Sleep Apnea Treatments
Available Scientific Treatments for Sleep Apnea
Introduction
Sleep apnea comes in a number of forms. One is when your throat collapses as you try to take a breath during sleep. This is called obstructive sleep apnea. The other form is when your brain delays sending a message out to take a breath. This is called central apnea. We are going to consider the treatment of the first form, that is, obstructive sleep apnea.
We breathe by making a vacuum in our lungs, by expanding the walls of our chest. This vacuum travels up our windpipe, which is made of cartilage rings so it can’t collapse, and emerges through our nose, which is made of bone so it can’t collapse. The problem is the area at the back of our mouth between the top of your windpipe and the back of your nose. That area is mostly soft tissue. If you put a vacuum in soft tissue, it will collapse. To prevent this, we have a ring of muscle surrounding this area, which we need to tighten before the vacuum arrives there. If we do this in time, the vacuum just passes through and the air that we inhale passes back down. We can then relax the muscle and rest for a moment, but then we must tighten it as soon as we start to expand our chest again. If we don’t tighten the muscle fast enough and the vacuum gets there first, then our throat will collapse. That is called apnea.
The obstruction in our throats, therefore can come from the slowness of our muscles or from something inside your throat passage that blocks it when there is a small contraction as the vacuum passes through that area. Enlarged tonsils may do this.
The goal of the treatment is obviously to get rid of the obstruction so one can breathe freely. Tonsils can be cut out but getting our muscles to work better is another story. We have three major ways of trying to prevent our throats from collapsing because our muscles are not working properly. We have one general way of trying to make more space in our throats.
The Three Specific Treatments
1) Surgery
i) Surgery to your soft palate
a) What is it? This is a surgical procedure that removes your uvula (that little bit of tissue that hangs down in the back of your throat) and trims back your soft palate. This can be done with a scalpel, or a laser scalpel, or with radio waves. This prevents your soft palate from falling back and blocking your airway.
b) Outcome: Not very successful; there is usually only about a 50% improvement.
Problems: The healing process can be quite painful. One usually needs to go on a narcotic analgesic for a few weeks.
c) Costs: It is quite expensive as it is not funded – it costs about $1,300.
d) Advantages: Its value is that if it works you do not have to use a gadget to sleep at night.
ii) Surgery to your stomach – various kinds. They are usually very effective in producing a very rapid and large weight loss, which often stays off.
2) Oral appliance (OA)
i) What is it? It is an appliance, a bit like a hockey mouthguard, that fits over your upper and lower teeth. The upper plate is connected to the lower one and this allows us to move your lower jaw forwards and hold it there while you sleep. This prevents your throat from collapsing. It also gets rid of the snoring. Oral appliances can be obtained from a dentist or denturist. The dentist will fabricate the device for you and then slowly titrate your jaw forwards over a few weeks or months. Once your symptoms and signs of sleep apnea settle, then the Sleep Lab will do a home study on you to see if the apnea has settled satisfactorily. If it seems to have then an in-lab study will be arranged to ensure that the apnea is properly settled. If the home sleep study indicates significant residual apnea then the dentist will continue to advance the device. Eventually an in-lab study will be done to prove efficacy.
ii) Outcome: 70-80% success rate for the apnea; 90% success for snoring.
iii) Costs: Anything from $900 to $3,000. Most, although not all, insurance companies fund it.
iv) Problems: It can hurt your jaw joint. This will most frequently happen in the first week or two of use if it is going to occur. It usually means that you cannot go on with it and will have to change to a different treatment modality. It is a significant problem, but it is rare. About 1% of patients stop using the OA because of this. OA’s also often cause your teeth to move if used for a long period of time. The movement, however, is usually small (about 0.5 mm) and thus not of any consequence. Some patients though can have a lot of movement and throw off their bite in the process. Your dentist will follow you up and watch your bite to ensure the movement does not cause you any difficulty. Other minor problems include sore teeth in the beginning, mouth abrasions, dry mouth, and general discomfort. To use the OA, you need to not have a history of jaw (TMJ) pain, to have your own teeth (partials are OK, but complete dentures prevent OA use), and there must be no problematic gag reflex.
v) Advantages: It is simple to use, simple to clean, and simple to transport. It usually settles the sleep apnea in 70-80% of appropriately selected patients.
3) Positive Airway Pressure (PAP) machine
i) What is it? This is an air pump. It pumps air under pressure into the back of your throat keeping it open. A PAP machine is fairly small these days, is quiet (only making white noise – the swishing of a fan) and stands on your bedside table. Room air, which is filtered by the machine, passes through a humidifier and then through a hose to a delivery system (a mask) that directs the air through your nose, mouth, or both to the back of your throat. There, if the air pressure is correct, it will stop your throat from collapsing when you try to take a breath. You will sleep in the lab one more night. We will put a PAP machine on you and slowly raise the pressure through the night until we find the lowest pressure that settles your apnea, normalizes your oxygen levels, and gets rid of your snoring. Some patients will need to get the machine before they come for their night titration study in order to get used to breathing on a PAP machine, most patients can just come for the night study. Patients will receive from the lab a prescription that will allow them to buy the machine, a pressure to which the machine will be set, and a list of respiratory companies in their local area who sell PAP machines.
ii) Outcome: 90% plus success rate.
iii) Cost: The Government pays about 75% of the cost of the machine (excluding the costs for the associated equipment, namely the hose, mask, and headgear); if you have medical insurance, it will usually pay 80-100% of the rest, and you will have to pay the remainder that may be about $100-$200. If you do not have medical insurance, it will cost you about $150, if you are just buying a new machine and no PAP equipment but about $500 if you have to purchase the equipment as well. Respiratory Companies may consider an instalment plan if you ask them, so you do not have to pay it in a lump sum. Respiratory companies may also offer you caretaker/service plans that will cover future costs for some years. Patients on disability (ODSP, OW) and military patients do not have to pay anything for the machine and related equipment.
iv) Problems: You have to learn how to use the machine. Success with a PAP machine mostly depends upon your attitude. If you think, “For the rest of my life I have to sleep with this thing stuck to my face!” then you are going to have trouble. If you understand that sleep apnea is a chronic disease that has many negative consequences for your daily functioning, for your general health, and for your longevity, and that it is going to happen to you every night, then using a PAP machine nightly is greatly to your advantage. You can go to bed every night for the rest of your life, choke yourself repeatedly, drop your oxygen levels, stress your brain, heart, and other body organs and threaten your life, or you can use a PAP machine and have a good sleep without these breathing-related problems.
If your attitude is right, then there are basically four things you have to learn:
a) How to use the humidifier – the Respiratory Company will teach you how to adjust the temperature and how to fill the humidifier properly. The humidifier is for your comfort. You only need to use it if your mouth/nose gets dry or too moist. Distilled water is only to prevent salts from precipitating onto the metal/heat plate in your water reservoir. So, if you go somewhere that does not have distilled water, use “safe” tap water or bottled water. Clean the metal plate in your water reservoir when you get home.
b) How to adjust the headgear properly – if it is too tight, you will hurt yourself (red nose, ulcers on nose, mask tracks on your face; if too loose, it will leak. You need to find the Goldilocks’ zone to get it right.
c) How to roll around in bed without knocking your mask off. Essentially this involves fixing your pillow. You need to get a pillow that does not bulge up to far on the sides of your head; if so, try a thinner pillow. You can also buy pillows from your Respiratory Company with cutaways on the sides. If leaking is a big problem, check it out in the daytime when you are wide awake. Turn your bedclothes back; put your mask on and turn on your machine. Now practice rolling from side-to-side. Find out what is too far; when does it start leaking. If your pillow is bulging up, then proceed as above. When you turn your head, might also bump it against your hand if you sleep with it up under your cheek? Check whether your hose is pulling the mask and making it leak. If so, you can buy a mask elevator. The HoZer is a good one. You can check them out online or see what your Respiratory Company has. Another cause for leaks can be identified as follows. Lie flat on your back and just turn your head from side-to-side – the friction of your headgear against your pillow may be causing the problem. If so, change your pillow slip to a smoother one or buy a slider for your mask. Finally, it may be the mask that is not fitting your face well. Go to your respiratory company and try other masks. Remember the one-month warranty you get from your manufacturing company that allows you to replace your mask within one month for another one at the same price for no fee.
d) How to get your brain to ignore this “thing” (your mask) stuck to your face. To do this quickly, it is most important that for the first few nights that you use the machine, you should try not to take it off. Your brain will wake you up every hour or so, telling you there is something stuck to your face and “get rid of it”. Resist this. If you start taking it off and going back to sleep without it, you will sensitize your brain to the presence of the mask, and it will continue waking you up. Be careful about telling yourself, “Well that is enough for tonight, I will try to use it longer tomorrow”. You will likely just train your brain to continue giving you a disruptive sleep.
If you spend a few bad nights struggling with it and not taking it off, your brain will learn quickly to ignore it and your nights will become more comfortable. If you keep on taking it off, you will have weeks even months of difficulty. If you say “I can’t get to sleep or back to sleep with it on” then you have let your brain win. You have to discipline it. It is trying to protect you, but it will always adjust to its circumstances if you insist on it. The sooner you insist on it, the sooner it will become comfortable.
Remember, when you wake up in the middle of the night and consider not putting it back on for the rest of the night, your choice isn’t having a more comfortable or less comfortable night, it is whether you want to “suffocate” yourself for the rest of the night or not. The more often you do do not put it back on, the longer it takes to get comfortable using it. And many patients discontinue their PAP therapy because they don’t help their brain to adjust to having this weird thing stuck on their face.
Patients often think they are waking up so frequently because of mask discomfort, leaks, or pressure that it too high. Sometimes, it is one of those things; many times, it is just your brain that is waking you up saying, “Get this off my face”. You can spend a lot of time and money trying and buying different masks and headgear.
If you are very anxious having a mask on your face, it is likely that you are claustrophobic. We can help you with this. Don’t just give up. Don’t think, “I have never been able to tolerate things on my face. I can’t do it.” I can help you get around this; help you to get your comfortable with the mask before you have to sleep with it on your face. Call the Lab and get an appointment to deal with this.
v) Advantages: This is very effective treatment and it gives you a whole lot of extra oxygen. It pumps more air into you when you breathe than you would normally inhale. This is very helpful to have, especially if your oxygen levels are low to begin with or if you are getting into your 60’s or above when every bit of oxygen counts. It is a treatment system that you will be able to use for your whole life, as it can usually treat all levels of sleep apnea and apnea tends to get worse with age and, especially, with increasing weight. PAP treatment can make you feel very much better and keep you feeling well for years to come.
One General Treatment
Weight loss and the Maintenance of Weight Loss
If you are overweight, then losing weight and keeping it off can be very beneficial for the apnea. It can significantly reduce the apnea frequency and occasionally even stop all the obstructions, which is a cure. However, this is difficult to do in our society and doing it effectively requires a long commitment of time. Using one of the methods of treatment above initially while one works on one’s weight is the sensible, practical step.
I will discuss which treatments are suitable for you during our interview.