October 08, 2009

Comparative Effective Study on sleep apnea

In the beginning (prior to 1978), there were two treatment options for obstructive sleep apnea: radical weight loss program and a tracheotomy. Then there was the UPPP. This was up until the introduction of Continuous Positive Airway Pressure, which according to the inventor was intended to be a stopgap treatment.


CPAP was so effective that it replaced surgery as the first line ( it became the "gold standard") treatment for OSA. Since its invention, there have been variations on UPPP using laser and ablation, which have had varying levels of success. Also introduced were other types of surgical interventions that are intended to manage the tongue.


Also developed with the intent of managing the tongue and enlarging the opening to the upper airway through moving the jaw forward are oral appliances - tongue retaining devices and mandibular advancement devices.


There are also more radical surgical procedures... breaking and moving the jaw forward and bariatric surgery.


Finally there are new therapies now the horizon such as Provent and Aura6000.


How do we establish the relative merits of these various therapies? What does it mean that they "work"? Is it the elimination of snoring and/or reduction of Apnea-Hypopnea Index and/or lowering blood pressure and/or reduced insulin resistance and/or improved psychomotor vigilance and/or improved cognitive functioning? Are we missing something if we stop at saying - four hours per night for 70% of the nights over a 30 day period.

It is difficult to measure quality in healthcare with respect to OSA if the benchmarks themselves vary from person to person.

It may be that the science of treating sleep apnea is still too young to have a specific number similar to diabetes, where if your HA1C is above or below a certain point there is a problem.

Today, I don't offer any answers. Today I only ponder.


October 06, 2009

Finding a place for the surgical option to treat Obstructive Sleep Apnea

Discussions around the subject of a surgical option for the treatment of obstructive sleep apnea are frequently passionate. One need only visit the ASAA's online support group to see the verbal fists fly over whether it is a good idea or an idea that is desperately wrong.

The most common surgical procedure for treating OSA is uvulopalatopharyngoplasty or UPPP for short. Developed in 1981 by Dr. Fujita (the same year CPAP was first described) as an alternative to what was the only treatment for sleep apnea a tracheotomy. UPPP involves removing a lot of tissue from around the opening to the upper airway. This procedure is often done in conjunction with others to improve air flow through the nose.

The success of this procedure is reported to be between 16% and 83%, depending on how you define success. Some see success or cure after surgery as a 50% reduction in the Apnea Hypopnea Index (AHI) and others say a 50% reduction with an AHI less than 20. Though an AHI in this range can still considered moderate and detrimental to health.

The medical literature has been recently had several studies looking at the efficacy of the UPPP option for sleep apnea. An article published in September issue of the Mayo Clinic Proceedings provides results of a retrospective study where lab sleep studies were reviewed on 63 UPPP patients pre and post (six months) surgery. The objective of study was to determine if there was improvement in the AHI and whether that improvement was specific to any patient type.

Quoting from the results section of the abstract... "Patients who attained an AHI of 5 or less were younger, had lower Body Mass Indexes (BMI) and had less severe OSA. Of the patients with a post-UPPP AHI greater than 5 received continuous positive airway pressure, with a mean reduction in pressure of 1.4 cm H2O."

The take-away for me from this study and from others I have seen recently is that surgery has a place in the treatment options of obstructive sleep apnea. It can be very effective in *some* cases.

But that said, in my opinion, for surgery to be appropriately more main stream the surgeon must have a way of identifying/screening the candidates for whom this invasive procedure will benefit prior to surgery. Because once it is done, there is no going back.