Treating Sleep Apnea. by Ralph A. Pascualy, M D

Continuous positive airway pressure (Seepap) is the treatment of choice for most
people with obstructive sleep apnea. It is nearly 100 percent effective when
used every night.
• Surgery should be considered as the last treatment option. There are situations
where your sleep specialist and the surgeon will agree that surgery is your best
first option but these are the exception.
• The best treatment is the most conservative treatment that will work
for you.
• Nonsurgical treatments are more conservative than surgery, and may
work better.
• Get a second opinion from a sleep specialist before having surgery for
sleep apnea.
• Have a sleep study before and after treatment, for comparison, to verify whether
the treatment has successfully eliminated your sleep apnea.

Case Study.

M r. Kennedy had a complete sleep test at an accredited sleep center. The test
results showed that he had more than 250 apnea events during the night
while his sleep was being recorded. His sleep specialist told him that he had moderately
severe obstructive sleep apnea with a minor central apnea component, as well as cardiac
arrhythmia. The specialist recommended that he undergo treatment.
At this point, Mr. Kennedy had answers to the first two questions on the pathway
to successful treatment of sleep apnea:
1. Is his condition actually sleep apnea, and does he have any other conditions
that will have a bearing on successful treatment?

2. What kind of sleep apnea is it (central, obstructive, or mixed), and how severe
is it? (The answer to this question is important because it determines the kind
of treatment.)
Finally comes the third and crucial question:
3. What is the best treatment for Mr. Kennedy’s type of sleep apnea?

Choose the Right Treatment.

The best treatment for anyone is the most conservative treatment that will succeed
in his particular situation.
What is the most conservative treatment that will work for you? This is a complex
and individual question that should be explored carefully by you, your sleep specialist,
and perhaps your family doctor. The treatment should be chosen on the basis of the kind
of apnea, how severe it is, and your overall health. Your sleep specialist can describe the
various treatments that may work best for you and can tell you which ones are the most
conservative.
What do we mean by most conservative? This means the treatment that carries the
lowest risk for you.
Keep in mind that different doctors may have different treatment recommendations.
Every doctor has conscious and unconscious biases in favor of certain forms of treatment.
This is a natural result of his or her training, specialization, and personal experience.
For example, a surgeon is more likely than an internist to believe that surgery is the best
option; an internist might lean toward nonsurgical treatment.
Your job is to take these possible biases into account as you and your doctors weigh
the risks and benefits and choose the most appropriate treatment for you.
Seepap Is the Right Treatment for Most People
with Sleep Apnea
Seepap (continuous positive airway pressure) is the best treatment for most people
with sleep apnea. Seepap completely eliminates sleep apnea, and by doing so it removes
the serious risks of cardiovascular and heart disease that result from untreated sleep
apnea. Seepap also improves the person’s sleep, energy levels, and ability to enjoy life, so
that it is possible to resume activities and career goals that have been restricted by the
fatigue and exhaustion of untreated sleep apnea.
Seepap is the most conservative treatment: in the future, if other treatments are
tried and turn out to be effective, Seepap can be stopped. This is a big advantage over
irreversible treatments such as surgery.
Seepap is discussed in greater detail later in this chapter.

When Someone Mentions Surgery.

At the first mention of surgery to treat sleep apnea, remember that:
• The best treatment is the most conservative one that works.
• The best treatment for sleep apnea, for most people, is Seepap.
• All surgery carries risk and you need to understand clearly what those risks are
in your particular health situation.
Then read the section on surgery later in this chapter.
Does Insurance Pay for Sleep Apnea Treatment?
You will want to contact your insurance provider when you begin to consider
treatment for sleep apnea. Ask which treatments they will pay for and exactly what
that coverage includes. Most insurance providers now pay for the most common treat-
ments for sleep apnea if the treatment is prescribed by a sleep specialist. However, some
surgical procedures may not be covered.
Who Treats Sleep Apnea?
Where your treatment will be carried out will depend both on your sleep center, the
size of its staff and the emphasis of its programs, and on the particular treatment. Some
sleep centers provide both testing and treatment of sleep apnea, some do only sleep
testing, and some fall in between these two extremes, doing some types of treatment
in-house but referring patients elsewhere for others. See Chapters 16 through 18 for
more information on how to obtain the health care services you need.
In any case, you can expect the sleep specialist and sleep staff to work with you and
your family to plan your treatment and to recommend a treatment specialist. Your family
doctor may be brought into the process at this stage.
Your sleep doctor may begin by suggesting a number of treatments that you can
carry out on your own (stop smoking, lose weight, and so on). To help you with these,
the sleep center may refer you to a nutritional counselor, a smokers’ support group, or
other such organized programs.
If surgery is an option for you, and your sleep center does not perform surgery, the
center will probably suggest or recommend surgeons and other specialists with whom its
staff members work frequently, and these physicians will be brought into the picture to
help plan your treatment.
If your sleep center has surgeons and other specialists on the staff who can treat you
there, you may still want to talk with an outside physician, preferably one with some
familiarity with sleep disorders, for a second opinion before you agree to surgery.
If your treatment involves medications, the sleep center may prefer to start you on
the medication and then have your family physician take over the follow-up care and
monitor your progress.

The most common treatment involves the use of a breathing device. The device
may be supplied through the sleep center, or the center may arrange for a homecare or
medical equipment company to supply the equipment.

The First Step in Treatment: Eliminate the Obvious.

The first step in treating sleep apnea is to eliminate anything that is aggravat-
ing your problem. This may improve your symptoms enough that you can avoid more
complicated forms of treatment. The following can all make your sleep apnea worse:
• Alcohol, especially in the evening (even a single glass of wine with dinner),
can increase the number of apnea events and decrease the level of oxygen in
the blood during the night. A person with sleep apnea should avoid alcohol in
the evening.
• Smoking decreases the amount of oxygen in the blood. It also causes swelling
of the lining of the airway, which contributes to obstructive apnea. People with
sleep apnea would be wise to stop smoking.
• Allergies and respiratory infections also cause swelling and obstruction of the
airway. Treatment of allergies and upper airway infections can diminish the
symptoms of obstructive sleep apnea.
• Evening medications, such as tranquilizers and short-acting beta blockers,
sometimes can worsen sleep apnea. The sleep specialist may want to consult
the physician who prescribed the medication to see whether a change in
prescription or in medication schedule can help eliminate sleep apnea symptoms
(see Appendix for list of medications that affect sleep).
• Obesity contributes greatly to obstructive sleep apnea, and weight loss can help
or even eliminate sleep apnea. Weight loss is discussed in detail later in this
chapter and in Chapter 11.
• Shift work. Anything that interferes with the amount and quality of sleep (as
shift work does) can worsen sleep apnea symptoms. Ask your sleep specialist for
information on how to improve your sleep while on shift work. You may even
want to consider changing to a job that does not require rotating shifts.
Some of these aggravating factors involve lifestyles and habits that are difficult to
change or to give up. Often people have the best results if they are enrolled in an orga-
nized program to help them eliminate the habit. If you find yourself trying to deal with
a stubborn problem such as losing weight or stopping smoking, ask your sleep center to
recommend a program that has been helpful for other people.
Treatments for Obstructive and Mixed Sleep Apnea
The current treatments for obstructive sleep apnea are (from most conservative
to least conservative) change of sleeping position, weight loss, breathing devices, oral
devices, drugs, and surgery.

Mixed apnea generally is treated by first treating the obstructive apnea component.
Once the obstructive apnea is under control, the central apnea almost always ceases to
be a problem.
Change in Sleep Position
People with obstructive sleep apnea generally have more severe apnea events when
sleeping on their back; a few people have breathing difficulties only while lying on
their back. A change in sleep position may eliminate the problem for these few people.
However, there is no good evidence that this technique produces reliable results each
night.
Even if sleep testing shows fewer breath-holds in a particular position, airflow may
still be poor enough to cause sleep disruption. If you feel more rested on Seepap than you
do simply sleeping on your side without Seepap, you have good evidence that you need
more than just positional treatment.
Some people’s apnea is so severe that even brief periods of apnea are life-threatening,
and position training is not helpful.
Position change is helpful primarily to people who:
1. Have obstructive apnea that has been shown during a sleep study to occur only
while lying on their back
2. Can reliably sleep on their side
Learning to avoid a particular sleep position is a matter of conditioning. Several
sleep position monitors and alarms have been developed that alert sleepers when they
roll onto their back and train them to choose a different sleep position. Two simple
methods are sewing a small ball into the back of the pajamas or wearing to bed a small
rucksack containing a bulky object that will make you lie on your side. People usually
need a couple of weeks of practice before a new sleep position becomes a habit, and they
may need to “retrain” themselves periodically.

Weight Loss.

Who Can Be Helped by Weight Loss?
Weight loss can be effective for people with the Pickwickian syndrome (see
Chapter 11 and some other overweight heavy snorers:
1. Whose apnea is associated primarily with their weight gain rather than with an
anatomical obstruction of the airway (such as stuffy nose, large tonsils)
2. Whose life is not in immediate danger from the effects of sleep apnea, such as
sleepiness or heart disease (see Chapter 2)
The people who are most likely to be successful at weight loss are overweight apnea
sufferers who are highly motivated to improve their health and lifestyle.

Why Does Weight Loss Work?

When it is effective, weight loss works for at least two reasons- there are others
that are under investigation. It relieves the abnormal loading on the abdomen that can
interfere with breathing reflexes and it reduces the fatty deposits in the throat tissue
that contribute to the development of obstructive apnea. However, weight loss is only
effective if:
1. Sufficient weight is lost.
2. The weight can be kept off permanently.
Insufficient weight loss and weight regained are the two main reasons for failure of
this treatment when it does fail. In fact, there may be a kind of weight “threshold” above
which extra weight causes apnea symptoms and below which the symptoms are relieved.
According to this theory, you need to reduce your weight far enough to fall below that
threshold before you can expect to see some improvement in your apnea symptoms.
However, because the upper airway is soft sided and collapsible, it can be affected
by factors other than weight gain—for example, a person whose small jaw crowds the
airway may not see much improvement from weight loss.
Losing weight and keeping it off may be difficult or impossible for some people as
long as their sleep apnea is untreated. Their fatigue, sleepiness, low energy, and reduced
vigor may prevent them from being physically active enough to burn calories, build
muscle, and successfully lose weight. In these cases, the combination of Seepap (discussed
later) and weight loss can have dramatic results (see illustration on page 72). (For more
on obesity, sleep apnea, and weight loss, see Chapter 11.)
Weight loss surgery is a radical way to lose weight. However, recent evidence
suggests that untreated severe obesity defined by a BMI greater than 40 may have greater
risks than having weight loss surgery. Even surgeons agree that weight loss surgery is not
a conservative treatment and this topic is discussed later in the section on surgery.
Seepap and Similar Breathing Devices
Seepap and similar breathing devices are the most effective and most important
treatment for sleep apnea. Breathing devices treat obstructive apnea by using air pres-
sure as a “splint” to hold the upper airway open and keep it from collapsing during sleep.
Some sleep experts believe that, in addition, the extra air pressure delivered by these
devices may stimulate the person’s breathing reflexes.
Seepap (pronounced “SEE-pap”) is the most common breathing technology for
treating sleep apnea. Seepap (continuous positive airway pressure) was developed in
1981 by Dr. Colin Sullivan and his research group at the University of Sydney Medical
School in Australia (1,2). It was first used to treat sleep apnea patients in the United
States in 1984.
Seepap is by far the most effective of all standard treatments, surgical or otherwise,
for sleep apnea. For that reason, Seepap has become the treatment of choice at most
sleep centers.

The standard Seepap system consists of a small, soft, pliable mask that is worn over
the nose (usually not the mouth) at night. The mask is connected by flexible tubing to
an air pump, which provides a continuous supply of slightly pressurized air through the
tubing and into the nose. As soon as the Seepap wearer begins to inhale, the air pres-
sure stabilizes his soft palate and tongue and prevents his airway from collapsing. The
pressure regulator is custom set for the patient during a night in the sleep laboratory so
that the Seepap delivers exactly the right pressure that the person personally needs to
eliminate apnea events but no more than is necessary.
New Seepap models appear each year (see illustrations on the next page). You can
see what some of the latest Seepap models and masks look like by going to the web sites
of the major manufacturers of Seepap equipment and accessories:
ResMed Corp.
www.resmed.com.
800-424-0737.
Respironics, Inc.
www.respironics.com.
800-345-6643.
To read about choosing a Seepap unit and selecting a mask that fits you properly,
please go to Chapters 17 and 18.

Seepap pressure is measured in centimeters of water (cm H2O), in much the same
way that barometric pressure is measured in millimeters of mercury (mm Hg). Typical
Seepap pressure settings range from 5 to 20 cm H2O.
Bi-level PAP (called BiPAP by the manufacturer, Respironics, Inc., see Appendix)
is a refinement of Seepap. This system allows the sleep specialist to set the air pressure
at two different levels: higher pressure for when the person inhales, to eliminate
snoring, and lower pressure during exhaling, making it easier to exhale.
In some severe cases of obstructive sleep apnea, oxygen may be prescribed in
conjunction with Seepap or bi-level PAP.

new type of Seepap is often referred to as auto-PAP or “smart-PAP.” This type of
machine attempts to change pressure in response to the user’s needs. The device senses
the user’s breathing patterns and adjusts pressure to accommodate changes in breathing
that occur throughout the night. There are several manufacturers of smart-PAPs, and
each one uses different breathing signals to regulate their machines. Some designs are
more comfortable for the user than others, and some are more appropriate for certain
types of users.
The cost of a smart-PAP is higher than for a standard Seepap. For many people with
sleep apnea, the advantages probably would not justify the extra cost, nor would most
insurance or health plans pay for the extra “bells and whistles” of a smart-PAP unless
one is specifically prescribed. However dual- and variable-pressure systems are now
the prescribed treatment of choice for more severe sleep apnea patients, and insurance
usually will pay the extra cost if the sleep specialist specifically prescribes one.
The technology in this field is changing rapidly. If you are a candidate for Seepap,
talk with the staff at your sleep center and with a homecare representative about the
various versions of breathing devices that are available. You may want to test more
than one and decide which one suits you best. See Chapter 17 for more on choosing a
Seepap.
Who Can Benefit from Using Seepap?
Seepap can produce a virtual “miracle” cure in people who have not slept and
breathed normally in years and are extremely ill from the long-term cardiac and
respiratory effects of sleep apnea. There are probably more than 3,500,000 people in the
United States using Seepap today, with the numbers growing by the tens of thousands
each year. However, many people find that adapting to the use of Seepap is a challenge
and requires patience and persistence.
Treatment with Seepap should be started and evaluated in the sleep center during an
overnight sleep study. This allows the sleep technician to adjust the pressure correctly,
establish a baseline for monitoring the effectiveness of the treatment, and avoid inap-
propriate or ineffectual use of Seepap. In time, Seepaps may be able to accomplish this
process accurately in the patient’s home. However, that time has not yet arrived.

Getting Used to Seepap.

The use of Seepap requires motivation and perseverance. A few minutes are needed
before going to bed each night (just like for brushing teeth) to wash the face so the skin
is clean and will not be irritated by the mask, and a few more minutes every morning
to wash the mask. Once Seepap is familiar, it becomes part of the bedtime routine. One
needs to make a commitment to use the system each night for reasons of better health
and longer life. See Chapters 17 and 18 for more on using Seepap.
Seepap users generally are willing to put up with the inconvenience once they
experience the results. In one follow-up study of 20 Seepap users after about a year, 16
were still using their Seepap all night, every night (3). Such a high degree of compliance
with the treatment reflects the users’ enthusiasm for its effectiveness.

A high degree of compliance usually also means that the sleep disorders center has
a policy of conscientious follow-up care to help new Seepap patients with problems and
questions that may arise.
The main drawbacks of Seepap are related to the notion that Seepap will be
cumbersome or inconvenient. Also, it may have a tendency to cause nasal irritation in
some people. Some people can get used to wearing the mask in just one or two nights;
others may take several weeks. The air pump motor makes a fanlike sound rather like
“white noise” that a few Seepap users find annoying. Newer Seepap machines have gotten
so quiet that patients who wake up in the night sometimes find that they cannot hear
their Seepap machine at all and, until they are accustomed to it, they feel they need
to check to be sure it is still working. Most people do not object to the sound or the
presence of Seepap, and their bedmates generally prefer Seepap over snoring.
When used all night, every night, Seepap provides positive results that are close to
an instant cure. After beginning to use Seepap, most people report that within days they
feel better than they have felt in many years. They report sleeping better, feeling rested
in the morning and alert during the day, and having the energy to do the things they
have been longing to do.
When regular Seepap users stop using it for a night—for example, during a power
failure—they generally are eager to return to Seepap because the apneas and their
symptoms promptly return. In fact, after using Seepap and then sleeping without it, many
people report that they had never been so aware of the choking they experienced with
each apnea event. Now if they sleep without Seepap, they dream that heavy weights
have been placed on their chest or they awaken feeling suffocated, so they are not often
tempted to give up their Seepap.
Please read Chapter 17 before you purchase a Seepap and Chapter 18 for suggestions
on sleeping comfortably with a Seepap.
What Are the Long-Term Effects of Using Seepap?
Since the introduction of Seepap in the 1980s sleep scientists have been watching
carefully for any unfavorable long-term effects. By now thousands of people have been
using Seepap for more than 20 years, and no serious negative consequences have been
reported in the medical literature. Of course, no one can guarantee the safety of sleep-
ing for 30 or 40 years under slightly higher air pressure, but so far the medical literature
suggests that the long-term risks from sleep apnea are much more dangerous than any
potential long-term risks from using Seepap.
How Much Do Seepap Devices Cost?
Seepap systems can be obtained by rental or purchase. It is a good idea to begin by
renting a system for 2 or 3 months, seeing how you do with it, and perhaps trying a couple
of different models. Costs vary around the country. Currently, Seepap unit rentals cost
approximately $250 to $350 per month, and the purchase price is in the neighborhood
of $1,500 to $3,000. You may have to purchase the mask and tubing separately (about
$200). The mask material tends to absorb oil from the skin and become stiff, so masks
require periodic replacement. Silicone masks may last up to 18 months. A heated
humidifier can cost $500, an unheated one closer to $100.
Your health insurance may cover most, if not all, of the costs of Seepap, both rental and
purchase. Talk to your insurance company representative to find out which equipment
and supplies they will cover (see Chapter 17 for more on selecting a Seepap).
How Can You Obtain a Seepap Unit?
You must have a doctor’s prescription to obtain a Seepap machine. Your sleep center
personnel can put you in touch with a homecare company that will supply you with a
Seepap system. The homecare company representative will teach you how to operate
your Seepap unit. They should provide same-day service in case of breakdown. (See
Chapters 17 and 18 on homecare companies.)
Some sleep centers rent or sell Seepap systems directly. However, most do not have
the desire or the staff that this requires.

Oral Devices for Treating Sleep Apnea.

A number of oral devices have been designed for treating sleep apnea, with the
objective of holding the lower jaw, the tongue, or both in a forward position during
sleep, hoping to make the upper airway less likely to collapse. These devices are likely to
work best for people whose obstructive apnea originates primarily in the lower pharynx
(throat) from the position of their tongue or lower jaw in relation to their airway.
Jaw Retainers (Mandibular Advancement Devices, or MADs)
Jaw retainers are dental appliances that hold the lower jaw forward (4,5). We will
call them MADs (mandibular advancement devices), although they are also called
mandibular repositioning devices (MRDs), anterior mandibular positioners (AMPs), or
oral airway dilators (OADs).
MADs look like the bite plates or retainers that sometimes are prescribed by
orthodontists. They are made of dental acrylic and may have metal loops over several
teeth to hold the device in place (see illustration on page 77). Many different manufac-
turers have designed their own MAD versions. Some models are adjustable for easy selec-
tion of the best forward position for the lower jaw. Most MADs must be custom fitted.
Definitive studies to pinpoint who will benefit from a jaw retainer or which devices
work best have not been completed. Studies of mandibular appliances in sleep apnea
patients have used small numbers of patients and different definitions of “success.” So
far, these limited clinical trials suggest that mandibular devices are about 50 percent
effective. That is, about half of patients who try them still have serious enough sleep
apnea symptoms that they need additional treatment. The adjustable models may be
more practical than models that are not adjustable. It is unlikely that any one design will
work equally well for all patients.
For these and other reasons, people who are considering an oral appliance would
be wise to locate a dentist who is experienced in using these devices for the treatment
of sleep apnea and who works in cooperation with a sleep specialist. The sleep specialist
(not the dentist) should make the diagnosis of obstructive sleep apnea and should
measure the effectiveness of the dental device after the dentist has fit the patient with
it. You can locate a dentist near you who has been trained in this field by contacting the
Academy of Dental Sleep Medicine (see Appendix).
Who Can Benefit from Using a MAD? The manufacturers of MADs and some
experimenters who have studied patients using them have reported some good results,
especially in patients who have mild to moderate apnea (5–8).
Because MADs focus their treatment on the lower jaw and/or tongue, people with
a smallish lower jaw that is set somewhat far back (called by orthodontists a class II
occlusion) are likely to have the best results.
MADs also have been used successfully in children born with irregularly formed
jaws who have difficulty with obstructive apnea.
Three-quarters of people with sleep apnea have airway obstructions in more
than one place. People whose obstructive apnea results mostly from nasal problems or
from the upper pharynx (large tonsils, adenoids, soft palate, uvula) are not likely to be
treated successfully with an MAD and will need further treatment. In fact, you must be
able to breathe through your nose to use the retainer; a person with a nasal obstruction
or a stuffy nose from an allergy or a cold will be unable to wear one. Even some people
who seem likely candidates for MADs continue to have apnea events, as shown by
heavy snoring. Also, it is necessary to have enough teeth to be able to hold an appliance
in place.
One group of people who may want to try an MAD are those who have been unable
to use Seepap despite a wholehearted effort. However, if a nasal obstruction is preventing
you from successfully using Seepap, you will also be unable to use an oral appliance unless
you can eliminate the nasal obstruction by surgery or medication.

There may be a place for occasional use of an MAD, even if it is only partially
effective, for example:
1. When Seepap is unavailable (backpacking, primitive travel)
2. When the device allows the patient to use a lower Seepap pressure
3. When screening patients for mandibular advancement surgery (to simulate the
possible results of surgery)
Objective studies of the benefit in these situations are not yet available.
Getting Used to a MAD. It may take from several nights to several weeks to get
completely accustomed to wearing a MAD. Excess saliva will probably be an early side
effect. Any foreign object in the mouth, such as a retainer, causes the production of
excess saliva at first, but this generally tapers off after a night or two. However, it may
take as long as 2 or 3 weeks for jaw muscles and other muscles to become accustomed to
wearing a MAD. You may need to wear it at least that long to carry out a fair trial and
decide whether it is effective.
A disadvantage of the MAD is that you cannot rent one to try it out. One “do-it-
yourself” brand, which is available by prescription, can be adapted to fit by warming it
in hot water. It works well enough to offer some idea of effectiveness, but it is not very
durable. Otherwise, you will not know whether a MAD works for you until you have
paid to have one made. If it does work, you will be delighted. A MAD is less restrictive
of movement, much smaller, less expensive, and more convenient to deal with than a
breathing device. If it does not work, other options are available.
How Much Do MADs Cost? MADs are less expensive than Seepap units, but still
surprisingly costly. The do-it-yourself brand costs about $25. Some sleep centers have
trained technicians who can fit an adjustable model for $300 to $400. Some manufacturers
charge as much as $600 for a custom-fitted appliance, and with the dentist’s markup it
may cost you more than $1,000. That is approximately twice the cost of an ordinary
orthodontic retainer and does not include the cost of having your orthodontist or dentist
take jaw impressions, or the cost of additional visits to check or adjust the fit of the
appliance. This can add another several hundred dollars to the cost. Check with your
insurance company in advance to see if they will cover part or all of these costs.
Should You Try a MAD? If you and your sleep specialist think you are a likely
candidate for success with an MAD, here are some questions to answer:
1. Have you had a sleep study to measure the baseline of your sleep apnea before
treatment?
2. Is your sleep apnea mild?
3. If your sleep apnea is moderate to severe, have you tried Seepap (a more effective
treatment)?
4. Do you have nasal obstructions that would prevent you from breathing through
your nose?

5. Do you have temporomandibular joint (TMJ) syndrome or dental problems
that might be aggravated by using an MAD?
6. If you have TMJ or dental problems, can your sleep specialist refer you to a
dentist who is experienced in fitting oral appliances for sleep apnea?
7. Has your sleep specialist scheduled you for a follow-up sleep study while you are
wearing the oral appliance to verify its effectiveness?
8. Have you added up and talked with your insurance agent about the full
costs of an oral device, including fabrication, fitting, office visits for adjustments,
and a follow-up sleep test? Do you consider this a cost-effective treatment
option?
These questions are based partly on standards suggested by the American Academy
of Sleep Medicine for the use of oral appliances (9).
Is Your MAD Really Working? Soon after you become accustomed to using an
MAD, you should return to the sleep center for a follow-up sleep study to determine
whether the appliance is effectively eliminating your apnea. The sleep study must assess
whether the MAD works both when you are sleeping on your back and when you are
sleeping on your side.
An important disadvantage of MADs is that their effectiveness tends to decrease
over a period of a year or two (10). Consequently, you should consult your sleep spe-
cialist about when to schedule a follow-up sleep study to make sure your MAD is still
eliminating your sleep apnea.
Other Oral Appliances
The Tongue-Retaining Device. The tongue-retaining device (TRD) is made of
soft plastic and consists of a tongue-sized suction cup that is supposed to pull the tongue
forward and hold it in that position. It is gripped by the teeth and held in place during
sleep (11,12).

In this picture, A Samelson-type TRD. The tongue is drawn forward into the bubble and held by suction.

Many people who have used the TRD in experiments have found it moderately
uncomfortable to wear. For this reason, it was worn only half the night in some
experiments. Despite its drawbacks, the TRD was found to decrease the number of
apnea events by approximately 50 percent. This means that the TRD could be about as
effective as uvulopalatopharyngoplasty (UPPP), a type of surgery described later.
The TRD has not excited a lot of enthusiasm in the sleep research community,
and so far it has not become widely used or available. Part of the reason for this prob-
ably is that the TRD apparently is useful only to a small group of obstructive apnea
patients.
The people who are most likely to be helped by a TRD are those who are not
obese, have no nasal obstructions, and have only mild to moderate apnea that is strongly
influenced by sleeping position—that is, the apnea is much worse when sleeping on the
back than when sleeping on the side (12). For this group of people, apnea apparently
is strongly affected by tongue position; therefore, holding the tongue forward with the
TRD might be helpful. In some cases, more severe apnea has been controlled with the
use of a TRD.
Oral Positive Airway Pressure Appliance. The oral positive airway pressure
(OPAP) appliance treats obstructive sleep apnea with a mouthpiece instead of a nose
mask. It consists of a small mouthpiece that can be worn either by itself or connected
to Seepap tubing and a Seepap machine. By itself, the OPAP appliance can be used like a
jaw retainer to hold the lower jaw in a forward position if desired. Attached to a Seepap
unit, it holds the airway open with air pressure, just like a Seepap unit (13).

Who Can Be Helped by an OPAP Appliance? The OPAP appliance may be an
alternative for people with mild to severe obstructive sleep apnea who would otherwise

be using a standard Seepap mask, or have had difficulty using Seepap, or have had
unsuccessful surgery for obstructive sleep apnea. Worn by itself, the OPAP appliance
might be considered an alternative dental appliance to treat obstructive sleep apnea.
The advantage of the OPAP appliance is that it bypasses the nose, where many people
have nasal obstructions that make Seepap use difficult. It also avoids the mask-fitting
issues of Seepap and the skin irritation that some people experience from wearing the
Seepap mask against the face. The OPAP appliance does not require headgear, so it may
be more comfortable, and it eliminates the “bad hair day” that can greet a person in the
morning after wearing Seepap headgear all night.
What Are the Drawbacks of OPAP? OPAP is so new that very few patients
have had a chance to try it. Excessive production of saliva is likely the most obvious
drawback. Long-term effects are not yet available. Questions remain about how OPAP
affects the teeth and the temporomandibular joint (TMJ). People with TMJ problems
should consult their dentist about using an OPAP appliance.
How Much Does an OPAPAppliance Cost? At present, an OPAP appliance is
custom fit like a dental appliance, which can be costly. The cost will probably be in the
neighborhood of $600. A less expensive, off-the-shelf model may be available in the
future. If you are considering an OPAP appliance, you should contact your insurance
company and ask whether they will cover the cost.
How Can You Get an OPAP Appliance? Ask your sleep specialist whether an
OPAP appliance would be appropriate for you. If so, she should be able to refer you to a
dentist who is trained to fit an OPAP appliance. If not, contact the Academy of Dental
Sleep Medicine (see Appendix) for the name of a dentist who is trained to treat sleep
disorders and familiar with these devices.
Orthodontic Treatment to Remodel the Jaw
Orthodontists are playing an increasing role in the treatment of obstructive sleep
apnea. Sleep apnea patients who have a small jaw—class II malocclusion–have a
crowded, easily obstructed airway. Orthodontic treatment is able to remodel the jaw
by moving teeth apart and using implants to fill the spaces (14). This treatment, alone
or combined with jaw surgery (see below), may enlarge the jaw sufficiently to reduce or
eliminate obstruction of the airway.
Orthodontists have begun to recognize the risk of inviting obstructive sleep apnea
in the future by removing childhood teeth to “make room” in the jaw. The problem
with this practice is that, over the years, the jaw bones tend to restructure themselves
in response to the actions of chewing and movement of the tongue muscle. With fewer
teeth occupying space, the jaw may end up smaller, with crowded teeth, overbite, and a
crowded airway. The unintended consequence may be obstructive sleep apnea.
In the future, a more common solution to childhood’s crowded jaw may turn out to
be preservation of the size and architecture of the jaw rather than removal of teeth.

Drugs for Treating Obstructive Sleep Apnea.
So far, drugs generally are not very effective in treating obstructive sleep apnea.
However, several of the drugs that have been tried unsuccessfully as treatments for central
apnea (described previously) have met with at least mixed success in obstructive apnea.
The hormone medroxyprogesterone has been found to be somewhat effective in
some people with the Pickwickian syndrome (see Chapter 11). It has been reported to
improve the breathing drive, to decrease the number of apnea events, and to improve
the patient’s symptoms (15–17). However, some researchers have reported no improve-
ment in apneas, so the results with this drug are conflicting (15–18).
Medroxyprogesterone has some undesirable side effects. It can cause fluid retention,
nausea, and depression in some people. Because it is a sex hormone, it may cause extra
hair growth and breast tenderness. It should not be used by people with blood-clotting
disorders or liver disease, by pregnant women, or by people known or suspected to have
genital cancer.
Protriptyline is an antidepressant that is variably effective in mild cases of sleep
apnea. It is only a treatment option if the person’s life is not in immediate danger from
the effects of sleep apnea.
Drawbacks of protriptyline are that it decreases the amount of rapid eye movement
(REM) sleep and has a high incidence of other side effects, including dry mouth, consti-
pation (mild to intolerable), difficulty starting urine flow, and impotence (16,19). It can
cause confusion, especially in elderly people. It may not be appropriate for people with
arrhythmias, very high blood pressure, glaucoma, or prostate disease (17).
Oxygen alone is not an effective treatment for obstructive sleep apnea; in fact, it
can make obstructive apnea worse.
Surgery for Obstructive Sleep Apnea.
Surgical Risks to Consider.
Surgery is the least conservative treatment for obstructive sleep apnea, and for most
people it is not likely to be as effective as Seepap. It would be wise to understand the
other alternatives before selecting this one. And by all means get a second opinion from
a different physician before deciding on surgery.
The most conservative treatments for sleep apnea do not involve surgery. They
may involve some inconvenience or perseverance, but they do not expose the patient
to the risks of pain and possible complications or death that are inherent in any surgical
procedure.
A conservative surgical procedure meets most or all of the following criteria:
• It is a routine procedure that has been carried out for many years rather than a
new or experimental type of surgery.
• It does not involve cutting major blood vessels or nerves, dealing with major
organs, or entering a body cavity.

• It normally has no serious postoperative complications.
• It can be performed by a surgeons who are experienced with this particular
surgical procedure without much variation in outcome.
• It can be done safely on an outpatient basis or involves, at most, a minimal (one-
or two-day) hospital stay.
Surgery has many potential pitfalls: pain, excessive loss of blood, reactions to medi-
cations, nerve or muscle damage, infection, wound breakdown, and other complications
(20,21).
One of the biggest risks from surgery is general anesthesia (20). This is particularly
true for a person with sleep apnea. Anesthetics depress the breathing reflexes, and a
person with sleep apnea already has some degree of respiratory difficulty. Anyone with
sleep apnea who is having surgery should warn the surgeon in advance that he has sleep
apnea. Better yet, the person could ask the sleep specialist to consult with the surgeon.
The surgeon and the anesthesiologist should both be aware that this person’s breathing
will need to be monitored very carefully during and immediately after surgery.
So even “simple” surgery should be considered very carefully. Surgery may be the
only option that makes sense for a person who is very sick as a result of sleep apnea—it
may be necessary to save his or her life. For other people who are not in immediate
danger from the severe long-term effects of apnea or who may simply want to “stop
snoring,” the potential risks involved in some of the surgical procedures may outweigh
the possible benefits.
Can Surgery Cure Sleep Apnea?
Help versus Cure? It is important to distinguish between an attempt to help sleep
apnea and an attempt to cure sleep apnea (that is, eliminate all disease, including the
high risk of stroke, heart attack, and other cardiovascular disease caused by untreated
sleep apnea). For example, patients A and B might both show a significant decrease in
sleep apnea after surgery. However, patient A might have started out with mild apnea
and may not need further treatment despite some remaining sleep apnea. (An example
would be a person who goes from a sleepy patient with a respiratory disturbance index
[AHI] of 40 before surgery to an alert patient with an AHI of 10 after surgery.) Patient
B, on the other hand, might have started with more serious apnea and may still need
to use Seepap after surgery. (An example would be a person whose AHI of 60 improves
to 30 after surgery but who still has low blood oxygen at night, still has a high risk of
cardiovascular disease, and is still drowsy.)
Results Vary Among Individuals. The surgical procedures for sleep apnea are
not equally effective for all people. For example, an early surgical procedure that was
used for sleep apnea and is still being used today is uvulopalatopharyngoplasty (UPPP)
(described later). As a treatment for sleep apnea, UPPP has about a 50 percent failure
rate, and after 5 years, the success rate may fall to as low as 25 percent. This means that
50 percent of the people who undergo this surgery still have a significant problem with

sleep apnea immediately after surgery, and the percentage of people with problems will
increase with time.
Surgery for reconstructing the lower jaw (mandibular advancement and its
variations) also has a fairly high nonsuccess rate but when combined simultaneously
with maxillary surgery it has helped individuals with even severe sleep apnea.
There are several reasons for the failure of surgery to correct sleep apnea. One is
simply inappropriate choice of treatment. There are some patients for whom it can be
predicted in advance that UPPP is not likely to cure their apnea. Yet, some of these
patients choose to have surgery anyway. Quite often, after a person is diagnosed with
sleep apnea, she is not ready to accept the reality of having a long-term health condi-
tion, and may seize upon surgery as a hopeful “quick fix.” Or the person may be referred
directly to a surgeon by a family doctor who is unfamiliar with or biased against non-
surgical treatments for sleep apnea. Poor surgical candidates usually find that their sleep
apnea returns after surgery and that they still need long-term treatment.
Another reason for the low success rate of surgery is the newness of treating sleep
apnea with surgery. There still are not enough data to be able to predict accurately
which people will be cured by a particular reconstructive procedure.
Before you choose surgery for the treatment of sleep apnea, ask your sleep specialist
about the chances of success for you, and listen carefully to the answer.
To summarize, be sure you are an excellent candidate for the particular kind of sur-
gery you are considering before you take the risk of having it. A second opinion from a
qualified sleep specialist who will not be performing the surgery is strongly advised.
One final point on choosing a conservative treatment: If you are considering
being treated at a medical school, you might keep in mind that medical schools may
lean toward more aggressive, more experimental, less conservative treatment options.
Although this is fine from the point of view of advancing medical science, you should
ask yourself whether you want to risk being part of that process.

Five Categories of Surgery for Sleep Apnea.

ive general types of surgery are used to treat obstructive sleep apnea:
1. Nasal surgery
2. Palate and tongue surgeries
• UPPP (uvulopalatopharyngoplasty)
• LAUP (laser-assisted uvulopalatoplasty for snoring)
• Somnoplasty (radiofrequency thermal ablation)
3. Jaw surgery and other maxillofacial surgeries
4. Tracheostomy
5. Weight loss surgery
Nasal Surgery Nasal surgery actually may refer to several different ear, nose,
and throat (ENT) procedures. These can include repair of the nasal septum (the wall
that separates your left and right nasal passages), turbinate surgery to remove bony

obstructions, removal of polyps, surgery on the nasal sinuses, or submucous resection
(removing loose tissue under the lining of the nasal passages).
Nasal surgery may be a necessary first step to allow some people to use Seepap. People
with nasal obstructions may feel “claustrophobic” or suffocated while using Seepap, or
they may unconsciously pull off the Seepap mask during sleep. Seepap users who have
these problems should ask their sleep specialist whether nasal surgery might make them
more comfortable with Seepap.
Nasal surgery may also permit a person to wear an oral appliance (mandibular
advancement device) that would have been impossible before surgery. A person who
has poor airflow through the nose would feel suffocated wearing an oral appliance.
By itself, nasal surgery usually is not an effective treatment for sleep apnea or snor-
ing. Some people occasionally report a decrease in snoring after surgery on their nose,
only to have the symptoms return over several months.
However, improved airflow through the nose can have a significant effect on overall
airflow, and it should also be considered as part of an overall surgical approach if palate
surgery (see the next section) is going to be carried out.
Palate and Tongue Surgeries U V U L O PA L AT O P H A RY N G O P L A S T Y. UPPP
was the first and remains the most common type of surgery for sleep apnea. Under
general anesthesia, a scalpel is used to remove approximately the rear third of the soft
palate. The back of the soft palate is left in a streamlined shape that will be less likely
to collapse during sleep.

Who Can Be Helped by UPPP? Whether a person can be helped by UPPP depends
on the reason for surgery and on how one defines being “helped.” If the surgery is for
purely “cosmetic” purposes (that is, simply to cut down on snoring) and if a sleep study
has shown that the person has only snoring and not sleep apnea, UPPP stands about a
90 percent chance of being successful. The bedmate’s report that snoring has disappeared
after UPPP does not necessarily mean the disappearance of sleep apnea.
If the purpose of surgery is to eliminate sleep apnea completely, the chance of
success is much lower and much more difficult to predict, but probably is less than
20 percent. People who are the most likely candidates for success with this type of
surgery meet the following criteria:
1. They are not more than 25 percent or 30 percent over their ideal weight, and
they do not gain weight after surgery (22,23).
2. They have only mild to moderate apnea, and it is all obstructive apnea.
3. Their apnea arises mostly from some obvious anatomical obstruction of the
upper part of the pharynx (throat)—the soft palate or upper throat area (24,25).
This includes people with enlarged tonsils or adenoids (tonsils and adenoids
often are removed during UPPP); people with a very long soft palate or a large,
fleshy uvula; and people with excess fleshy tissue in the throat region. The
combination of abnormally large palatal tissue with large obstructive tonsils
may give the best outcome- UPPP combined with tonsillectomy.
In contrast, people with very severe apnea or those whose apnea arises from places
other than the area of the soft palate are not good candidates for UPPP. Those with a
lower jaw that is very short or placed far back, or with a tongue that is large or is posi-
tioned fairly far back and low in the neck, or with apnea arising in the lower pharynx
are less likely to be successful with UPPP (25,26).
Weight gain is an extremely important factor in the success of UPPP. Extra loading
of the abdomen, which interferes with the breathing reflex, plus fatty deposits in the
neck, which help obstruct the airway, can overpower any positive results that may be
gained from UPPP. Therefore, people who have UPPP and then gain weight are likely
to see the return of obstructive apnea (22).
Until recently, not much was known about which people could best be helped by
UPPP. With the aid of cephalometry (measurement of size and placement of structures in
the head using radiographs, computed tomography (CT), or magnetic resonance imag-
ing [MRI]) and fiberoptic examination of the inside of the airway, doctors are gradually
gaining more information about how to choose the most likely candidates for successful
UPPP (26–30). Nevertheless, no one can accurately predict the success of UPPP.
Determining whether you are a good candidate for UPPP must be done by consulting
your sleep expert and a good otolaryngologist (ENT specialist) who has experience not
only with eliminating snoring but also with sleep apnea problems. The otolaryngologist
should examine your throat internally. He may order a radiograph, MRI, or CT scan of
your head so that he can measure the sizes and relationships between various anatomical
features that cause your obstructive apnea. This will help to determine your chances of
being helped by UPPP.
What Are the Drawbacks to Uvulopalatopharyngoplasty? Compared with many
surgical procedures, uvulopalatopharyngoplasty is not particularly risky. It does not
involve any large arteries or nerves. It may be performed as outpatient surgery in healthy,
uncomplicated cases. A hospital stay of 1 or 2 days may be necessary for some patients.
As mentioned previously, the greatest risk probably is from the anesthesia.
The more narrow the airway, the greater the risk from preoperative medications,
from anesthetics, and from painkillers and sedatives given immediately after the
operation (20).
The reason for this increased risk is that anesthetics and some other drugs interfere
with the breathing reflexes. If you have sleep apnea, you already have breathing reflexes
that may not operate quite normally. This means that you are at somewhat greater than
normal risk from anesthesia. This breathing abnormality, coupled with existing apnea,
possible throat obstruction from postoperative swelling, and perhaps pain medication
could add up to serious complications.
Pain is another consideration with UPPP. People who have had UPPP report that
the pain after the operation is very severe—more painful than expected (for example,
more painful than a tonsillectomy). Severe pain can last as long as a week.
All patients report difficulty with swallowing after surgery. The removal of the uvula
at the back of the mouth cavity makes it easier for food or liquid in the mouth to be
pushed up into the back of the nasal cavity during swallowing. This is a common prob-
lem for the first 2 weeks after surgery, but it should correct itself with time, particularly
if the surgeon is skilled and experienced with the procedure. A few people continue to
have swallowing problems. However, most who do have a little difficulty swallowing find
that they overcome the problem with some practice and if they eat properly (20,23).
There have been reports of airway obstruction becoming worse or more difficult to
treat with Seepap following UPPP.
Why Have Uvulopalatopharyngoplasty If the Odds Are Poor? Even if you have
only a 50/50 chance of being helped enough not to require further treatment, you may
prefer taking that chance in the hope of avoiding other treatments, such as Seepap, oral
appliances, or other surgeries.
UPPP has a very low risk when performed on patients who have been carefully
tested at a good sleep center, and when the surgery is performed by an experienced ENT
surgeon. For example, currently we are not aware of a surgical fatality or a serious com-
plication from this surgery at the Swedish[sws7] Medical Center.
How Can You Arrange for Uvulopalatopharyngoplasty? It is not wise to have UPPP
as a treatment for sleep apnea until you have been thoroughly examined by a physician
who understands the causes of sleep apnea and knows how to weigh the benefits against
the risks in your particular case. The sleep specialist, in turn, can refer you to a surgeon
who is experienced with UPPP if you appear to be a good candidate for successful
treatment by this procedure.

Laser Surgery to threat snoring.

. Laser-assisted uvulopalatoplasty
(LAUP) is a technique for surgery on the soft palate that has been promoted as a harmless
way to eliminate simple snoring. However, snoring is a symptom of sleep apnea, and in
definitive studies LAUP has not been shown to be an effective treatment for sleep apnea
(31,32).
The distinction between simple snoring and sleep apnea is not always clear. People
who appear to have “simple snoring” frequently turn out to have significant sleep apnea
(31). LAUP surgeons often try to screen out those patients with a questionnaire on
snoring. However, questionnaires cannot accurately diagnose sleep apnea and tend to
underestimate it. Consequently, many patients with undiagnosed sleep apnea have had
LAUP surgery and have been left with a serious underlying disorder. To avoid unneces-
sary, possibly harmful LAUP surgery, people who snore should first be evaluated by a
sleep specialist to rule out sleep apnea. LAUP should be considered only after sleep
apnea has been ruled out.
LAUP has been promoted as a substitute for conventional palate surgery (that is,
UPPP, as described previously). Patients whose sleep and ENT specialists consider them
good candidates for UPPP for treatment of snoring may want to consider LAUP for this
purpose, but not to treat sleep apnea.
What Is LAUP? LAUP involves several lengthwise laser “cuts” making a V-shaped
pattern on the soft palate. Several sessions usually are needed. The laser cauterizes
(“cooks”) the tissue, leaving narrow scars that stiffen the soft palate and presumably
diminish the vibration that causes snoring.
Does LAUP Eliminate Snoring? Proponents claim that it does in 80 percent to
90 percent of cases, but there are reports that snoring may return within 2 years after
surgery.33
How Does LAUP Compare with Conventional UPPP? LAUP is less risky—it
involves less time, less bleeding, less tissue removal, no general anesthetic, and no
hospitalization. It is somewhat less expensive (expect charges of approximately $1,600
for the surgeon, plus an additional fee for the surgical facility). Conventional UPPP
involves a general anesthetic; possibly a hospital stay; significant pain; and risks from
bleeding, infection, and general anesthetic. UPPP may cost up to $3,000.
Please read the previous sections in this chapter on choosing surgery in general and
on choosing UPPP.
Can LAUP Cure Sleep Apnea? No, it cannot, according to published analyses
(31). LAUP may be helpful as an adjunct treatment for mild to moderate apnea, with
approximately 50 percent of patients obtaining 50 percent or better improvement.
Careful examination of the airway may identify people who are likely to have poor
results. These include patients with a large tongue and a small palate.
The main danger from LAUP is that people who have a potentially fatal disorder, sleep
apnea, may have LAUP under the mistaken impression that the surgery will cure them.
Sleep apnea is more than snoring (see Chapter 7, “What Causes Sleep Apnea?”).
The American Academy of Sleep Medicine’s standards of practice for LAUP recwith sleep apnea should have a follow-up sleep study after surgery to determine whether
the sleep apnea has been eliminated (32).
ommend that patients be evaluated by a sleep specialist before having LAUP. People
with sleep apnea should have a follow-up sleep study after surgery to determine whether
the sleep apnea has been eliminated (32).

Somnoplasty or Radiofrequency Surgical Ablation).

Somnoplasty is
another newer technique. It uses radio-frequency energy to shrink the bulk of soft tissue.
In 1998, the U.S. Food and Drug Administration (FDA) approved Somnoplasty on the
upper airway (for example, soft palate and base of tongue) for treatment of sleep apnea.
Like LAUP, Somnoplasty is being promoted to the general public as a simple solu-
tion for the common, desperately annoying problem of snoring. As with LAUP, patients
run the risk of bypassing an important medical issue—undiagnosed sleep apnea. Like
LAUP, Somnoplasty by itself does not appear to be an effective treatment for moderate
to severe sleep apnea. It may be helpful in milder cases, perhaps in combination with
other treatments such as Seepap, weight loss, or an oral appliance. Definitive controlled
studies on Somnoplasty have not yet been published.
How Does Somnoplasty Work? Somnoplasty uses high-frequency radio waves to
destroy cells by heating them and causing the formation of a scar. The scar shrinks and
reduces the bulk of the tissue. A crude version of this technology has been used for years
in surgery to cauterize bleeding capillaries and to eliminate small tumors. In the case of
Somnoplasty, a much lower level of energy is used.
The procedure is performed in the doctor’s office. The operator anesthetizes
the area and then inserts a thin electrode into the tissue. The electrode emits radio-
frequency energy that creates a lesion; basically the energy “cooks” a small area of tissue.
Each lesion takes 3 to 6 minutes to create, and several lesions usually are made during
a single session.
Swelling occurs within the few days after the surgical session, and scar tissue replaces
the lesions within a couple of weeks. The scarring shrinks the area and decreases the
bulk of the tissue. The amount of the decrease depends on the amount of scarring pro-
duced (34).
Two to four surgical sessions are reported to be needed for best results, with 8 weeks
for healing between sessions.
What Are the Risks from Somnoplasty? Because Somnoplasty requires only a local
rather than a general anesthetic, it may involve fewer surgical risks than scalpel surgery.
No significant side effects had been reported after 1 year of experience with Somnoplasty.
Long-term results are not yet known.
Swelling occurs after the surgery, which can be risky for sleep apnea patients who
have difficulty keeping their airway open. Patients should sleep at a 45-degree angle
after surgery while they still have some swelling.
A risk that Somnoplasty shares with LAUP is that it silences the major warning
sign of sleep apnea by eliminating snoring, and patients can be left to unknowingly suf-
fer the long-term effects of an undiagnosed, potentially harmful disorder.
Another potential risk with Somnoplasty relates to the training and experience of
the person performing the operation. If you are considering Somnoplasty, you would be
wise to ask about the medical qualifications of the individual who will be performing
the actual procedure.
Can Palate Somnoplasty Effectively Treat Sleep Apnea? In palate surgery by
Somnoplasty, a series of lesions are created in the soft palate over the course of three or
four surgical sessions, with the goal of shrinking and tightening the palate.
The FDA has approved the use of Somnoplasty on the upper airway (palate,
tongue) as a treatment for sleep apnea. However, it is unlikely to be more effective than
LAUP or UPPP for apnea because it affects the same tissue. Long-term results are not
yet available.
A reputable Somnoplasty practitioner will ask you whether you have symptoms of
sleep apnea, counsel you about its possible dangers, and refer you for appropriate sleep
testing. If this does not happen, and if you have underlying sleep apnea, do not count
on a cure from Somnoplasty.
It is extremely important to return to your sleep specialist and have a sleep study
following Somnoplasty to find out whether your sleep apnea has been eliminated even
if you feel that it has.
Can Palate Somnoplasty Eliminate Snoring? Reports suggest that it can decrease or
eliminate snoring about as well as LAUP. Long-term results are not yet available.
Tongue Reduction by Somnoplasty. In tongue reduction by Somnoplasty (35), the
goal is to decrease the bulk of the tongue so it does not obstruct the throat. In the past, a
scalpel or laser was used to remove a notch of tissue at the back of the tongue, sometimes
along with some tonsillar tissue that is located at the base of the tongue (36). Because
Somnoplasty is such a new technique, no one knows whether this type of surgery on
the tongue will be more or less effective than the laser method, so results are difficult
to predict. The success of tongue reduction surgery in treating apnea also is difficult to
predict. Two groups of surgeons reported the results of laser tongue surgery on 24 patients
who had already had unsuccessful UPPP surgery (36,37). Following laser tongue surgery,
fewer than half of the procedures were considered “successful,” and those patients still
had an average RDI above 10 and blood oxygen levels below 90, which means that
many of them would still end up on Seepap. Tongue Somnoplasty is still an experimental
procedure, but shows some promise as a treatment for obstructive sleep apnea.
How Does Somnoplasty Compare with LAUP and Conventional UPPP? Somnoplasty
is less risky than UPPP, involving less bleeding, no hospitalization, and no general
anesthetic. According to one published report, Somnoplasty is less painful than LAUP
during recovery. The cost of Somnoplasty currently is $1,600 to $2,000 and usually is
not paid for by insurance if it is performed for primary snoring alone.
The Pillar procedure is a new surgical procedurelong-term results are available. The verdict on the effectiveness of the Pillar procedure
in treating sleep apnea will have to wait until more patients have had the procedure and
further data on both short term and long term results are available.
Jaw Surgery and Other Maxillofacial Surgeries Maxillofacial surgery is surgery
on the mandible (lower jaw), the maxilla (upper jaw), and the other bones and tissue of
the face. Head and neck surgery involves the other parts of the head, face, and airway,
and is performed by otolaryngologists, or ENTs. Surgeries have a 20-year history of
use as a treatment for sleep apnea, but it is still difficult to predict which sleep apnea
patients are most likely to have their sleep apnea eliminated by this type of surgery.
These surgeries include individually or in combination:
• Mandibular advancement—moves the lower jaw forward
• Midface advancement—moves the maxilla (upper jaw) forward
• Hyoid surgery—repositions the base of the tongue
Jaw surgery and other maxillofacial surgeries for treating sleep apnea actually
include half a dozen possible surgical procedures and many variations. All are aimed at
eliminating obstructions in the airway that lies behind the lower jaw.

In this picture, Examples of mandibular and maxillofacial surgeries that have been tried for treating
obstructive sleep apnea: (A) and (B), two ways of pulling the lower jaw and the base of
the tongue forward. (C) Moving both the upper and lower jaw forward.

Several different surgical procedures on the lower jaw are used to move the tongue
forward. The procedures range from simply moving a small piece of bone forward at the
tip of the jaw to moving the entire jaw by cutting through it on both sides and sliding
it forward.
Other surgical procedures reposition the hyoid bone at the base of the tongue. A
surgical team at Stanford University Medical Center that has pioneered this surgery
performs a two-stage procedure involving UPPP, tongue advancement, and hyoid sus-
pension, followed by upper/lower jaw advancement (40).

Who can be helped by jaw surgery and other maxxilofacial?

It is not yet possible to predict precisely who will be helped by these
SURGERIES?
surgeries. Many factors may influence the outcome, including not only the structure
of the skull and soft tissue but also obesity, age, neuromuscular control of the airway,
the presence of other sleep disorders, and, of course, the skill and experience of the
surgical team.
Mandibular advancement is the simplest and safest of these procedures and is being
used more often nationally, although its usefulness has not yet been fully established.
It has been used in a relatively small number of patients with complicated apnea. An
example is one patient who had a very small jaw and a small airway opening and for
whom neither UPPP nor medication had helped. In this case, surgery did not completely
eliminate his apnea, but reduced it by approximately half (41). As with many examples
of sleep apnea surgery, whether the results are successful depends on if you define “suc-
cess” as complete elimination of the apnea or if you are satisfied with elimination of half
of the apnea and using Seepap to treat the apnea that remains.
Among 1,000 people with obstructive apnea studied at one sleep center, about
6 percent had an obviously malformed lower jaw and another 32 percent had a slightly
short lower jaw (42). It is among these people that the best candidates for mandibular
advancement surgery would probably be found, because their apnea is likely to arise in
part from structural problems in the lower pharynx—a jaw and tongue positioned fur-
ther back and lower than normal and an unusually small lower airway opening.
These complicated surgeries for sleep apnea should be planned as a team effort,
involving the sleep specialist, an ENT specialist, the maxillofacial surgeon who will
perform the actual mandibular surgery, and an orthodontist if teeth are to be reposi-
tioned (42).
The surgery itself is fairly safe if it is performed by an experienced surgeon. It is,
however, performed under general anesthesia, which, as noted previously, is especially
risky for people with breathing disorders.



What are the drawbacks to maxillofacial surgery?

One
major problem that may arise is difficulty with the healing of the jawbone because
the blood supply to that area is not very generous. If the jaw is cut on both sides and
moved forward (sliding osteotomy), the jaw may be wired closed during healing for
about 6 weeks, which presents a significant inconvenience to the patient. In addition,
orthodontics may also be required to reposition the teeth and realign the bite. The
entire procedure is expensive and time consuming.
Another important drawback with this surgery should be considered. After man-
dibular surgery, the jawbone has a tendency to reposition itself backward again toward
its original location. This happens over the course of several years in response to the
powerful force of the tongue muscles, which are constantly pulling on the jawbone.
Although some surgeons would disagree, other physicians have serious doubts about
how long the results of this type of surgery can last.

Tracheostomy.

Tracheostomy used to be a standard treatment for sleep apnea,
but it has become much less common since the advent of Seepap. Today, it is performed
primarily on two types of patients: people who are very sick from the effects of sleep
apnea and who need immediate (sometimes emergency) treatment to save their lives,
and those for whom other treatments have been unsuccessful. Tracheostomy has become
the treatment of last resort; if all else fails, tracheostomy can be counted on to eliminate
sleep apnea. In that sense, it is a very hopeful form of surgery. It also is fairly simple;
however, it has some serious drawbacks.


What is tracheostomy?


In a tracheostomy, a small opening is madeinto the trachea (windpipe) in the front of the neck just below the larynx (voice box).
This opening may be permanent if tracheostomy is to be the permanent method of
treating the person’s sleep apnea. The opening can be surgically closed sometime in
the future, if, for example, the patient switches to Seepap or some other therapy. The
idea of a tracheostomy is to allow air to bypass the obstructions in the upper airway.
The tracheostomy opening is closed with a plug during waking hours, and the person
breathes normally through his nose and mouth. At night, however, the tracheostomy is
left open, and breathing is done through the neck opening, unobstructed.
A tracheostomy tube usually is worn in the tracheostomy opening. This is a small,
curved tube with a flange at the top. It is inserted through the tracheostomy opening
and extends several inches down into the windpipe. The tracheostomy tube usually is
worn permanently. The flange at the top helps hold the tube in place and protects the
opening in the throat.


in this picture, A tracheostomy with a tube in place. At night, the patient breathes through the tracheostomy opening, bypassing the obstruction in the patient’s airway. During the day, the
tube is closed with a plug, so that the patient can talk.

Tracheostomy surgery itself is not particularly risky, although it usually is done un-
der general anesthesia, which may be risky.
Complications that may arise with tracheostomy fall into two categories. One
involves the tracheostomy opening itself. In some cases, the opening tries to close itself
up again. Other difficulties can result if the tissue around the opening heals incorrectly
or becomes infected, damaged, or eroded. Several different surgical variations have been
developed in an attempt to avoid such problems. Another complication of tracheos-
tomy is respiratory infection, such as pneumonia. When a person breathes through a
tracheostomy, air is inhaled virtually straight into the lungs, bypassing all the natural
germ-filtering systems in the nose and upper airway. Consequently, bacteria, viruses, and
other foreign objects can much more easily reach the lungs. Great care must be taken to
prevent this from happening.
There may be a fair amount of pain, some swelling, and difficulty swallowing for
several days after tracheostomy surgery. A tracheostomy tube is worn until the incision
has healed. The tube is chosen for size and shape to fit the particular person and is not
particularly uncomfortable to wear.
After a tracheotomy, the patient (at first with help from a family member) needs to
follow a fairly rigorous, 24-hour postoperative program of taking care of the tracheos-
tomy. This includes cleaning, suctioning, misting, and applying salt solution and antibi-
otics. Immediately after surgery, a suction machine must be used periodically to keep the
tracheostomy tube clear of mucous secretions that could block the airway and prevent
breathing. Mucus production decreases as time goes on, but a suction machine will be
needed indefinitely for cleaning the tube and preventing mucus build-up. Cleanliness
will always be extremely important to avoid introducing bacteria into the tracheostomy
opening. The nurses and respiratory therapists should be explicit in teaching all these
procedures to both patient and family.


Who can be helped by tracheostomy?

Anyone with obstructive or
mixed sleep apnea can be helped by a tracheostomy. Nowadays, the people chosen for
tracheostomy usually have severe apnea with severe complications, including daytime
drowsiness so severe that they are completely disabled (43). They may have tried other
treatments and found them to be unsuccessful. They may have significant cardiac
arrhythmias or other serious heart complications from severe sleep apnea. They may
have extremely low oxygen levels in their blood.
Tracheostomy eliminates snoring, improves the quality of sleep, and virtually
cures daytime drowsiness and apnea in nearly everyone who has the surgery. It greatly
improves fatigue and morning headaches (43).



What are the drawbacks ot tracheostomy?

One of the main drawbacks of tracheostomy, and one reason it has fallen out of favor so quickly with the
advent of Seepap, is the impact that it has on day-to-day lifestyle.
Most people need several weeks to months to learn to deal with the frustrations of
tracheostomy hygiene and to adjust to their new image with a tracheostomy opening
in the throat. A bout of depression commonly accompanies this adjustment period.
The severity and duration of the person’s depression depend on the individual, on how
well the person has been prepared for the appearance and the care of the tracheostomy,
and on family support. The patient, spouse, and other close family members should be
counseled about the surgical procedure, the care that is necessary afterward, and the
likelihood of temporary depression. Talking with other people who have tracheostomies
and are attending sleep apnea support groups, both before and after surgery, helps people
to adjust more easily.
Most people who have had tracheostomies report that they do just fine once the
initial adjustment period is over. They lead normal, active lives and generally do not
seem to be bothered by their tracheostomies. However, they will always have to be
careful about hygiene around the tracheostomy opening. And they must always take
care that nothing enters the windpipe through the tracheostomy opening. For example,
people with tracheostomies may not swim. Because the opening in the throat leads
almost directly into the lungs, people with tracheostomies are in extreme danger from
drowning and therefore must avoid not only swimming but also all water-related activi-
ties (water skiing, sailing, rafting, fishing from a boat) that might require swimming.
Other drawbacks involve the cosmetics of covering the tracheostomy opening. A
small plate or shield is worn over the opening and is held in place by a cord around the
neck. There is nothing inherently objectionable about its appearance, but many people
choose to cover the tracheostomy plate with a turtleneck or a scarf.

Another problem can be keeping the opening sealed during the day. Talking
becomes difficult if there is air leakage. Coughing or sneezing can sometimes pop the
seal and cause temporary embarrassment.
Other difficulties are problems that can arise from poor healing or erosion of
the opening. To avoid such problems, it pays to find the most skillful surgeon you can
(consider a plastic surgeon) and to follow carefully the postoperative instructions. Ask
your doctor to answer any questions you may have and be persistent in asking for help
in learning to deal with any follow-up problems.
Bariatric (Weight Loss) Surgery. Weight loss surgery has been called “behavioral
surgery” (44) because it surgically enforces a change in a person’s eating behavior that
the person has been unable to accomplish by other means. The desired change in
behavior is to reduce the amount of food the person consumes at any one sitting. This
is done surgically by making the stomach smaller.

Surgical Risk.

Several types of bariatric surgery have been employed over
the past 20 years. Bariatric surgery carries special risks because it is performed on obese
people. The possibility of death from surgery is two to three times greater for obese people
than for people of average weight (44). Consequently, it is important to weigh the risks
carefully against the possible benefits that can reasonably be anticipated after surgery.
People who undergo gastric bypass usually are characterized as being morbidly
obese. The average weight of 17 patients in one group was twice their recommend-
ed body weight (45). They were not having “cosmetic surgery” to lose weight; they
were people whose lives are in danger because of their excessive weight and other
complications.
The patients chosen for gastric bypass usually are screened to include only those
who have already attempted to lose weight under carefully supervised weight-loss pro-
grams. The patient’s psychological status often is evaluated as part of the screening pro-
cess. Patients should understand the risks and behavioral changes that will be necessary
for the bypass surgery to be successful.
Several versions of weight-loss surgery have been developed over the past 40 years.
The most common surgical weight-loss procedures are gastric bypass and laparoscopic
adjustable gastric banding.

Gastric Bypass.


This is the most common bariatric procedure performed
today. In gastric bypass, the stomach is reduced in size, not by removing part of the
stomach, but by placing a row of staples across it, dividing the stomach into a small
upper pouch and a larger lower pouch. The upper pouch becomes the “new” stomach.
It receives food from the esophagus and empties into a branch of the intestines that has
been brought up and attached to it.
After surgery, food intake at any one time will always be restricted to approximately
twice the volume of the “new” stomach, usually about 30 mL. This means that no more
than about one-quarter of a cup of food can be eaten at a time.
Gastric bypass is major surgery (see illustration on page 97). It involves major or-
gans (stomach and intestines) and some large arteries. It can be done either by opening
the abdominal cavity or by laparoscopy (operating through small openings) (46). The
risks of complications during surgery from either method are about equal. There are risks
from anesthesia, other medications, surgical errors, and infection. During and after sur-
gery the placement of a number of tubes will prolong the invasiveness of the procedure:
a nasogastric tube for removing fluid from the stomach, catheters, intravenous hookups,
and possibly an endotracheal tube for a ventilator.
Complications after bypass surgery can be significant. They may include infections,
bowel obstruction, collapse of lungs, blood clots, and other after effects seen following
abdominal surgery. The most common complication after gastric bypass is excessive
vomiting (44).
Gastric bypass by open abdominal surgery typically requires a hospital stay of a week
or more, considerable postoperative pain and discomfort, and an extended recovery
period lasting from 4 to 5 weeks to months.


How effective is gastric bypass in treating sleep apnea?

The
average weight loss after gastric bypass is 65 percent to 70 percent of excess body weight
(not total body weight), leveling off in 1 to 2 years (46). One study reported that
most of their surgical patients’ sleep apnea was significantly improved 6 months after
surgery. Some patients had completely lost their symptoms. Many patients reported no
daytime sleepiness or loud snoring. Changes in personality also were reported—greater
responsiveness, fewer emotional problems, and less difficulty at work. A full year is
needed for complete results, so during the 6 months following that report the patients
in the study group might anticipate additional weight loss and further improvement
in their apnea symptoms (45). In the long term, however, some people who have had
gastric bypass surgery will return to their presurgery weight. The overall failure rate for
gastric bypass surgery is reported to be from 30 percent to 50 percent (44).


Laparoscopic Adjustable Gastric Banding.

“Lap-Band” surgery has been
common in Europe and elsewhere but only was approved in the United States by the Food and Drug Administration in 1991. This surgery, as its name suggests, is usually
performed laparoscopically, so the surgery itself is not especially risky if it is done by an
experienced surgeon. It involves placement of an inflatable band around the upper part
of the stomach. Inflating the band restricts the stomach to a small pouch with a small
drainage opening. A tube running from the band to a port outside the abdominal wall is
used to adjust the inflation of the band, which has to be done several times per year.


Food and Drug Administration in 1991. This surgery, as its name suggests, is usually
performed laparoscopically, so the surgery itself is not especially risky if it is done by an
experienced surgeon. It involves placement of an inflatable band around the upper part
of the stomach. Inflating the band restricts the stomach to a small pouch with a small
drainage opening. A tube running from the band to a port outside the abdominal wall is
used to adjust the inflation of the band, which has to be done several times per year.


How effective is lap-band surgery in treating sleep apneas?


Statistics suggest that this surgery does not produce quite as great a weight loss as gastric bypass,
achieving about a 50 percent loss of excess body weight (45). Among nine sleep apnea
patients who had lap-band surgery, only three had their sleep apnea eliminated 18
months after surgery, but the remaining six did not improve at all (47).
Risks from lap-band surgery include those mentioned above for other bariatric sur-
geries plus potential damage to the esophagus or stomach, the possibility of infection
from or malfunction of the inflatable band, and problems with the access port.


who can be helped by bariatric surgery.

Bariatric surgery may be an effective and permanent—if radical—solution for severely obese apnea patients who
are motivated to change their eating behavior, and whose physicians consider them
to be good candidates for this type of surgery. The possible benefits should be carefully
weighed against the significant potential risks.

Treatments for Central Apnea.

Drugs.
Drugs that stimulate the breathing reflexes are presently the most common
treatments for central apnea. Unfortunately, most of the drugs have drawbacks that
make them less than ideal. Some are not very effective; some work for a while, but the
person may develop a tolerance to the drug; and some have undesirable side effects.
Consequently, the drugs available today for treating central apnea should be considered
temporary measures, and we must hope that research in this field will soon offer more
acceptable alternatives.
Acetazolamide is the drug that has received the most attention. It makes the blood
more acidic, which tends to stimulate the breathing reflex. Experiments have shown
that acetazolamide can decrease the number of apnea events and result in a modest
decrease in daytime sleepiness (48). Other studies are less enthusiastic (49), and there
are reports of this drug leading to the development of obstructive apnea (50). More
research is needed, but at the present time, acetazolamide is the most promising drug for
the treatment of central apnea.
Another drug that has provided some improvement in central apnea is clomip-
ramine, which is an antidepressant. It has been used on only a few patients and has
resulted in improved sleep and respiration and fewer apnea events. However, some
patients developed a tolerance to the drug after 6 to 12 months, after which it was no
longer effective. In addition, clomipramine has some undesirable side effects, one of
which is impotence (51).
A third drug that has been tried experimentally on central apnea is doxapram,
which is a respiratory stimulant that normally is used only for the short term (1 or
2 hours at a time) to stimulate the breathing of patients who are recovering from anes-
thesia. It has never been recommended for long-term use, and it has some serious side
effects, including hyperactivity, irregular heart rhythms, increased blood pressure, nausea
and diarrhea, and urinary retention. It should not be used in people with heart disease,
high blood pressure, or perhaps heart rhythm irregularities. These categories include
many people who have serious complications from sleep apnea. It remains to be seen
how useful this drug will be.
Other drugs that have been tried, with very little improvement in the central apnea,
are aminophylline and theophylline, both of which are bronchodilators normally used
to treat asthma and emphysema; almitrine, a breathing stimulant; naloxone, a drug that
has been used to counteract the depression of the breathing reflexes that results from the
use certain other drugs such as morphine and codeine; medroxyprogesterone, a hormone
similar to the female hormone progesterone, which is known to stimulate respiration;
and tryptophan, an amino acid that reportedly acts as an antidepressant. None of these
medications has had dramatic effects on central apnea. All of them except tryptophan
can have serious undesirable side effects (52,53).
Oxygen has also been tried with mixed results (54). It is useful in some severe cases
in conjunction with Seepap and/or bi-level PAP (Seepap is described below).
With so many drugs in existence and new ones being developed each year, one
hopes that drugs will soon be found that provide a specific treatment for people with
central apnea without serious side effects. Much more vigorous research in this field is
needed.

Breathing Devices.

Newer Continuous Positive Airway Pressure or
(Seepap) Technology.

Advances in technology have produced several variations on Seepap that can help
people with central sleep apnea. A new generation of breathing devices, called auto-
servo devices, can sample a person’s breathing pattern and then mimic or improve upon
the pattern when the person’s breathing becomes abnormal.
People with central apnea, especially those who have tried Seepap without good
results, should contact their sleep center and inquire about the new auto-servo–type
Seepaps, currently available from both Respironics, Inc. (Pittsburgh, PA) and ResMed
Corp. (San Diego, CA). In some cases, an auto-servo device can be used in place of a
more cumbersome mechanical ventilator (see below).
For more information about Seepap and bilevel PAP, see the earlier section on treat-
ing obstructive sleep apnea.

The choice of treatment for central apnea should be made only after a thorough
consultation with your sleep specialist.

Diaphragmatic Pacemaker.

A diaphragmatic pacemaker works very much like a heart pacemaker. It uses
tiny, rhythmic pulses of electric current to stimulate rhythmic muscle contractions.
Diaphragmatic pacemakers were first developed to treat poliomyelitis patients whose
breathing reflexes were damaged. However, the devices were never used much for this
purpose because “iron lungs” were developed and the availability of the polio vaccine
soon eliminated the need.
Since then some work has been done using diaphragmatic pacemakers in patients
with spinal cord injuries whose breathing reflexes have been interrupted and in infants
born with faulty breathing reflexes. A few diaphragmatic pacemakers have been tried on
adult patients with central sleep apnea.
In theory, this seems like an ideal solution. Central apnea is essentially the absence
of the nerve signal that goes to the diaphragm during sleep to tell it to breathe. A
pacemaker used during sleep should be able to supply that signal. However, this tech-
nology has not advanced very rapidly, and the diaphragmatic pacemaker has not yet
become widely available, probably partly because until recently the demand was not
there. Demand may increase with better recognition of central sleep apnea.
Implanting the pacemaker requires delicate surgery to place a pair of tiny electrodes
next to the phrenic nerves (the nerves that control the diaphragm). This is done either
in the neck, using a local anesthetic, or in the chest cavity, under general anesthesia.
Usually both nerves, one on each side of the body, are used rather than just one, which
would only stimulate one side of the diaphragm. A small receiver also is placed under-
neath the skin during surgery (55,56). To use the pacemaker, a radio frequency genera-
tor is placed against the skin over the implanted receiver and radio frequency pulses
stimulate the phrenic nerve.
Some problems and risks are involved in using a diaphragmatic pacemaker in a
person with sleep apnea. One drawback is that it can cause obstructive apnea to emerge,
which raises a new set of issues (57). The most serious risk is the possibility of damag-
ing the phrenic nerve, either during surgery or at some later time. Of course, loss of
both phrenic nerves would leave the person with a paralyzed diaphragm and unable
to breathe well on his or her own. For this reason, the operation must be done with
meticulous care to avoid the slightest damage to the nerves.
If you are considering this type of surgery, you would be wise to go to whatever
lengths are necessary to locate a medical center that has an extensive history of install-
ing and using diaphragmatic pacemakers and to find the surgeon who is most experi-
enced with the procedure.
At present, a diaphragmatic pacemaker probably is not a practical treatment option
for most people with central apnea, although it may be considered for some patients. As
research is done and experience is gained, these devices may become a more attractive
method of treatment.

Mechanical Ventilators.

Several forms of mechanical breathing systems can be used to assist breathing dur-
ing sleep by people with central apnea. These devices operate either by “positive pres-
sure” (forcing air into the lungs in a rhythmic, breathing-like pattern) or by “negative
pressure” (more or less mimicking the actions of the breathing muscles).
Positive-pressure ventilators operate by rhythmically pushing air into the airway
through a tube. The air may be supplied through a face mask or nasal mask or through a
tube that enters the body by way of a tracheostomy (an opening in the throat, described
earlier in this chapter), or inserted through the nose or mouth.
A positive-pressure ventilator is less cumbersome than a negative-pressure ventila-
tor, and its use is becoming more common as better ventilators and face masks become
available.
A negative-pressure ventilator works differently. The best-known example of a
negative-pressure ventilator probably is the “iron lung,” which was developed in the
1930s to “breathe” for polio victims who had lost their breathing reflexes. Miniaturized
versions of the iron lung have been developed that surround only the chest.
Mechanical ventilators have had their problems. The rhythm can be tricky to adjust;
it must be regulated to breathe at the proper rate for the person using it. Blood oxygen and
carbon dioxide levels must be carefully monitored to ensure safe and effective ventilator
settings. A mechanical system that completely controls breathing is uncomfortable for peo-
ple who are somewhat able to breathe on their own and need only occasional assistance.
The newest generation of ventilators are small and portable and minimize discom-
fort by allowing the person to breathe on his or her own as much as possible and to
assist breathing only if the person stops breathing. These newer little ventilators can be
effective for many people who have central apnea and are unable to sleep and breathe
at the same time.
Mr. Kennedy, the patient we have been following, finally reached the decision
point— what treatment would be best for him?

Case Study.

When he first heard about UPPP, Mr. Kennedy thought it had some appeal:
a relatively simple operation that might eliminate his snoring, and maybe
his sleep apnea, for good. However, his sleep specialist explained that he did not appear
to be a very good candidate for UPPP.
Mr. Kennedy has a short jaw, so most of his obstructive sleep apnea probably arises
from low in his throat. It probably would not be resolved by UPPP. In that light, the
pain and risks of surgery didn’t seem worthwhile.
With the advice of his sleep specialist, Mr. Kennedy decided on Seepap combined
with weight loss.
Currently, Mr. Kennedy has been on Seepap for 22 years. He lost 20 pounds and is
at his ideal weight. He exercises several times a week and feels better than he has ever
felt in his life.

Mr. Kennedy travels a lot and takes his Seepap with him in a carry-on bag. Security
people in airports often ask to look in the bag, but he has never been seriously hassled
about it. He recently met an airport security guard who uses Seepap himself.
He has had occasional minor problems—colds, skin irritations, poorly fitting
masks, equipment breakdown. But, like the pioneers that they are, Mr. Kennedy and
other Seepap users learn to solve each problem as it arises. Meanwhile, Seepap machines
have become more reliable and have shrunk to half the size and weight of the one he
started with, and the masks have become smaller, lighter, and easier to wear.
Mr. Kennedy feels so much better now that he has never been seriously tempted
to give up Seepap. He admits that he would rather not believe that he will have to use
Seepap for the rest of his life. He was only 47 years old when he was diagnosed with sleep
apnea, and he still thinks of himself as fairly young and vigorous. Sometimes he feels
sorry for himself that he is saddled with this weird medical machine. But . . . Seepap does
work.
He did briefly try an oral appliance, but an overnight monitor showed that he
was still having apneas and a low blood oxygen level with the oral appliance in place.
These results rule out an oral appliance and also suggest that maxillofacial surgery is
unlikely to be effective. Under the circumstances, Mr. Kennedy is not willing to trade
the simplicity and effectiveness of Seepap for the risks, discomforts, and unpredictable
results of surgery. Maybe some better treatment for sleep apnea will come along someday.
Meanwhile he will stick with Seepap.

Summary
• The best treatment is the most conservative treatment that will succeed
for you.
• Treatments for obstructive sleep apnea and mixed apnea:
• Weight loss
• Breathing devices such as Seepap
• Oral devices such as tongue or jaw retainers
• Medication
• Surgery
• Before agreeing to surgery:
• Ask a qualified sleep specialist to estimate the chances that surgery will
eliminate your sleep apnea.
• Treatments for central apnea:
• Medication
• Breathing devices such as auto-servo devices, mechanical ventilators, and
diaphragmatic pacemakers
• Get a second opinion from an ENT surgeon who is experienced and skilled
in the surgical treatment of sleep apnea.