – 1981 Apr 18;1(8225): 862-5

Low levels of pressure completely prevented upper airway occlusion during sleep in each patient and allowed an entire night of uninterrupted sleep.  Continuous positive airway pressure appliance in this manner provides a pneumatic splint for the nasopharyngeal airway and is a safe, simple treatment for the obstructive apnoea syndrome.

Ref. 22:

Pathophysiology and Pathogenesis of Snoring:

Chest 1996;109:201-222

Victor Hoffstein PhD, MD

N-CPAP – Application of continuous positive airway pressure (CPAP via nasal mask revolutionized medical treatment of sleep apnea.  This ingeniously simple pneumatic splint, used to treat the vast majority of patients with sleep apnea abolishes snoring and sleep apnea.

However non apneic snorers are reluctant to accept the CPAP system, use it inconsistently, tolerate it very poorly and eventually abandon it. Raucher et al offered it to 59 nonapneic snorers, all of whom complained of excessive daytime sleepiness.  Only 11 patients agreed to try the device.  When assessed 6 months after the initiation of treatment, these patients admitted to using CPAP for less than 3 hours a night.  They regard CPAP as a major nuisance and although they may agree to try it for awhile, the trial is usually short lived.  It seems highly unlikely that CPAP will enjoy the same success in treatment of nonapaneic snoring as it does in treatment of sleep apnea.

Ref. 23:

Nasal continuous positive airway pressure for nonapneic snoring?

Raushcer H – Chest – 1995 Jan;107(!): 58-61

The feasibility of nasal continuous positive airway pressure (CPAP) for heavy snoring associated with daytime sleepiness was studied in 118 consecutive patients with an apnea hypopnea index below 5.  Fifty-nine of them reported daytime sleepiness in a questionnaire and were offered treatment with nasal CPAP.  Whereas 48 patients refused it,  the remaining 11 (19%) accepted nasal CPAP for home therapy.  By dividing the hours of operation by the days since initiation of treatment, we found a mean daily use time of only 2.8 (+/- 1.5) hours. Nevertheless, eight patients (73%) reported that their daytime sleepiness had improved with therapy.  We conclude that only a minority of nonapneic snorers accept treatment with nasal CPAP on a long-term basis and that this subgroup is not predictable from polysomnography.

Ref. 24:

Evaluations of efficacy and compliance of CPAP and UPP in treatment patients with obstructive sleep apnea:

Sleep disorders center of Beijing Shuili Hospital , Beijing 100036, P.R. China

Patients with AHI under 30 showed lower compliance.

n  20.3% of patients used their CPAP devices about 4 hours per night..

n  52.2% terminated CPAP treatment within 1 to 5 months after initially used because CPAP prevented them entry into deeper sleep stages and very frequent arousals established poorer sleep quality although CPAP normalized sleep related breathing.

n  30.9% of patients refused this therapy after a single night’s use in the lab.  The high incidence of side effects mainly centered on nasal problems may alter long term compliance to CPAP.

Patients with an apnea/hypopnea index of greater than 30 showed a high compliance.

n  (78.3%) of patients who may be with or without extreme obesity, chronic carbon dioxide retention, mandibular deficiency, hypertrophied tongue or tonsils were
tolerant of using the CPAP every night.

n  (23.6%) of patients with severe OSA were too uncomfortable attempting to sleep without CPAP.

While the efficacy of treatment with CPAP is unquestioned, the treatment modality is challenged by the issue of compliance.

2.  SURGERY

Ref. 25:

Chest Vol 109 Number 1 – January 1996

Victor Hoffstein PhD, MD

UVULOPALATOPHARYNGEOPLASTY (UPPP):

When a snoring patient has obvious anatomic abnormality leading to nasal or pharyngeal obstruction (eg. enlarged adenoids, deviated nasal septum, blockage of the nasal valve, large tonsils, etc) surgery is usually recommended.  The vast majority of asymptomatic snorers do not have obvious anatomic deformities. UPPP was first described by Fuijita et al in 1981 for treatment of OSA.  Because snoring is a cardinal symptom of sleep apnea, and because it is associated with upper airway abnormalities that are similar but not as severe as those observed in sleep apnea, within a very short time UPPP was offered to patients without sleep apnea whose only compliant was habitual snoring.

In a review of other studies they uniformly point out that surgery never completely eliminates snoring, but only reduces it to the level that is no longer objectionable to the listeners and socially embarrassing to the snorer.

The high rate of improvement reported in all studies may diminish with time.  For example, Levin and Becker reported that the initial 87% rate of success dropped to 46% at the end of 13 months.  The desire for success on the part of the patient is so strong that Miljeteig et all in a survey of 69 patients (apneic and nonaponeic snorers) who had UPPP found that although there was no difference in the measured AHI and snoring indices before and after surgery, 80% of surveyed patients reported improvement in their snoring and quality of sleep.

It appears that the best surgical candidates who are likely to benefit from UPPP are nonobese, nonapneic snorers.  Apneic snorers should be advised of nonsurgical treatment such as lifestyle modification, oral appliances, and n-CPAP; they should be considered for surgery only if the above alternatives are unacceptable or cannot be easily accomplished.

Side Effects:

Haavisto and Suonpaa reported that 57% of patients had at least one complaint directly related to the surgery as late as 1 year post operatively, with 24% complaining of nasopharyngeal regurgitation.  Post operative deaths have been reported, usually due to unsuspected upper airway obstruction.

Ref. 26:

UPPP may compromise nasal CPAP therapy in sleep apnea syndrome:

American Journal of Respiratory and Critical Care Medicine 1996 Dec;

154(6Pt.1):1759-62

Loube DI, MD

This report describes three cases who underwent uvulopalatopharyngoplasty for severe snoring and who subsequently developed progressive excessive daytime sleepiness.  All three cases were shown to have sleep fragmentation as a result of non-apneic episodic upper airway narrowing.  These cases raise the possibility that increased upper airway resistance during sleep may be exacerbated or even caused by UPPP.

LASER ASSISTED UVULOPALAOPHARYGEOPLASTY (LAUP):

Ref. 27:

Yearbook of Otolaryngology – Head and Neck Surgery 1998

Uvulopalatopharygoplasty versus Laser-Assisted Uvulopalatoplasty for the treatment of obstructive sleep apnea.

Walker RP et al

After surgery, the successful surgical response rate was:

n  51.2% in UPPP patients and 47.4% in LAUP patients.

n  Postoperative complications in LAUP patients included:

n  bleeding in 2

n  oral candidiasis in 2,

n  temporary velopalatal insufficiency in 1.

n  Postoperative complication in UPPP patients included:

n  bleeding in 2,

n  temporary velopalatal insufficiency in 3

n  lower extremity deep venous thrombosis in 1.

Ref. 28:

LAUP for snoring and obstructive sleep apnea: results in 170 patients.

Laryngoscope – 1995 Sep’105(Pt1): 938-43

Walker RP

LAUP treatment in the snoring only patients resulted in complete or nearly complete elimination of snoring in 60%, partial improvement in 29% and no improvement in 10%.  However 21% had repeat polysomnograms that were worse that their preoperative polysomnograms and 5% had no significant change.

Ref. 29:

Long term follow up of patients with OSA treated with UPPP

ArchOtologaryngol Head Neck Srug/Vol;123 March 1997

Christer Janson, MD

Department of Public Health Medicine, United Medical and Dental Schools St., Thomas Hospital, London England

Larrson et al found that the rate of responders to UPPP was 60% after 6 months but had decreased to 39% after 2 years.  In a second study using the same patient population the response rate was found to be 50% when the patients were examined after 3to 6 years.  In another long term study, Le et al reported that in 10 patients who had been defined as responding to treatment with UPPP in an initial postoperative examination the respiratorydistress index had increased significantly when the were reexamined after more than 5 years.

Ref. 30:

Practice Parameters for the Use of LAUP

An American Sleep Disorders Association Report

Standards of Practice Committee of the ASDA

By attempting to eliminate the snoring and not the underlying pathophysiology causing OSA, the use of LAUP in this context may, in fact increase morbidity by eliminating the snoring and lulling both the physician and the patient into a false sense of security.

Two groups of researchers report that the moderate to severe postoperative pain lasts from 1 to 8 days in 60-70% of patients who undergo UPPP.  Other reports indicate that patients experience pain for a longer period, often up to 14 – 21 days after surgery.  Postoperative swelling can result in airway complications for patients who have marginal airways and clinical examination does not always disclose this marginal airway.

Subjective sleepiness is reduced and a short-term reduction in snoring occurs in 76% and 76-94% respectively, of patients who undergo a UPPP operation for the treatment of OSA.  However, objective testing demonstrates that less than 50% of patients have a greater than 50% reduction in their apnea hypopnea index.  Flow limitations often persist and, therefore, these patients may be at risk of developing OSA.

No evidence from controlled studies indicates  that LAUP alters pathologic respiration, therefore procedures such as LAUP that are directed at eliminating this disruptive noise may place patients at unknown risk.

Because adequate peer-reviewed objective data do not exist regarding the effectiveness of LAUP for the treatment of sleep related breathing disordered, including OSA, LAUP is not recommended for the treatment of these disorders

A significant number of patients who present with a symptom of snoring will have underlying, undetected, sleep-related breathing disorders.

Ref. 31:

Histopathologic changes of the soft palate after LAUP:

Department of Otolaryngology Head and Neck Surgery, Meir General Hospital , Kfar Saba, Israel.

Berger G, Finkelstein Y, Ophir D

After laser-assisted uvulopalatoplasty, all soft palates displayed marked and progressive pathologic changes that increased with every additional treatment and extended far beyond the point of laser beam application.  The loose connective tissue present in the lamina propria was replaced by diffuse fibrosis, which also extended to the central layer, on the expanse of seromucous glands and muscle fibers.  Other changes included ulceration of the oral epithelium and a patch inflammatory reaction.

Conclusions: Extensive thermal-induced changes, involving the 3 layers of the organ were found.  They are compatible with clinical observations reported elsewhere and are probably responsible for the worsening of the obstructive sleep apnea status and the sensation of the pharyngeal dryness that developed months after the LAUP.  Although it has immediate benefits, the procedure is still relatively new and all its implications are as yet unknown.

3.  ORAL APPLIANCE THERAPY

Ref. 32:

Oral Appliance Therapy for Obstructive Sleep Apnea

Clinical Pulmonary Medicine

Walter Reed Army Medical Center Washington DC

Loube D, MD

Traditional treatment options for OSA are CPAP, pharyngeal surgeries, weight loss, pharmacologic therapies, and positional therapy.  Efficacy rates for OSA treatment measured by nocturnal polysomnography are less than 20 % with weight loss, pharmacolologic therapy ore positional therapy.  Although CPAP is at least 95% effective for OSA treatment, compliance is only 40%-70% and may be even lower in other than optimized research settings.  Multiple pharyngeal and jaw surgeries are required to obtain an OSA treatment efficacy rate higher than 30% to 50%.

Oral appliances may be an effective alternative to CPAP or pharyngeal and jaw surgeries for OSA treatment.

Ref. 33:

Oral Appliance Therapy for Obstructive Sleep Apnea Syndrome:  Progressive mandibular advancement during polysomnography:

The Journal of Craniomandibular Practice – Vol 16., NO.1 January 1998

Raphaelson M,MD, Alpher E., DDS

Progressive mandibular repositioning during polysomnography has proved, in our patients, to be a helpful adjunct for dental appliance therapy.  Dental appliance adjustments with the Silencer device can be made within three minutes.  We have demonstrated that incremental mandibular advancement and repositioning allow us to determine the most effective jaw position to treat sleep apnea and snoring, which is also most likely to be most tolerated by the patient.

Ref. 34:

Oral Appliances in the Treatment of Snoring and Sleep Apnea

Clinics in Chest Medicine, Vol. 19- No.1 March 1998

Millman, RP, Rosenberg DDS,MSD, Kramer NR, MD

Two studies compared mandibular advancement oral appliance to treatment with CPAP. Both studies were randomized crossover evaluations and both demonstrated that the oral appliance was effective in mild to moderate disease and less effective than CPAP in more severe cases.  In both studies, the patients strongly preferred the oral appliances over CPAP because of comfort.

Ref. 35:

A prospective randomized study of a dental appliance compared with UPPP in the treatment of OSA.

Wilhelmsson BO et al

Scandinavian University Press ISSN 0001-6489

The enthusiasm for UPPP in the treatment of obstructive sleep apnea has declined in recent years, partly because of a lower success rate over time and partly because of adverse effects.  CPAP is not satisfactorily tolerated by many patients and hence may not be justified in the treatment of mild to moderate OSA.  Consequently there is a need for an alternative treatment preferable one that is non-invasive in character.

The aim of this study, was to perform a clinical trial comparing dental appliance and UPPP.

There was a significant difference between the two groups, to the advantage of the dental appliance group, concerning AI(Apnea Index) and AHI (Apnea Hypopnea Index).  According to the criteria for OSA (AI less than 5 or AHI less than 10) 78% of the patients in the dental appliance group and 51% of the patients in the UPPP group attained normalization after 12 months.  The difference between the groups was significant.

It is widely known that for some patients UPPP entails shortcomings, including considerable pain, problems in swallowing and a mostly transient difficulty with open nasality in the postoperative period, but occasionally resulting in long-term problems as well.  Moreover, many patients are fearful of surgical procedures.  Whereas some individuals find a one-stage surgical procedure more rational than a life-long use of a dental appliance, it is our impression that most patients prefer the non-invasive dental appliance method.

In conclusion, this study has shown that the dental appliance technique is a valuable complement to the arsenal of treatment procedures now available to deal with OSA.  There is evidence to suggest that it might be the preferred method for treatment of mild to moderate OSA.

Ref. 36:

A short term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnea.

Thorax 1997, 52:362-368

Ferguson K. –  Et Al

Although oral appliances are effective in some patients with OSA, they are not universally effective.  A novel anterior mandibular positioner (AMP -The Silencer) has been developed with an adjustable hinge that allows progressive advancement of the mandible.  The objective of this prospective cross-over study was to compare efficacy, side effects, patient compliance and preference between AMP and CPAP in patients with symptomatic mild to moderate OSA.

This is one of the first prospective clinical studies to compare an oral appliance with CPAP in treatment of an unselected group of patients with mild to moderate OSA.

Eight patients were treatment successes with both treatments, seven of whom preferred the Silencer and one preferred the CPAP as long term treatment.

The long term preference was overwhelmingly in favor of the Silencer with 10 of 11 patients who were successfully treated with the Silencer preferring it as their long term treatment option.  The Silencer is associated with improved treatment success and fewer compliance failures compared with a nonadjustable mandibular repositioning appliance when identical outcome definitions are used.  No patient developed Temporomandibular dysfunction.  “Our results suggest that oral appliances should be considered first line treatment for patients with symptomatic mild to moderate OSA as most prefer this treatment to CPAP when both treatments have been shown to be effective”.  80% were moderately or very satisfied with the Silencer.

Conclusion: The Silencer is an effective treatment in some patients with mild to moderate OSA and is associated with greater patient satisfaction than CPAP.

Ref. 37:

Oral appliances for the treatment of snoring and OSA.

Sleep ;Vol 6 1995 – 18(6):501-510

An American Sleep Disorders Association Review

Schmidt-Nowara W MD etal

The 21 publications selected for this review describe 320 patients treated with oral appliances for snoring and OSA.  Despite considerable variation in the designs of these appliances, the clinical effects are remarkably consistent.  Snoring is improved in almost all patients and is often eliminated.  Mean results of studies show that OSA improves in the majority of patients.  Comparison of the risk and benefits of oral appliance therapy with those of other available treatments suggests that oral appliances present a useful alternative, especially for patients with simple snoring and others with moderate OSA who cannot tolerate CPAP.

Ref. 38:

Practice Parameters for the Treatment of snoring and OSA with oral appliances.

Sleep, Vol 18, No6 1995 18(6):511-513

An American Sleep Disorders Association Report

Oral appliances are indicated for use in patients with primary snoring or mild OSA who do not respond to or are not appropriate candidates for treatment with behavioral measures such as weight loss or sleep position change.  Oral appliances are indicated for patients with moderate to severe OSA who are intolerant of or refuse treatment with CPAP.  Oral appliances are also indicated for patients who refuse or are not candidates for tonsillectomy and andenoidectomy, craniofacial operation.

Workplace Related Studies

THE IMPACT OF OBSTRUCIVE SLEEP APNEA AND DAY TIME SLEEPINESS ON WORK LIMITATION

C.F. Ryan, J. A. Fleetham et al

Department of Medicine and Division of Respiratory Medicine, University of B.C., Vancouver, B.C.  – 2007

–         We have demonstrated a clear relationship between excessive sleepiness and decreased work productivity in a population referred for suspected sleep-disordered breathing.

–         Screening for sleepiness and sleep-disordered breathing in the workplace has the potential to identify a reversible cause of low work productivity.

–         There is a gradual increase in work limitations with severity of subjective sleepiness.

–         The study showed a deleterious effect of OSA on time management and work output.

–         Snorers and OSA patients showed difficulties with concentration, learning of new tasks and performing new tasks.

–         Snoring patients showed far more work impairment than nonsnorers.

–         There is a robust relationship between subjective sleepiness and work limitations.

–         Patients may have occult depression associated with work limitations.

–         Screening for SDB in the workplace has the potential for decreased “presenteeism” and improvement of work productivity.

–         Sleep fragmentation leads to:

  • Poor quality of sleep
  • Excessive daytime sleepiness
  • Reduced vigilance
  • Microsleeps
  • Neurochemical dysfunction
  • OSA has an adverse effect on productivity


MEDLINE PLUS 10/28/2007

–         20 Million people in the USA have diabetes.

–         18 Million people in the USA suffer from OSA

–         36% of diabetics suffer from OSA.

–         There is a relationship between OSA, glucose intolerance and insulin resistance.

OSA is related to a multitude of health risks, including heart disease, high blood pressure, depression, sexual dysfunction and an increase in car accidents

PUBMED – NATIONAL LIBRARY OF MEDICINE (SLEEP 2004)

Department of Respiratory and sleep Medicine, St George Hospital , The University of New South Wales, Sydney, Australia.

– Oral appliance therapy for OSA over 4 weeks results in a reduction in blood pressure , similar to that reported with continuous positive airway pressure (CPAP) therapy.

PUBMED – NATIONAL LIBRARY OF MEDICINE (Int J. Prothodontics  – 2006)

–         These data suggest that effective oral appliance therapy for OSA patients with Hypertension can lead to a substantial reduction in daytime blood pressure.

AMERICAN ACADEMY OF SLEEP MEDICINE

Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005

– Oral appliances (OAs) are indicated for use in patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP.

THE AGE – November 19, 2002

–         Patients with OSA show a dramatic early loss of grey matter.

–         OSA patients suffer disordered wiring in brain regions that control muscles of the airway.

–         Healthy men’s brains were between two and 18% larger in the areas that control breathing.

–         OSA patients often display other traits that suggest subtle brain damage, including problems with memory, thought and motor skills.

–         The repeated oxygen loss from OSA may damage other brain structures that regulate memory and thinking.

–         38% of OSA patients reported a history of stuttering or speech impairment.

–         75% of the American population stutters.

NATIONAL SLEEP FOUNDATION – 09/10/2007

–         65% of Americans are overweight or obese.

–         A 10% decrease in weight can lead to a significant clinical improvement in the severity of OSA..

–         1 in 3 American children born in 2000 will develop diabetes

–         A build up of “sleep debt” over a matter of days can impair metabolism and disrupt hormone levels.

–         Glucose tolerance tests showed short sleepers were experiencing hormonal changes that could affect their function, body weight and impair long term health.

–         To keep blood sugar levels normal, short sleepers needed to make 30% more Insulin.

–         We tend to eat when we are actually sleepy, because our bodies confuse fatigue as a sign of hunger.


CHEST – NOV, 8, 2007

Sleep apnea and the Commercial Motor Vehicle Operator

–         Medical research has shown that OSA is a significant cause of motor vehicle crashes (resulting in a twofold to seven fold increase in risk) and increases the possibility of an individual having significant health problems such as hypertension, stroke, ischemic heart disease, and mood disorders.

–         USA Federal Motor Carrier Safety Regulations state:

o   “the driver must have no established medical history or clinical diagnosis of respiratory dysfunction likely to interfere with the ability to control and drive a commercial motor vehicle safely.”

WORKSAFE BC SEPTEMBER 20, 2005

–         According to WSBC, in the five years from 2000 through to 2004, there were 21,700 time loss claims, including 116 fatalities and 533 serious injuries, resulting in more that 650,000 productive work days lost.  These injuries and fatalities cost the BC trucking industry $101 Million in workers’ compensations costs alone.

–         “The trucking industry and this province cannot afford the continuing human and financial cost of these injuries and fatalities.”

American Academy of sleep Medicine – Spring 2000

Life Insurance Risk Assessment in Patients with OSA

–         The diagnosis of obstructive sleep-disordered breathing is now considered by the insurance industry to be a significant risk for mortality in this assessment and may be used to determine insurability.

–         Current evidence suggest that patients who are compliant with proven effective therapy for sleep apnea should be expected to have little or no risk of excess mortality due to sleep apnea.

–         Life insurance carriers should not assess excessive risk of mortality based on sleep-disordered breathing if the sleep disordered breathing is effectively treated.

DAMION LEGER – The cost of sleep-related accidents: A report for the National Commission on Sleep Disorders Research.  Sleep – 1994

Unite de Sommeil de l’Hotel-Dieu, Paris, France

Sleep Research Center, Stanford University, Palo Alto, Ca, USA

This report, prepared for the National Commission on Sleep Disorders Research explores the economic implications of sleepiness in relation to accidents.

–         52% of all work place accidents in 1988 were sleep related.

–         Chronic sleep disorders affect 60 – 80% of all shift workers.

–         When people with sleep disorders are asked about driving and accidents, their answers indicate that the frequency with which they fall asleep while driving could be between 30 and 93%.

Mark B. Berger, MD FCCP, Wendy Sullivan, RN, Ross Owen, MPA and Charlotte Wu,  MS Precision Pulmonary  Diagnostics Inc., Schneider National, Inc., and Definity Health Corp. Houston, Texas USA.

This study deals with the health care and community risk factors resulting from OSA conditions in the employee group of a large US trucking firm.

–         Only 10% of adults with SDB have been diagnosed.

–         Only 10% of primary care physicians inquire about SDB related symptoms.

–         A witnessed apnea event by a bed partner is nearly 100% accurate in predicting a diagnosis of SDB.

–         It is estimated that Commercial truck drivers have an SDB rate of 28%.

–         SDB affected drivers have from 2-15 times more frequent MVAs, as compared to unaffected drivers.

–         In 348 drivers who suffered from SDB, CPAP therapy resulted in a 47.8% reduction in per member per month health care spending.

–         There was a drop of 73% in preventable accidents in a sub group of 225 full time CPAP treated drivers.

–         The average cost per large truck crash involving a fatality was $3.5 Million and in cases of injury, $217,000.

–         Risk of SDB and comorbitities are evident in 1 out of 3 drivers.

–         After intervention, SDB patients had 25% as many hospital visits and spent 50% of the health care dollars when compared with a similar period prior to intervention.

–         The employer enjoyed a 129% greater employee retention rate following corporate intervention for SDB.

–         Appropriate treatment for SDB can ameliorate co-morbities of

  • Cardiovascular disease
  • Hypertension
  • Diabetes
  • Obesity

a) Federal University of San Paulo – 2007

CPAP vs Oral Appliance Therapy

Efficiency & Efficacy

–         More than 50% of patients who start with CPAP treatment will not be using it one year later.

–          “Efficiency” of Oral Appliance Therapy = 2X CPAP Therapy

b)  ALBERTA TRUCKING– 2006

L. Wayne Halstrom, B.A., D.D.S., D-A.D.S.M.

–         Industry must take the initiative to work with regulatory authorities to produce an environment conducive to “bringing in” the sleepy driver.

Canada.com – Truck driver who killed Mountie found guilty.

–         “A truck driver who killed an RCMP constable when his truck slammed into the Mountie’s cruiser has been found guilty of dangerous driving causing death.”