National Sleep Foundation

Chapter 3: Sleep-Related Breathing Disorders

Treatment

There are several possible treatments for OSAS, including:

• Positive Airway Pressure (PAP) Therapy
• Oral Pressure Therapy
• Expiratory Positive Airway Pressure (EPAP)
• Oral Appliances
• Upper Airway Surgery
• Hypoglossus Nerve Stimulation
• Behavioral Treatments

Patients are advised to refrain from driving or operating heavy machinery until their OSAS and excessive daytime sleepiness have been optimally treated. Long-term follow-up is necessary to ensure the therapies’ continued effectiveness.

Positive Airway Pressure Therapy

Positive airway pressure (PAP) is the first-line of therapy for patients with moderate or severe OSAS.1 A small blower delivers air pressurized to 5-20 cm H2O to the upper airway via a nasal mask, full-face mask, or nasal pillow (an air seal in the nostrils). The air pressure prevents the upper airway from collapsing during sleep.

This method of treatment is highly effective and has enormous health benefits when the PAP device is used consistently and as recommended. This therapy dramatically improves the quality of sleep, reduces Excessive Daytime Sleepiness (EDS)2, improves mood and function,3 and decreases the incidence of motor vehicle accidents.4

Continuous positive airway pressure (CPAP) devices deliver a single fixed pressure during both inhalation and exhalation. Some patients find it hard to sleep while using the CPAP device, however, and initial acceptance rates are only around 70 percent.5 Long-term adherence can be challenging, and studies demonstrate that up to 50 percent of patients who have initially accepted CPAP will not wear the apparatus for a full night of sleep.67 Adherence is lowest for individuals with mild OSAS, compared to those with more severe disease, because they derive least subjective benefit from CPAP.8

Bilevel positive airway pressure (BPAP) delivers a higher air pressure during inhalation (inspiratory positive airway pressure [IPAP] and a lower expiratory positive airway pressure [EPAP]). The BPAP device can sense a patient’s efforts to exhale and drops the air pressure accordingly.9 This mode of PAP therapy may be useful for patients who have difficulty exhaling against the air pressure of traditional CPAP, require high PAP settings, or develop gastric distention from swallowing air while on CPAP therapy.

Autotitrating positive airway pressure (APAP) devices provide the same pressure during inhalation and exhalation, but the setting can vary during sleep, depending on the presence or absence of apneas, hypopneas, or snoring. This minimizes the average overnight pressure, and may improve patient adherence. 10,11 In addition, APAP can be used to initially establish therapeutic pressure, avoiding a second night in the sleep laboratory.

Oral Pressure Therapy (OPT)

Oral Pressure Therapy (OPT) is a proprietorial treatment for OSA that does not use a mask. Instead, the system uses a mouthpiece fitted to the specific individual, a small vacuum console, and flexible tubing that connects the two. The system applies a light vacuum to reposition the tongue and soft palate, thereby opening the sleeper’s airway and reduces OSAS. The benefits of this system are that the individual can easily sleep in any position, and does not have to wear a mask.12

Expiratory Positive Airway Pressure (EPAP)

Another treatment development uses nasal Expiratory Positive Airway Pressure (EPAP) to treat OSAS. The nostrils are covered with a disposable adhesive valve. During inhalation, the value opens and facilitates unobstructed airflow; during exhalation, the airflow is directed into small channels, which increases resistance and creates pressure in the airway, keeping it open and minimizing OSA.

A prospective, multi-center, randomized controlled trial compared outcomes from using the nasal EPAP device vs. a sham device for three months. Among the 144 study participants, EPAP users demonstrated significantly lower Apnea-Hypopnea Index (AHI) and Epworth Sleepiness Scale (ESS) outcomes, as well as improved reports of daytime sleepiness, compared to the control group. Adherence was excellent and no negative outcomes were reported. 13

Oral Appliances

Oral appliances move the tongue or lower jaw forward and upward, which moves the tongue forward, increases the size of the upper airway, and helps the patient breath. These devices look like mouth guards, and should always be fitted by a dentist who is trained in sleep medicine.

These devices are mainly used for the treatment of patients with snoring or mild to moderate OSAS, and those for whom CPAP therapy has been unsuccessful.14 Oral appliances can treat any severity of OSAS and are better tolerated than CPAP, however.

Upper Airway Surgery

In patients with anatomical facial abnormalities that contribute to obstructed airways, maxillary-mandibular advancement may be considered to improve upper airway space.15

In severely overweight or obese patients, bariatric surgery may be considered as part of a multi-disciplinary approach to assist the patient with weight loss efforts.16

Limited information exists on the long-term outcomes of surgery with respect to OSAS. The degree of success depends on the anatomy of the upper airway and on the type of surgery.17

Hypoglossus Nerve Stimulation (HGNS)

In 2014, the Food and Drug Administration approved a new OSAS treatment using hypoglossus nerve stimulation, which is targeted at adults with moderate to severe OSAS who cannot be treated successfully with other treatments. The treatment is indicated in such patients who have a BMI of less than 32, and in whom drug induced sleep endoscopy excludes concentric obstruction of the airway during sleep.

The system is a nerve stimulator that is implanted in the patient’s chest; leads are connected to the hypoglossal nerve (cranial nerve XII), which controls tongue movement, and to a breathing sensor. The system monitors the patient’s breathing patterns and stimulates the hypoglossal nerve during inhalation in order to maintain an open airway and minimize OSA. The patient operates the system using a remote control that is activated before going to sleep and that deactivates upon waking. In the largest study published to date the median Apnea-Hypopnea Index (AHI) score decreased 68 percent. The overall rate of serious adverse events was less than 2 percent, and 98 percent of participants were still using the system at the end of the 12 months.18

Behavioral Treatments

Behavioral treatments may be successful in the milder forms of OSAS and primarily involve such lifestyle modifications as weight loss and limiting the use of alcohol or sedatives. 19

In patients with positional OSA (for whom OSA is only present when the patient sleeps in a supine position), devices may be used to help the person reposition him or herself and minimize the OSA. For example, there are several types of wearable sensors that use vibrations to train the individual not to sleep on his or her back, thereby minimizing OSAS symptoms.20

References

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  2. Redline S, Adams N, Strauss ME, et al. Improvement of mild sleep-disordered breathing with CPAP compared with conservative therapy. Am J Respir Crit Care Med. 1998;157:858-865.
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  4. Findley L, Smith C, Hooper J, Dineen M, Suratt PM. Treatment with nasal CPAP decreases automobile accidents in patients with sleep apnea. Am J Respir Crit Care Med. 2000;161:857-859.
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  13. Berry RB, Kryger MH, Massie CA, “A novel nasal expiratory positive airway pressure (EPAP) device for the treatment of obstructive sleep apnea: a randomized controlled trial,” SLEEP 2011;34(4):479-485.
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