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Alternatives to CPAP for Sleep Apnea
Dr. Anita Bhola explains some little known risk factors, treatments and medical conditions associated with sleep apnea. She discusses non-CPAP treatments and safety concerns that can result from a lack of quality sleep.
Featured Speaker:
Anita Bhola, MD, FCCP
Dr. Anita Bhola, Medical Director of the St. Luke's Cornwall Hospital Center for Sleep Medicine in Cornwall, NY, is a board-certified physician in Internal, Pulmonary, Critical Care and Sleep Medicine. Her practice includes both consultations with patients suffering from sleep disorders and interpretation of sleep studies. She has lectured extensively on many topics in sleep medicine at professional symposiums and to patients in community settings. She actively participates in A.W.A.K.E meetings, a sleep apnea patient support group. Her article about how sleep disorders can impact women and their careers was recently published in U.S. News & World Report. Transcription:
Alternatives to CPAP for Sleep Apnea
Melanie Cole (Host): There are several treatment options for obstructive sleep apnea. While CPAP, continuous positive airway pressure is the most popular treatment for sleep apnea; there are other therapies available. My guest today is Dr. Anita Bhola. She’s the Medical Director of St. Luke’s Cornwall Hospital’s Sleep Center. Dr. Bhola let’s start with some of the risk factors for sleep apnea. What are those?
Anita Bhola, MD, FCCP, FAASM (Guest): Hi Melanie and thanks for having me back on this podcast series. So, the factors that increase the risk for sleep apnea would be excess weight, so obesity greatly increases your risk for sleep apnea. There are fat deposits in the tongue, the soft palate, and the back of the throat and these can obstruct the breathing. Having a neck circumference – patients who have thicker necks will have narrow airways so a collar size in men greater than 17 inches is a risk factor for sleep apnea. And then a narrow airway could also block the air especially in children where there is tonsils and adenoids enlarged can cause sleep apnea as can craniofacial abnormalities such as retrognathia. Retrognathia is a condition in which the lower jaw is set back, and these patients may develop sleep apnea. Being male carries a tow to three-fold increased risk for having sleep apnea than women, however when women gain weight or when they reach menopause; their risk approaches that of men. Being older increases the risk of developing sleep apnea and there is a higher prevalence in certain races such as African Americans, Asians also have a risk that is comparable to that in western countries. Nasal congestion is a high big risk factor. We see this a lot in our practice if you have difficulty breathing through your nose, whether from an anatomical obstruction like deviated septum or allergies; you are more likely to develop sleep apnea. A family history of sleep apnea may increase your risk. Having an underactive thyroid, a condition called hypothyroidism is a risk factor as is polycystic ovarian disease. Acid reflux is a risk factor and then the use of alcohol and sedatives which are all muscle relaxants can worsen sleep apnea. And lastly, smokers have almost a three-fold increase in developing sleep apnea than patients who have never smoked before because smoking is an upper airway irritant and increases the amount of inflammation and fluid retention in the upper airway and just makes it narrower.
Melanie: Wow, that is certainly a lot of risk factors and a lot of people that are at risk for sleep apnea and so what are some of the medical conditions associated with it? Comorbidities as it were; what can sleep apnea do that can cause other issues and vice versa what other issues can also contribute?
Dr. Bhola: Right so high blood pressure is probably like the best-known medical comorbidity associated with sleep apnea and this has to do with the sudden drop in the oxygen levels during sleep which increase the blood pressure and they strain the cardiovascular system. Having sleep apnea will increase your risk of high blood pressure by about 50% and the converse is also true and sometimes patients will present with newly diagnosed high blood pressure and we will screen them for symptoms of sleep apnea because the association is so great. We also see often that blood pressure will often become refractory to treatment with medications if the sleep apnea is present and remains untreated. Obstructive sleep apnea also increases your risk of recurrent heart attacks, stroke and abnormal heat beats, we call them arrythmias and the most common arrythmia associated with sleep apnea is called atrial fibrillation. This also carries a high risk of stroke and what we do see is actually we have a number of patients referred by the cardiologist with newly diagnosed atrial fibrillation who screened positive for sleep apnea. Because we have seen is that atrial fibrillation will often recur after ablation or after shocking if the underlying sleep apnea remains untreated.
Then if you have a heart disease, these multiple episodes of low blood oxygen or hypoxia during the night can sometimes lead to sudden death from an irregular heartbeat. Heart failure up to one third of patients with heart failure will also have sleep apnea both central and obstructive. I don’t have time to cover central sleep apnea during this podcast. But obstructive sleep apnea can make heart failure worse and these patients often have a higher readmission rate to the hospitals and a higher morbidity compared to those who don’t. And this is one condition where CPAP really does help.
And then type 2 diabetes and insulin resistance have a high association with sleep apnea and the converse is also true because these are two very common conditions. Sleep apnea and type 2 diabetes often coexist in up to 40% of patients. We often, as sleep specialists are invited to go and give talks in the diabetic clinics where we talk to the newly diagnosed diabetics and ask them if they have any symptoms of snoring or daytime sleepiness. In other words, we screen them because the association is quite strong. Conversely, patients who have newly diagnosed sleep apnea should also be screened for diabetes by measuring and following their hemoglobin a1c so if I see somebody with sleep apnea I’ll ask that they get their hemoglobin a1c checked.
Erectile dysfunction and low testosterone levels in men can be seen. Sleep apnea can also – this is actually very interesting. Sleep apnea can lead to high risk pregnancy. A condition called preeclampsia during which pregnant patients can get dangerously high blood pressure levels and in addition, sleep apnea in pregnant patients can also cause gestational diabetes and some low birth weight babies born. Sleep apnea also increases the risk of depression and this is especially true in patients who have severe sleep apnea and there have been studies done showing that there has been a great association especially in men. We have also heard about sleep apnea increasing the risk of cognitive impairment and Alzheimer’s dementia in the elderly patients.
Melanie: Dr. Bhola, tell us about some non-CPAP treatment options for sleep apnea. People hear about CPAP, they hear about it in the media. They have heard that they are not that comfortable, adherence could be an issue. Some people want to look into other options. So, review some of the non-CPAP treatments for us, whether it is weight loss or some of the dental devices we have heard about. Just give a brief review of some of the others.
Dr. Bhola: Sure. So, weight loss is beneficial, however, it is hard to lose weight because you are so tired if you have sleep apnea. In terms of positional therapy, there are a number of positional devices available that help to keep you off your back. One of them is called a Zzoma Positional Sleeper and these are typically could be an option in patients who have mild sleep apnea where the sleep apnea has been determined to be greater in the supine position. So, if the patient has supine positional dependent sleep apnea and it’s mild; they could be a candidate for the Zzoma Positional Sleeper which is an FDA approved modality.
There are other nonprescription treatments such as Breath Right Strips, Nasal Cones and even ProVent which have variable results. In terms of the non-CPAP options; for mild to moderate sleep apnea patients who are CPAP intolerant; they could be candidates for what is called a custom fitted oral appliance made a dental sleep specialist and one such is called a mandibular advancement device. This may be easier to use, however, there are some issues with TMJ and measuring compliance could be an issue.
Surgical options are usually sought after only if other treatment options have failed. So, generally, you will the patient about a three-month trial of other treatments such as CPAP before surgery is considered. And typically, the patient would be evaluated, examined and have an endoscopy performed by an ENT surgeon to look at the airway passages to see where the obstruction is. So, some of the surgical options would include tissue removal, procedure called UPPP. This can be done surgically or through radio frequency ablation. Other surgical options are nasal surgery if the patient has some form of a nasal obstruction such as a deviated septum, a polyp or turbinate hypertrophy. These may actually help the patient breath better but may not necessarily cure the sleep apnea. For patients who have moderate to severe sleep apnea, who are CPAP intolerant; there is the jaw positioning surgery such as a maxillary mandibular advancement. That could be an option. These surgeries are typically performed by oral surgeons or maxillofacial surgeons. In this procedure, the jaw is pulled forward from the remaining of the facial bones.
Then there is hypoglossal nerve stimulation which has been in the news more recently. And Inspire happens to be FDA approved. This requires a surgical procedure to insert a stimulator for the nerves that control the tongue movement and that’s called a hypoglossal nerve. The stimulation helps keep the tongue in a position that keeps the airway opened. So, this procedure is performed in certain designated centers and is performed by ENT physicians.
And then in very rare severe life-threatening sleep apnea where all other treatment options have failed; the surgeon may need to perform a tracheostomy which involves making an opening in the neck and inserting a metal or a plastic tube through which the patient breathes at night, thereby bypassing the obstructive airway. I have actually never seen this in my entire career. So, those are really the non-CPAP treatment options.
Melanie: What a wonderful summary Dr. Bhola. You went over those so beautifully and explained them all for people that really are concerned about trying CPAP. Wrap it up for us with your best advice, questions you would like patients to ask you as the Medical Director of the Sleep Center at St. Luke’s Cornwall Hospital. What would you like them to ask you when they have sleep apnea, they are concerned about CPAP, maybe they have tried it and maybe they haven’t. What do you tell them? What would you like them to ask you?
Dr. Bhola: So, when I see patients in my practice; I want to ask them about comorbid conditions and if they do have comorbid conditions or if there is a risk for a comorbid condition; I would like to refer them to the necessary specialist such as a cardiologist or the endocrinologist to get screened for these conditions. I educate them on all these associations between sleep apnea and comorbid conditions which by the way also include the risk of accident proneness, driving accidents and accidents at the work place, in addition also decreased productivity at the job. So, I will talk to them about that. I talk to patients about all the treatment options and really – I’m not in favor of pushing CPAP if the patient doesn’t want it because this really is life long therapy. You could have somebody who would accept CPAP initially, but they need to actually use it for the rest of their life. So, they really need to be comfortable. So, I try and elicit what the patient’s preference is and if the patient doesn’t prefer CPAP, I try and then send them to other specialists or I go over other treatment options and send them to other specialists where they could benefit from therapy.
Melanie: Great information. Thank you Dr. Bhola for being on with us today and sharing this great information with listeners so that they know what to ask and what to expect when they visit a sleep disorder center and they know how they can get help with their sleep apnea. Thank you again for joining us. This is Doc Talk presented by St. Luke’s Cornwall Hospital. For more information please visit www.stlukescornwallhospital.org, that’s www.stlukescornwallhospital.org. I’m Melanie Cole. Thanks so much for tuning in.
Alternatives to CPAP for Sleep Apnea
Melanie Cole (Host): There are several treatment options for obstructive sleep apnea. While CPAP, continuous positive airway pressure is the most popular treatment for sleep apnea; there are other therapies available. My guest today is Dr. Anita Bhola. She’s the Medical Director of St. Luke’s Cornwall Hospital’s Sleep Center. Dr. Bhola let’s start with some of the risk factors for sleep apnea. What are those?
Anita Bhola, MD, FCCP, FAASM (Guest): Hi Melanie and thanks for having me back on this podcast series. So, the factors that increase the risk for sleep apnea would be excess weight, so obesity greatly increases your risk for sleep apnea. There are fat deposits in the tongue, the soft palate, and the back of the throat and these can obstruct the breathing. Having a neck circumference – patients who have thicker necks will have narrow airways so a collar size in men greater than 17 inches is a risk factor for sleep apnea. And then a narrow airway could also block the air especially in children where there is tonsils and adenoids enlarged can cause sleep apnea as can craniofacial abnormalities such as retrognathia. Retrognathia is a condition in which the lower jaw is set back, and these patients may develop sleep apnea. Being male carries a tow to three-fold increased risk for having sleep apnea than women, however when women gain weight or when they reach menopause; their risk approaches that of men. Being older increases the risk of developing sleep apnea and there is a higher prevalence in certain races such as African Americans, Asians also have a risk that is comparable to that in western countries. Nasal congestion is a high big risk factor. We see this a lot in our practice if you have difficulty breathing through your nose, whether from an anatomical obstruction like deviated septum or allergies; you are more likely to develop sleep apnea. A family history of sleep apnea may increase your risk. Having an underactive thyroid, a condition called hypothyroidism is a risk factor as is polycystic ovarian disease. Acid reflux is a risk factor and then the use of alcohol and sedatives which are all muscle relaxants can worsen sleep apnea. And lastly, smokers have almost a three-fold increase in developing sleep apnea than patients who have never smoked before because smoking is an upper airway irritant and increases the amount of inflammation and fluid retention in the upper airway and just makes it narrower.
Melanie: Wow, that is certainly a lot of risk factors and a lot of people that are at risk for sleep apnea and so what are some of the medical conditions associated with it? Comorbidities as it were; what can sleep apnea do that can cause other issues and vice versa what other issues can also contribute?
Dr. Bhola: Right so high blood pressure is probably like the best-known medical comorbidity associated with sleep apnea and this has to do with the sudden drop in the oxygen levels during sleep which increase the blood pressure and they strain the cardiovascular system. Having sleep apnea will increase your risk of high blood pressure by about 50% and the converse is also true and sometimes patients will present with newly diagnosed high blood pressure and we will screen them for symptoms of sleep apnea because the association is so great. We also see often that blood pressure will often become refractory to treatment with medications if the sleep apnea is present and remains untreated. Obstructive sleep apnea also increases your risk of recurrent heart attacks, stroke and abnormal heat beats, we call them arrythmias and the most common arrythmia associated with sleep apnea is called atrial fibrillation. This also carries a high risk of stroke and what we do see is actually we have a number of patients referred by the cardiologist with newly diagnosed atrial fibrillation who screened positive for sleep apnea. Because we have seen is that atrial fibrillation will often recur after ablation or after shocking if the underlying sleep apnea remains untreated.
Then if you have a heart disease, these multiple episodes of low blood oxygen or hypoxia during the night can sometimes lead to sudden death from an irregular heartbeat. Heart failure up to one third of patients with heart failure will also have sleep apnea both central and obstructive. I don’t have time to cover central sleep apnea during this podcast. But obstructive sleep apnea can make heart failure worse and these patients often have a higher readmission rate to the hospitals and a higher morbidity compared to those who don’t. And this is one condition where CPAP really does help.
And then type 2 diabetes and insulin resistance have a high association with sleep apnea and the converse is also true because these are two very common conditions. Sleep apnea and type 2 diabetes often coexist in up to 40% of patients. We often, as sleep specialists are invited to go and give talks in the diabetic clinics where we talk to the newly diagnosed diabetics and ask them if they have any symptoms of snoring or daytime sleepiness. In other words, we screen them because the association is quite strong. Conversely, patients who have newly diagnosed sleep apnea should also be screened for diabetes by measuring and following their hemoglobin a1c so if I see somebody with sleep apnea I’ll ask that they get their hemoglobin a1c checked.
Erectile dysfunction and low testosterone levels in men can be seen. Sleep apnea can also – this is actually very interesting. Sleep apnea can lead to high risk pregnancy. A condition called preeclampsia during which pregnant patients can get dangerously high blood pressure levels and in addition, sleep apnea in pregnant patients can also cause gestational diabetes and some low birth weight babies born. Sleep apnea also increases the risk of depression and this is especially true in patients who have severe sleep apnea and there have been studies done showing that there has been a great association especially in men. We have also heard about sleep apnea increasing the risk of cognitive impairment and Alzheimer’s dementia in the elderly patients.
Melanie: Dr. Bhola, tell us about some non-CPAP treatment options for sleep apnea. People hear about CPAP, they hear about it in the media. They have heard that they are not that comfortable, adherence could be an issue. Some people want to look into other options. So, review some of the non-CPAP treatments for us, whether it is weight loss or some of the dental devices we have heard about. Just give a brief review of some of the others.
Dr. Bhola: Sure. So, weight loss is beneficial, however, it is hard to lose weight because you are so tired if you have sleep apnea. In terms of positional therapy, there are a number of positional devices available that help to keep you off your back. One of them is called a Zzoma Positional Sleeper and these are typically could be an option in patients who have mild sleep apnea where the sleep apnea has been determined to be greater in the supine position. So, if the patient has supine positional dependent sleep apnea and it’s mild; they could be a candidate for the Zzoma Positional Sleeper which is an FDA approved modality.
There are other nonprescription treatments such as Breath Right Strips, Nasal Cones and even ProVent which have variable results. In terms of the non-CPAP options; for mild to moderate sleep apnea patients who are CPAP intolerant; they could be candidates for what is called a custom fitted oral appliance made a dental sleep specialist and one such is called a mandibular advancement device. This may be easier to use, however, there are some issues with TMJ and measuring compliance could be an issue.
Surgical options are usually sought after only if other treatment options have failed. So, generally, you will the patient about a three-month trial of other treatments such as CPAP before surgery is considered. And typically, the patient would be evaluated, examined and have an endoscopy performed by an ENT surgeon to look at the airway passages to see where the obstruction is. So, some of the surgical options would include tissue removal, procedure called UPPP. This can be done surgically or through radio frequency ablation. Other surgical options are nasal surgery if the patient has some form of a nasal obstruction such as a deviated septum, a polyp or turbinate hypertrophy. These may actually help the patient breath better but may not necessarily cure the sleep apnea. For patients who have moderate to severe sleep apnea, who are CPAP intolerant; there is the jaw positioning surgery such as a maxillary mandibular advancement. That could be an option. These surgeries are typically performed by oral surgeons or maxillofacial surgeons. In this procedure, the jaw is pulled forward from the remaining of the facial bones.
Then there is hypoglossal nerve stimulation which has been in the news more recently. And Inspire happens to be FDA approved. This requires a surgical procedure to insert a stimulator for the nerves that control the tongue movement and that’s called a hypoglossal nerve. The stimulation helps keep the tongue in a position that keeps the airway opened. So, this procedure is performed in certain designated centers and is performed by ENT physicians.
And then in very rare severe life-threatening sleep apnea where all other treatment options have failed; the surgeon may need to perform a tracheostomy which involves making an opening in the neck and inserting a metal or a plastic tube through which the patient breathes at night, thereby bypassing the obstructive airway. I have actually never seen this in my entire career. So, those are really the non-CPAP treatment options.
Melanie: What a wonderful summary Dr. Bhola. You went over those so beautifully and explained them all for people that really are concerned about trying CPAP. Wrap it up for us with your best advice, questions you would like patients to ask you as the Medical Director of the Sleep Center at St. Luke’s Cornwall Hospital. What would you like them to ask you when they have sleep apnea, they are concerned about CPAP, maybe they have tried it and maybe they haven’t. What do you tell them? What would you like them to ask you?
Dr. Bhola: So, when I see patients in my practice; I want to ask them about comorbid conditions and if they do have comorbid conditions or if there is a risk for a comorbid condition; I would like to refer them to the necessary specialist such as a cardiologist or the endocrinologist to get screened for these conditions. I educate them on all these associations between sleep apnea and comorbid conditions which by the way also include the risk of accident proneness, driving accidents and accidents at the work place, in addition also decreased productivity at the job. So, I will talk to them about that. I talk to patients about all the treatment options and really – I’m not in favor of pushing CPAP if the patient doesn’t want it because this really is life long therapy. You could have somebody who would accept CPAP initially, but they need to actually use it for the rest of their life. So, they really need to be comfortable. So, I try and elicit what the patient’s preference is and if the patient doesn’t prefer CPAP, I try and then send them to other specialists or I go over other treatment options and send them to other specialists where they could benefit from therapy.
Melanie: Great information. Thank you Dr. Bhola for being on with us today and sharing this great information with listeners so that they know what to ask and what to expect when they visit a sleep disorder center and they know how they can get help with their sleep apnea. Thank you again for joining us. This is Doc Talk presented by St. Luke’s Cornwall Hospital. For more information please visit www.stlukescornwallhospital.org, that’s www.stlukescornwallhospital.org. I’m Melanie Cole. Thanks so much for tuning in.