For the past 25 years, I have been a practicing ear, nose, throat and sleep surgeon who is board certified in sleep medicine. I cannot recall a time where I have had so many patients come into the office wanting to ditch their CPAP (continuous positive airway pressure) machine in search of other means of sleep apnea therapy.
Directed consumer marketing has become a leading method of patient education, which thankfully brings them into the office with more informed questions and ownership of their health management. You have heard the commercials: If you have a CPAP you can get rid of your mask and hose and treat your sleep apnea with just a push of a button.
Just to make sure all are on the same knowledge level, in obstructive sleep apnea there are pauses in your breathing where airflow is diminished by 30% or more. If those events are happening 5-15 times an hour, then it is considered mild apnea; 16-30 is moderate apnea; and greater than 30 events an hour would be considered severe sleep apnea.
The gold standard of treatment of obstructive sleep apnea is continuous positive airway pressure, or CPAP. Sometimes, depending on severity of apnea, desaturation, and specific type of apnea, bilevel therapy or BiPAP may be needed to completely rid one of the respiratory events.
The CPAP machine itself delivers pressurized air to the upper airway by a hose and interface or mask. The interface or mask can range from the typical one imagined covering the nose and mouth, or a less invasive sitting in the nostril similar to an oxygen cannula.
CPAP’s huge advantage is that there is no downtime or surgical intervention that is needed, it is widely available, and for the most part it provides instantaneous relief to persons with sleep apnea. Its drawbacks are related to needing to be plugged in or the expense of the battery that is not often covered by insurance; daily cleaning and use of an externally visible interface with monthly replacement of filters; and quarterly to biannual replacement of the mask or its parts.
Oral appliance therapy is probably the second most commonly used method of treating sleep apnea. It is essentially an upper and lower dental tray that interlocks and advances the lower jaw or mandible forward. By bringing the mandible forward it brings the tongue forward, which opens up the posterior airway space.
Its advantages are that it does not require surgery or electricity, fits in a pocket, and no additional supplies are needed. It is especially desirable if the patient travels frequently, because although CPAP can be brought onto the plane without being counted as baggage or carry on, the ability to use it on a plane is limited by the need for electricity, as well the very visible mask and hose. With an oral appliance the patient can simply put it in their mouth and sleep with less snoring and apnea, which is particularly useful for transatlantic flights, especially when for business, so that you arrive feeling rested.
So who is a candidate for the cranial nerve XII stimulating implant? Upper airway stimulation implants have been around for more than 20 years, but with recent marketing they have gained tremendous patient awareness and have become more and more the subject of conversation as to patient candidacy.
What I am most often having to educate patients about who come to the office with questions is the fact that it involves surgery. In an initial surgery called a drug-induced sleep endoscopy, the physician assesses the type of airway collapse looking to see if it is concentric. This means the airway collapses as a circle narrowing and from all sides, as opposed to collapsing anterior to posterior in a more horizontal fashion.
If the collapse is concentric, the patient is not considered a candidate for the implant. For patients who are candidates, a second surgery is generally scheduled for about two hours for placement of a stimulator with a respiratory sensing lead and stimulation lead.
Generally two incisions are made, one for the stimulator on the chest wall and the other on the neck to attach the stimulator lead to the anterior division of 12 cranial nerves that cause tongue protrusion. Once the patient has healed from the surgery, over the course of the next month, the device is tested and turned on and checked for efficacy. The baseline criteria to be a candidate for consideration for the Inspire Implant upper airway stimulation is age 22 -65 years, close to ideal body weight, AHI 20 -65, failed prior attempts with CPAP or oral appliance therapy with additional hesitancy if with any other implant stimulating devices eg. Pacemaker.
The effects of untreated sleep apnea impact all aspects of life, and therefore treating it improves health and wellness on all levels. The bottom line is that sleep apnea is treatable and there are more and more methods being discovered and used to effectively treat it.
If you have daytime tiredness, hypertension that is difficult to control, atrial fibrillation, diabetes, a history of heart attacks or strokes prior to age 60, or other comorbidities, please talk to your healthcare provider to be screened for sleep apnea.
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