Sleep apnoea affects more than 18 million Americans, according to the National Sleep Foundation. It’s an involuntary cessation of breathing that occurs while a person is asleep. Those with untreated sleep apnoea sometimes stop breathing hundreds of times during the night, often for a minute or longer. In most cases, sleepers are unaware of these breathing stoppages because they don’t completely wake them up.
Risk factors include being male, overweight and over age 40, but the condition can hit anybody, even kids. Untreated, sleep apnoea can cause high blood pressure and other cardiovascular disease, memory problems, weight gain, impotence and headaches. Moreover, untreated sleep apnoea may be responsible for job impairment and motor vehicle crashes.
As the disorder reaches epidemic proportions, the selling of sleep has become big business. The number of devices promising to treat it has become so vast you could lose sleep just trying to pick one. Not to mention a few surgical options that sound grisly and that doctors acknowledge are painful.
Does any of it work?
“There’s a big debate in the sleep community as to what is ‘effectiveness’. If you go to different sleep doctors, they all have different criteria, because there is no real standard, since the field is still kind of new,” says Dr. Warren Boardman, a Ridgewood dentist and diplomate of the American Board of Dental Sleep Medicine. As part of his general practice, Boardman fits patients for oral appliances that reposition the jaw and tongue – just one of many treatment options for sleep apnoea.
Several North Jersey doctors agree, though, that you first need to go to a doctor specialising in sleep disorders (like a pulmonologist) to get a confirmed diagnosis of sleep apnoea. For one thing, depending on what kind of insurance coverage you have, a doctor’s diagnosis and prescribed treatment will get you reimbursement. For another, you’ll need the doctor’s guidance in settling upon which treatment to choose.
While getting diagnosed used to mean thousands of dollars and sometimes a two-night stay at a sleep clinic for observation, new home lab tests are widely available at a fraction of the cost and simply entail your affixing a few sensors to yourself for monitoring, according to Dr. John Villa, director for the Institute for Sleep/Wake Disorders at Hackensack University Medical Centre.
“It’s very cost-effective, and it’s exactly what we do in the sleep lab,” he said. The home test is not, however, for patients with significant pulmonary or artery disease, he noted.
Once you’ve been diagnosed, then what? In the ocean of devices and treatments for the disorder, there are four or five main options, each with its own pluses and minuses. Here’s a look:
- Continuous Positive Airway Pressure (CPAP) machines. “They remain the gold standard,” Villa said. The devices are the most widely used treatment and have received the endorsement of the American Academy of Sleep Medicine. They work best for patients with moderate to severe sleep apnoea, Villa said. The machines blow pressurised air into the sleeper’s throat to prevent the airway from collapsing and causing episodes of breathing cessation that interrupt deep sleep. The latest models are battery-operated, more lightweight and portable, quieter, and automatically fluctuate to the proper level of air pressure needed, based on the user’s breathing pattern. The machines can range anywhere from $400 to $2,500. With guidance and follow-up visits with your doctor, it works. But only for as long as you use one. It doesn’t train your throat to stay free and clear on its own. The other problem: Patients don’t stick with it. “There is the issue of having something tightly placed over your nose and mouth, blowing in air. You have to wear it every night, there is tubing, there’s a long hose – it’s uncomfortable. It can be problematic. We see about a 55 to 60 per cent adherence rate,” said Dr. Jag Sunderram, associate professor of medicine at Rutgers Robert Wood Johnson Medical School and medical director of the school’s Sleep Centre in New Brunswick.
- Oral appliance therapy. Increasing in popularity as a less cumbersome alternative to the CPAP machine are more than 100 different kinds of oral appliances approved by the FDA. Most, say doctors, come down to about the same basic concept. “It moves your bottom jaw forward in relationship to your upper jaw. You wear it when you sleep at night,” Villa explained. “It tends to work in patients with moderate sleep apnoea, who aren’t super-large. It’s a legitimate option.” There are a few things the consumer should be mindful of, however. While so-called “boil and bite” versions of the device can be purchased online, whereby you mail an impression of your teeth and have a fitted device mailed back to you, it’s probably not going to fit as well as if you went to a dentist who has done this for years. “Some of the dentists in Bergen County are getting pretty good at it. It’s all about the art of it. The art of adjusting it, trial and error, over multiple visits. They are slowly pulling your jaw forward,” Villa said. Dr. Jeffrey Salizzoni, director of pulmonary and sleep medicine for Aspen Medical Associates in Teaneck, agreed. “I would advise against the “boil and bite”-type mouthpieces. I would recommend being fitted by a certified sleep medicine dentist, for quality assurance and effectiveness.” According to some experts, there is also an insurance issue. The appliances fall under “medical” insurance, which covers them. But many dentists don’t take “medical” insurance – they take “dental”. So you end up having to pay, and then you have to deal with getting reimbursed by the insurance company. While a little less effective than using a CPAP machine, the appliances have a higher compliance rate, according to Sunderram. About 80 per cent of patients stick with them.
- Chin strap. These are only to be used in conjunction with CPAP machines for certain patients who are mouth breathers, say local doctors. They are not effective in preventing sleep apnoea when used alone, despite being advertised that way sometimes.
- Hypoglossal stimulators. This is a pacemaker-like device that is surgically implanted in the neck area and sends signals to the tongue to clear the airway. Recent studies show it to be highly effective and, while still limited in availability, could be the next best thing. “Your Body Mass Index has to be on the lower side,” Villa said. “This isn’t for super large patients. Some sleep centres in New York City are doing it. And there are other devices like this being used on a trial basis. But it is still reasonably new. They’ve been doing it for a while, but it got FDA approval in 2015.”
- Surgery. When all else fails, patients can undergo surgery whereby the uvula is removed along with part of the palate.
“It’s pretty significant surgery,” Sunderram said. “It works in mild forms of sleep apnoea and for people with a lot of tissue at the back of the throat. But it is only 50-per cent effective. And you’d have a sore throat for weeks.”
Doctors note that the foremost weapon against sleep apnoea is a healthy lifestyle. “This has become an epidemic because of obesity. Plus smoking and drinking can cause swelling at the back of the throat, worsening it,” Sunderram said.
Villa agreed. “Losing weight is key, as part of a comprehensive programme. CPAP plus weight loss is better than either by itself.” – John Petrick, The Record