Is surgery the solution for obstructive sleep apnea ?

 Image Courtesy  Freepik.com

Image Courtesy Freepik.com

Author: Stephanie Anderson Edited by: Ruchi Maniar

Nearly 100 million people worldwide suffer from Obstructive Sleep Apnea (OSA), a sleep disorder that causes one to repeatedly stop breathing while asleep (1). Such a disorder tends to go undiagnosed due to its overnight active period, with perhaps a few nonspecific symptoms such as loud snoring or daytime sleepiness. OSA is considered a serious medical condition and should be treated accordingly due to the risk of complications that could follow. There are many treatments already available for OSA that include continuous positive airway pressure (CPAP), oral devices, and surgery. With patients having difficulty adhering to their OSA treatment regime, research for a more convenient yet efficient treatment was in demand, and an alternative has finally been found (2). This new treatment, called upper-airway stimulation or Inspire Therapy, will evolve the way doctors treat moderate to severe OSA.

OSA occurs when both the muscles in the pharynx relax and collapse during sleep, or the tongue/other soft tissue block the airway, leading to an interruption of normal breathing. There are two types of breathing interruptions which can occur: 1) apnea, whereby airflow is completely blocked and 2) hypopnea, which is a partial blockage of at least 50% of the airway. There are several factors that increase the risk of OSA, including being overweight, smoking, drinking alcohol, taking sedative medications, being a male over 40 years old, and having a large neck circumference (3). The UK National Health Service stresses the importance of receiving treatment for OSA due to the complications that can originate from a combination of OSA and other health risk factors. Some of the complications can involve developing high blood pressure, atrial fibrillation, metabolic disorders, pregnancy complications, type 2 diabetes or even experiencing a stroke/heart attack, (4).

The most common OSA treatment is the use of breathing devices, a CPAP machine. This device requires a mask to be placed over the nose and/or mouth, to which piece a long tube is attached that will force air into the lungs. The CPAP is rather uncomfortable and loud to many patients, making sleep difficult (1). This makes adhering to the treatment at night rather difficult, which increases risk of complications. The most recent surgical treatment, known as upper-airway stimulation, removes all these inconveniences and provides an effective treatment that is more efficient and comfortable.

  Upper Airway Stimulation in OSA (Figure courtesy B. Bender (5))

Upper Airway Stimulation in OSA (Figure courtesy B. Bender (5))


Upper-airway stimulation is now being used for those who are unable to tolerate standard treatment.  A FDA-approved device (similar to a pacemaker) is implanted into the patient and delivers mild stimulation to the hypoglossal nerve to keep the airway open during sleep (5). An outpatient procedure is done whereby one lead (wire) under the chin is connected to the nerve that controls the tongue. Another is placed below the collarbone (for the battery) and finally, one sensory lead is located between the patient’s 4th and 5th rib to monitor breathing as seen in Figure 1 (5). During the procedure, the first lead that is attached to the hypoglossal nerve is checked for accurate placing. The nerve is stimulated and if accurately placed, there will be tongue protrusion. The surgical team uses electromyographic monitoring throughout the surgery to ensure proper functioning of the muscles and the implanted device. During a month or so into recovery, the patient may feel some slight discomfort at the beginning but reports of pain have been minimal (6).

After full recovery, the device is activated and set to initial stimulation parameters by the physician. The patient will receive a handheld remote to turn the device on and off based on their sleep schedule. There is an extra setting on the remote so the device can be set to start at a certain time interval to give the patient adequate time to fall asleep. As the patient sleeps, the device monitors their breathing and stimulates the nerve only on inhalation when sleep apnea events occur.

This new surgical treatment for those suffering from moderate to severe OSA is life changing. It is an easy, quiet and more comfortable device that allows the patient to sleep more peacefully throughout the night. According to the Werner Medical Center in Ohio, USA, studies show a 78% decrease in sleep apnea events and 85% of patients demonstrated minimal to no snoring. Importantly, patients acknowledged an improved daytime functioning and quality of life (6). The amount of time poured into research can only increase the possibilities of new advancements in sleep apnea treatments. With researchers hitting this milestone already, the near future seems quite bright and awakening.

References

1.      Mayo Clinic Staff. 2018. Mayo Clinic. [ONLINE] Available at: https://www.mayoclinic.org/diseases-conditions/obstructive-sleep-apnea/symptoms-causes/syc-20352090.

2.      Strollo, Soose, etc. 2014. Upper-Airway Stimulation for Obstructive Sleep Apnea. PubMed, [Online]. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24401051

3.      National Heart, Lung, and Blood Institute. 2017. Sleep Apnea. [ONLINE] Available at: https://www.nhlbi.nih.gov/health-topics/sleep-apnea.

4.      National Health Service UK. 2016. Obstructive Sleep Apnea. [ONLINE] Available at: https://www.nhs.uk/conditions/obstructive-sleep-apnoea/.

5.      Bender, B, 2016. Upper Airway Stimulation in OSA. PubMed.gov, [Online]. 95/11, 795-807. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27829262

6.      Ohio State University. 2018. Upper Airway Stimulation. [ONLINE] Available at: https://wexnermedical.osu.edu/ear-nose-throat/sleep-surgery/upper-airway-stimulation.