"I can't wear that #!%{&!!# mask!"
Associate Clinical Professor of Medicine
Case Western Reserve University School of Medicine, Cleveland
Board Certified in Pulmonary and Sleep Medicine
|
First, do no harm. |
[Notes: 1) Names and some features of the patient have been changed to protect identity. None of the information in this story should be construed as specific medical advice for any individual. Anyone concerned about excessive sleepiness or abnormal sleep should consult his/her physician. 2) Ads by Google relevant to sleep are placed to help defray the cost of site maintenance. The ads have no influence on the content of this web site.]
The first visit on February 6 for Jimmy Nemiewski, age 56, was straightforward. The guy weighs 280 lbs. and is 5'9" tall; his neck size is 19 inches. He snores heavily, his wife can't sleep in the same room, and before moving out to another bedroom she told him, "you stop breathing Jimmy, go see a doctor." They are happily married, but he's just stubborn. By the time he got around to seeing me (on referral from his primary care doctor), it was apparent that he suffers from "obstructive sleep apnea," the common condition where the upper airway closes periodically during sleep.
How common? OSA affects 2% of adult female and 4% of adult male populations. People with OSA have transient episodes where air flow stops or slows considerably. Each event lasts 10 to 30 or more seconds. If there are many such episodes an hour (e.g., 15-20 or more), real harm can result:
- sleep apnea can be accompanied by a drop in oxygen levels, risking heart disease, high blood pressure and stroke.
- OSA causes interrupted sleep, which can cause severe daytime drowsiness, leading to car and work accidents.
- Over time, the most severe patients can develop respiratory and heart failure.
- Sudden death can occur.
The diagnosis is suspected in patients who are obese, have a history of heavy snoring or sleep disruption, and who have excessive daytime fatigue or sleepiness. The diagnosis is confirmed by a sleep study, called a polysomnogram, a test I arranged for Jimmy after the February 6 office visit (he insists I call him Jimmy, which I do; he is sensitive about the pronounciation of his surname). He had the sleep study February 20; it is now March 3 and he is here for the results.
"How'd the sleep study go?" I ask.
"I don't know. You've got the results."
"No, I mean did they treat you OK? Any problems at the hospital?" The study is done in the hospital, but is considered an outpatient test.
Yea," he says deferentially. "No problems. They were very nice."
"Well, as I suspected, you have sleep apnea. In fact it's a pretty severe case." He looks at me impassively, waiting for more information.
"You stopped breathing over 60 times an hour, and your oxygen level fell also." There is actually an enormous amount of data generated from a sleep study, but I try to summarize the essence for each patient. (For any sleep medicine professional reading this story, Jimmy's respiratory disturbance index was 62.5/hr. before CPAP was applied, resulting from both obstructive apneas and hypopneas. His low SaO2 was 76% and he spent 55 minutes at an SaO2 < 90%. His arousal index was elevated at 35.5/hr. and he had no periodic limb movements of sleep.)
"That mask they put on you actually helped quite a bit," I continue. (Again for sleep professionals: His RDI improved to 8.6/hr. with CPAP pressure of 12 cm H2O.)
"Yea, but I can't wear that -------- mask." His choice of adjective was irreverant and explicit.
"Why not?"
"It chokes me. The mask is not for me."
"But you wore it that night."
"I know, but I don't want to do it again. It's just not for me." Jimmy works as manager of a fast food restaurant, and from what I can tell is a hard worker, meaning many hours a week on his feet. He falls asleep easily during the day, occasionally on the job and at least once while driving. He often pulls the car over when he feels sleepy and takes a nap. On his Epworth Sleepiness Scale (range 0-24) he scored 18 out of 24; 10 or over indicates excessive daytime sleepiness.
His sleep study confirmed severe obstructive sleep apnea. At 2:30 a.m. in the middle of the study a sleep technician woke him up to fit a CPAP mask over his nose, which, despite his complaints, he wore until about 6 a.m.
Picture of man (not my patient) with CPAP mask. The hose is attached to machine which sends air under pressure with each breath, to keep the airway open.
CPAP works. If the patient can get past the early discomfort of the CPAP mask, and can tolerate the whooshing sound of the machine, he or she will usually get a good night's sleep and, often, be a new person. No more daytime somnolence, no more excessive fatigue. Even blood pressure will improve in many patients. And certainly the risk of sudden death improves.
About 50% of patients with OSA tolerate and stay with the treatment. CPAP often gives OSA patients a new lease on life. Jimmy was going to be part of the other 50%. During our discussion he makes it clear "no way, no how can I use that thing." More often, people are willing to give it a try, but he doesn't want to.
"Would you consider surgery?" I ask.
"What does that involve?" Excellent question, I think to myself. I am not a surgeon but frequently refer patients for surgery. The type of surgery is left up to the surgeon and patient; I just make the referral. I explain this to Jimmy, then add: "It has an overall success rate of about 50%, and there are no guarantees." He agrees to see a surgeon, and my nurse arranges an appointment for the following week. Everything that has transpired is written in his chart, including a typed copy of his sleep study interpretation.
Available treatments for OSA can be loosely divided into "Medical" and "Surgical."
|
The first line medical treatment, continuous positive airway pressure (CPAP), has been declined by my patient. Weight loss is theoretically ideal but almost impossible to achieve and maintain; in any case it would take many months and Jimmy needs more immediate treatment. Sleep hygiene is rarely beneficial for severe OSA cases (and, in any case, Jimmy neither drinks nor smokes). Dental devices are not widely accepted, although their use is increasing. For practical purposes a patient intolerant of CPAP will usually consult a surgeon for possible upper airway surgery.
There are several surgical approaches for OSA, and none is considered ideal or even widely accepted. Any surgery needs to be tailored to the unique characteristics of each patient. Whereas CPAP at, say, 10 cm H2O, is the same for every patient, a given surgical procedure is apt to vary depending on the surgeon and unique patient characteristics. Because results also vary all over the place, it is difficult to establish any standard surgical procedure for OSA.
Before presenting the menu of surgical procedures, it will be helpful to first contrast CPAP therapy with surgery for the treatment of OSA.
CPAP vs. Surgery for Obstructive Sleep Apnea (OSA) |
||
CPAP |
Surgery |
|
What it is |
A tight-fitting mask (CPAP mask) that fits over the nose or into the nostrils, through which air is delivered under pressure with each breath; this mask is worn only while sleeping |
An operation performed by a surgeon; there are several such operations, each designed in some fashion to 'open up' the throat area (see next table) |
Physician involved |
Usually a pulmonary or 'sleep medicine' specialist, but CPAP can be ordered by any physician after appropriate studies |
Always a surgeon; usually a specialist in otolaryngology (ear nose and throat or "ENT") |
Minimal studies required |
An overnight sleep study (polysomnogram) to document OSA and show that CPAP is effective therapy |
An overnight sleep study (polysomnogram) to show that the patient has OSA |
Cost (not counting sleep study and clinical evaluation) |
Initial cost of machine and supplies an estimated @ $1500 (usually covered by insurance), but after that the cost is negligible |
Variable, depending on complexity and number of procedures that have to be performed (often multiple procedures with some techniques, such as laser surgery); total will range from a few thousand dollars up |
Success Rate |
Overall, probably 50%, which takes into account that many patients are intolerant of the mask |
Overall effectiveness less than 50% for treating OSA. One comprehensive review noted: The studies to support the use of the surgical treatment of obstructive sleep apnea syndrome contain biases related to small sample size, limited follow-up and patient selection. In other words, these operations are not supported by large scale, scientific studies as to their efficacy. |
Overall Advantages |
Standardized technique (CPAP is essentially the same wherever it is
prescribed); usually effective for OSA; can do 'trial and error' for various masks
and pressure settings; allows patient time to lose weight and perhaps
remove need for machine; CPAP not painful or disfiguring;
is relatively inexpensive, and no time lost from work; if CPAP fails patient
is simply back to baseline and can consider other options
If surgery successful patient doesn't need any further therapy; short period of pain for lifetime free of problem | |
Overall Disadvantages |
Have to wear mask nightly, usually indefinitely (unless there is
substantial weight loss); can be uncomfortable, and noise of machine can bother
patient and/or bed partner; can cause nasal congestion & dryness;
doesn't cure the underlying problem of OSA
Not standardized -- techique for any particular operation (e.g., 'UVVP') may vary from surgeon to surgeon; there is pain and morbidity with any procedure, including finite risk of death (particularly if general anesthesia used); if not successful patient has gone through unnecessary pain and suffering; expensive, including time lost from work. |
Despite the general preference for CPAP over surgery, many patients do fail (or are intolerant of) CPAP, and opt for surgery. The following table includes the various surgical techniques for treating snoring and obstructive sleep apnea.
Surgical Techniques for Snoring and Obstructive Sleep Apnea (OSA)
Operation |
Description of Surgery |
Perspective |
Result for snoring alone (without OSA) |
Result for OSA |
tracheostomy |
placing an opening in the trachea or wind pipe, effectively bypassing all upper airway obstruction |
done only for patients whose sleep apnea is considered life threatening; these patients usually have concomitant respiratory failure, i.e., failure to bring in oxygen even while awake. |
Never done for snoring alone |
Considered curative, since opening establishes an effective bypass for air to enter the lungs; however, rarely performed for OSA alone since it is considered a 'drastic' option. |
nasal surgery |
making the nasal air passages larger via traditional surgical techniques (e.g., fixing septal deviation), or newer methods such as laser or radiofrequency |
this surgery is commonly performed in patients with or without OSA who "can't breathe through my nose"; for patients with OSA, nasal surgery may help improve tolerance of the CPAP mask |
Since blocked nasal passages is rarely the sole cause of snoring or OSA, nasal surgery is not expected to cure either condition. |
Not helpful, except in faciliating use of CPAP mask when nasal passages are blocked |
genioglossal advancement, with hyoid myotomy and suspension (GAHM) |
'Facial reconstruction surgery': essentially moving the tongue forward to open up the back of the throat |
Operation performed only in highly selected cases: people with large tongues that tend to fall back and block the throat. Specific technique will vary with surgeon and patient's anatomy. Under general anesthesia; can be associated with major morbidity. |
Not for snoring alone |
Uncommon therapy for OSA; can be effective in selected cases |
maxillomandibular osteotomy and advancement |
'Facial reconstruction surgery': Essentially re-aligning the jaw by moving both the upper and lower jaws forward, maintaining dental occlusion; the result is that the tongue is advanced forward, opening up the back of the throat (the "retropalatal airway") |
Operation performed only in highly selected cases. Specific technique will vary with surgeon and patient's anatomy. Under general anesthesia; can be associated with major morbidity. |
Not for snoring alone |
Uncommon therapy for OSA; can be effective in selected cases |
UVVP (uvulopalatopharyngoplasty) |
Using a scalpel to remove part of the soft palate, and the uvula, to open up the back of the throat; tonsils are also removed if no prior tonsillectomy |
The 'traditional' surgery for OSA, UVVP is a major operation performed by ENT surgeon, under general anesthesia. There is significant post-operative pain. Specific technique will vary with surgeon and patient's anatomy. UVVP is now a second option, for patient's who can't tolerate CPAP or in whom CPAP has failed to correct OSA |
Up to 80% have immediate improvement, but snoring recurs in half of these patients |
Analysis of the uvulopalatopharyngoplasty papers revealed
that procedure is, at best, effective in treating less than
50% of patients with obstructive sleep apnea syndrome. The site of
pharyngeal narrowing or collapse, although
identified by different and unvalidated methods, has a
marked effect on the probability of success of
uvulopalatopharyngoplasty. |
LAUP (laser assisted uvulopalatoplasty) |
using a laser to remove part of the soft palate and sometimes part of the back of the tongue, to open up the back of the throat; tonsils also removed if no prior tonsillectomy. Specific technique will vary with surgeon and patient's anatomy. |
Outpatient procedure. Doesn't require general anesthesia, but is painful; also, more than half of patients require multiple procedures (and hence is expensive long term) |
Up to 50% effective, after multiple procedures |
Not effective; can actually worsen OSA in some patients |
RFTVR (radio frequency tissue volume reduction); also known by trade name Somnoplasty |
essentially heat treatment to soft palate, to accomplish the same objectives as UVVP and LAUP. Tiny radiofrequency electrodes are inserted into soft palate and back of tongue. Radiofrequency (heat) energy travels out from the needle, causing tissue to heat up, coagulate, and over time reduce the volume of tissue. Specific technique will vary with surgeon and patient's anatomy. |
Office procedure, under local anesthesia - little pain, but usually requires more than one procedure to be effective |
Effectiveness increases with multiple procedures, up to 61% effective (Ferguson M, Smith TL, Zanation AM, Yarbrough WG. Radiofrequency tissue volume reduction: multilesion vs. single lesion treatments for snoring. Arch Otolaryngol Head Neck Surg 2001;127:1113-18.) |
Effective in some cases of OSA |
Sclerotherapy |
injecting a sclerosing agent into soft palate, to 'scar down' the tissue; sodium tetradecyl sulfate is used (same agent use to sclerose varicose leg veins |
92% effective if snoring is generated from soft palate; not effective if snoring generated from base of tongue (Ferguson M, Smith TL, Zanation AM, Yarbrough WG. Radiofrequency tissue volume reduction: multilesion vs. single lesion treatments for snoring. Arch Otolaryngol Head Neck Surg 2001;127:1113-18.) |
Not tested; may be effective for mild OSA |
Office procedure, under local anesthesia - also 'low tech' and so less expensive than laser and radiofrequency procedures |
About three weeks later I receive a letter from Dr. Banner, ENT surgeon. After thanking me for the referral he explains the patient's condition, adding:
|
...March 28 ...I have recommended UVVP and Mr. Nemiewski and his wife have agreed to the procedure [only Jimmy is having surgery of course]. I have explained the risks of surgery, including the possibility that it may not cure his obstructive sleep apnea. I will schedule him for a repeat polysomnogram about three months after surgery, to assess any degree of improvement. Etc. Etc., Yours truly, ... Richard H. Banner, M.D., FACS |
My next contact with Jimmy was indirect. In early August, about 4 months after Dr. Banner's letter, I see his follow up sleep study in my box for interpretation. The study had been ordered by Dr. Banner. With interest I read the history section (the technician writes down a brief medical history).
"Patient previously here February 20 for split night study [the original study when the lab made a diagnosis and applied the CPAP mask; it is called "split night" because the night is split between diagnosis and therapy]; it showed severe OSA with RDI of 62.5. Now back after UVVP surgery April 2. Surgeon requests diagnostic study only [no mask to be applied]."
Jimmy still has OSA. But it is not as bad as in February. In fact, surgery appears to have helped his daytime sleepiness; his ESS score is now 9, compared to 18 earlier in the year. I note he also weighs 10 lbs. less. I make a little comparison box for my typed interpretation.
Feb 20 |
July 25 |
|
ESS [Epworth Sleepiness Scale; over 10 indicates excessive daytime sleepiness] |
18 |
9 |
RDI [respiratory disturbance index; over 5 abnormal; the higher the number the worse the sleep apnea] |
62.5/hr. |
12.7/hr. |
Lowest SaO2 [oxygen level; normal during sleep is above 90%] |
76% |
87% |
I summarize report by stating: "Overall, the patient still has evidence of obstructive sleep apnea, but it is now mild and definitely improved compared to before surgery."
I see Jimmy in my office one more time, in mid September. This time it's for a respiratory infection, nothing to do with his OSA or surgery. I look in his throat: his posterior palate (the back of the 'roof of the throat') is missing, surgically excised. The throat opening is twice as big as I remember it from February.
"Did the surgery help, you think?"
"Yes, I'm not as sleepy as before."
"That's great, I noticed you lost about 10 lbs. too."
"Yea, I don't work at [fast food restaurant] any more. I'm now working at Sears.
"What do you do?"
"I manage their kitchen wares department."
"Still on your feet a lot?"
"Yea, I guess so."
"Falling asleep during the day?"
"No, it's really not bad. Glad I didn't have to wear that mask."
I give him medication for bronchitis, and ask him to call me if he's no better in three days. I also ask him to return in a year, to see if the daytime sleepiness has recurred or if he has any new symptoms that related to worsening sleep apnea. I am curious to know if his improvement from surgery will be sustained.