Sub-Optimal Surgery As Effective As CPAP?

January 10, 2011

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?

Written by Steven Park · Filed Under Blog | 6 Comments

Sleep Apnea Success: What Does It Mean?

October 20, 2009

If you have sleep apnea, success has many meanings. In the ideal situation, it means that you feel great, you don’t have to use any gadget or device when you go to bed, and your sleep apnea score (AHI) is 0.

Unfortunately, the definition of success in the sleep apnea research fields keeps changing depending on who’s reporting it. In general, the surgical definition of success is a drop in the final AHI (apnea hypopnea index) of greater than 50%, and the final number is less than 20. Some use an AI (apnea index) being less than 10. Rarely, some people use 5. Some studies report two or three definitions simultaneously. Studies report anything from 40% to 95%, depending on different types and combinations of procedures.

For CPAP users, there are multiple definitions of success. One common definition is when CPAP is used at least 50% of each night for at least 4 out of 7 nights. Actually, this is a measure of compliance, meaning, how well did the patient stick to using the machine? Reported compliance rates using different criteria range widely from 20% to 90%.

Surgical success and CPAP compliance doesn’t measure the effectiveness of the form of therapy. In other words, do you actually feel much better? Is it lowering your blood pressure, or are you feeling less depressed? You can be using CPAP 100% of the time 7 days a week, or your AHI after surgery can drop from 45 to 3, and you may not feel any better. These same concepts apply to oral appliances as well.

What you may find is that although you’re using CPAP every night, your "effective" AHI each night is still relatively high, and not anywhere near the near 0 levels that were obtained during the CPAP titration study. Since the vast majority of CPAP machines that are prescribed will only measure "compliance" data, you’ll never actually know how effective the treatment is when you’re actually using it. Some of the more advanced models are able to tell you what the effective AHI is every night. For only a few hundred dollars more, it’s probably worth giving every patient models with these features.

Even if you’re "successful" in the beginning, how will you feel 20 to 30 years from now? Will you still be using your CPAP machine 100% of the time, or will your AHI remain at the same levels just after surgery? Probably not.

As I’ve describe with my sleep-breathing paradigm, all modern humans are susceptible to sleep-breathing problems to various degrees. It’s a normal part of being human, mainly due to our ability to talk. So thinking of any of these treatment options as a cure is a mistake, since the forces that create collapses in your throat will only get worse as you get older. (Find out more about these important concepts in my book, Sleep, Interrupted.)

Just like any chronic condition, managing sleep apnea has to be considered a life-long process of constant adjusting and fine-tuning, rather than thinking of these treatments as a one time "cure."

Are you a successful sleep apnea patent? How has your mindset changed regarding "success" since you first started treatment? Please enter your responses below in the comments box.

Written by Steven Park · Filed Under Blog | Leave a Comment