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New Options Offered for Sleep Apnea
Date:5/18/2009

No 'magic bullet,' experts say, but alternatives may help some

MONDAY, May 18 (HealthDay News) -- Two new treatments -- one surgical and the other an appliance that adjusts the jaw -- might help people with sleep apnea, which has proven tough to treat.

In sleep apnea, the upper airway becomes blocked, and people stop breathing during sleep, usually in 10- to 20-second bouts that can occur 30 or more times an hour. The problem is usually treated with a device that increases air pressure in the throat, keeping the airway open. Called continuous positive airway pressure, or CPAP, the therapy involves wearing a mask attached to a machine.

Though effective, many people find it uncomfortable.

"Whilst continuous positive airway pressure is the gold standard treatment, it does not adequately serve all patients, with some that fail to tolerate treatment and others that simply refuse treatment," said Dr. Neville Patrick Shine, of St. Johns Hospital in Edinburgh, Scotland, and the lead author of a study that tested a surgical treatment for sleep apnea.

The surgery, called transpalatal advancement pharyngoplasty, enlarges the space behind the roof of the mouth.

When the obstruction is significant, "the choice may lie between surgery or no treatment, with the potential attendant cardiovascular and neurocognitive sequelae of sleep apnea," Shine said. "So in this cohort, transpalatal advancement surgery offers a reasonable treatment option."

For the study, Shine and his colleague Dr. Richard Hamilton Lewis, from the Royal Perth Hospital in Perth, Australia, reviewed the medical records of 60 people who had this surgery to treat sleep apnea.

The researchers looked for reductions in sleep disturbances and increases in the amount of oxygen in the individual's blood. With these criteria, the surgery was deemed successful in 38 people. Sleep apnea was cured in 21 people.

"One of the limitations of the procedure is the inability to accurately predict the positive responders to surgery from preoperative characteristics, and all patients undergoing this surgery must be made aware of this fact," Shine said.

"Although this surgery is not a magic bullet treatment for sleep apnea, it does have a role in those patients who have failed conservative treatment, have putative retropalatal disease and are willing to undergo surgery with no absolute guarantee of success," he said.

Dr. Jose W. Ruiz, an assistant professor of otolaryngology at the University of Miami Miller School of Medicine, noted that the surgery is only one of the surgical procedures used to treat sleep apnea.

"Most sleep apnea surgeries have success rates that range from 50 percent up to 70 percent," Ruiz said. "Most of it comes down to selecting the correct patient for the surgery and doing the right surgery. We haven't found the best surgery to do for everyone. That's why we are coming out with new techniques every year."

The ideal candidate for surgery is someone who has tried CPAP therapy but cannot tolerate it, Ruiz said. The success rate of CPAP therapy is very high, more than 90 percent, he noted.

"The problem is that only about 50 percent of the people tolerate it," Ruiz said. "So even though it works really well, most people don't use it." In fact, he said, some people have had surgery to make CPAP therapy more tolerable.

Another new study, though, offers a different alternative to surgery. Its findings are published in the May issue of Archives of Otolaryngology, Head & Neck Surgery, as is Shine's study.

The alternative tested in the study was an appliance called a mandibular advancement device, designed to prevent the airway obstruction of sleep apnea. It does this by moving the lower jaw forward.

A research team led by Dr. Chul Hee Lee, from Seoul National University Bundang Hospital and Seoul National University College of Medicine, evaluated 50 people with sleep apnea who used the device. Based on reductions in shallow or stopped breathing, the device worked in 37 of the participants, including a mix of people with mild, moderate and severe sleep apnea, the researchers found.

"The mandibular advancement device is a simple, non-invasive, easy-to-manufacture and easy-to-use device and showed good treatment outcome in nocturnal respiratory function and sleep quality in Korean patients with obstructive sleep apnea," including those with a severe condition, the researchers wrote. They described it as a "good alternative option" for anyone with obstructive sleep apnea.

However, Dr. Shirin Shafazand, an assistant professor of medicine in the Division of Pulmonary and Critical Care Medicine at the University of Miami Miller School of Medicine, said that devices such as the one tested in the Korean study, are really for people with mild sleep apnea and should be prescribed only after people have undergone sleep studies to determine the severity of their condition.

"It wasn't a surprise that there is improvement," Shafazand said. "But the numbers are too small to know whether people with severe sleep apnea will truly benefit long-term with this device."

She noted that the severity of the condition was reduced in those with severe sleep apnea, but the best result still reduced it only to the level of moderate sleep apnea.

There are a number of devices available that do the same thing, Shafazand said. But, she added, over-the-counter devices don't really work very well.

"The oral appliances that we recommend are to patients who have the sleep studies, so we know their level of severity," Shafazand said. "If their sleep apnea is mild, and they don't want to use continuous positive airway pressure therapy or can't tolerate it, we refer them to a dentist that fits them properly."

However, given the available options, Shafazand said she prefers to start most people on CPAP therapy.

"I always advise patients to try continuous positive airway pressure therapy, especially if it's moderate to severe," Shafazand said. "It's my first-line agent. If they absolutely can't do continuous positive airway pressure therapy, then oral appliances and surgery are alternatives -- but they are not perfect alternatives."

More information

The U.S. National Heart, Lung, and Blood Institute has more on sleep apnea.



SOURCES: Neville Patrick Shine, F.R.C.S., St. Johns Hospital, Edinburgh, Scotland; Shirin Shafazand, M.D., assistant professor, medicine, Division of Pulmonary and Critical Care Medicine, University of Miami Miller School of Medicine, Miami; Jose W. Ruiz, M.D., assistant professor, otolaryngology, University of Miami Miller School of Medicine, Miami; May 2009, Archives of Otolaryngology, Head & Neck Surgery


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