There are only a few effective treatments for OSA.
They fall into several categories:
weight loss/lifestyle changes
surgery
dental appliances
implantable devices
air splint device.
The most popular and most effective is the latter one, a device which delivers air under slight pressure to the airway by way of a mask. This is a type of ‘air splint’ that keeps the airway open, thereby allowing the patient to breathe normally. There are different types of air splint devices, but are commonly referred to as CPAP (Continuous Positive Airway Pressure)
There is no guaranteed, permanent, device-free “cure” for sleep apnoea!
Weight loss/lifestyle change
It is wiser and safer to get professional treatment. You can use the techniques below, in consultation with your sleep specialist/doctor, while your treatment progresses. Sleep Apnoea is a disorder and as such cannot be cured, it can however be managed effectively. There are several things doctors suggest you do that can greatly alleviate it:
If you’re overweight, loose it! Excess weight contributes to obstructive sleep apnoea in two ways:
Fat deposits in the neck tissue compress the airway and make it more likely to collapse.
Excess weight in the abdomen makes the breathing muscles operate inefficiently, which contributes to breathing difficulty when sleeping.
Weight loss by itself is very difficult (as many of us know). Sometimes people are only able to lose their excess weight after treatment for sleep apnoea has begun, they are able to be more awake and vigorous, and increase their energy use.
Naturally, weight loss is just a generally very healthy thing (if you’re overweight – if your weight is normal, don’t starve yourself!)
Smoking
As with the loss of excess weight, this is, of course, just a good idea in general. However, quitting might also help your sleep apnoea in addition to its countless other health benefits, by returning lung capacity to normal.
Alcohol
Eliminate alcohol in the evening. Alcohol depresses your breathing reflexes and significantly worsens sleep apnoea.
Apnoea sufferers should be very careful about excessive drunkenness. The same thing goes for sleeping pills, drugs, or anything that might affect your breathing.
Allergies and respiratory infections:
These cause nasal congestion, which narrows the airway and contributes to apnoea. Consult your physician for medications to treat these which will not interfere with sleep.
Medications:
Many common medications interfere with either the breathing reflex or sleep or both. Some of the most common are “sleeping pills”, tranquilizers, and short-acting beta blockers. Consult your sleep specialist and/or pharmacist about more suitable medications.
Air Splint Devices
Continuous Positive Airway Pressure (CPAP)
“Nasal CPAP” is the Gold Standard treatment for Sleep Apnoea and is the treatment of choice for most people with obstructive and mixed apnoea. It is the most reliable and effective treatment for the condition. Millions of CPAP devices are now in use treating obstructive sleep apnoea worldwide. An added advantage with this treatment is the elimination of snoring.
It involves using a small air flow device connected via a hose to a nasal or full face mask you wear while you sleep – much like a regular oxygen mask, with straps to keep it in place. Essentially, this device blows air into your nose, or nose and mouth to keep your airway from collapsing and creating an obstruction to breathing. It increases the air pressure in your airway, thereby stopping its collapse. It isn’t as unpleasant as it sounds – most people get used to the sensation quickly.
Admittedly, having to wear a face mask to bed isn’t the most attractive thing in the universe. Most bed partners are usually happy to live with that rather than snoring! And it is infinitely preferable to the effects of apnoea, both the fatigue and the other physical effects (additional strain on the heart). The exact results vary, but a great many people report significant changes in their lives when they start using CPAP – they feel more awake, more alive – “like a whole different person”, in some cases.
Auto Adjusting Positive Airway Pressure (APAP)
In the belief that the reduction of total airway flow would provide greater comfort to the patient and encourage patients to use the airway pressure treatment on a regular basis, APAP devices were introduced. These devices incorporate flow and pressure sensors and automatic regulation systems to ensure that the correct air pressure is delivered to the airway, only when required (rather than the same constant pressure).
The algorithms used in these devices are designed to offer greater patient comfort insofar as the overall pressure is reduced, if the changes in pressure reduce or eliminate apnoea, snoring, or flow limitation.
Bi-Level Positive Airway Pressure
Bi-level positive airway pressure is a type of Non-Invasive Ventilation (NIV). Instead of providing air at a constant, fixed pressure all night, the machine “senses” how much air a person needs, based on inspiration and expiration, and varies its level of pressure accordingly. On inspiration, a higher pressure is needed to prevent Apnoea’s, hypopneas, or snoring. But on expiration the patient typically requires several centimetres less pressure.
What is the purpose of this? Well, some people find that they simply cannot sleep with regular CPAP due to the constant air pressure. Bi-level pressure helps this problem by providing less pressure when you are breathing out (exhaling) and more when you are breathing in (inspiring).
Bi-level pressure devices are significantly more expensive than regular CPAP.
Adaptive Servo Ventilators (ASV)
These devices are the very latest technology for treating Central Sleep Apnoea, Cheynes Stokes Respiration and other ‘difficult to treat’ conditions. As the name suggests they are a type of Non-Invasive Ventilation (NIV) and are best described as a further advance in Bi Level therapy.
Oral Appliances
Oral Appliances also referred to as Dental devices have been in use for almost as long as Continuous Positive Airway Pressure (CPAP).
Oral Appliances have been referred to as ‘second line’ treatment (after CPAP), but advances in technology and the skills of certain dentists have improved their results in treating certain types of Apnoea. Typically, they have proven successful in treating mild and moderate apnoea, in the main.
Oral Appliance Therapy (OAT) is safe and in some cases an effective alternative to CPAP. OAT may be indicated for cases of mild to moderate apnoea, under the guidance of a sleep physician (consultant). OAT is also indicated in severe sleep apnoea for those who cannot tolerate CPAP and whose sleep apnoea does not improve sufficiently with weight loss and other measures. Your sleep physician may wish you to have a further sleep study whilst wearing your appliance to verify its effectiveness. Although not routinely recommended in those with severe apnoea, many in this situation will do very well with an appliance, but their effectiveness is certainly not enough to recommend their routine use and again it must be stressed that the most effective treatment for moderate to severe apnoea remains CPAP.
FOR SUCCESSFUL TREATMENT WITH AN ORAL APPLIANCE, THE TRAINING, SKILL AND EXPERIENCE OF THE DENTIST IS PARAMOUNT.
There are two distinct groups of OAT:
1. Mandibular Advancement Devices (MADs), sometimes referred to as Mandibular Splints
These are the more successful type of appliance and are the most commonly used. These specialised dental devices should be provided by a dentist with suitable training and understanding of this treatment. As most dental schools worldwide do not routinely provide this training for dentists, it is often provided by dentists with specialist post-graduate training. The appliance is like a small upper and lower teeth gum shield and correctly fitted will hold the lower jaw in a forward position which serves to keep the airway open whilst sleeping and prevent snoring whilst in certain cases relieving the blockage which causes apnoea.
As with CPAP they are only worn at night and ideally to get maximum benefit they must be worn all night, every night. The best appliances are correctly and individually made to fit the teeth and so do not interfere with sleep but may take a few nights to get accustomed to. It is crucial that the appliance can be adjusted by the wearer as its effectiveness is dependent on having the jaw in the correct position. Simple versions (Boil and Bite) of these appliances can be bought over the counter and on the internet. These are not adjustable and are bulky and uncomfortable and although inexpensive are generally not very successful.
Side effects include excess salivation and joint and muscle pain (soreness) in some cases and these usually disappear within weeks, where they do occur. Once your dentist and sleep consultant are happy with the results you are attaining with your appliance you will usually be checked with your appliance once yearly to ensure that all is well.
A certain number of ‘natural’ teeth are required to anchor this type of device.
2. Tongue-Retaining Devices (TRDs)
This is a suction cup that is gripped between the teeth or lips and which sucks the tongue forward, thus opening the airway behind the tongue. People, who snore only when lying on their back, and whose tongue is the main source of obstruction, sometimes find this device helpful. It is not as effective as a mandibular advancement appliance and is usually reserved for those who are missing most or all of their teeth.
What can I do about my snoring if I don’t have sleep apnoea?
Oral appliance therapy (OAT) if correctly used is almost universally effective in eliminating snoring. It has been used for this purpose in the USA for as long as CPAP has been used to treat sleep apnoea. As their correct use involves specialist training most of the dentists with the experience to provide effective treatment have had post-graduate specialist training in the USA.
Despite the failure of other home remedies, snorers and their partners and families can rest assured that there is a relatively simple, non-surgical treatment that is tried and tested and does actually work!
Footnote: SDSF.ie wish to acknowledge and thank Dr. John O’Brien, Dental Surgeon, BDS, NUI. Cert. OFP. (UCLA) (Orofacial Pain) for his kind assistance in compiling this update on OAT.
Implantable Devices
These devices have been around for about 10/15 years now and in the early stages, their development was plagued by power issues (batteries). Several companies now produce them and they have been clinically cleared for use in Europe (CE Approval), and recently (2016) have received clearance for use in the USA (FDA Approval).
The devices comprise a small box, similar in size and construction to a cardiac pacemaker, with two ‘wires’ that sense breathing patterns (connected to the airway/lung) and delivers mild stimulation (electrical impulse) to maintain multilevel airway patency during sleep (connected to the hypoglossal nerve). Approx. thirty days after being implanted the device is ready for use. Thereafter the device is ‘switched on’ before going to bed and switched off in the morning by way of a remote control unit.
The lifetime of the battery (needed to power the device) is reported as being up to ten years. There are reports that rechargeable batteries are being developed (without the need to remove the device).
These devices are quite expensive (reported at €18,000+ VAT). This does not include the cost of the surgical procedure to implant the device. It may be necessary to have the device ‘implanted’ abroad.
Positional Sleep Apnoea Devices
In cases where Mild or Moderate Apnoea is diagnosed, and its primary cause is the position in which the patient sleeps (supine position/on their backs), it is referred to as Positional Sleep Apnoea. This condition can, in some cases, be adequately treated using a ‘device’ that stops the sufferer sleeping on their backs. This device is strapped to the sufferer’s back by way of a harness. It is like a block of wood or polystyrene and makes it extremely difficult to roll on to the back.
Surgeries
General
Surgery (of any type) where anaesthesia is used, poses a very real danger to people suffering from Sleep Apnoea. In all cases your surgeon and anaesthetist should be informed (in advance) if you suffer from Sleep Apnoea. You also need to inform your sleep specialist of any impending surgery, as they may need to send medical data to your surgeon. If using CPAP, you will probably be advised to bring your CPAP machine to hospital and possibly to the operating theatre. It may be required during the post-operative recovery period.
Surgery for Sleep Apnoea
The goal of surgery is to enlarge the airway and prevent snoring and airway collapse. Surgery is site specific (to enlarge a specific portion of the airway). Due to the risks associated with anaesthesia or an operation, surgery should not be considered as a first option. There is also a risk that surgery may cure snoring, but if the patient has Sleep Apnoea, one of the primary symptoms (snoring) will be removed while the Sleep Apnoea remains and may go undiagnosed while further damage is being done to the respiratory and cardiovascular systems possibly leading to a stroke (which may have been avoided).
We are unable to source reliable figures for success/failure with surgery. In general, except for a tracheostomy (see below) surgery for ‘curing’ Sleep Apnoea is not successful and is quite painful. There are incidences where there is temporary relief post-surgery, but research indicates that the apnoea will return, anytime up to five years’ post-surgery. In America, an increasing number of ENT (Ear Nose and Throat) surgeons continue to pioneer this method of treatment and now offer a ‘cocktail’ of surgical procedures over a period of two to four years, (please see section on multi-phase surgery) In some cases ‘success’ has been claimed, however they are usually short lived as symptoms of Sleep Apnoea start to reappear within a short space of time. There are no ‘quick fixes’ for Sleep Apnoea.
The following is a list of all known surgical procedures currently in use to treat/cure Sleep Apnoea. There are no reliable figures available for the success or failure of any one procedure. The best estimates for UPPP surgery is ‘a 50% improvement in 50% of cases’. Unfortunately for anyone with mild to severe Sleep Apnoea this means that CPAP must still be used after the operation.
SOME OR MANY OF THESE PROCEDURES MAY NOT BE AVAILABLE IN IRELAND.
Nasal Surgery
Septoplasty
The septum is the divider between the two nasal passages. A deviated (crooked) septum may obstruct the nasal airway. A Septoplasty is performed through the nostrils. The cartilage and bone of the septum is straightened. For someone with a ‘blocked nose’ (injury) this type of surgery is ideal to increase airflow and is helpful in becoming compliant with CPAP, at possibly reduced air pressure. It is not successful in ‘curing’ sleep apnoea.
Turbinate Reduction
The turbinates within the nose are made of bone surrounded by soft tissue whose function are to warm and moisten the air as you breathe. There are three turbinates’ in each nostril (lowest, middle and upper). Reduction of the size of an enlarged turbinate can improve the size of the nasal airway. Turbinate reduction may be performed with surgical instruments, lasers. Radio frequency energy or cauterised.
Removal of Polyps
Nasal polyps can obstruct the nasal airway. Removal of polyps can ‘free up’ the airway.
Sinus Surgery
Sinus infections can contribute to nasal obstruction and surgery may be necessary.
Upper Airway Surgery
Uvulopalatopharyngoplasty (UPPP) surgery
This surgery removes the uvula, the lower edge of the soft palate trimmed. If present, the tonsils are generally removed and tissues around the tonsils trimmed. It can be done separately or in conjunction with other treatments, depending on where in the airway the obstructions occur. There are the usual surgical risks involved with this surgery. Notable ones are general anaesthetic (depresses breathing reflex and can be risky in people with breathing problems like sleep apnoea), swelling of the airway, need for pre-and post-operative medications (may depress the breathing reflex), bleeding, and significant pain lasting up to several weeks.
This surgical procedure (introduced around the same time as CPAP) has proven to be ineffective in ‘curing’ sleep apnoea over an extended period. We have been unable to source ‘independent’ research on its success/failure beyond a three/five-year period.
The clear majority of people who have undergone UPPP for the treatment of Obstructive Sleep Apnoea do have to continue using CPAP, or return to CPAP.
Laser-Assisted Uvulopalatopharyngoplasty (LAUP)
LAUP involves laser surgery on the uvula and soft palate that is reported to diminish snoring, but no controlled studies have been done to show that it reduces sleep apnoea. Because it is less extensive than UPPP, it is unlikely to be any more effective than UPPP in treating obstructive apnoea. It is usually done in several steps, and is an outpatient procedure. For that reason, it is less risky than UPPP.
Potential patients should be careful that they don’t see an advertisement in the paper, call the doctor, and rush into an LAUP procedure without research and consideration.
Despite some advertising claims that LAUP can be carried out during lunch hour with the patient returning to work, this procedure is extremely painful.
TORS (Trans Orbital Robotic Surgery)
This type of surgical device was originally developed in the US to remove ‘hard to reach’ cancerous tumours in the airway. It is now being used in the US (by some practitioners), using the Da Vinci Robot to carry out what is in effect the Uvulopalatopharyngoplasty (UPPP) surgery.
Early indications are that it is no more effective than the traditional procedure, however it is not in use for long enough to determine its effectiveness. Anecdotal reports indicate that recovery time may be extended through its use.
Somnoplasty (Radio-frequency Tissue Ablation of the Palate)
Deliverance of Radio-frequency waves by a needle electrode to the underside of the soft palate to cause contraction of excessive tissues that cause snoring. This procedure involves a progressive shrinkage of the soft palate and uvula. Usually patients require up to four treatment sessions of 15/20 minutes, under local anaesthesia.
Tonsillectomy and Adenoidectomy
Tonsils are tissues on the sides of the upper throat and if enlarged may narrow the width of the upper airway. Adenoids are at the back of the nose and can obstruct the nasal airway. This surgery is most common with children as Adenoids usually shrink with age.
This procedure is ineffective in adults.
Lower Airway Surgery
Genioglossus Advancement
The Genioglossus muscle attaches from the back of the tongue to a spot on the back of the chin. This surgery attempts to pull the back of the tongue forward to enlarge the air space behind the tongue. The procedure pulls forward a rectangular or circular segment of chin bone (below the front four teeth) and holds it in place with a plate or screw. A minimal change in the appearance of the chin results (millimetres).
Hyoid Advancement
The Hyoid bone is just above the Adam’s apple. The Hyoid bone is moved forward and either attached to the Adam’s apple or jaw bone. The purpose is to enlarge the air space behind the tongue.
Midline Glossectomy, Lingualplasty, and Lingual Tonsillectomy
Midline Glossectomy involves a reduction in the size of the tongue (if enlarged). The back of the tongue is reduced in size by excising a V shaped portion of the centre part of the tongue. Lingualplasty is a more aggressive resection with additional removal of side wedges. Lingual Tonsillectomy involves the removal of tonsil like tissue on the back part of the tongue, it may also be removed with a laser. A temporary tracheostomy is usually performed with these procedures to avoid breathing difficulty that might result from temporary swelling. The purpose is to reduce the size of the tongue thereby increasing the air space behind the tongue.
Bimaxillary Advancement (Lafort 1 Maxillary Osteotomy with Bilateral Sagittal Split Mandibular Osteotomy)
The upper and lower jaw bones are moved forward along with all teeth to pull soft tissue structures forward and make more room for the tongue. Metal plates and screws are used to hold the realigned jaw bones in place. Orthodontic work prior to or following the procedure may be necessary to maintain proper alignment of the teeth. Change in facial appearance relates to the extent of the advancement.
Tongue Suspension Suture (Repose)
The tongue is pulled forward by way of a permanent stitch attached to a screw which has been placed through the back of the tongue. This is to prevent the tongue falling back during sleep and obstructing the airway.
Surgical Bypass of the Airway
Tracheostomy
An opening is made at the front of the neck to the windpipe and a plastic or metal pipe is inserted. During sleep the patient breathes through the tube, while during the day the tube is covered to allow normal speech and breathing. There are considerable hygiene problems with this procedure.
This procedure is the only surgery that is guaranteed to ‘cure’ sleep apnoea.
Multi-Phase Surgery/Stanford Protocol
A relatively new concept (10/12 years old) is a series of surgical procedures pioneered by surgeons at Stanford, California (hence the name).
The Protocol involves two phases, the first of which involves Uvulopalatopharyngoplasty (UPPP) and one or more of Genioglossus Advancement or Hyoid Suspension. If this is unsuccessful, the second phase of the operation involves maxillomandibular advancement.
