What are the options for treating sleep apnea?

Dr David Cunnington discusses treatment options for obstructive sleep apnea, including CPAP, mandibular advancement splints (MAS), Provent, positional treatment such as with the Night Shift device and surgery including hypoglossal nerve stimulators.

Video timeline:

  • 00:00 – 00:48 Lifestyle measures
  • 00:48 – 01:33 Continuous positive airway pressure (CPAP)
  • 01:33 – 01:54 Nasal EPAP (Provent / Theravent)
  • 01:54 – 02:23 Mandibular advancement splints (MAS)
  • 02:23 – 02:53 Hypoglossal nerve stimulator
  • 02:53 – 03:44 Positional therapy (Night Shift device)
  • 03:44 – 04:14 Managing tiredness and health risk
  • 04:14 – 05:12 Surgery

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Transcript:

What are some of the commonly used treatments for sleep apnea? Well, sleep apnea occurs because of muscle relaxation in the upper airway, often at the base of the tongue. So in general principle, the treatments need to keep the airway open when the muscles are relaxed.

Lifestyle measures: The simplest of treatments are lifestyle measures, often easy to say but hard to do; things like losing weight, ensuring we’ve got good fitness and good nutrition and not irritating the upper airway such as by smoking.I generally find those measures are helpful for milder forms of sleep apnea or when weight really is a major factor when losing weight can make a big difference to sleep apnea.

CPAP: Once we’ve addressed those lifestyle factors but we’re still having problems with sleep apnea, then one type of treatment is using devices that increase the air pressure in the back of the airway. That keeps the airway open and prevents the tongue from falling back towards the back of the airway and causing narrowing. The most well-known of those devices is something called CPAP which stands for Continuous Positive Airway Pressure.

That’s essentially a machine that sits on the bedside table and blows air down through a tube, airtight mask that fits over the nose or nose and mouth, and increases the pressure in the back of the airway. A very effective treatment for both snoring and sleep apnea but does take a bit of work getting used to.

Nasal EPEP (Provent / Theravent): A similar principle of increasing pressure in the back of the airway is a device called Provent or its snoring-related sort of brother Theravent. These are adhesive patches that go over the nostrils. As you breathe in, it feels pretty normal. But as you breathe out, there’s a one-way valve that increases the pressure and builds up a pressure in the back of the airway.

Mandibular advancement splints: Another category of treatment that’s used in the treatment of sleep apnea is treatments that bring the base of the tongue forward and hold that forward away from the back of the airway. Dental appliances such as mandibular advancement splints are the most common of these. They are custom made appliances that fit in the top and bottom teeth with the aim of holding the lower jaw forward during sleep.

They’re quite effective at holding the tongue away from the back of the airway and effective at reducing therefore snoring and sleep apnea.

Hypoglossal nerve stimulator: There has been a new surgical device approved in the United States recently, the hypoglossal nerve stimulator, which works on a similar principle. It stimulates the nerve that contracts muscles in the base of the tongue to hold the tongue forward during sleep.

Still not clear where that’s going to fit in practice in Australia because the devices are expensive, about US$20,000 and actually they weren’t tested in people with severe sleep apnea. So we’re not sure about funding and neither exactly where those devices will fit.

Positional therapy (Night Shift device): Another category of treatment for sleep apnea is avoiding sleeping on our back. For some people, sleeping on our back is what triggers sleep apnea because they have maybe mild sleep apnea or it’s all just about when they’re on their back, the gravity effect of the tongue falling towards the back of the airway. In those people, staying off the back can be enough of a treatment.

There are devices such as the Night Shift device which measures when we’re on our back, vibrates to put us on our side. I like this device because it enables us to look at the data, see how well it’s working and see how effective it has been at keeping people off their backs. There are some simpler devices such as cushions that people can construct to prevent them sleeping on their back but those type of device has never been proven to be effective beyond six weeks and my experience is a lot of people get acclimatised to them in the longer term.

Managing tiredness and health risk: Sometimes people have problems with sleep apnea such as tiredness during the day or high cardiovascular risk and aren’t able to specifically manage the sleep apnea because they have trouble with each of the treatments I’ve discussed. In that case we may use treatments such as medication to help people feel a bit more alert during the day or focusing on reducing their cardiovascular risk through modifying other risk factors such as managing their blood pressure, their cholesterol, their weight, their fitness and their nutrition.

Surgery also has a potential role in the treatment of sleep apnea. In days gone by, surgery consisted of surgical procedures on the palate such as a uvulopalatopharyngoplasty or UPPP as it’s sometimes called. What’s really done now is the UPPP alone was really not shown to be an effective surgery for sleep apnea.

However there has been some recent Australian research showing a combination procedure of a modified uvulopalatopharyngoplasty together with tonsillectomy of the tonsils present and tongue channelling coblation to reduce the volume of the base of the tongue can be an effective treatment for people with sleep apnea.

Importantly though, the more severe sleep apnea is, the less likely we are to get a good result with those surgical procedures.

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