Online Health Chat with Alan Kominsky, MD, and Douglas Trask, MD, PhD
February 20, 2015
Nearly 18 million Americans suffer from sleep apnea, most commonly obstructive sleep apnea (OSA). OSA accounts for approximately 90 percent of sleep apneas. Untreated OSA can lead to secondary health issues that may include:
- High blood pressure
- Heart disease
It is also related to other health risks.
Many patients who are prescribed CPAP for treatment do not endure this therapy well. Current surgical options available can range from nasal surgery to removing tonsils to more extensive procedures involving the base of the tongue. A new surgical treatment that is FDA-approved, called Inspire Therapy, is now available. This is an implantable device that can stimulate tongue muscles in order to stimulate airway opening during sleep in selected patients.
Drs. Alan Kominsky and Douglas Trask discuss questions about who could benefit from the different surgical options for patients based on their physical exam and disease severity.
About the Speakers
Alan Kominsky, MD, is an otolaryngologist specializing in sleep disorders at Cleveland Clinic’s Head & Neck Institute. He is a board-certified otolaryngology/sleep medicine surgeon who earned his medical degree at Temple University School of Medicine in Philadelphia, PA. He completed his general surgery and otolaryngology residency at Temple University Hospital.
Dr. Kominsky’s clinical interests include management of obstructive sleep apnea, snoring, nasal airway surgery, adult and pediatric general otolaryngology, nasal-sinus disease and surgery, chronic sinus disease, laryngopharyngeal reflux, medical management of otolaryngology problems in adults, and hearing loss.
Douglas Trask, MD, PhD, is an otolaryngologist specializing in sleep disorders at Cleveland Clinic’s Head & Neck Institute. He is a board-certified otolaryngology/sleep medicine surgeon who earned his medical degree from Dartmouth Medical School in Hanover, NH. After completing his residency at the University of Michigan Medical Center, he served on the faculty of the University of Iowa College of Medicine for eight years and later worked in private practice in Grand Rapids, Michigan.
Dr. Trask’s specialty interests include sleep apnea, nasal and sinus surgery, and the surgical treatment of thyroid disease and head and neck tumors.
Let’s Chat About New Treatment Options for Sleep Apnea.
LucyintheSkies: Is there a difference between sleep apnea and obstructive sleep apnea? I am wondering because my husband slightly holds his breath, then “squeaks” a sound like descending musical notes – and then blows out forcefully before he starts all over. I am not sure if this is a big deal and he should be evaluated for anything, or if I should just continue to ignore it and kick him, which makes him stop. What are your thoughts?
Alan_Kominsky,_MD: The term “sleep apnea” can include several different sleep-related breathing problems. The most common is obstructive sleep apnea, which means that there is a complete blockage or slowing down of breathing while sleeping. This can be associated with high blood pressure, heart disease or strokes if left untreated. I would recommend that you stop kicking your husband and make an appointment with a doctor to investigate further.
OSA: Diagnosing the Disorder
GeorgeBMac: What are the criteria for diagnosing sleep apnea? A normal weight 8-year-old who keeps a normal bedtime and gets nine to 10 hours of sleep has been identified by his mother as a snorer. His second grade teacher and counselors have identified daytime sleepiness and hyperactivity with possible ADHD. His primary care physicians and an ENT have identified “large tonsils” unrelated to an infection. All of them have suggested having the child's tonsils removed. Is it necessary or advisable to obtain a sleep study (or some other diagnostic test) to confirm sleep apnea prior to proceeding to a surgical intervention? Would a home sleep study provide meaningful information? If so, how would the family obtain one? Does it need to be prescribed?
Douglas_Trask,_MD,_PhD: The child in question has many signs and symptoms consistent with obstructive sleep apnea. In this age group, tonsils and adenoids are the most common cause of obstruction. Endoscopy to check for adenoid enlargement is appropriate. A sleep study is not an absolute pre-requisite, but is the only way to definitively diagnose OSA. Consultation with an ENT physician with regard to OSA is the next step.
Francis: Hello. My question is: Will it make a difference in my sleep apnea treatment to lose weight in order to be removed from it? I have mild OSA, but also have DM, PM and ILD. Would your opinion be that this is from lung disease or actually from being 30 pounds overweight? The reason I ask is that my cardiologist said I could be removed if I lose the weight. Do you agree? My lung function was 34 percent 2 1/2 years ago. It now is 80 percent. Immune suppressants have helped tremendously in my recovery. Thank you.
Alan_Kominsky,_MD: It can sometimes be very difficult to determine the exact underlying cause of obstructive sleep apnea when there are a combination of underlying medical problems. It has been proven that weight loss can reduce or eliminate obstructive sleep apnea in some cases. This is dependent on many factors, including the starting weight and how much weight is lost.
ldsuz: How can I find out if I am a candidate for alternative sleep apnea treatment, such as a surgical procedure. I am a light sleeper and find that I am getting less sleep and more disruptive sleep when using the machine because of the noise and readjusting the nose piece, and the tubing gets tangled when I try to adjust positions.
Alan_Kominsky,_MD: Determining treatment if CPAP has not been found to work for you would rely on your sleep study, the severity of your obstructive sleep apnea and a physical exam.
Hockey Fan: Have either of you had experience with a mouth device called the Thornton Adjustable Positioner? The information on it looks very promising for some levels of OSA. I’m not trying to discourage surgery as a treatment, just wanting to explore all options. Thank you.
Alan_Kominsky,_MD: The device you mention is commonly known as the TAP device. This is one of many dental devices that can be used for mild or moderate obstructive sleep apnea.
Apnear: I've been diagnosed with moderate OSA for 1.5 years and have struggled with using a CPAP or a dental device (Tap3) since then. I am only set at a 5 on my CPAP, which I know is not enough. I am now taking trazodone 125mg at bedtime along with Neurontin® 600mg also at bedtime. I also suffer from fibromyalgia. What other alternatives might I have to be able to effectively treat my sleep apnea? What would Cleveland Clinic be able to offer me?
Douglas_Trask,_MD,_PhD: Alternatives to CPAP include weight reduction, positional therapy, dental devices and surgery. Based upon the degree of OSA you have and the source of obstruction in your airway, recommendations regarding treatment options can be refined.
Red: What are my other treatment options if I can’t tolerate CPAP?
Alan_Kominsky,_MD: Thanks for asking this important question. It is very common for patients to be intolerant of CPAP. We often discuss with patients that CPAP is the first-line treatment for obstructive sleep apnea. If the patient can't tolerate CPAP, we then discuss the other options for treatment. Some of these suggestions will be dependent on the results of the sleep study, weight or BMI and any underlying medical problems. In general, the other options include either a dental device or surgery. Surgery can include soft tissue surgery of the throat, bony surgery to address the facial skeleton or even an implantable nerve stimulator that acts like a pacemaker to the tongue.
medicalmarvel: What is auricular plaster and how does it work?
Douglas_Trask,_MD,_PhD: I am unfamiliar with this technique.
kids2: How does upper airway stimulation therapy differ from other types of sleep apnea surgery?
Douglas_Trask,_MD,_PhD: Traditional surgery usually involves the removal or rearrangement of excessive tissue in the throat. Sometimes, facial bones or the jaw are altered to provide more room for breathing. Inspire Therapy has a sensor that monitors breathing patterns and provides a mild stimulation to key airway muscles to keep your airway open. No tissues are removed and no bone is altered.
4567: Will people see the device or know that I had an operation performed?
Douglas_Trask,_MD,_PhD: The device is completely under the skin. There are no external components. Three small incisions are made; one under the chin, one below the collar bone and one on the side of the chest. Once these are healed, you will look the same as before surgery.
rebelfor life: How is the device controlled?
Douglas_Trask,_MD,_PhD: People who have the device implanted are given a remote control. You turn on the therapy before you go to sleep and turn it off when you wake up. You can set the therapy to turn on after a certain period of time so that you are asleep before the device starts to work.
miamibound: Is Inspire upper airway stimulation therapy for me?
Douglas_Trask,_MD,_PhD: You are a candidate if you are unable to use CPAP, you have a body mass index of 32 or less (meaning you are of normal weight or slightly overweight), you are an adult and have documented moderate to severe obstructive sleep apnea.
stjohns: Is there a long hospital stay after the operation?
Douglas_Trask,_MD,_PhD: Usually, you will stay in the hospital the night after the procedure or, in some cases, you may go home the same day as surgery.
VincentH: I know that this may be basic, but will you explain CPAP, and then explain what it means when you “fail CPAP”.
Alan_Kominsky,_MD: CPAP stands for "continuous positive airway pressure." It consists of a device that sits on the nightstand and connects to the patient via a hose and a mask. This device delivers pressurized air into the upper airway to prevent it from collapsing while sleeping. Failing CPAP means that the patient is not using the machine for at least 70 percent of the nights for at least four hours.
ldsuz: Who would make that determination?
Alan_Kominsky,_MD: A sleep surgeon. Here at Cleveland Clinic in the Head & Neck Institute.
Ed95: I have been on CPAP therapy for about seven years now. I’m 100 percent compliant and have noticed a great improvement since I began therapy. My issue is leak rate. I’ve tried every mask available in every category (full-face mask, nasal pillows, hybrid, nasal mask, etc.) and still cannot find a mask that will not leak. My prescribed CPAP pressure is 18, so I realize that’s high and problematic regarding my leak issues. My readings for the past week have been: Leak: 0.9L/s | AHI: 21.6 | AI 8.9. My doctor’s litmus test for if my therapy is effective is “Do you feel tired during the day?” And for the most part I do not. Do you have any suggestions on how to get my leaks under control? I feel as though my only available option is for a deep sea diving bell helmet. At least that would fix the leak problem.
Alan_Kominsky,_MD: In some cases, a repeat sleep study to concentrate on adjusting the CPAP may be needed. There is another type of PAP called bi-level pap that adjusts the pressure differently based on whether you are breathing in or out. This may be helpful in cases where high pressures are needed.
ldsuz: Are the dental devices you mentioned obtained from an ordinary dentist?
Alan_Kominsky,_MD: Experience with dental devices varies by dentist. It is important to go to a dentist who has experience making these devices. Some otolaryngologists also make these devices in their offices. It is always important to have a follow-up sleep study with the device in place to make sure it is effective.
ldsuz: Can you give an approximate cost for a dental device? And is it covered by insurance?
Alan_Kominsky,_MD: Costs and insurance coverage vary by device.
medicalmarvel: What is the normal light sleep/deep sleep ratio? I have an Up24 that tracks my sleep. Do you know if these are sensitive enough to pick up on the disruptions caused by apnea? I wear an MAD and it seems to be doing the job but I'm curious.
Douglas_Trask,_MD,_PhD: There are multiple stages of sleep. In general, early on in the night you are in lighter sleep and you progress to deeper sleep. Rapid eye moment sleep is the deepest stage of sleep and the only stage that remains constant as we age. As we get older, we spend less time in deep sleep and more time in lighter sleep, so the ratio is not a constant. Most fitness trackers measure movement or lack thereof (then defined as sleep) and have no way to measure depth of sleep.
ldsuz: Can you recommend an otolaryngologist?
Alan_Kominsky,_MD: Dr. Trask and I are board certified in both otolaryngology and sleep medicine.
Moderator: That is all of the time we have for questions. Thank you everyone for participating today; and thank you, Dr. Kominsky and Dr. Trask, for your insightful answers to our questions about new options for treatment of obstructive sleep apnea.
To make an appointment with Alan Kominsky, MD, Douglas Trask, MD, PhD, or any of the other sleep specialists in the Head and Neck Institute, please call 216.444.8500 or toll-free at 800.223.2273, ext. 48500, or visit us online at www.clevelandclinic.org/hni.
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