Sub-Optimal Surgery As Effective As CPAP?

One of the more heated debates in sleep medicine is the role of surgery for obstructive sleep apnea. There are some sleep doctors that say that there’s no role for surgery at all, except for nasal issues. Then there are physicians who argue that some improvement is better than not using CPAP at all.

Here’s a study that compared non-optimal use of optimal therapy (CPAP) with optimal effect (100%) of non-optimal therapy (surgery). What they found was that the more severe the AHI, the higher percentage of the total sleep time CPAP must be used to significantly reduce the AHI. For example, patients with moderate OSA who use CPAP for 4 hours per night with an effective AHI from 0 to 5 will reduce the average AHI by 33 to 48%.

Medicare’s new guidelines regarding CPAP compliance for coverage requires that you use the CPAP machine at least 4 hours per night for at least 70% of the time over a 30 day period. So if you normally sleep 8 hours, you’ll have to use  your CPAP machine at least 35% of your total sleep time (40% if you sleep 7 hours per night) to meet Medicare Guidelines. This doesn’t take into consideration what your average AHI is during the time that you’re using your CPAP.

Since reported non-compliance rates range from 29 to 83%, it’s safe to estimate that about 50% won’t be considered compliant.

The study authors argue that rather than calculating the average AHI only during the time it’s being used, you should also include in the calculation all the sleep times where the patient is not using CPAP. During this time, there’s no improvement at all, so your total average AHI will be significantly lower.

With surgery, however, even if you have mild residual disease, and since your final AHI will remain constant, it will remain at that level during 100% of your sleep times. So the average AHI for the total sleep time can be as good, if not better than CPAP that’s not being used 50% of the time.

This may explain an old VA study that showed that patients who underwent UPPP only had higher survival rates than people placed on CPAP after a few years, but not by much.

While I agree with the basic premise of their paper, there are a few caveats. Many people use their CPAP machines religiously 100% of the time, with an excellent average AHI (less than 5). Clearly, these people should continue with CPAP, and surgery is not an option. However, there are some people who are perfectly happy with CPAP, but wish to be able to come off of it entirely.

Compliance studies are an average measure of large groups of people, and this data can’t be extrapolated to individual situations. As I’ve stated before, there’s a lot more that sleep physicians, ENTs, and DME vendors can do to increase effective CPAP use. But there will alway be some people who try everything with CPAP and just give up. So if this person has an AHI of 59, isn’t an AHI of 11 after suboptimal surgery (which is considered mild sleep apnea) better than staying at 59?

Once surgeons go beyond the soft palate and begin to address the entire upper airway from the nose to the tongue, soft tissue surgical success rates will improve. If you think of obstructive sleep apnea as a craniofacial problem, then it explains why the skeletal framework options (including dental appliances, orthodontic appliances that expand the jaws, and jaw surgery) also work well to significantly lessen the severity of obstructive sleep apnea.

I admit I’m a bit biased being a surgeon, but it’s important to look the practical and real-life aspects of CPAP treatment, and not just the superficial numbers. What are your thoughts on this issue?

Please note: I reserve the right to delete comments that are offensive or off-topic.

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6 thoughts on “Sub-Optimal Surgery As Effective As CPAP?

  1. I guess decreasing the AHI is better than not decreasing it, but from my experience, I can be perfect all night but if I sleep (on my back) without protection for even half an hour during REM sleep, my day is ruined. something bad happens to the brain during that struggle to breathe that clearly goes even beyond hypoxia because I have UARS. (I suspect it is something similar to cortical spreading depression and would love to see a study on this) so from my perspective, to have an effect on quality of life, the airway needs to be open during all sleep time. and if negative intrathoracic pressure during the struggle to breathe can cause the heart to collapse, then only decreasing the AHI is not going to eliminate that risk. I think ultimately the patient has to be informed of what each of the modalities are able to do and then make their own individual decision regarding what is best for them.

  2. Here is something that I think is very important to mention about the subgroup of CPAPers who are very successful with CPAP. (By successful I mean an AHI less than 5 and often less than 2, compliance 100%, and able to function normally during the day with little sleepiness most days.)

    What members of this subgroup often have in common is an understanding of the devastating effects of sleep-disordered breathing (SDB); a desire to be personally responsible for their own treatment and not rely on medical professionals to optimize their CPAP treatment; a commitment to CPAP; a commitment to self-education about CPAP and SDB; the use of a CPAP machine which has software to track nightly details of breathing; and membership in an internet support group forum run by fellow CPAPers.

    If your patient doesn’t fit this subgroup and is not doing well with CPAP, surgery might be a better option.

  3. Hi,

    Cpap has it limitation for many reasons….for examples, outdoor sleeping, napping in the vehicles, just to names a few. both surgical and cpap treatments are just options and no one size fits all solutions. At least for now.


  4. CPAP or UPPP- isn’t that like saying contact lenses or lasik? Contact lenses are great when they work but require compliance to a usage and cleaning routine. Laser eye surgery is a one off hit that works well most of the time but may not work forever, and can result in bad outcomes for a minority of patients. Contact lenses are easy to adjust for changes in condition, and easy and low cost to start and stop.

    For me, any appliance that can be used unobtrusively to treat a condition has to be a better option than surgery, for others having to comply with sticking lenses to your eyes, or putting a mask on your face, may be too much for them and they prefer a surgical option. Hey – some people even elect for surgery because they don’t like the shape of their nose!