Pillow Talk on Sleep Apnea Treatments

by Ryan Zantua, MD

If you have Obstructive Sleep Apnea (OSA) and you cannot tolerate continuous positive airway pressure (CPAP), what else can be done? And if all fails, what are your options? And are they as effective?

In most adults, first-line therapy for OSA consists of behavioral modification, including weight loss, if indicated, and CPAP therapy. CPAP is highly effective in treating OSA, but as many as 50% patients discontinue CPAP within the first year. When you are unable to tolerate CPAP, you are less inclined to use it. Non-adherence is generally defined as less than 4 hours of CPAP use per night, as normalizations of side effects of OSA improve with 4 or more hours of use. CPAP should be used daily and properly for it to work, but failure to do means the apnea problems will persist and even worsen. Many factors come into play when one is not adherent to treatment, including poor understanding of the importance of therapy, failure to understand instructions, lack of social support, and intolerable side effects or discomfort of CPAP. Some of these issues are correctable and avoidable if identified and corrected early, but sometimes, treatment failures are due to things that are beyond one’s control, like nasal or sinus abnormalities, claustrophobia, or daily congestion. Identifying and addressing these factors early can lead to an improvement in compliance and have a great impact in management.

For patients who fail or are unable to tolerate CPAP therapy, the choice among second-line options, including surgery and oral appliances, depends on the severity of the OSA and the patient’s anatomy, risk factors, and preferences. You may be asked to try a different kind of noninvasive ventilation, such as Auto Positive Airway Pressure (APAP) and Bilevel Positive Airway Pressure (BiPAP). The goal then is to find a suitable therapy to correct your sleep disorder. Although CPAP is considered the gold standard for OSA, it is important that an alternative be sought in the event of CPAP failure. The consequences of leaving OSA untreated are detrimental, and it would not be in your best interest to assert on using the ideal treatment if you’re unable to comply with it.

Patients who fail CPAP may benefit from a formal upper airway evaluation by a surgeon/otolaryngologist to identify surgically correctable causes. Surgery is usually reserved as a second-line therapy for OSA in patients who cannot adhere to CPAP, or as adjunctive therapy along with CPAP or an oral appliance. Given its risks and the fact that outcomes have been inconsistent, surgery is not recommended for use as initial treatment. Also, evidence regarding the effectivity of surgical intervention alone versus CPAP for OSA treatment is insufficient. Options for what type of surgery may vary depending on what is appropriate for you and would be decided upon by you and your surgeon following proper evaluation. These may include septoplasty, turbinate reduction, oropharyngeal surgery, maxillomandibular advancement surgery, and tracheostomy.

Non-surgical treatments include behavioral strategies like weight loss, positional therapy, and avoidance of alcohol and sedatives. Oral appliances (OA) can be another option, and this may include Mandibular Repositioning Appliances (MRA), which stabilize and position your jaw to maintain an open airway, or Tongue Retaining Devices (TRD) that hold the tongue in a forward position without mandibular repositioning. Although not as efficacious as CPAP, oral appliances are indicated for use in patients with mild to moderate OSA who prefer OAs to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, or fail CPAP or behavioral measures.

The desired outcome of all these modalities is the resolution of the clinical signs and symptoms of OSA and normalization of your apnea and oxygenation. Whatever option deemed suitable for you, it is very important that you are monitored well to assure that all the side effects are addressed, efficacy is documented, and comfort and adherence is assured.

Talk to your sleep specialist about all your concerns, as they have the best information and treatment alternatives suited to your situation. Often, you may need to see a multidisciplinary team that ideally would include an internist, sleep specialist/pulmonologist, respiratory therapist, otolaryngologist, and maxillofacial surgeon. Do not be afraid to ask questions. Be educated and understand your condition. Sleep apnea management is a two-way relationship, and the success in treatment not only lies on your doctors but also on you.

(Sources: Clinical Guidelines for Evaluation, Management and Long-term care of OSA in Adults, Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine; Management of obstructive sleep apnea in adults: A clinical practice guideline from the American College of Physicians)

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