By Terence M. Davidson, M.D.
Professor of Surgery
Associate Dean for Continuing Medical Education
University of California, San Diego School of Medicine
San Diego VA Health Care System
This article is reprinted by permission of the author, Dr. Terence M. Davidson. This material was updated by Dr. Davidson in March of 2001.
Editor’s note: Opinions on specific testing options and treatment options expressed in this article are those of Dr. Davidson. Your own physician may follow different testing procedures, (a full in-lab study, for example) and have a differing view on some treatment options. That is the nature of medicine and the perspective of each physician. TalkAboutSleep.com recommends that all patients suspecting sleep-disordered breathing discuss their condition with their primary physician and with a sleep specialist, preferably one board certified in sleep medicine.
This consultation is part of a series of consultations with Head and Neck Surgery specialists at the University of California, San Diego. The case is a hypothetical patient chosen to represent a composite of the usual and most common patients with this specific disorder.
The consultation is presented for purposes of general information. Specifics about an individual case and specific treatment must be discussed between the patient and the treating physician.
The hypothetical patient portrayed in this consultation is a 48 year old male. He is referred by his Primary Care Physician for complaints of loud snoring.
Initial Office Visit
Doctor: Good Morning. How can I help you today?
Patient: My wife tells me that I am snoring.
Doctor: How loud and how long has this gone on?
Patient: Well, it is a somewhat sensitive subject, so excuse my embarrassment.
Doctor: I fully understand that. All of the patients who come here with snoring are embarrassed. However, it is a very common problem, and it is one that we can help you with, so I am interested in knowing as much as I can.
Patient: Well, I have probably snored my entire adult life. I remember my roommate in college saying that I snored and that sometimes it even kept him up. I am always hesitant to go camping with friends because they say I snore so loudly in the tent that they don’t like to sleep in the same campsite with me. In any case, my wife has complained that I snore so loudly that she can no longer sleep with me. She has therefore shoved me out of bed and I now have to sleep on the couch in the living room. It is bad enough that the neighbors called at 3 o’clock in the morning last Tuesday and asked my wife to turn me over.
Doctor: Do you have any other symptoms of sleep apnea?
Patient: I do not know what sleep apnea is, but I am not aware that I have any other symptoms.
Doctor: Has your wife or anyone ever said that you stop breathing at night?
Patient: Oh, she has commented that very often I will stop breathing and I’ll hold my breath for as long as 30 or 45 seconds. She then kicks me to breathe, and then I will take a couple of gasps and deep breaths, and fall back to sleep.
Doctor: Does this happen often?
Patient: She says that when she watches me sleep, which she now does not do, that I will sometimes do this very frequently.
Doctor: We call the absence of breathing “apnea”, and the spells “apneic episodes”.
Patient: Ah, I understand. Yes, I have apneic episodes, at least as witnessed by my wife.
Doctor: Are you sleepy during the day?
Patient: Am I sleepy during the day? You’re looking at someone who can sleep 24 hours a day. I am always sleepy. If I don’t have something important to do, or something keeping me up, I am always falling asleep at my desk.
Doctor: How long has this been?
Patient: Well, you know, it’s funny. It’s just sort of crept up on me. When I was younger, I used to be able to sleep 6 hours and work for 18. The older I get, the heavier I get, and it seems I have to sleep longer and longer, and the more I sleep the sleepier I get. Even if I take a nap for an hour or two, it doesn’t really seem to refresh me. I seem to wake up just as tired as when I went to bed. I have always assumed that this was a normal part of the aging process.
Doctor: Have you ever fallen asleep driving?
Patient: I have never fallen asleep driving, but I can tell I am getting sleepier and sleepier. I do not like driving long distances, and I have actually dozed off once or twice and so I have gotten somewhat afraid of driving. Fortunately I live close to work and I do not need to do much driving.
Doctor: Have you had any weight gain in the past years?
Patient: Yes. I have been successful at work and I have slowly added this to my midriff. I would say I have gained thirty pounds in the past ten years alone.
Doctor: Do you exercise?
Patient: I used to exercise and I used to enjoy it. But now I am so sleepy, I just come home, have dinner and go to bed. I lack the energy to exercise.
Doctor: Do you ever have a headache in the morning when you wake up?
Patient: Yes, I often do and I am not traditionally headache-prone, but very often when I wake up I will have this absolutely horrible headache right in my forehead. Fortunately, it dissipates over half an hour to forty-five minutes, and by the time I finish my fourth cup of coffee, it is invariably gone.
Doctor: Well, you have described the classic symptoms of sleep apnea.
Patient: What do we do from here?
Doctor: Well, first I have to examine you. Then you will need to have a sleep test, and then we will need to look at treatment options.
Patient: Well, what kind of treatments can you do?
Doctor: Let’s do the exam. Let’s do the sleep test. Let’s do it one step at a time. We will do this thoroughly and we will do this well. I will let you know what you have as we go along, and we will certainly develop the best evaluation and treatment possible.
My examination includes using a light and examining your nose, your mouth and your throat. Following that I will spray some medicine in your nose and examine your nose and your pharynx, that is the swallowing tube or your throat with a fiberoptic endoscope. This is not uncomfortable, but this is your breathing passage, and so I need to look for any anatomic obstructions that might contribute to your sleep disordered breathing.
Patient: What is sleep disordered breathing?
Doctor: Sleep disordered breathing is what I call the entire gambit from snoring to severe sleep apnea. It is what I prefer to call your condition until I have more specific details.
I know from your chart that you are 5’6″ and that you weigh 170 pounds. This gives you a BMI of 27. BMI stands for Body Mass Index and is a measure of how big you are. Normal, thin people have a BMI of 25 or less. As we gain weight into adulthood, you will often see the BMI increase between 25 and 30. As it goes over 30, one is beginning to have what we call obesity and when it goes over 35 then this is considered morbidly obese.
I also need to know your neck circumference.
Patient: I have no idea.
Doctor: Well, what size shirt do you wear?
Patient: Oh. I actually find I need bigger and bigger neck collars, so I now require an 18-1/2 shirt.
Doctor: Do you have blood pressure problems?
Patient: Yes, I do have hypertension and my Primary Care doctor is treating that.
Doctor performs the examination and notes regarding the findings are recorded.
Doctor: There are many kinds of sleep tests. The traditional has been an in-house polysomnogram. Today this is primarily used for research, but for the in-house polysomnogram you sleep in a laboratory. Brain waves called the EEG are recorded and respiration, leg movements, oxygen, etc. are also recorded. For most sleep-disordered breathing such as yours, a multi-channel home sleep test is much more comfortable, far less intrusive and provides excellent information.
Patient: You mean I don’t have to sleep in a lab?
Doctor: No. You will sleep at home in your own bed. Your breathing is measured with little nasal canulae. Your oxygen is measured by an oximeter wrapped around your finger and then we record your chest movements and body position with a strap loosely fit around your chest. All of this is connected to a small computer. You simply put the monitors on before going to bed, connect the wires to a computer, turn the computer on and go to sleep. The next morning, turn the computer off and disconnect the wires. You will return them to our sleep technician and the information is transferred to one of our computers. It is evaluated and a sleep report is generated.
Patient: That sounds relatively simple. What if I have to get up in the middle of the night?
Doctor: That is not a problem. You simply disconnect the wires from the computer, and reconnect when you go back to bed. Do not turn the computer off, for then it would start all over again, but other than that one mistake, this is common and not problematic.
A week later the sleep test is performed, and several days following that the patient returns to the office.
Follow-up Office Visit After Home Sleep Study
Doctor: Good afternoon. How are you today?
Doctor: How was the sleep test?
Patient: That was certainly easy to do. Did I record anything?
Doctor: Yes, you did. We got a good measure of your night’s sleep.
Patient: What did it show?
Doctor: Well, it shows that you have moderate sleep apnea. You stopped breathing 45 times every hour, so every minute and a half you stop breathing for period as long as 30, sometimes 45 seconds. During this period your oxygen will frequently fall and during periods of REM sleep, when you are dreaming and having your deepest sleep, your oxygen will fall as low as 80%, a number which we consider a dangerous fall in oxygen.
Patient: Well, what does all this mean?
Doctor: This means that you have what most people call obstructive sleep apnea.
Patient: Is it dangerous?
Doctor: Yes, it is, because every time that you obstruct your breathing, it is like someone is choking you. You secrete adrenaline, your heart rate goes up, your blood pressure goes up, and if you continue to do this day in, day out, you will end up with hypertension, ultimately with heart attacks, and ultimately with a stroke.
Patient: Well, is it treatable?
Doctor: Yes, it is and that is what you and I have to deal with next. I would like to schedule an appointment for you and your spouse to discuss the treatment of sleep apnea.
Patient: Can we do it soon?
Doctor: Yes, and I agree that we should proceed expeditiously.
Treatment Discussion with Patient and Spouse
One week later, the patient and spouse return.
Patient: Doctor, I would like you to meet my spouse and bed partner.
Doctor: How do you do. I am pleased that you have come, for we have found that the management of sleep apnea is important to health and longevity, and the best chance of success comes when there is strong spousal support.
Patient: So, I have discussed with my wife the fact that I have sleep apnea. We have reviewed some of the materials on your website and we have also read some of the materials available to us at the public library. I must say, neither one of us had any idea that this was such a common medical problem, and neither one of us had any idea that it had any, let alone such serious, health consequences.
Doctor: Well, you have taken the first step in the management of sleep apnea. Nasal CPAP is the preferred treatment for all sleep disordered breathing including snoring, upper airway resistance syndrome and obstructive sleep apnea. CPAP stands for Continuous Positive Airway Pressure.
Nasal CPAP is typically delivered with a small mask that is held against the nose with a head strap. Tubing affixed to the mask is connected to a high tech machine, which blows air into the mask and maintains a fixed pressure in your nose and throat. This pressure splints the collapsing airway. It prevents obstruction at night. It cures snoring, upper airway resistance syndrome and obstructive sleep apnea.
While it is true that some look at this apparatus and opine that it is not terribly sexy, the fact of the matter is it works, people do sleep with the CPAP machine, and those who use it successfully stop snoring, sleep better, feel better and recognize marked improvement in their ability to function both at work and at home.
CPAP is typically fitted by spending one night trying different pressures to determine the best possible pressure. This is called a CPAP titration. Once this pressure is determined, a fixed pressure CPAP machine is delivered. Some people find that the forced air is very drying and uncomfortable for their nose. For these individuals, humidifiers inserted in line with the CPAP will humidify the CPAP air and reduce nasal and pharyngeal discomforts.
Patient: That sounds easy.
Spouse: It doesn’t sound easy to me. How are we supposed to have sex while he is wearing this mask?
Doctor: You can do whatever bedtime activities you would like. The patient only needs to put the mask on prior to commencing sleep. If for some reason you want to take it off in the middle of night, that is certainly okay. There is absolutely no reason why CPAP should interfere with normal life, bedtime activities included.
Spouse: Well, does this work all the time?
Doctor: CPAP works very well for the vast majority of patients. Some take to it quickly. Some have to work a little harder. Some have to adapt. Some even have to modify certain sleeping habits, but the majority of patients derive substantial benefit from the CPAP and ultimately recognize and appreciate its benefit. There is no question that you as a spouse need to be very supportive and encouraging.
Patient: Well, maybe I could just lose a little weight and then I wouldn’t have to wear the CPAP.
Doctor: While it is true that sleep apnea is a very weight-dependent illness, most individuals with sleep apnea are so tired and so without energy that weight loss is not a possibility until the sleep apnea is corrected. I would encourage you to treat your sleep apnea with the CPAP. Once you are feeling better, you can exercise and diet. As you lose weight, your sleep apnea will dissipate, perhaps even disappear and then we can reevaluate and see if you can get off the CPAP treatment.
Patient: Are there any upcoming innovations in CPAP therapy?
Doctor: The latest innovation in CPAP delivery is a variable pressure CPAP machine. Variable Pressure CPAP units contain software which recognize the collapsing airway and can modulate the pressure at the lowest possible number to maintain a patent or otherwise open airway. The advantage of Variable Pressure CPAP is that most airways do not require high pressures for all of the evening. It is these high pressure, high flow conditions that cause the drying.
By lowering the pressure and lowering the flow, drying and pressure discomfort occur less frequently and are far less intrusive. The future is definitely with the Variable Pressure CPAP machines. For those who are having difficulty with Fixed Pressure CPAP machines, they are strongly encouraged to inquire about and try the Variable Pressure CPAP.
Patient: I am curious, is CPAP only for people with sleep apnea, or are there other kinds of sleep abnormalities treated by CPAP.
Doctor: There are a multitude of variations for nasal CPAP. Individuals with congestive heart failure can often be greatly improved by the use of specially designed CPAP machines. The same is true for individuals with transient ischemia attacks and strokes. They have a very different kind of breathing. They need a very different kind of CPAP delivery. Software is available to deliver whatever will improve the patient’s breathing. While nasal masks work for most, full-face masks are sometimes required, particularly for those individuals who are obligate mouth breathers.
Patient: If you had to give one word of advice regarding treatment with CPAP, what would it be?
Doctor: The spouse must be involved. An individual who is challenged to use CPAP without spousal support is doomed to failure. Those whose spouses care enough, attend the CPAP fittings, the CPAP demonstrations and the CPAP instructions and then go out of their way to encourage and support the use of the CPAP will lead to CPAP compliance. Those whose spouses fail to provide this kind of loving support doom their bed partner to failure. While CPAP tends to be most successful in those with severe sleep apnea, it does work in milder forms and in many cases is very successful even in the treatment of snoring. For this reason, virtually anyone with sleep disordered breathing deserves a CPAP trial.
Spouse: What happens if CPAP does not work?
Doctor: In the event that CPAP is not a satisfactory treatment, other options exist. The best are surgical options and these will be described in a moment. Other options that some recommend are dental appliances. These are devices which shove the lower jaw forward at night. It is the author’s opinion that they move teeth and that they will ultimately cause problems with the temporomandibular joint. I personally could not imagine someone electing to wear a device that shoves their teeth and their jaw out of alignment 8 hours a night, 7 nights a week, year in year out for the remainder of their life. Nonetheless, there are those who believe in the oral appliances, and as you can well imagine, there is now a whole industry of dentists and companies producing these.
Patient: Can you tell me more about surgery?
Doctor: Surgery is a good option for many forms of sleep disordered breathing. It is particularly attractive for those individuals who are young. It is particularly attractive for those individuals who have obvious anatomic obstructions and it is obviously necessary for those who have tried CPAP and have failed. The following are my current thoughts on surgical treatments for sleep disordered breathing.
Surgery For Snoring And Sleep Disordered Breathing
As the field of Sleep Medicine evolves, better understanding and newer treatments are being developed. For those with snoring alone or those with snoring and sleep apnea, nasal CPAP is the premier treatment. Those who do well with CPAP are cured of snoring, are essentially cured of all obstructive sleep apneas. For those who do well with this the treatment is safe, effective and cost-effective.
Not everyone does well with nasal CPAP. Some find it an intrusion into their lives. Others find it claustrophobic or otherwise not tolerable. For these individuals, consultation for surgery is recommended.
The evaluation of an individual interested in surgical therapy includes a thorough examination of the nose, mouth and pharynx (throat). If obvious obstructive anatomy is evident, and if the nature of the sleep apnea is such that surgery stands to improve the condition, then surgery will be recommended.
Surgical therapies vary from very simple operations with minimal risk to very complex operations with significant discomfort and concerning risks and potential complications. Surgeries that have been used in the treatment of snoring and sleep apnea include septoplasty, an operation to straighten the cartilage on the interior of your nose, turbinate reduction, and operation to reduce the natural filters of the nose, filters which often become swollen and congested, particularly in patients with allergic rhinitis.
Adenoidectomy is certainly recommended in those with swollen adenoids. Tonsillectomy is recommended for those with big tonsils, particularly those in whom the tonsils are felt by the examining physician to potentially play a role in the nighttime airway obstruction. Snoring is produced for the most part by vibrations of the uvula. This is the little tissue that hangs down at the far end of your soft palate.
Snoring is therefore often treated either by removing the uvula or removing the uvula and a portion of the soft palate. Several variations on this theme exist and the operations are of necessity tailored to the individual. The most difficult problems are those in whom the obstructions and the snoring are caused at least in part by the tongue falling backward. Several operations attempting to reposition the tongue have been developed. All are successful some of the time. None are successful all of the time. The names of these surgeries include: genioglossus advancement, hyoid suspension and tongue reposition.
If all else fails, almost all sleep apnea can be successfully treated by maxillomandibular advancement. This is a complex operation in which the bones holding the upper teeth and the bones holding the lower teeth called the mandible are surgically cut and moved so that the lower part of your face is moved forward approximately 12 millimeters. By doing this, the airway in the back of the throat is expanded and the sleep apnea cured.
While an excellent operation, this is the most extreme of undertakings and is only employed for disabling sleep apnea in patients in whom all other treatments have been unsuccessful.
There are myriad of fly-by-night medical and surgical treatments. Our general philosophy is that unless these are being evaluated in a University-approved research study, they are a waste of money and place patients at undue risk.