Adult Sleep Apnea : Treatment - Lots of Options

by Food and Drug Administration (FDA)

(Page 2 of 3)

A physician can diagnose sleep apnea and suggest treatment based on the patient's complaints of daytime sleepiness, insomnia, awareness of obstructed breathing during sleep, snoring, and headache or dry mouth on waking. The physician examines the bones of the face and jaw and throat structures such as the palates, uvula and tonsils while the patient is in various positions, to see the sizes of spaces through which inhaled air can pass. X-rays may help envision how these structures lie.

Definitive diagnosis of sleep apnea depends upon the results of a battery of tests, called polysomnography, run in a sleep lab (see "Sleep Lab — First Step to Treatment"). A diagnosis of sleep apnea is made when polysomnography indicates more than five apneic episodes, of 10 seconds or longer duration per hour of sleep, plus an irregular heartbeat, frequent arousal during sleep, or dips in arterial oxygen saturation.

For mild obstructive sleep apnea, treatment often consists of avoiding sleeping on one's back, says Shepard. "Other people have a significant problem when the nose is congested, so decongestant therapy may be helpful for them. A more drastic treatment, if the patient is very overweight, is weight reduction. Also, avoid central nervous system depressants, such as alcoholic beverages or hypnotic or sedative drugs," he adds.

Most serious sleep apnea cases can be relieved by a treatment called nasal continuous positive airway pressure, or CPAP. CPAP uses a small mask held onto the nose by straps, and has pouches that insert into the nostrils. The mask is connected to a motor that regulates the amount and pressure of air sent into the nose, exerting pressure to keep the nasal passages open. The pressure is determined by polysomnography. CPAP works by holding open the nose and the back of the throat — Shepard compares it to inflating a bicycle tube.

CPAP usually brings immediate relief. Snoring stops. A smooth breathing pattern is restored. Blood oxygen levels stabilize. During the first week of CPAP therapy, the sleep pattern may still be grossly abnormal, but with peaceful stretches of sleep gradually growing, as if the body is trying to catch up. Sleep eventually settles down to a more normal pattern, often for the first time in years.

Unfortunately, many CPAP users never continue therapy beyond the first night, let alone the first week, because they find sleeping with a mask on the face uncomfortable. Colin Sullivan, M.D., the University of Sydney researcher who invented CPAP in 1981, admits that "sleeping with a nose mask and feeling the pressure sensation of CPAP, while not uncomfortable, are certainly novel experiences." Shepard points out, however, that the spouses of successful CPAP users are most grateful for the newfound silence!

Several CPAP devices have been cleared for marketing by FDA. "The typical approval process for any medical device involves the manufacturer submitting an application describing a product, and how it is similar to or different from devices that are already on the market. We determine if the new device is as safe and effective as the previous product," explains Arthur Ciarkowski, of FDA's Center for Devices and Radiological Health. Newer CPAP devices cleared for marketing by FDA attempt to make the experience more pleasant by building air pressure slowly, moisturizing the air to stem the common complaint of dry throat, and filtering out dust and pollen.

Before CPAP was invented, severe sleep apnea was treated by tracheostomy — a hole made surgically in the throat and a tube inserted to ease breathing. Choosing to live with a hole in the throat is a drastic measure, but several studies found that tracheostomy patients felt it was worth it to get complete relief from their apnea symptoms. Today, this procedure is used only in the most extreme cases, such as a person who cannot tolerate CPAP and who has severe hypertension with a high risk of heart failure due to apnea.

Other forms of surgery might provide relief for the 10 percent of patients with serious sleep apnea for whom CPAP does not work. In the nearly unpronounceable but helpful uvulopalatopharyngoplasty (UPPP), the back part of the soft palate and tissue at the back of the throat are removed, opening up more airspace. "It's like a big tonsil- adenoidectomy," says Shepard.

UPPP improves apnea in only about half the cases in which it's used, and the ways to predict who will benefit from the procedure are still controversial. "We do a skull cephalometric x-ray, which is a lateral skull film. This gives us an idea [whether] the patient has a chance of success with surgery," says Scharf. In another surgical procedure, called maxillary or mandibular advancement, the jaw is fractured and moved forward, creating more airspace.

For people with mild sleep apnea for whom first-line measures are ineffective and who dislike CPAP, another alternative is a dental device that brings the jaw forward, holds back the tongue, or raises the soft palate, or some combination of these. Dental devices, too, must be cleared for marketing by FDA. In one study of 68 patients using a dental device, researchers at the University of New Mexico in Albuquerque found 75 percent compliance after seven months, and decreased snoring and daytime sleepiness, plus a decrease in the average number of apnea events per hour from 47 to 20. Dental devices are not as consistently effective as is CPAP, according to the American Sleep Disorders Association.

Whatever treatment is prescribed, a follow-up evaluation in a sleep lab should take place within three to six months of the start of therapy. And, happily, in most cases, the person who once spent most of each night not breathing can now enjoy a blissfully restful night — and those close by can too!

About the Author

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FDA is A United States government body that oversees medical devices, including contact lenses, intraocular lenses, excimer lasers and eyedrops. In the US, these products must be approved by the FDA before they can be marketed.