Obstructive Sleep Apnoea - Surgical Treatment or CPAP Machine?

Obstructive Sleep Apnoea is a condition where an individual stops breathing for a period of time during their sleep. This cycle repeats many times during the night interrupting a person's sleep. The obstruction may be complete or partial but is usually sufficient to waken the sleeper for just a few seconds so that they resume breathing again. This interruption prevents a person from achieving the restful states of sleep, such as REM (rapid eye movement - the dream phase) sleep.

Although the exact causes is unclear, the site of obstruction is usually involves the soft tissues at the back of the mouth and nasal cavity. During the day, the muscles in this area help keeps the airway intact. At night, the muscles relax to a point where the airway collapses and breathing is obstructed.

The people at risk for developing Obstructive Sleep Apnoea are those who have:

• have weight gain (especially in the neck area)
• certain anatomical features (e.g. receding chin)
• enlarged tonsils and adenoids, a family history (although it is not genetically linked)
• use alcohol and sedating drugs
• smoke (smoking causes swelling and narrowing of the upper airway)
• certain medical conditions (such as hypothyroidism, acromegaly, amyloidosis, neuromuscular disorders, Marfan's syndrome, Down's syndrome)
• nasal congestion

Common symptoms are:

• excessive sleepiness during the day
• personality changes
• depression
• decreased memory
• erectile dysfunction
• morning headaches
• frequent need to urinate

People who suffer from Obstructive Sleep Apnoea are rarely aware that they wake up frequently during the night. The physical signs that suggest a person may have Obstructive Sleep Apnoea are:

• obeisity
• loud snoring
• a witnessed episode of apnoea by a sleep partner (e.g. the spouse)

People with Obstructive Sleep Apnoea also often suffer from high blood pressure and tachycardia (rapid heart beat).

Five simple questions may be used to identify a person with sleep apnoea:

1. Do you fall asleep easily during the day (e.g. while driving) despite having an adequate amount of sleep?

If a person says "yes" to three or more of the above questions, they are most likely to have Obstructive Sleep Apnoea. It has also been found that some 80-90% of cardiac patients suffer from Obstructive Sleep Apnoea. A sleep study may be required to properly diagnose the condition. Untreated Obstructive Sleep Apnoea increases the risk of developing heart disease and stroke.

There are several treatment options available for people with Sleep Apnoea:

• Surgical (The Pillar Procedure is one new surgical treatment option that has received considerable media attention in recent times)
• CPAP Machine

The Pillar Procedure is a relatively simple surgical procedure for treating Obstructive Sleep Apnoea. It involves implanted three pins into the soft palate to maintain the airway during sleep. The procedure was first introduced in 2003, and has been hailed as somewhat of a breakthrough in the management of Obstructive Sleep Apnoea.

The studies so far are somewhat limited and the longevity of this procedure has only been tested up to 15 months. Success rate is about 50-60% in a study of about 20 odd. Although risk of infection from this procedure is low, irritation to the tissues and protruding implants are two post-operative issues cited.

Recommended by a cardiologist who has had quite a bit of experience in this area is the CPAP machine. He feels a CPAP machine is a far safer option than undergoing surgery. Some of the reasons why he disagrees with surgery and the Pillar Procedure:

1. Airway obstruction occurs only at night when the muscles are relaxed and not during the day which suggests that there is nothing overtly wrong with the soft tissues in the airway. Surgery seems rather aggressive.

2. What are the long term effects of surgery? Long term is defined as 10 years. The Pillar procedure has only been around for a couple of years - insufficient to determine the long term effects.

3. What are the effects of implants in the palate on eating and speech? The oral environment is a very dynamic environment, constantly undergoing change.

4. The Pillar Procedure only addresses the soft palate. Obstructive Sleep Apnoea involves other soft tissues as well (e.g. the tongue).

What is a CPAP machine and how does it work?

CPAP is the abbreviation of Continuous Positive Airway Pressure. A person with Obstructive Sleep Apnoea wears a mask which is hooked up to a machine that monitors the person's breathing throughout the night. When the machine detects that breathing has stopped, it will send a pulse of air to open the airway so breathing may resume.

There are many different models of CPAP machines that are now available.

There are basically three types of masks - a full face mask that covers the whole face, one that covers only the nose and mouth, and one that covers only the nose (although this is only suitable for people who are not mouth breathers).

The newer CPAP machine models are now so compact (even smaller than the unit shown in the picture below) that it can even be used on an aeroplane on overnight flights.

Some companies that manufacture CPAP machines:

DeVilbiss

Fisher & Paykel Invacare Puritan Bennett ResMed Respironics

It is advisable to get a thorough check up with your ENT specialist before using a CPAP machine to ensure that blockage of the airway are not due to other physical obstructions, e.g. nasopharyngeal carcinoma (cancerous growth blocking the airway), enlarged adenoids/tongue, etc.

CPAP machine are not advised for people who have suffered a pneumothorax previously. Encasing your lungs is a sack containing fluid. A pneumothorax is a condition where there is a communication between the lungs and that sack and air becomes trapped inside that sack.