Putting Sleep Apnea to Bed

An estimated 50 to 70 million Americans suffer from serious chronic or intermittent sleep disorders that undermine the quality of their sleep and, more importantly, their health. Sleep apnea, the most common disturbance, is also potentially the most serious, raising the risk of high blood pressure, arrhythmias, diabetes, heart failure, heart attack and stroke. At its most severe, it can even cause death.

Fortunately, modern medicine can diagnose and treat obstructive sleep apnea before it ever reaches such dangerous stages. Key to our success was the development of the continuous positive airway pressure device known as CPAP. The front-line therapy for nearly 30 years now, CPAP is a safe, non-invasive and highly effective treatment for the disorder, when used as directed. However, compliance can be a problem.

Tune in to the full podcast with Dr. Stanley Chia.  

Why?  

Some people find the devices noisy and uncomfortable. Those with claustrophobia have problems adjusting to a mask that covers the nose and, with some models, also the mouth.  And restless sleepers have trouble keeping them on.  

As a result, only between 30 and 60 percent of patients with the devices actually use them regularly and for the prescribed amount of time each night.  

So clinicians and researchers have come up with new methods to tackle the problem. 

Understanding Obstructive Sleep Apnea

First, it helps to understand the mechanics behind sleep apnea, which is marked by pauses in breathing called apnea episodes, or shallow breathing called hypopnea episodes, during sleep. When you sleep, the throat muscles that normally keep your airway stiff and open relax, narrowing the passageway. That’s normal.  However, certain conditions or even the physical structure of your mouth can momentarily prevent enough air from getting to your lungs. A partial blockage produces loud snoring or irregular breathing, while a complete obstruction usually results in a sudden snort or gasp as the oxygen-starved brain startles the body awake.

These breaks in breathing can last from a few seconds to minutes, and have been recorded over 100 times an hour.  

Among the causes of sleep apnea are age, sex (with males at a higher risk) and, increasingly, obesity as excess fatty tissue can thicken the wall of the windpipe, narrowing the opening.  

Finding the Right Fix

Beyond lifestyle changes and CPAP, specialists have a range of other approaches to treat sleep apnea. Choosing the right therapy depends upon determining the source of the problem and on patient preference. We start with a careful and thorough evaluation, including physical examination, a detailed medical history, an overnight sleep study and an endoscopy to look at the airways and arrive at the correct diagnosis.  

For patients with large tonsils or an elongated soft palate, treatment can include removing the tonsils and shortening the palate. Another approach, especially when patients have excess or enlarged tissue at the back of the tongue, is transoral robotic surgery to remove the excess tissue, or radio frequency ablation which shrinks the tongue or soft palate.

In other cases, the very structure of the upper or lower jaw is the culprit. To eliminate the condition, oral surgeons can actually advance the upper and lower jaws to open up the airway.  These procedures have a high success rate, sometimes accompanied by an unintended consequence: a better-looking jaw line!

But a newer approach is proving to be even better for some individuals.   

Novel Approach Offers Improved Solution

Approximately two years ago, the FDA approved a promising new technology to treat sleep apnea called the hypoglossal nerve stimulator. (Full disclosure:  I sat on the final FDA review board.) Basically, the technology acts like a pacemaker, helping to synchronize the intake of air with the action of the tongue.  The pacemaker apparatus is implanted in your right chest, and connected to a wire that is wrapped around the nerve that controls tongue movement. A second wire implanted in the side of the right chest senses when you breathe in, causing the pacemaker to signal to the tongue to move forward and out of the way, opening the airway. The device is turned on and off by the patient, so daytime breathing is not affected.  

To date, the stimulator has been used in hundreds of patients with very good success. I’ve personally used it on about 15 patients with an 85% success rate. However, not everyone is a candidate for the approach.  Patients must have moderate to severe sleep apnea, as indicated by a sleep apnea severity score (Apnea Hypopnea Index or AHI) between 20 and 65, and a body mass index (BMI) less than 32. The latter, in particular, rules out many who could benefit from the procedure. As a result, I often refer my obese patients for consideration of bariatric surgery to help lose weight instead.

But for those who fit the criteria, the hypoglossal nerve stimulator is an important breakthrough. And for specialists, it’s a nice complement to the range of other treatments available and yet another tool to give patients what they need to put sleep apnea to bed.   

Listen to the full podcast with Dr. Chia.

 

Sleep Apnea Treatment Options

Obstructive sleep apnea is a potentially serious disorder that causes periods of interrupted breathing while you are asleep. One of the reasons this happens while sleeping is that all of the muscles in your body relax during this period, including those that help keep your throat open to allow air to flow into the lungs, explains Stanley H. Chia, MD, FACS, associate chair of Otolaryngology at MedStar Washington Hospital Center.  New sleep apnea treatment options do exist and one, called Upper Airway Stimulation (UAS), is making a difference for some patients for whom standard therapy  was not effective.

Sleep Apnea: The Health Effects

With sleep apnea, the airway becomes narrowed or partially blocked when the muscles in the upper throat relax. The tissues then close in, block the airway and cause you to stop breathing. This is called apnea.

One of the most common symptoms of sleep apnea is snoring, which happens when the air is squeezed through this narrowed airway. Another symptom is constant exhaustion from a chronic lack of sleep. 

The consequence of sleep deprivation isn’t simply exhaustion, however. “This disorder can cause or worsen some serious disorders, such as high blood pressure, stroke and heart disease,” says Dr. Chia. “In very severe cases of sleep apnea, patients may stop breathing over 100 times an hour. They try to get air in their lungs, but the airway collapses, blocked by tissue in the back of their throat. Their oxygen levels drop, and they awake repeatedly during the night. Often they aren’t even aware of waking, until a partner complains about the snoring and gasping for air—the most common symptoms.”

What are sleep apnea treatment options?

CPAP (Continuous Positive Airway Pressure) is the gold standard treatment for sleep apnea. The CPAP mask is worn over the mouth and/or nose, and is connected to a pump by a hose that pushes air into the wearer’s throat and keeps the airway open.

“It’s effective for many people,” Dr. Chia says. “But nearly half of patients prescribed CPAP cannot wear the mask through the night, so they are not treated adequately. Until recently, the only other surgical treatments available have had mixed results, and recovery is painful.”

Today, there is another option called Upper Airway Stimulation (UAS) therapy —the first new treatment option for obstructive sleep apnea in more than a decade. “This new technology, which was recently approved by the FDA, offers a subset of patients an effective therapy,” says Dr. Chia.

The Upper Airway Stimulation Option

For one 33-year-old Washingtonian, sleep was treacherous—and a good night’s rest had eluded him since childhood. He had suffered with obstructive sleep apnea for decades—gasping for breath dozens of times during the night. Sleep-deprived and literally tired of feeling that way, he sought help from Dr. Chia.  A thorough evaluation found that he was an excellent candidate for UAS therapy.

“The Upper Airway Stimulation procedure isn’t for everyone,” Dr. Chia explains. “But it is one of the sleep apnea treatment options proving effective for people with moderate to severe sleep apnea who don’t respond to other treatments.”

Candidates for the UAS sleep apnea treatment option must meet some criteria. “They need to have a body mass index of less than 32, and a sleep apnea score of between 20 and 65, determined by a sleep study,” he says. During the surgery, a small generator device similar to a pacemaker is implanted under the skin below the collarbone. Another incision is made on the side of the patient’s chest where a wire sensor is tunneled under the skin and attached to the generator and senses the individual’s breathing.

Another incision is made in the neck and a lead is connected to the hypoglossal nerve, which stimulates tongue movement. With every breath the patient takes, a signal is sent to the nerve to stimulate the tongue, which moves forward in the mouth and opens the upper airway.

Sweet, Sleep Relief

After a month to allow tissues to heal, the device is calibrated. Then patients simply turn it on at bedtime, using a remote control.

“Like more than 70 percent of those who have had the UAS procedure, my patient’s sleep apnea has improved dramatically,” says Dr. Chia. “In fact, he told me that he is sleeping deeply enough to have dreams for the first time that he can remember—and getting a good night’s sleep for the first time in years.”

Obstructive Sleep Apnea Fast Facts

Risk Factors

  • Having small upper airway, or large tongue, tonsils or uvula
  • Having recessed chin, small jaw or large overbite, large neck size
  • Smoking and alcohol use
  • Being age 40+ and/or overweight
  • Being African-American, Pacific-Islander or Hispanic
  • Having a family member with the disorder 

Symptoms

  • Chronic snoring
  • Feeling sleep deprived
  • Difficulty concentrating, depression
  • Falling asleep at work or driving
  • High blood pressure or morning headaches
Have Any Questions?

We're here to help! Contact us for more information about sleep apnea treatment options or to schedule an appointment with Dr. Chia. Call us at 202-877-3627.

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