OSAHS is a condition with high prevalence. It is costly to treat and is associated with important co-morbidity, decreasing the patients quality of life. Investment should be made in its diagnosis and treatment. The economic impact of those with OSAHS unable to work and requiring costly medical attention should make OSAHS a priority in the public health system.
All treatment for snoring and OSAHS share one common goal: to increase the diameter of the upper airway, thereby reducing its resistance to air flow. This immediately improves the quality of the patients lives, allowing them to return to normal sleep patterns. Their associated health risks diminish and their life expectancy increases. OSAHS treatment depends upon the level of severity of the condition and ranges from conservative treatment such as weight loss, postural changes whilst asleep. It may also be treated through the use of Continuous Positive Airways Pressure (CPAP) devices. Surgical techniques are also sometimes used e.g. uvulopalatophayngoplasty (UPPP). Intra-oral appliances are sometimes suitable as an effective method of non-invasive treatment.
The treatment for OSAHS attempts to remedy the wide spectrum of symptoms associated with it. Above 30 IAR episodes per hour has been long considered a severe case of OSAHS associated with serious consequences. However, there is some evidence which shows that an IAR of above 15 can be associated with a cardiovascular risk factor independently of the rest of the symptoms experienced by the patients. The American Academy of Sleep Medicine recommends prescribing CPAP treatment when there is an IAR ≥ 15, regardless of the presence of other symptoms, or where there is an IAR ≥ 5 accompanied by excessive daytime sleepiness.
Once the diagnosis is made an appropriate treatment plan should be prescribed so that the normal sleep pattern can be recovered. The treatment plan should be based on the severity of the OSAHS, taking into account the preferences and constraints of the patient. The therapeutic alternatives for snoring and OSAHS are not mutually exclusive, allowing for a multidisciplinary approach.
Treatment strategies range from the so called conservative options such as the modification of postural habits, significant weight reduction and correction of poor sleep hygiene to more invasive surgical options for patients with physical anomalies or those who are unresponsive to other treatment methods. All factors, including the location of the pharyngeal collapse, craniofacial characteristics, dental health, obesity, age, occupation etc. should be evaluated before choosing between the alternatives. Successful treatment is that which achieve a reduction in the number of respiratory events per hour, normalizes blood gas exchange whilst improving sleep quality and daytime symptoms.
These conservative measures are indicated in cases of patients with mild OSAHS. They consist of a modification of dietary habits and sleep hygiene practises in order to reduce symptoms and avoid situations which favour pharyngeal collapse. These measures include weight loss, reducing smoking, alcohol and the use sedatives along with taking regular physical exercise.
Excess weight is present in 60-90% of patients with OSAHS as so should be one of the first recommendation made. In many patient a 5-10% reduction in weight leads to a significant decrease in the number of apneas and allows for a normalization of hypoxia. It must be stressed that weight loss alone does not eliminate the problem but reduces the severity of the symptoms and the associated risks. Obese patients accumulate fat in the neck region which directly affects the upper airway by reducing its diameter. Weight loss reduces these fat deposits and increases the pharyngeal dimensions. Gastric surgery may be an adjunct in the treatment of OSAHS in obese patients.
A healthy sleep routine is essential so that the rest period can be the most advantageous. This bedtime routine is referred to as "sleep hygiene" in the literature. It is recommended that smoking, alcohol and certain medicines are abstained from before bedtime as they are known to aggravate OSAHS and snoring. Giving up smoking should be a priority for OSAHS sufferers as it promotes irritation and secondary inflammation of the upper airways leading to increased resistance to airflow. Alcohol has a depressant effect on the pharyngeal muscles leading to insufficient muscle tone which predisposes to pharyngeal collapse.
Simple snoring and mild OSAHS cases are usually aggravated by a postural component. The supine position (lying face up) allows gravity to cause the soft tissue of the pharynx to collapse, decreasing the size of the lumen of the upper airway. Some patients only snore whilst lying on their backs. Adopting sleeping positions where gravity does not cause the soft tissues to reduce the calibre of the pharynx works for many patients. Apneas occur more frequently in the supine position than in the lateral decubitus (lying on the side) or prone position (lying face down). Prone position, with the head resting on the arm is the ideal sleep position to avoid apneas. This position encourages the lower jaw, tongue and soft palate to fall forward, leaving the upper airway patent. However, this position is uncomfortable for many patients and so experts recommend sleeping on ones side, which is better tolerated. Various devices exist on the market to help change postural positions. From the simple ball sew into the pyjamas, to modern electrical systems which produce a mild electrical stimulus encouraging the patient to change position. Unfortunately these products often wake the patient, further aggravating the already disturbed sleep pattern.
The use of nasal dilators as treatment for OSAHS has variety of opinions in the medical literature. Nasal dilators are external or internal prostheses used to dilate the nose, thereby improving airflow. When nasal obstruction is present, breathing takes place through the mouth which increases the tendency of the pharynx to collapse. In mild snoring cases, those suffering from allergic rhinitis or colds, an improvement in symptoms may be seen using nasal dilators. Although nasal dilators have proved to be successful in treating simple snoring, this is not the case for OSAHS sufferers.
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:
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.
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.
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).
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.