Frustrated CPAP users are constantly asking me what other options are available. There are literally dozens of over-the-counter, natural, prescription, and surgical options that are available. I’ve chosen 9 options that have proven results, based on published research in peer-reviewed medical journals. There may be other options that may work very well, but as of date, I’m not aware of any prospective studies showing significant improvement based on sleep studies as well as quality of life questionnaires.
7. Throat and tongue surgery interview (mp3).
8. Jaw surgery interview (mp3)with Dr. Kasey Li
If you found this podcast helpful, please go to iTunes to rate and review this program. This way, more people can find this information to help themselves and others.
It’s a given that if you use CPAP, you’ll run into problems. The good news is that the vast majority of these problems can be solved, with some guidance and trouble-shooting.
In this podcast episode, Kathy and I will reveal the Top 7 CPAP Problems you’ll most likely face, with solutions.
Download MP3 file
Top 7 CPAP Problems with Solutions:
- Air in stomach/bloating
- Mask leak
- Water in tubing
- Too strong pressure / I can’t breathe out
- Facial marks / skin irritation
- Dry mouth
- Stuffy Nose
VA Study: CPAP vs. UPPP
CPAP hose holder: Hose Buddy
Bruce Stein’s book: Sleep Apnea and CPAP: A User’s Manual By A User
Interview with Chip Smith of Restoration Medical Supply on CPAP
Unstuff Your Stuffy Nose E-book
Interview with Eric Cohen of National Sleep Therapy
Interview with Dr. Carl Stepnowsky
Interview with Nicole Garrison with Respironics
Please tell me your biggest problem with CPAP and how you solved it in the area below.
If you liked this podcast, please go to iTunes to rate and review this program. This way, more people can find this information to help themselves and others.
During downtime while away on vacation, my two younger boys were watching Teen Titans on TV. I joined them to watch one episode, where all the young super-heros revealed their deepest secrets. When it was Robin’s turn, he initially refused, but later revealed that he was hiding a big secret: He had an amazingly beautiful male face that drove women and even other men crazy.
What was portrayed were big eyes, prominent cheekbones, and wide, masculine jaws. A modern version of this type of face can be seen with Fabio (see photo). If you remember the old movie stars from the mid-1900s, most of the men and women had wide jaws and well developed cheekbones. Now, most celebrities have triangle-shaped faces.
I’ve describe in great detail why this is happening in past articles and in my book. But here’s a summary: Due to a major change in our diets from organic to processed, softer foods, as well as shifting our infants from breast-feeding to bottle-feeding, our jaws are not growing to their full potential, along with more crooked teeth. It’s almost a given that your child will need braces. It’s not a problem with their teeth—it’s a crowding problems caused by smaller jaws.
Although most doctors believe that being overweight is the main reason for obstructive sleep apnea, more and more people with obstructive sleep apnea are now relatively thin. These people will have narrow jaws and a high arched hard palate. Because the roof of the mouth doesn’t drop during development, the upper molars are more narrow, and the nasal septum buckles to one side, causing a deviated nasal septum.
As you can see, this is not only a cosmetic problem. Unchecked, it can lead to poor breathing, poor sleep, low energy, and lack of productivity. Later on, as your sleep-breathing problem worsens into sleep apnea, you’ll be at higher risk of developing diabetes, high blood pressure, heart disease, stroke, and even cancer.
Do you have any other examples of public figures or celebrities with an “attractive” face? Please enter your examples below.
If you tuned in to our last episode, I talked about the 7 reasons why oral appliances may be a good option for those of you with obstructive sleep apnea, and in today’s episode, we’re going to talk about the 8 reason why you may not want to consider oral appliances for sleep apnea.
It’s challenging to find a qualified dentist for every patient
It can change your bite
It’s much more expensive than CPAP
It can be lost or damaged
If you have severe sleep apnea
If you’re severely overweight
If your nose is stuffy
Sometimes, the tongue may not move forward with jaw movement.
Plus two more bonus reasons.
Links and references mentioned:
American Academy of Dental Sleep Medicine
American Academy of Sleep Medicine
Interview with Dr. David Lawler iTunes link #55.
Unstuffy Your Stuffy Nose e-book
The other day, my 12 year-old son and I were invited to go fishing on the Long Island Sound. We drove two hours to get to the Eastern end of Long Island, expecting to catch 3 or 4 fish. The three of us went out on a small boat just after high tide. It started slowly in the beginning, but around 2 hours after high tide, we were catching porgies every few minutes. Between my son and me, we caught well over 100 fish! We ended up keeping just under 50 fish due to size restrictions. This was the most amazing fishing experience I have ever had. My son was ecstatic, as he caught the vast majority of the fish.
There were a number of other boats in our area, but they caught only a handful of fish. Some caught none at all.
You may be asking, what does this have to do surgery?
It turns out that the friend that invited me had been fishing here for over 40 years. Despite having a small boat with basic equipment, his experience and fishing skills trumped all the other fishermen with bigger boats and fancier fishing equipment.
In the same way, you may think that surgeons who use the latest gadgets and cutting tools make better surgeons, but this is not always the case. One of the most common questions that I get asked is if I use a laser for surgery. I usually answer this question with my Tiger Woods analogy: If Tiger Woods bought a $60 Wilson golf set at K-Mark, he can still beat your pants off, no matter how expensive your golf clubs are.
It’s not how new or fancy or cutting-edge the tool you use. It’s the user’s skill and experience that makes the biggest difference, no matter how fancy or basic the tool. Similarly, a good surgeon will still be able to get great results, even with older, less fancy equipment.
The good surgeon also knows when to use the right tool for the job. You can sometimes use the most expensive screwdriver to turn a Phillips screw head, but a basic Phillips screwdriver will work much better. You can use the latest laser to cut tissues for a tonsillectomy, but a simple knife or electrical cautery will get the job done much faster, with much less expense.
Just last week, I had to perform a complicated sinus surgery. The patient had undergone sinus surgery previously by another surgeon, and the anatomy was difficult to navigate. For complicated or repeat sinus procedures, I usually order a sinus CAT scan with 3D image navigation. During the case, the navigation system had to be re-calibrated over and over again, wasting a lot of time. I had to use the standard CAT scan images to do the operation, which made it go much smoother and faster. Image navigation can be a very useful tool for certain situations, but in many cases, it can actually hinder good surgical outcomes. Especially if the surgeon uses it as a crutch, rather than relying on basic anatomy fundamentals.
Everyone has preconceived ideas about what it takes to be a good surgeon. I have to admit that being into gadgets myself, I’m also guilty being attracted to the latest technology. But my recent fishing experience reminded me again that focusing on the fundamentals of any trade, or skill is what makes you a true professional.
Many people hate the idea of using a CPAP mask attached to a hose every night. Fortunately, a good alternative to this is a mandibular advancement devices (also called oral appliances) come in various models, but they all have one thing in common: The lower jaw is pushed forward against the upper jaw, moving your tongue forward, opening up your airway.
In this podcast episode, I will go over the 7 reasons why I like using mandibular advancement devices to treat obstructive sleep apnea.
1. No headgear or straps around your face.
2. It’s silent. CPAP 26 dB. 30 is a quiet whisper
3. It’s small and convenient
4. More dentists are available to make these devices, and are usually covered through most major insurances.
5. Equal to CPAP for people with mild to moderate obstructive sleep apnea.
6. An oral appliance can used as a CPAP mask holder
7. It can be used effectively for snoring and UARS, even if you don’t have obstructive sleep apnea.
Resources and links mentioned:
American Academy of Dental Sleep Medicine
Photo of hybrid oral appliance / CPAP nasal pillow
Unstuffy Your Stuffy Nose E-book
Breathe Better, Sleep Better, Live Better Podcast on iTunes (#54)
One of the most common requests I get is for a referral to a sleep apnea surgeon, particularly if they live in another state. Just like giving a referral for a lawyer or a plumber, there are a number of issues to consider. Some people don’t have access to any surgeons that perform sleep apnea procedures on a regular basis, or the nearest surgeon is located hundreds of miles away. Sleep apnea surgery is not commonly performed by all otolaryngologists, and even the ones that do may not perform these procedures on a regular basis. Here are some factors to consider when looking for a sleep apnea surgeon:
1. Academic or private practice?
There is a general perception that specialized medical and surgical care is better in academic medical settings. Yes, the academic medical centers teach and do more research, but clinicians in private practices can also be well trained and be more than competent. Ultimately, it is the individual surgeon’s passion and desire to constantly learn and apply these techniques that makes for a good doctor.
2. Do you do tongue base procedures?
Many otolaryngologists will do the nasal procedures and the UPPP procedure well, but not do any other procedures for the tongue base. If this surgeon is the only one that available for miles around, then you may not have a choice. My personal bias is that if you are going to be doing sleep apnea surgery at all, you should be well versed in all areas of the upper airway, especially in the tongue base area. Regardless, a good sleep apnea surgeon will know when an additional tongue base procedure is needed, but also what specific type of palatal procedure is needed.
3. How many have you done?
This is a requisite question that everyone is supposed to ask any surgeon, but there are inherent problems with asking such a question. First of all, it puts the surgeon in a defensive state, having to justify his or her qualifications on something that they do for a living. Do you ever ask a plumber how many drains he is unplugged? You may argue that unclogging a drain is not the same as major throat surgery, but there are certain similarities. Both the surgeon and the plumber has to know when and when not to do a procedure, which tools to use, how to explain to the patient/customer what’s to be expected, and how to deal with any potential complications.
Both surgeons and plumbers can be new on the job, but if trained properly, both can get the job done quickly and effectively. This is the point of residency, where residents perform high volumes of surgical procedures over many years. Ultimately, what is more important than the number of procedures is how well it’s performed. Doing a tonsillectomy 2000 times does not make you a good tonsillectomy surgeon. Learning how to do it properly, and constantly striving to improve the technique and the outcomes is what makes for a good surgeon.
The challenge in sleep apnea surgery is not so much the technique, but choosing the right patients to operate on, as well as knowing where in the airway to perform the operations. You could be the best UPPP surgeon in the world, but if you do not do any tongue base procedures, then your overall success rates will never be above 40%.
Honestly, the technical aspect of sleep apnea surgery is relatively straight forward. It is like an elevator operator that has worked for 25 years but was never asked to go to the penthouse floor. Would you ask him how many times he has pressed the penthouse button in his career?
Similarly, once a surgeon is properly trained, minor variations of surgical techniques in the throat are not difficult to master. If you were to ask me to do an appendectomy, I’ve done a dozen or so in my surgical internship year. But that’s not what I do on a regular basis, so I’m not going to offer to take out your appendix. If I read about a new UPPP technique, I can apply it right away and get good results from the start. Of course I’m honest with my patients that I have never done this variation before. But if you build up a good relationship with your surgeon, being the whether or not he’s performed the procedure is a moot point.
4. What are your results?
What is more important than how many procedures have been done is how effective are your results? If the surgeon has published a paper on success rates for UPPP, then you already know the answer. Most busy surgeons do not write papers all the time, but should know what their success rates and should be able to tell you.
5. What is your complication rate?
A good surgeon should know what his or her complication rate is. If a surgeons states that he’s had no complications, go to the next surgeon. Every surgeon, by definition, has had complications. There is a saying in general surgery, “If you do not have any complications, then you’re not being aggressive enough during surgery.
6. Who else do you work with?
A sleep surgeon should not be a one-man show. A good sleep surgeon will work intensively with various other physicians and medical health professionals. It has to be a team approach, like what is seen in comprehensive cancer centers. Proper follow-up and care are critical with any type of sleep apnea treatment, especially before and after any type of surgical procedure.
7. What are your options if the procedure does not work?
You should never undergo a procedure “just to see” whether or not it will work. Your surgeon should be able to give you a reasonable predicted success rate based on research findings, his or her experience, and your particular anatomy. There should be a discussion about the steps that may be necessary in the small chance that the procedure does not work. What are the expected potential reasons why the procedure may not work? This is a discussion that should occur before, and not after surgery.
8. Are you board certified?
It is a given that the for the most part, your surgeon will be board-certified in their main specialty, such as otolaryngology, oral surgery and general or plastic surgery. It takes one to two years to pass the written and/or oral exams after finishing residency, so a newly practicing surgeon may be a top notch surgeon, but not yet board certified. Your new surgeon may have trained with a prominent sleep surgeon during residency, be up to date on the latest research and surgical techniques, so if you go only by board-certification, you’re ruling out working with a potentially great surgeon. Not passing the boards usually reflects more on test taking ability, and not one’s clinical or surgical abilities.
Recently, more otolaryngologists are becoming double board certified (like myself) in sleep medicine. Honestly, I do not think being certified in sleep medicine makes me a better surgeon. I think the field of sleep medicine is fascinating, and only wanted to further my education and provide a more balanced form of care to my patients. However, you can still not be certified in sleep and be an excellent sleep surgeon, as evidenced by the fact that many of the pioneers of sleep apnea surgery are not board certified in sleep medicine. Sleep surgery is definitely within the realm of otolaryngology, and not sleep medicine, although there is beginning to be more cross-collaboration between the two specialties.
The vast majority of sleep surgeons will be otolaryngologists, but some oral surgeons also perform overlapping procedures, since they deal with the facial skeleton. There may be some general and plastic surgeons who have an interest in sleep apnea surgery as well.
Ultimately, what is more important than how may procedures I have done, or the training programs that I attended, is whether or not you and I develop a quality patient-physician relationship, where there is mutual trust and understanding. Obviously, this takes time and effort by both parties.
This is an excerpt from my forthcoming book, “The Sleep Apnea Solution: Dr. Park’s Complete Guide to Getting the Sleep You Need for the Life You Want.”
In my last post, I listed 7 Reasons Not to Undergo Sleep Apnea Surgery. For this post, I will give you 7 good reasons why you should consider sleep apnea surgery. There is a heated debate about sleep apnea surgery within the sleep medicine community. Some sleep physicians are adamant that you should never do surgery, whereas some surgeons downplay CPAP or dental appliances entirely. My belief is that you should do everything possible before considering surgery. However, there’s no “one size fits all” surgery for everyone (except for a tracheotomy), and any kind of surgery must be custom-tailored for every individual, since everyone is different.
1. I hate CPAP
This is the most common reason for wanting to consider surgery. In general, what I find is that most patients give up too soon with CPAP, without proper troubleshooting with the sleep doctors and equipment company. For the vast majority of issues that come up with CPAP, there are simple solutions. On the other hand, some of you have tried religiously for 9 months, going through 4 different masks and 3 different machines. Some find that CPAP makes things much worse, no matter what you try. At a certain point, you have to say enough is enough and consider trying another option. Einstein once said that the definition of insanity is doing something over and over again and expecting different results. Check out the CPAP pro and con posts. I will talk about CPAP in much more detail in later posts.
2. Oral appliance is not helping
In general you want to try every mainstream non-surgical option before considering surgery. Practically speaking, insurance companies also want documentation about what’s been tried in the past. Sometimes, pushing the jaw forward won’t move the tongue forward very much. This can be seen with endoscopy in the office. Some people won’t have enough teeth, or may have TMJ issues.
3. You have a stuffy nose
For both CPAP And oral appliances, you need to make sure that you’re able to breathe well through your nose. One recent study found that “non-compliant” CPAP users went from 30 minutes to over 5 hours after nasal surgery alone. Similar results have been found for oral appliances as well. This is why I have a very low threshold to offer nasal surgery. Once thing to note is that in general, nasal surgery doesn’t cure sleep apnea.
4. You have large tonsils or adenoids
In children, removing tonsils and adenoids is the first-line recommended way of treating obstructive sleep apnea. But even with adults, removing huge tonsils or adenoids can make a big difference. One staging criteria called the Friedman classification found the if you have huge tonsils and a low positioned tongue, and your BMI is less than 40, then you chances of surgical success from UPPP alone is 80%.
5. Previous surgery didn’t work
Just because your previous surgery didn’t work, doesn’t mean that you’re not a candidate anymore. In most cases surgical failure happens because you didn’t address other areas of obstruction. The other possibility is that the areas that you addressed surgically wasn’t aggressive enough to make a difference.
6. If you can’t breathe out through your nose
Notice that I said breathe out through your nose. I’ve described a phenomenon where the soft palate and uvula flops back into the nose, causing you to keep waking up due to your nose becoming clogged with each exhale.
7. You’ve tried everything
Some of you have tried literally everything. CPAP, APAP, oral appliances, nasal strips, tongue exercises, acupuncture, nasal surgery, and even playing a didgeridoo. Still no relief.
If you think that you fit the bill for sleep apnea surgery, please read my past post on why you shouldn’t consider surgery for sleep apnea. If you don’t meet any of the criteria from this post, talk to your surgeon about what he or she recommends. Please share your experiences with sleep apnea surgery on Facebook, Twitter, or Linkedin below.
For many of you, the idea of sleeping with a mask or something inside your mouth makes you cringe. Sleep apnea is taking a toll on your personal and professional life, and you’re willing to consider surgery. You do your research, but find that there are so many different opinions about sleep apnea surgery, it’s impossible to make any sense in deciding on the options. For a summary of how to decide if surgery is right for you, read my report, “The Truth About Sleep Apnea Surgery.”
In this post, I will reveal 7 reasons why you should avoid sleep apnea surgery. In my next post, I’ll go over 7 good reasons to think about surgery for sleep apnea.
1. You’re severely overweight
Studies have shown that the more overweight you are, the less likely any surgery for sleep apnea will succeed. In general losing significant weight will lower your sleep apnea severity by only one level (severe to moderate, moderate to mid, etc.). However, once you do lose a lot of weight, you can be a better candidate for surgery.
One type of surgery that I recommend often is nasal surgery. In general, it’s not going to cure you of your sleep apnea. However, being able to breathe better through your nose can make CPAP or dental appliances (or even future surgery) work much better.
2. You have severe OSA
In general, the more overweight you are, the less likely you’ll respond to sleep apnea surgery. If you can lose a significant amount of weight, then the better your chances for surgical success.
3. Your surgeon recommended a UPPP only
There are exceptions to this situation, but in general, a uvulopalatopharyngoplasty (UPPP) along has less than a 40% chance of surgical success. “Let’s do the UPPP to see if it works” is not a good answer. Your surgeon should make recommendations based on the published data, personal experience and your unique situation.
4. Many hospitals and surgeon are not experienced with OSA surgery
Most ENT surgeons will be familiar with basic sleep apnea procedures, but there are very few that do a variety of different surgical procedures at different levels of the throat. Since undergoing anesthesia with sleep apnea also places you at a higher risk, it’s important that the anesthesiologist and hospital is well experienced in treating patients with obstructive sleep apnea.
5. You haven’t tried CPAP or dental devices
From a practical standpoint, it’s unlikely that your insurance company will approve any kind of surgery if you have not tried a CPAP or dental appliance first. Medically speaking, it’s generally recommended trying non-surgical options before considering surgery.
6. Your nose is stuffy
The more stuffy your nose is, the less likely throat surgery will help. This concept applies to CPAP and dental appliances, and it applies to surgery as well.
7. You don’t have family or friend’s support
Undergoing any type of surgery is a big commitment. You’ll need help making errands, doing chores around the house and to help you cook and eat meals. Most importantly, it’s vital that your family members are supportive of your decision.
If you’re considering undergoing surgery for sleep apnea, how many of the above reasons do you have not to undergo the procedure? Please participate in the discussion in your favorite social media link below.
This is a continuation of my love/hate series on treatment options for obstructive sleep apnea.
In my last post, I described 7 reasons why I like using CPAP for my patients with obstructive sleep apnea. In this post, I will go ever 7 reasons why I hate CPAP. As you can see from this post and past posts, I have a love/hate relationship with all the diagnosis and treatment options for obstructive sleep apnea.
1. Always the wrong pressure
Traditionally, your CPAP pressure is calibrated to cover the worse-case scenario—REM sleep on your back. We know that apneas happen most often in this situation. You’ll get the same pressure the entire night no matter which sleep stage you’re in and which position you’re sleeping in.
Automatic machines are designed for limitations of CPAP, but despite advances in APAP technology and algorithms, it’s still not able to predict when you will enter REM sleep or switch onto your back.
2. The Heisenberg uncertainty principle
One of the principles of physics is that whenever you observe an atom using light, you’re changing the position of the atom. In the same way, having a mask strapped to your face with positive pressure will by definition change the quantity and quality of your sleep. For many people, the benefits will far outweigh with side-effects, but for others, CPAP causes more arousals than it helps.
3. Often used with stuffy noses
Many people with obstructive sleep apnea have stuffy noses, and we know from studies that having nasal congestion can significantly lower CPAP effectiveness. Allergy medications or nasal saline irrigation may help some people, but even if you’re able to benefit from CPAP, it’s probably not working as well it could work due to a stuffy nose. To adjust for these issues, a full face mask can be used, which cover both your nose and mouth. In theory, this can work better, but full face masks are generally more uncomfortable.
4. CPAP doesn’t address milder forms of obstruction
When you undergo a CPAP titration, the pressure is usually calibrated to get rid of apneas and hypopnea, especially when you’re on your back and in REM sleep, when your muscles are most relaxed. However, more subtle degrees of obstruction that don’t meet the 10 second threshold criteria and not addressed. This is why many people can have CPAP adherence data showing an AHI of .1, no leaks, and using 100% of total sleep time, but they don’t feel any better.
5. Potentially makes your teeth crooked
Dentists say that about 50 grams of force is enough to move your teeth. That’s about 2 ounces. Nasal and full-face masks place constant pressure on your front teeth. There are documented reports of patients using CPAP where the upper incisors were found to be shifted back.
6. The system is broken
Studies have shown that with proper education and good follow-up, most people can do well with CPAP. However, due to a broken health care system, many patients slip through the cracks, with minimal to no education and not enough follow-up visits that are needed for troubleshooting. In the academic published literature, “adherence” rates range from 40% to 80%. In the real world, only about 20 to 30% people who start using CPAP are still using it effectively at 1 year.
7. Not a permanent solution for most people
Even if you’re able to use CPAP, life situations change. You may gain more weight. Or you may be in a new relationship. Although I see many people who are very happy using CPAP over decades, some people will want other options at a later time.
8. Flawed CPAP “Adherence” requirements
Medicare and some insurance companies will require that you use CPAP for about 50% of your total sleep time. Otherwise, your machine is taken away. If you start with an AHI of 50 and use your CPAP 50% of the time (4 hours every night), technically, you’re “adherent.” But your average AHI level during your total sleep time is still 25, since you didn’t use CPAP during the other 4 hours during the night. CPAP may be very effective in lowering your AHI to minimal levels, but it’s completely useless if you’re not using it at all.
9. Periodic cleaning and maintenance is needed
This may not matter for people who are regimented and find it important to maintain their CPAP devices on a regular basis, but many others find it cumbersome. Additionally, your body’s CPAP pressure needs will change over the course of months to years, so it’s important to check the pressure at least every 6 to 12 months.
Despite these 9 reasons why I don’t like CPAP, it’s the best that we have, so I do recommend it for most people with moderate to severe. obstructive sleep apnea.
Here are three ways to maximize the chances that your CPAP will work for you:
1. Find the right mask
Many people don’t know that you can ask for a different mask within 30 days. The combination of the right mask and headgear can make a major difference in your comfort levels and whether or not CPAP will work for you.
2. Unstuffy your stuffy nose
Having nasal congestion wil significantly lower the chances CPAP will work. Higher nasal resistance will raise up your CPAP pressures, and it’s also more likely that you’ll open your mouth, causing a mouth leak, which can cause you to wake up. Do everything to make sure that you’re breathing optimally through your nose. This can involve nasal saline, nasal dilator devices, allergy medications, or even surgery.
3. Talk to your health care professionals
Communicate with your sleep physician and equipment company often, especially in the first few weeks. They can troubleshoot only if you give feedback.
In the following posts, I will go over reasons why CPAP may not work, and why I like and dislike surgical options for obstructive sleep apnea.
What has been your experience using CPAP? Was it good or bad? How were you able to overcome challenges to be able to get to the point of sleeping better?
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