Management of Obstructive Sleep Apnea (OSA)
Oct 19 Written By Stephen Bray
OSA is a potentially fatal disease of epidemic proportions in our society today. With 26% of Canadians estimated to have OSA (5.4M Canadians) chances are that you or someone close to you has OSA. Management is crucial and the two primary ways are by CPAP (Continuous Positive Airway Pressure) which comprises a mask, bedside pump and joining hose and OAT (Oral Appliance Therapy), which comprise an oral appliance similar to a mouth guard. Both have advantages and disadvantages.
Pros of CPAP (Continuous Positive Airway Pressure)
- Immediate relief from symptoms is often experienced.
- Many patients can acclimatize to CPAP masks and systems.
- CPAP is described as the ‘Gold Standard’ of OSA management, as it will always work if the pressure can be adjusted high enough.
- The disposables (mask and hose) required are relatively inexpensive.
- Actively growing children may be better suited to CPAP rather than regular replacement of appliances as the jaws develop.
- The average life expectancy of a CPAP or BIPAP machine is approximately 20,000 hours, or about seven to eight years full time use, or longer if maintained and cared for carefully.
- Some of the difficulties with CPAP can be resolved with BiPAP (Bi-level Positive Airway Pressure) and APAP (Automatic Positive Airway Pressure)
- Costs can range but are often in the range of $1,500-4,500 depending on type and complexity.
Cons of CPAP (Continuous Positive Airway Pressure)
- Leaks around the mask
- Skin Marks or Rashes From mask
- Dryness in the Nose or Mouth Possible damage or permanent change to jaw position/bite.
- Discomfort Breathing out against the air pressure delivered.
- Swallowing air.
- Developing Central Sleep Apnea
- Facial growth problems in children.
- Inability to open your mouth during sleep
- Difficulty breathing when nose is ‘pugged’ (i.e. with a cold, etc.) or with deviated nasal septum or injury.
- Pump or air noise
- Reduced sex drive
- Adjustment requirements for CPAP setting changes following aging, weight change, etc.
- It is not recommended to buy without adequately trained back-up support, nor to buy used equipment or disposable items.
- CPAP is however not everything to everyone and although many people are not given the available options, an individual approach is necessary given the likelihood of management being required for ever.
- I would recommend people try CPAP, although certain groups such as those with jaw joint problems (TMD) or nighttime tooth grinding (Nocturnal bruxism) require re-consideration.
- Those with primary snoring alone do not require CPAP.
Overview – CPAP
- Alternative options must be provided as CPAP is not for everyone, nor the answer to everyone’s problem. Overall, CPAP compliance is inadequate.
- The criteria for success has been questioned as being too little wear for optimal effectiveness. Management of OSA has been shown to save lives, reduce co-morbidities, early death and a reduced quality of life for both the sufferer and partner.
- CPAP is a good first choice and by far the most prescribed.
Pros of OAT (Oral Appliance Therapy)
- Many patients find dental devices to be more comfortable and tolerable to wear as opposed to CPAP masks.
- There is less equipment to become entangled with during sleep, or knock off during slumber, for patients who are active movers during sleep.
- There is a lot less equipment involved, and therefore easier to travel with.
- They are easier for bedpartners to ‘live with’ and not so much of a challenge to intimacy. (You can kiss your spouse “good night”.)
- Consequently, OAT has a better compliance rate.
- Patients with mild to moderate sleep apnea are often ideal candidates. It can work on moderate to sever and sever cases but CPAP may be trialed first for those people.*
- Patients with Upper Airway Resistance Syndrome (UARS) are often ideal candidates. These tend to be young, slim and fit men and women.
- Patients with primary snoring are often ideal candidates.
- Patients who have tried and failed at CPAP therapy are often ideal candidates.
- Patients who were unsuccessful with or refused surgeries such as tonsillectomy, adenoidectomy, craniofacial operations, or tracheostomy.
- Oral appliances may provide help for those with Bruxism (nighttime tooth grinding) and / or jaw joint problems (TMD.)
- There are different types of Oral Appliances for both those with teeth and those without.
- The newer custom appliances will likely last in excess of 5 years as per CPAP.
- Although OAT is designed to assist in noes breathing, mouth breathing is available unlike CPAP.
Cons of OAT (Oral Appliance Therapy)
- There may be transient or temporary jaw or muscle pain, soreness, or tension
- Excessive salivation or even dry mouth may occur
- Changes to the bite, jaw position, teeth alignment.
- Loosening of dental restorations has been claimed, only occurs with defective dental restorations.
- OAT does not work on everyone. Approximately 60-70% of people are successful although this may be seen in comparison to CPAP’s compliance rate of less than 50%. There are means of predictively testing for success prior to commitment.
- As CPAP, costs of appliances range from $1,500-3,500.
- Appliances are generally ‘Custom made’ so a trial is not as easily performed as with CPAP. Temporary appliances can be bought over the counter and may indicate later success. Success indicates that success is likely in the custom appliance, failure of the temporary appliance does not indicate failure of the custom appliance due to their greater benefits.
- Adjustment requirements for OAT setting changes following aging, weight change, etc. With an adjustable appliance these changes can be made relatively easily.
Overview Oral Appliances
- Oral appliances are simpler to use and often have similar advantages to CPAP, however, just as CPAP they are not for everyone and may not work for everyone.
- They are more portable but are prescribed less, often due to unfamiliarity, bias or lack of knowledge by those prescribing.
- Combination OAT/CPAP
- In combination with CPAP, OAT can help lower patient’s apnea/hypopnea index for more tolerable air pressure settings.
- A combination can also protect the patient from tooth and jaw joint damage when an OA is inadequate by itself.
- While combination therapy may be seen as costly (paying for both) the savings (avoiding broken or worn teeth, jaw joint damage, facial pain, swallowed air) can be significant.
Overall, OSA management.
Overall, OSA management is an individual decision based on many factors. Inability in awareness or discussion of these factors may lead to dissatisfaction and failure to wear and therefore manage a potentially serious disease. The clinician must be adequately knowledgeable or willing to get a second opinion, in order to help the patient, understand all options, not just the one they provide.
OAT and CPAP are the commonest prescribed means of managing OSA. Other options such as surgery exist. Optimal treatment by either is improved with a good nasal airway. Adjunctive intervention such as weight loss, positional therapy and other behavioral treatments should be considered to support either therapy.
Assistance, interest in the patient and support increases the success of any therapy.