Behavioral changes,
Medications,
Dental appliances,
Surgeries,
CPAP (continuous positive airway pressure).
Medications,
Dental appliances,
Surgeries,
CPAP (continuous positive airway pressure).
Behavioral changes
Behavioral changes are the simplest treatments for mild obstructive sleep apnea, but often the hardest to make. Occasionally, apneas occur only in some positions (most commonly lying flat on the back). A person can change his or her sleeping position, reduce apneas, and improve their sleep.
Obesity is a contributing factor to obstructive sleep apnea. A healthy lifestyle and diet that encourages weight loss will improve obstructive sleep apnea. Unfortunately, most people with obstructive sleep apnea are tired and do not have much energy for exercise. This is a difficult behavioral spiral since the more tired a person is -- the less they exercise -- the more weight they gain -- the worse the obstructive sleep apnea becomes -- and the more tired they become. Frequently, after obstructive sleep apnea is treated by other methods, people are able to lose weight, and the obstructive sleep apnea improves.
Behavioral changes are the simplest treatments for mild obstructive sleep apnea, but often the hardest to make. Occasionally, apneas occur only in some positions (most commonly lying flat on the back). A person can change his or her sleeping position, reduce apneas, and improve their sleep.
Obesity is a contributing factor to obstructive sleep apnea. A healthy lifestyle and diet that encourages weight loss will improve obstructive sleep apnea. Unfortunately, most people with obstructive sleep apnea are tired and do not have much energy for exercise. This is a difficult behavioral spiral since the more tired a person is -- the less they exercise -- the more weight they gain -- the worse the obstructive sleep apnea becomes -- and the more tired they become. Frequently, after obstructive sleep apnea is treated by other methods, people are able to lose weight, and the obstructive sleep apnea improves.
Medications
Many medications have been studied for obstructive sleep apnea; however, because obstructive sleep apnea is due to an anatomic airway narrowing, it has been difficult to find a medication that will help. In people with nasal airway obstruction causing obstructive sleep apnea, nasal steroid sprays have been shown to be effective. Topical nasal decongestants, like oxymetalizone and neosynephrine, also can temporarily improve nasal swelling. The problem is that they cannot be used for more than 3-5 days without decreased effectiveness and withdrawal symptoms.
People who have obstructive sleep apnea secondary to hypothyroidism (low thyroid hormone production) improve with thyroid replacement therapy. However, people with normal thyroid function, will not improve with this therapy.
People who have obstructive sleep apnea due to obesity may improve with diet medications, if they are effective in helping them lose weight.
There are also new medications to help increase alertness. They may be temporarily successful in increasing attention; however, they do not treat the sleep deprivation or the cause of obstructive sleep apnea.
People who have obstructive sleep apnea secondary to hypothyroidism (low thyroid hormone production) improve with thyroid replacement therapy. However, people with normal thyroid function, will not improve with this therapy.
People who have obstructive sleep apnea due to obesity may improve with diet medications, if they are effective in helping them lose weight.
There are also new medications to help increase alertness. They may be temporarily successful in increasing attention; however, they do not treat the sleep deprivation or the cause of obstructive sleep apnea.
Dental appliances
A dental appliance holds the jaw and tongue forward and holds the palate up thus preventing closure of the airway. This small increase in airway size often is enough to control the apneas. Dental appliances are an excellent treatment for mild to moderate obstructive sleep apnea. It is reported to be about 75% effective for these groups. A dental appliance does not require surgery; it is small, portable, and does not require a machine. A dentist is needed to fit and adjust the appliance. A dental appliance requires natural teeth to fit properly and must be worn every night.
Continuous positive airway pressure (CPAP)
Continuous positive airway pressure (CPAP) is probably the best, non-surgical treatment for any level of obstructive sleep apnea. CPAP uses air pressure to hold the tissues open during sleep. As a person breathes, the gentle pressure holds the nose, palate, and throat tissues open. The CPAP machine blows heated, humidified air through a short tube to a mask. The mask must be worn snugly to prevent the leakage of air. The CPAP machine is a little larger than a toaster. It is portable and can be taken on trips. .
Determining CPAP pressure.
With CPAP it is important to use the lowest possible pressure that will keep the airway open during sleep. This pressure is determined by “titration.” Titration frequently is performed with the help of polysomnography. In the sleep laboratory, an adjustable CPAP machine is used. A mask is fit to the subject, and he or she is allowed to fall back asleep. During baseline sleep, the apneas and hypopneas occur. The technician then slowly increases the CPAP pressure until the apneas and hypopneas stop or decrease to a normal level. A different pressure may be needed for different positions or levels of sleep. Typically, laying on the back and REM sleep promote the worst obstructive sleep apnea. The lowest pressure that controls obstructive sleep apnea in all positions and sleep levels is prescribed
With CPAP it is important to use the lowest possible pressure that will keep the airway open during sleep. This pressure is determined by “titration.” Titration frequently is performed with the help of polysomnography. In the sleep laboratory, an adjustable CPAP machine is used. A mask is fit to the subject, and he or she is allowed to fall back asleep. During baseline sleep, the apneas and hypopneas occur. The technician then slowly increases the CPAP pressure until the apneas and hypopneas stop or decrease to a normal level. A different pressure may be needed for different positions or levels of sleep. Typically, laying on the back and REM sleep promote the worst obstructive sleep apnea. The lowest pressure that controls obstructive sleep apnea in all positions and sleep levels is prescribed
Effectiveness of CPAP.
CPAP has been shown to be effective in improving subjective and objective measures of obstructive sleep apnea.
It decreases apneas and hypopneas.
It decreases sleepiness as measured by surveys and objective tests.
It improves cognitive functioning on tests.
When adjusted properly and tolerated, it is nearly 100% effective in eliminating or reducing obstructive sleep apnea.
It decreases apneas and hypopneas.
It decreases sleepiness as measured by surveys and objective tests.
It improves cognitive functioning on tests.
When adjusted properly and tolerated, it is nearly 100% effective in eliminating or reducing obstructive sleep apnea.
Bi-level positive airway pressure (BiPAP)
Bi-level positive airway pressure (BiPAP) was designed for people who do not tolerate the higher pressures of CPAP. It is similar to CPAP in that a machine delivers a positive pressure to a mask during sleep. However, the BiPAP machine delivers a higher pressure during inspiration, and a lower pressure during expiration. That allows a person not to feel like they are breathing out against such a high pressure, which can be bothersome. It is most helpful for people who require a higher pressure to keep their airway open.
Auto-titrating continuous positive airway pressure
A new development in sleep apnea treatment is the auto-titrating CPAP machine. These “smart” CPAP machines make pressure adjustments throughout the night. At a given pressure, if a person starts to have an apnea or hypopnea, the machine adjusts the pressure higher until the episodes are controlled. If a person is in a sleep level or position that doesn’t need a higher pressure, the pressure is reduced.
A new development in sleep apnea treatment is the auto-titrating CPAP machine. These “smart” CPAP machines make pressure adjustments throughout the night. At a given pressure, if a person starts to have an apnea or hypopnea, the machine adjusts the pressure higher until the episodes are controlled. If a person is in a sleep level or position that doesn’t need a higher pressure, the pressure is reduced.
Surgical treatments for obstructive sleep apnea
There are many surgical options to treat obstructive sleep apnea. The type of surgery that is chosen is dependent on an individual’s specific anatomy and severity of sleep apnea. People often want surgery because it promises a cure with a single treatment. Surgery sounds easier than losing ten pounds and more convenient than wearing a dental appliance or mask every night.
However, surgery should be considered only after all the risks, benefits, and alternatives to surgery are understood. For example, CPAP, if tolerated, controls most sleep apnea, and this is better than all surgical options. It is difficult to have a serious, permanent complication using CPAP as compared to the possible of such a complication with surgery.
Any surgical treatment for sleep apnea must address the anatomic problem areas. There may be one or several areas that compromise airflow and cause apnea. Surgical treatments can address the nose, palate, tongue, jaw, neck, obesity, or several of these areas at the same time. Each surgery’s success rate is determined by whether or not a specific airway collapse is prevented. Therefore, the ideal surgery is different for each patient and depends on each patient's specific problem. Some surgical options include:
However, surgery should be considered only after all the risks, benefits, and alternatives to surgery are understood. For example, CPAP, if tolerated, controls most sleep apnea, and this is better than all surgical options. It is difficult to have a serious, permanent complication using CPAP as compared to the possible of such a complication with surgery.
Any surgical treatment for sleep apnea must address the anatomic problem areas. There may be one or several areas that compromise airflow and cause apnea. Surgical treatments can address the nose, palate, tongue, jaw, neck, obesity, or several of these areas at the same time. Each surgery’s success rate is determined by whether or not a specific airway collapse is prevented. Therefore, the ideal surgery is different for each patient and depends on each patient's specific problem. Some surgical options include:
nasal airway surgery,
palate implants,
uvulopalatopharyngoplasty,
tongue reduction,
genioglossus advancement,
hyoid suspension,
maxillomandibular procedures,
tracheostomy,
bariatric surgery, and
combinations of the above.
palate implants,
uvulopalatopharyngoplasty,
tongue reduction,
genioglossus advancement,
hyoid suspension,
maxillomandibular procedures,
tracheostomy,
bariatric surgery, and
combinations of the above.
Many people have several levels of obstruction; therefore these surgical techniques frequently are performed together, for example, uvulopalatopharyngoplasty with genioglossus advancement and hyoid suspension.
Nasal airway surgery
The nasal cavity can be obstructed by swelling of the turbinates, septal deviation, and nasal polyps. Surgeries to address each of these potential causes of obstruction can improve the flow of air through the nasal passages. Nasal surgery is most successfully used for sleep apnea to improve the effectiveness of CPAP.
The nasal cavity can be obstructed by swelling of the turbinates, septal deviation, and nasal polyps. Surgeries to address each of these potential causes of obstruction can improve the flow of air through the nasal passages. Nasal surgery is most successfully used for sleep apnea to improve the effectiveness of CPAP.
Palate implants
Palate implants stiffen the palate. They prevent the palate from collapsing into the pharynx where it can obstruct the airway. They also decrease the vibrations of the palate that cause snoring.
Palate implants stiffen the palate. They prevent the palate from collapsing into the pharynx where it can obstruct the airway. They also decrease the vibrations of the palate that cause snoring.
Uvulopalatopharyngoplasty (UPPP)
Uvulopalatopharyngoplasty (UPPP) is a long and fancy term to describe a surgery aimed at preventing collapse of the palate, tonsils, and pharynx which is common in sleep apnea. UPPP is most successful in patients who have large tonsils, a long uvula (the most posterior part of the palate that hangs down in the back of the throat), or a long, wide palate. It also is more successful in patients who are not obese. In simple terms, the tonsils are removed, the uvula is removed, and the palate is trimmed higher. A UPPP is successful 50-60% of the time in preventing or decreasing obstructive sleep apnea.
Uvulopalatopharyngoplasty (UPPP) is a long and fancy term to describe a surgery aimed at preventing collapse of the palate, tonsils, and pharynx which is common in sleep apnea. UPPP is most successful in patients who have large tonsils, a long uvula (the most posterior part of the palate that hangs down in the back of the throat), or a long, wide palate. It also is more successful in patients who are not obese. In simple terms, the tonsils are removed, the uvula is removed, and the palate is trimmed higher. A UPPP is successful 50-60% of the time in preventing or decreasing obstructive sleep apnea.
Tongue reduction surgery
In some people with obstructive sleep apnea, the area of collapse is between the base of the tongue and the back wall of the throat (pharynx). Several surgeries have been used to decrease the size of the base of tongue and to open the airway. Most of these procedures are performed as an addition to other surgical procedures.
In some people with obstructive sleep apnea, the area of collapse is between the base of the tongue and the back wall of the throat (pharynx). Several surgeries have been used to decrease the size of the base of tongue and to open the airway. Most of these procedures are performed as an addition to other surgical procedures.
Genioglossus advancement
The genioglossus muscle is the muscle that attaches the base of the tongue to the inside front of the jaw bone. The genioglossus pulls the tongue forward. In people with obstructive sleep apnea, it has been shown that the genioglossus is more active in holding the airway open at rest. When this muscle relaxes during sleep, the airway narrows and collapses. A genioglossus advancement typically detaches the part of the jaw bone where the muscle attaches and moves it forward about 4 mm. This pulls the base of the tongue forward. This usually is performed in combination with hyoid suspension or UPPP.
The genioglossus muscle is the muscle that attaches the base of the tongue to the inside front of the jaw bone. The genioglossus pulls the tongue forward. In people with obstructive sleep apnea, it has been shown that the genioglossus is more active in holding the airway open at rest. When this muscle relaxes during sleep, the airway narrows and collapses. A genioglossus advancement typically detaches the part of the jaw bone where the muscle attaches and moves it forward about 4 mm. This pulls the base of the tongue forward. This usually is performed in combination with hyoid suspension or UPPP.
Hyoid Suspension
The hyoid bone helps support the larynx and tongue in the neck. It is located below the mandible and tongue, but above the laryngeal cartilages. It is not directly attached to any other bones, but rather is attached to strap (tongue) muscles above and below. The strap muscles elevate or depress the larynx during swallowing. As part of a surgery to bring the tongue and soft tissues up and forward, the hyoid bone may be suspended. This is usually performed with other surgical procedures like UPPP or genioglossus advancement. In general, the hyoid bone is sutured up closer to the mandible. This pulls the tongue forward and up.
The hyoid bone helps support the larynx and tongue in the neck. It is located below the mandible and tongue, but above the laryngeal cartilages. It is not directly attached to any other bones, but rather is attached to strap (tongue) muscles above and below. The strap muscles elevate or depress the larynx during swallowing. As part of a surgery to bring the tongue and soft tissues up and forward, the hyoid bone may be suspended. This is usually performed with other surgical procedures like UPPP or genioglossus advancement. In general, the hyoid bone is sutured up closer to the mandible. This pulls the tongue forward and up.
Maxillomandibular advancement
Maxillomandibular advancement is a surgical procedure that moves the jaw and upper teeth forward. This pulls the palate and base of the tongue forward and opens the airway. This procedure is best suited for a thin patient with a small jaw. Both the jaw and maxillary bones are cut, moved forward, realigned, and plated into place.
Maxillomandibular advancement is a surgical procedure that moves the jaw and upper teeth forward. This pulls the palate and base of the tongue forward and opens the airway. This procedure is best suited for a thin patient with a small jaw. Both the jaw and maxillary bones are cut, moved forward, realigned, and plated into place.
TracheostomyA tracheostomy is a procedure to bypass the narrowed airway. If the obstruction to airflow is occurring above the larynx, a tracheostomy can be inserted to direct airflow directly into the trachea. The tracheostomy tube is passed through the skin of the lower neck directly into the trachea. Tracheostomy generally is reserved for morbidly obese patients with severe obstructive sleep apnea who are not candidates for other treatments. They usually can keep the tracheostomy tube capped during the day while breathing normally through their nose and mouth, and then open the tracheostomy tube at night. That way, they will have a normal voice and mouth breathing while awake, and breathe through the tracheostomy tube only at night.
A tracheostomy can be a temporary procedure, and is kept in place only as long as it is needed. It is easy to remove the tube, and the body will usually heal the skin and close the opening rather quickly. Tracheostomy has close to a 100% rate of cure for obstructive sleep apnea because it bypasses the problem in the upper airway. In mixed sleep apnea, obstructive apneas resolve immediately, but central apneas, which are due to metabolic changes caused by the obstructive apneas, usually take some time to resolve.
Bariatric surgery
This is a surgery on the stomach and/or intestines to help a person with extreme obesity lose weight. There are two main types of bariatric surgery, adjustable gastric banding and gastric bypass. In adjustable gastric banding, insertion of a band restricts the size of the opening from the esophagus to the stomach. The size of the opening to the stomach determines the amount of food that can be eaten and can be controlled by the surgeon by inflating or deflating the band through a port that is implanted beneath the skin on the abdomen. The band can be removed at any time.
Gastric bypass is a permanent reduction in the size of the stomach. The proximal portion of the stomach is used to create an egg-sized pouch that is connected to the intestine in a location that bypasses about 2 feet of normal intestine. The amount of food that can be eaten is limited by the size of the pouch and the size of the opening between the pouch and the intestine.
It is effective for sleep apnea caused by or worsened by obesity. Bariatric surgery is associated with a marked reduction in weight post-operatively. Bariatric surgery is only an option for morbidly obese patients with severe obstructive sleep apnea. It must be noted that patients can regain the weight they lost after surgery.
Note: Difference in Goals of treatment for snoring vs. sleep apnea
The treatments for obstructive sleep apnea are similar to the treatments for snoring.
It must be noted that snoring, without the presence of obstructive sleep apnea generally does not pose much of a problem to the patient. However, snoring may and usually is a problem for the bed partner or roommate. Therefore, successful treatment should include the goal of achieving a successful night’s sleep for the other person. This makes treatment of snoring a difficult challenge. For example, someone may have a successful treatment if their snoring decreases from a jackhammer level to that of a passing truck. If their bed partner is happy, then the snoring problem is “cured.” However, another person whose snoring decreases from a mild sound to the level of heavy breathing may still have an unhappy bed partner. Hence, the successes of treatments for snoring are subjective to each particular case.
This is a surgery on the stomach and/or intestines to help a person with extreme obesity lose weight. There are two main types of bariatric surgery, adjustable gastric banding and gastric bypass. In adjustable gastric banding, insertion of a band restricts the size of the opening from the esophagus to the stomach. The size of the opening to the stomach determines the amount of food that can be eaten and can be controlled by the surgeon by inflating or deflating the band through a port that is implanted beneath the skin on the abdomen. The band can be removed at any time.
Gastric bypass is a permanent reduction in the size of the stomach. The proximal portion of the stomach is used to create an egg-sized pouch that is connected to the intestine in a location that bypasses about 2 feet of normal intestine. The amount of food that can be eaten is limited by the size of the pouch and the size of the opening between the pouch and the intestine.
It is effective for sleep apnea caused by or worsened by obesity. Bariatric surgery is associated with a marked reduction in weight post-operatively. Bariatric surgery is only an option for morbidly obese patients with severe obstructive sleep apnea. It must be noted that patients can regain the weight they lost after surgery.
Note: Difference in Goals of treatment for snoring vs. sleep apnea
The treatments for obstructive sleep apnea are similar to the treatments for snoring.
It must be noted that snoring, without the presence of obstructive sleep apnea generally does not pose much of a problem to the patient. However, snoring may and usually is a problem for the bed partner or roommate. Therefore, successful treatment should include the goal of achieving a successful night’s sleep for the other person. This makes treatment of snoring a difficult challenge. For example, someone may have a successful treatment if their snoring decreases from a jackhammer level to that of a passing truck. If their bed partner is happy, then the snoring problem is “cured.” However, another person whose snoring decreases from a mild sound to the level of heavy breathing may still have an unhappy bed partner. Hence, the successes of treatments for snoring are subjective to each particular case.
Note: Central Sleep Apnea
In adults with central sleep apnea, the apneas are treated by treating the underlying heart disease, medication interaction, high altitude, or other primary problem.
In adults with central sleep apnea, the apneas are treated by treating the underlying heart disease, medication interaction, high altitude, or other primary problem.
Source: Medicinenet.com
Contributed by John Lee
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