Treatment Options for Obstructive Sleep Apnea

Many people benefit from CPAP therapy, but some require surgery.

For people with sleep apnea, sleep isn’t restful—it’s punctuated by interruptions in breathing that cause them to wake up frequently. Those with mild sleep apnea might experience this a few times an hour; in severe cases, it can happen hundreds of times a night.

Twenty-five million adults in the U.S. have obstructive sleep apnea. As a result, they deal with daytime sleepiness that can hurt their productivity at work and even make it dangerous to drive. Sleep apnea also increases a person’s risk of developing other serious health problems, such as high blood pressure, heart attack and stroke. Snoring is common in people with sleep apnea, and their bed partners often complain that their sleep suffers as a result.

Eight in 10 cases of sleep apnea are obstructive, meaning the muscles that control the airway become relaxed during sleep, so the airway becomes obstructed or blocked. Two less common types are central sleep apnea, in which the airway is not blocked but the brain does not signal the airway muscles to breathe, and complex sleep apnea, in which people have both a blocked airway and faulty brain signaling.

If you have obstructive sleep apnea, there are several effective treatment options. To find out more about them, we spoke with Trevor G. Hackman, MD, an ear, nose and throat surgeon at UNC Medical Center in Chapel Hill.

  1. The first step in the treatment process is to confirm whether you have sleep apnea.That means having a clinical evaluation and a sleep study done at a sleep laboratory, such as the one at theUNC Sleep Disorders Center. You will spend the night in the sleep lab, where sensors will be attached to your head, chest, arms and legs to measure your heart rate, brain waves, breathing and body movements.
  2. Treatment with continuous positive airway pressure (CPAP) is the most common next step after diagnosis.This involves wearing headgear and a mask that fits over the nose, or a mask that fits over the nose and mouth, while you sleep. The mask is connected by a hose to a small machine that delivers a precisely measured flow of air to keep your airway open. CPAP works well for many people, but some find that similar therapies such as automatic positive airway pressure (APAP) or bilevel positive airway pressure (BiPAP) work better.
  3. Medicare and most commercial health insurance providers will pay for the first three months of rental for a CPAP, APAP or BiPAP machine.For many health insurance groups to continue paying after three months, you will be required to have a follow-up visit with your doctor after the first 30 days, and you will have to use the machine at least four hours per night on 70 percent of the nights over 30 days. (Some of the newer machines automatically keep a record of how many hours you use the machine each night.) It’s important for you to talk to your health insurance provider about the costs and requirements associated with use of a CPAP, APAP or BiPAP machine.
  4. For some people, treatment includes learning to sleep on their sides. That’s because sleep apnea is more likely to happen, and to be worse, when you sleep on your back, Dr. Hackman says.One way to do this is to sew a tennis ball to the back of a nightshirt or belt to recondition yourself to be a side or stomach sleeper. You can also buy sleep belts and other devices.
  5. Good sleep hygiene is important for the treatment of sleep apnea. “Sleep hygiene” refers to things you can do on your own to improve your sleep. These include using your bedroom for sleep only, eating your evening meals at least two hours before going to bed, and avoiding caffeine, alcohol and refined sugars in the evening.
  6. There is no prescription medication to treat the underlying cause of sleep apnea, but sometimes medications such as nasal steroids may be given to help open the nasal airway to improve CPAP compliance. One recent study found that a combination of atomoxetine and oxybutynin, taken as two pills at bedtime, reduced patients’ frequency of airway obstruction.
  7. Surgery may be considered after trying nonsurgical options. Some people who try CPAP and other nonsurgical treatment options don’t find relief. Fortunately, there are several surgical approaches available. But airway obstruction can happen in many ways, and different surgical approaches are required depending on the obstruction’s location and cause. Dr. Hackman says he uses a procedure called sleep endoscopy to help him decide which surgical approach has the best chance of success.
  8. The most common surgical procedure for sleep apnea is uvulopalatopharyngoplasty, called UPPP or UP3. In this procedure, excess tissue is removed from the soft palate and pharynx. The tonsils are also removed if present, and sutures are used to close the wounds and reshape the palate to add stiffness to the structure, to keep it open. UPPP is effective for some patients (such as those with very large tonsils and mild apnea) but often does not work for patients with more severe apnea or problems with their tongue base.
  9. One newer surgical approach is implanting a small, pacemaker-like device in the chest just under the skin.The Inspire device, approved by the Food and Drug Administration, delivers stimulation to key airway muscles while you sleep to keep your airway open. Dr. Hackman began treating patients with this device in 2018 and says he has seen “very promising” results.
  10. Several other surgical procedures are available.These include tongue base reduction,nasal surgery, soft palate implants, hyoid advancement (moving the hyoid bone can create a bigger airway), tongue advancement, lower jaw advancement and tracheostomy (surgically creating an opening in the neck into the trachea, which bypasses the obstruction). Tracheostomy is recommended for patients with severe refractory sleep apnea for whom other therapies have failed.

Think you might have sleep apnea? Talk to your primary care doctor about a referral to an ENT specialist or a neurologist. Need a doctor? Find one near you.