Sleep Apnea Treatment

Treatments

The sleep apnea syndrome because of its high prevalence, comorbidity, high economic costs and obvious decline in quality of life of patients is a health problem of first order, that requires investment in specific treatments. The economic impact associated with low employment and high consumption of health system resources, amounting to OSAHS priority to the forefront of medical and public health problem. Developments in treatment response to growing demand and fortunately increases more and more the number of cases diagnosed OSAHS subsidiary to receive treatment.

All treatments for snoring and sleep apnea are governed by a common goal, to increase the diameter of the calibre and reduce the resistance of the UA ensuring an immediate improvement in patients' quality of life recovering normal sleep patterns and reducing health risks to their apneic events triggered by increasing life expectancy. OSAHS treatment varies according to the specific conditions of each patient and can include conservative treatments such as weight loss, postural changes or the surgery. Current therapies consist of positive pressure ventilation (PPV), surgical techniques (uvulopalatopharyngoplasty) and intraoral prosthesis. For patients, who require non-invasive treatments, oral appliances are an effective method with more acceptable results.

The treatments for sleep breathing disorders attempted to remedy the wide spectrum of symptoms attached to the disease, ranging from simple snoring to OSA in its most severe expresion. The cut of 30 episodes per hour has been used to qualify the severity of the disease, that was refined in recent years. The practice is endorsing some evidence indicating, that an AHI higher than 15 can be a cardiovascular risk factor independently of the rest of the symptom picture. In this regard, the recommendations of the American Academy of Sleep Medicine recommend prescribing CPAP treatment when there is an IAR ≥ 15, regardless of the presence of symptoms, or an IAR ≥ 5, with excessive daytime sleepiness.

Once finalized the diagnosis an appropriate treatment plans should be prescribed to offset as far as possible associated symptoms, so that the patient could regain normal sleep patterns and desaturation. The chosen treatment should be the most flattering option for the patient taking into account the severity of the disease, clinical peculiarities, personal constraints and findings in the examination conducted by the medical team. The therapeutic alternatives for snoring and OSA are not mutually exclusive and the choice of treatment allows a multidisciplinary approach. There is no single effective treatment option, the decision will always have to be agreed between doctor and patient under the patient characteristics and feasibility of options.

Treatment strategies cover a wide range of possibilities, from the so called conservative option, modification of postural habits, significant weight reduction or correction of poor sleep hygiene to more invasive surgical options for patients with ENT anomalies and unresponsive to other treatments. The factors related to patients personal circumstances, such as the location of the pharyngeal region, where the collapse occurs, the craniofacial characteristics, dental health, obesity, age, occupation and the dependence of the episodes to the position sleep, as well as treatment-related factors should be evaluated before submitting a final proposal and before choosing between the alternatives. Successful treatment are those, who achieve remission of symptoms during the day, reducing the number of respiratory events per hour and the normalization of blood gases and sleep quality.


Conservative Measures
The general measures are indicated in cases of patients with mild OSA are not serious and the modification of dietary habits and hygiene has achieved remission of clinical symptoms. These measures promote healthy living habits to correct situations, that favor the collapse. These exogenous factors are weight loss, suppression of tobacco, alcohol and sedatives and regular physical exercise.

Weight reduction
Excess weight is present in 60-90% of patients with OSAHS diagnosis, therefore, weight reduction is the first action to be recommended to overweight OSAHS patients. In many patients, a reduction of 5-10% leads to a significant decrease in the number of apneas and normalization of hypoxia. Weight reduction as a unique action does not eliminate the problem by itself, but the transfer of the severity of symptoms improves the clinical picture of patients and is beneficial as a general measure or action before using any of the other treatment options. Obesity is associated with the accumulation of fat in the neck, that has an impact on reducing the size of the UA. A weight loss reduces these deposits and this may ease the resistance by increasing pharyngeal caliber. Bariatric surgery may be an adjunct in the treatment of OSAS in obese patients.

Sleep Hygiene
The healthy sleep routines are some orienting guidelines, so that the rest period could be possibly the most construvtive. These routines at bedtime are those that the literature called "sleep hygiene." A daily changing practices of rest, some additional recommendations on the removal of toxic habits such as smoking, alcohol and certain drugs, all aggravating the symptom picture of OSAHS and snoring. The abandonment of tobacco should be a general priority measure in snorers and OSAHS bearers, because of the irritating and secondary inflammatory consequences leading to an increased resistance of the UA. For its part, the consumption of alcohol has a depressive effect on the pharyngeal muscles and may cause a situation of insufficient pharyngeal tone, that predisposes to collapse.

Positional Therapy
In cases of mild OSA, recurrent episodes of respitatory flow interruption and snoring are subject to a component, that takes the patients posture during sleep. The supine position is aggravating to the occurrence of obstructive events by the action of gravity on the soft tissues of the pharynx, that reduces pharyngeal light to fall. As mentioned above, there are postures, that favor more than others the collapsibility of the UA. The supine position causes a backward traction of the soft tissues of the upper airway, that predisposes to collapse. There are postural treatment works for people to remain during sleep in positions in which the action of gravity does not cause displacement reducing pharyngeal caliber. There are many cases of patients with simple snoring and non severe snoring, where the snoring image occurs only in the supine position showing the importance of night posture. In these cases, the goal is not to favorize these positions dueing to snoring and finally to the OSAHS. Apneas occur more easily in supine than in lateral decubitus or prone. It should be recommend the lateral decubitus position (lying on its side) or prone (face down). The ideal position would be sleeping on your stomach (prone) head resting on the arm, thereby encouraging the lower jaw, tongue and soft palate tend towards the front, clearing the upper airway. In practice, this position is uncomfortable at night, so experts recommend lateral, which is better tolerated at the hour of sleep. To change postural habits in patients, multiple devices are designed like the primitive ball to the back (snoring ball) to modern electrical systems, that cause mild shocking to the patient forcing him to change his position. These "antisupino"measures can’t cure snoring in no case but they awake snoring patient, even more disturbing sleep patterns. A recent invention is a jacket, in which a cylindrical object is fitted in the back sponge.

Use of nasal dilators
The use of nasal dilators as OSAHS treatment has indifferent support in the medical literature. The difficulty in nasal breathing obstruction tends to be the trend of increasing pharyngeal oral collapse. The decrease of nasal resistance at dilators might be beneficial for mild snorers, patients with rhinitis or with a cold but as an apnea prevention it has no scientific backing. Nasal dilators are prosthesis to dilate the nose improving nasal airflow, that can be external or internal. Although its function against simple snoring is guatanteed, in cases of developed OSAHS it doesn’t respond effectively.


Intraoral prosthesis
The American Academy of Dental Sleep Medicine (AADSM) defines intraoral devices as devices, that are inserted into the mouth by changing the position of the jaw, tongue and other supporting structures of the upper airway for the treatment of snoring and / or the OSAHS. After years of study and clinical testing, they are now an effective alternative for the treatment of sleep breathing disorders, with levels of efficiency assimilable to the positive pressure masks. Designed and implemented by dental professionals the market offers more than 300 proprietary models with varying degrees of effectiveness. The final document by the SGS (Spanish group of sleep) also defends the use of intraoral treatment:

“Mandibular advancement devices increase of the space in the upper airway and an alternative in the treatment of OSAHS, usually for non-serious cases and also in patients, who do not tolerate or refuse CPAP. The best results are obtained with mandibular advancement devices that allow a gradual progression of progress. It is considered essential that the prostheses are shown, projected and adapted clinically prescribed by dentists with enough specific training and in coordination with the units of sleep”.

The generalization of the use of devices appeared in the '80s as an alternative to the monopoly of the CPAP, and offering patients a new therapeutic side to subtract the drawbacks of irreversible and invasive surgery and the annoyings and the low levels of adaptation to the mechanisms of positive ventilation (CPAP). The oral appliances are a great way to treat snoring and sleep apnea with proven advantages over other forms of treatment or as a complement to the other alternatives. The functional mechanism of the intraoral devices is to modify the anatomy of the upper airways and prevent obstruction, which occurs during sleep. Its function is prefixing the lower jaw during sleep and thus increasing the oropharyngeal space. Oral appliances should be installed by qualified dentists, who are experienced in the overall care of oral health and the ATM. The choice of intra-oral prosthesis as a first option for the treatment of OSAHS patients due to its safety, simplicity, ease of use, reversible action and favorable acceptance by patients against the bulkiness of the mechanism that requires CPAP.

Pharmacological Treatments
The pharmacological cure of OSA is still a medical utopia. Tested in over a hundred proposals, all have shown mixed results in the treatment of snoring and obstructive sleep apnea. There is no drug on the market with proven efficacy to solve the problem, which can be enforced as a therapeutic alternative. Most common pharmacological agents, which are used are medroxyprogesterone and tricyclic antidepressants such as protriptyline. The lower prevalence of OSAHS in women is related to the effect of progesterone, that protects women in their childbearing years. The increase of the disease in postmenopausal women could be explained by lower levels of sex hormones. Exogenous administration of medroxyprogesterone to reduce AHI since it acts as a stimulant of breathing and may improve oxygenation. In the OSAHS drugs have been used such as methylxanthines, supplements of estrogen or progesterone, with mixed results and diverse secondery effects. Clinical practice discourages its use for the lack of long-term benefit. Also propriptyline has been tried, a non-sedating tricyclic antidepressant. The mechanism of protriptyline is favorable through its effects of the suppression of REM sleep, by its inhibition virtue of recap monoamines, serotonin and noradrenaline. His administration has shown a slight improvement in the AHI in patients with predominantly respiratory events in REM sleep. Although protriptyline may induce a moderate improvement of AHI in OSA patients and may partially prevent oxygen desaturation, the latest studies were published in the 80s and there has been no recent evaluations of its effectiveness in treating OSA and currently it is not recommended as primary treatment. Another pharmaco that has been studied detailed is modafinil, a central nervous system stimulant, that enhances wakefulness in patients with excessive sleepiness (hypersomnia) associated with sleep disorder, shift work, obstructive sleep apnea or narcolepsy .

Although inhibitors of serotonin recap have shown a moderate reductions in the apnea-hypopnea index (AHI) during REM sleep, they have not proven generally effectiveness as a treatment for OSA and may even aggravate the symptoms with a secondary weight gain. Topical nasal corticosteroids may improve the AHI in OSA patients and rhinitis, and therefore can be a useful adjunct to primary therapies for the OSAHS. There are also other tests with nicotine as a respiratory stimulant rejected by his profuse side effects, Almitrine, is a central stimulant of breath or strychnine, all with negative results.

In 2006, Smith et al.,tesed in a study of 394 participants the effectiveness of 21 drugs proposed for treatment of obstructive sleep apnea. These pharmacological proposals included a sample of the drugs available on the market to reduce the severity of the disease with different effects: an increase in the tone of the dilator muscles in the upper airway, increased ventilatory drive, decrease in the proportion of REM sleep, increased cholinergic tone during sleep, reduction of the resistance of the UA and a reduction in the surface tension in the upper airways. Although some drugs were specific reducers of AHI and daytime sleepiness improver, long-term effects on symptoms were not desired. The authors concluded, that there were sufficient safeguards to recommend the use of drug therapy in the treatment of OSAHS and this trend is maintained clinical practice today.


CPAP
The introduction of continuous positive airway pressure equipment (CPAP) by Sullivan in the OSAHS therapeutic landscape, represented the most significant development in the therapeutic advances of the disease. Until the application of positive pressure treatment, tracheotomy was the only effective alternative, that was offered to symptomatic patients.

The pharyngeal size depends on the balance between the forces tending to collapse the walls (negative inspiratory pressure) and those that tend to keep them open (dilator muscles). During sleep there is a decrease in muscle tone, that predisposes to pharyngeal collapse. Using this mismatch of respiratory forces as a starting point, Sullivan developed in 1981 a mechanism to remedy this imbalance, that occurs in OSAS subjects during sleep. The negative pressure suction produces occlusion of the upper airway therefore positive pressure, avoiding the closure or occlusion. This is the genesis CPAP (Continuous Positive Airway Pressure), which is a mechanism that produces a flow of air, that is blown through a mask. The positive air pressure removes partial obstructive events, hypopnea and total apneas, avoiding systemic damage caused by these intermittent episodes of hypoxia-reoxygenation, hypercapnia, normocapnia.

Respiratory efforts disappear and thus associated arousals that fragment sleep. The treatment works on two fronts, the eradication of respiratory pauses with consequent disruptions in oxygen saturation and recovery of normal sleep pattern by removing the arousals and recover the sleep quality of patients. The apparatus consists of a compressor, which introduces atmospheric air with adequate and pre-adjusted pressure through a mask fitted on the patient. The level of pressure must be calibrated individually for each patient to achieve the success of the treatment to be certified with the disappearance of apneas / hypopneas, the elimination of snoring and the normalization of arterial oxygen saturation and sleep pattern. The mask should be placed every night, during sleep on the patient a lifetime. The CPAP is not a comfortable treatment and side effects are common in the first weeks of use. There are variations of pressure systems, mechanisms similar to CPAP, but did not exert a continuous flow and the pressure varies between inspiration and expiration. It is also a positive pressure device through a mask given to the patient a certain air pressure in the inspiration and a different size (usually less) during expiration (autoCPAP).

Surgical treatments
The goal of these surgical solutions is to restore the size of the UA so that the air flow is sufficient and regular. This is used mainly against anatomical malformations, in which has been proven, after exhaustive study, that these are the cause of obstruction and are correctable by surgery. Through surgery, modifying the morphology of the upper airway correcting its tendency to collapsibility. These procedures are effective, when maxillofacial abnormalities, that directly affect the permeability of the UA can be corrected by modifying the detected areas collapsible. The main surgical problem lies in the previous location of the blockage area. Once the area is determent it can be continued surgical with it. The success of surgery is unconditionally associated with a precise topographic diagnosis. Currently, detailed knowledge of the peculiarities of the disease make it easier to detect the site of the blockage or blockages in the pharyngeal region, facilitating surgical treatment options to correct the alterations in the airways obstruction, affecting adversely or affecting the permeability. Thanks to the technological development in the exploration and diagnostic systems knowledge about the behavior of the pathogenesis of, OSAHS can be more easily located and it is easier to correct the blockage in the section where it occurs.

Evolution of surgical treatments
The cure for snoring through surgery was raised in the essays published in the eighteenth century. In 1772, Morand described the first surgical treatment of snoring by the removal of the uvula. From the pioneering proposals of Morand, there have been several surgical techniques to solve the problem of snoring. In 1828 Matthews invented an instrument for the excision of the uvula and tonsils, in 1964 Ikematsu developed a surgical procedure called paladin, in 1977, a study published by Quesada reflected a technique, that reached a 50% success in treating sleep apnea and 100% in snoring and that consisted on a partial excision of the soft palate. In 1981 Fujita adapted the technique for snoring, developed by Ikematsu, and OSA was the first time adapted as uvulopalatopharyngoplasty (UPPP) and it was demonstrated its effectiveness in the treatment of OSAHS, especially in secondary processes of oropharyngeal obstruction obtaining favorable results of a 50% reduction in the number of apneas, 76% in daytime sleepiness and a 94% reduction in snoring. In 1990 Kamami treated chronic snoring with CO2 laser and local anesthesia, making the first uvulopalatoplasty, which is a sectional part of the uvula and soft palate tissue, without removing the tonsils or tissues of the lateral pharyngeal walls. Snoring associated with the vibration of the soft tissues, decreases with the reduction of the uvula and palate. Surgical procedures can be divided according to the subject of the action: content reducing surgery including nose surgery, surgery of the throat and tongue and surgery of widening the continent, further increasing the airspace and maxillofacial surgery.