Sleep Disordered Breathing Treatment and Management

Treatment and Management
Weight loss in obese patients with SDB can significantly reduce or eliminate the respiratory events. For positional apnea, sewing a pocket to the back of a nightshirt and placing a tennis ball inside the pocket is a simple, noninvasive method to avoid lying in a supine position. Alcohol and sedating medications should be avoided, as these may exacerbate the severity of the apnea. Smoking cessation may help.

The treatment of choice for obstructive sleep apnea is continuous positive airway pressure (CPAP). This machine is connected by a hose to a face mask worn over the patient’s nose. Positive pressure is administered continuously at an appropriately titrated level, acting as a splint to keep the airway from collapsing during sleep. When used appropriately, CPAP is extremely effective in eliminating the respiratory events, the oxygen desaturations, the snoring, and the excessive daytime sleepiness. CPAP has also been found to improve measures such as mood, general health, fatigue, and functional status even in mild cases of SDB. However, CPAP does not cure SDB, and it must be worn every night unless another solution, such as weight loss or surgery (see following), is achieved. Compliance is therefore an important issue, and initial acceptance rate has been found to be 70% to 80%. Long-term compliance has been found to be 80% to 90%.

Surgical procedures for the correction of anatomic abnormalities of the airway have been developed for the treatment of obstructive sleep apnea. Obstructions are most often found in three major regions, including the nose, the soft palate, and the base of the tongue. Usually patients have multiple obstructions. The goal of surgery is to cure the apnea or to obtain results comparable to those observed with CPAP treatment.

Nasal reconstruction is used for the correction of obstruction in the nasal airway. Pharyngeal reconstruction, or uvulopalatopharyngoplasty (UPPP), is indicated for the correction of excess tissue in the soft palate, a large uvula, and enlarged tonsillar adenoidal tissue. Unfortunately, UPPP is only effective in about 50% of the cases. Laser-assisted uvulopalatoplasty (LAUP) is a similar procedure mostly used for the treatment of snoring. Its success rate for obstructive sleep apnea is lower than that of UPPP. Genioglossus advancement is used for obstruction at the base of the tongue, with the tongue being moved forward to enlarge the airway. UPPP combined with genioglossus advancement has a success rate of 61%. Maxillomandibular advancement is indicated for patients who do not respond to other forms of surgery. It is relatively contraindicated in the elderly population as they tend to have more risk factors such as heart disease, for example, atherosclerosis, placing them at risk for complications from this invasive surgical procedure. Tracheostomy was one of the first procedures for obstructive sleep apnea. Today it is used only for severe cases, when all else has failed, or in conjunction with UPPP.

Drug treatments for SDB have generally been only marginally successful. For central sleep apnea, respiratory stimulants such as progesterone and acetazolamide may be appropriate. For SDB associated with REM sleep, tricyclic antidepressants may be indicated, as they reduce the amount of REM, thus indirectly reducing the number of respiratory events.

Oral appliances have been developed for both obstructive sleep apnea and snoring, including the tongue- retaining device and the mandibular advancement device. Both devices are designed to enlarge the airway at the base of the tongue by advancing the tongue or the mandible forward. Although compliance rates are estimated to range between 50% and 100%, success rates (i.e., achieving a RDI < 10) are only about 50%. Thus, oral appliances are indicated for patients who do not respond to behavioral treatment such as weight loss or body position, who are intolerant to CPAP, or who are not candidates for surgery. Treatment options are based on the severity of the apnea, the patient’s medical status, the level of urgency in treating the apnea, and the patient’s own preference.

Provided by ArmMed Media
Revision date: June 21, 2011
Last revised: by Andrew G. Epstein, M.D.