Sullivan's description of the use of nasal continuous positive airway pressure (CPAP) ventilation for OSA established a "gold standard" against which other treatments can now be measured. CPAP functions as a "pneumatic splint" to maintain a patent airway, preventing pharyngeal collapse despite the negative pressure of inspiration. The effects of even a single night's treatment may be remarkable. Advances in CPAP technology include ramp settings to allow gradual increases in pressure at the start of the night, systems to maintain appropriate pressure settings despite small leaks, BIPAP (bilevel CPAP), and alternate delivery masks and apparatus. Although nasal CPAP is a mainstay of treatment, some patients are not able to adapt to it. In addition, as many as 30 percent to 40 percent of patients provided CPAP cannot be confirmed as using it on a regular basis in long-term follow-up studies.
The first reported use of an oral prosthesis to open the mouth and advance the mandible was by Robin. In 1985, the use of such a device in adults with OSA was reported by Soll and George. Three years earlier, Cartwright and Samelson described a tongue-retaining device (TRD) used to bring the tongue forward and away from the posterior pharyngeal walls.Oral Prosthesis
Menn and associates from our group have reported on our experience with 23 patients with OSA ranging from mild to severe. We treated them with an oral prosthesis, the mandibular repositioning device (MRD), and followed for a period of 27 to 36 months. Twenty reported dramatic improvement in snoring (per bed partner report). Improved daytime alertness was reported in 18 to 20 and was objectively confirmed in nine of the 12 patients tested. Our experience confirmed that the MRD provided acceptable treatment of mild to moderate OSA for a period of up to two years.
In general, use of alcohol(Drug information on alcohol) and most other CNS depressants in the hours before bedtime should be avoided. For example, Mitler and colleagues have shown that a 2 mL per kg dose of 100-proof alcohol (about 4.7 oz for a 70 kg individual) can double the number of apneas seen in asymptomatic snorers. Sedatives presumably worsen apnea by promoting relaxation of the airway musculature and by decreasing arousability. It is not clear that the benzodiazepine and imidazopyridine hypnotic agents significantly worsen apnea, but until proven otherwise these agents are best avoided by the apneic patient.
It is often erroneously assumed that all sleep apnea patients are grossly obese. Although snoring and apnea usually worsen with weight gain, weight loss alone is rarely a viable treatment option for obstructive apnea. Many patients with significant sleep apnea are thin, within a normal weight range or only mildly overweight. In these "thin" patients, oropharyngeal or mandibular/maxillofacial abnormalities are likely to be present. Even for severely overweight patients, weight loss substantial enough to reduce apnea severity is generally elusive. Many have been advised for years to reduce weight to decrease risks of hypertension, heart disease or other diseases, but have been unable to do so.
A number of surgical approaches have been tried in treatment of OSA. Septoplasty and tracheostomy have both been used but have fallen from favor, although for different reasons. Nasal surgery rarely alleviates snoring and is of less help for OSA. Although tracheostomy is effective in immediately reversing even very severe sleep apnea, it is now rarely used even when no effective alternatives are immediately available. It can be of great benefit to patients who are intolerant of or refuse to use nasal CPAP.
Uvulopalatopharyngoplasty (UPPP) surgery to remove tissue from the soft palate and oral mucosa, developed to treat snoring, has been used in OSA. Although it may provide relief for simple snoring and perhaps for mild apnea, it does not improve survival rates for patients with significant sleep apnea and has been performed with decreasing frequency as a treatment for OSA in recent years.
Laser-assisted uvuloplasty (LAUP) is a modified version of UPPP. It may reduce snoring with fewer side effects than the "scalpel" UPPP. It is not yet clear that LAUP is superior to the traditional UPPP treatment for sleep apnea. Further studies are needed to determine whether it is an acceptable alternative.
Other surgical procedures utilized in OSA include mandibular-maxillary advancement, combined with UPPP and other techniques. These procedures are usually reserved for young patients with anatomic abnormalities or patients with significant sleep apnea intolerant of or unwilling to use nasal CPAP.
Obstructive sleep apnea is a remarkably common medical disorder. Laboratory or other objective evaluation is usually needed to determine whether simple snoring or frank obstructive apnea is present, and to characterize the severity of the apnea. Great strides have been made in the development of medical and surgical therapies, so that a broad range of options is available. There is now improved likelihood of successful outcome provided by individualized treatment approaches with efficacy to reduce the long-term health risks associated with this disorder.