The Gold Standard Treatment For Obstructive Sleep Apnea

In the sleep community, CPAP is consistently mentioned as the “gold standard” treatment option for obstructive sleep apnea. I find this odd, since the overall success rate for CPAP is disappointing, especially if you look at overall acceptance and compliance numbers. Some people may take exception to what I have to say, but here are the facts:

Theses are only rough estimates, but if you take 100 people who are newly diagnosed with obstructive sleep apnea, only about 1/2 are willing to even try it. Of the people who give it a try, maybe about 1/2 end up using it regularly, and of those who use it regularly, perhaps 1/2 continue to use it for more than 1-2 years. Even if you’re using it regularly, not everyone feels any significant improvement in their symptoms.

As you can see, out of all the possible people who are candidates for CPAP, only a small fraction ever end up benefitting at all. It’s shocking how many CPAP machines sit in the closet after only a few weeks use. In controlled research studies, compliance can be quite high, even up to 60 or 80%, but in the real world, it’s probably more like 20-30% long-term.

Despite the grim statistics, CPAP is still the best option that we have. Millions of people benefit from its’ use significantly, and in many cases, it’s a life-saver. There’s also so much more that can be done to educate and support new CPAP users so that more people are able to use and benefit from it.

The frustrating thing is that there are alternative forms of treatment that can be just as good, if not better than CPAP. But in most cases, they’re simply dismissed as being not effective.

The first treatment option that’s available that should be considered the real “gold standard” is tracheotomy. This is where a hole is surgically made just below your voice box into your windpipe, essentially bypassing your entire upper airway. This has essentially a 100% cure for obstructive sleep apnea.

The two other major options for sleep apnea are oral appliances and surgery. The criticism by certain sleep doctors against these two options is that it never gets the AHI down to normal levels. But even a 50% drop in the severity of your breathing pauses is much better than not using your CPAP at all. This was borne out in one Veterans Administration study that showed that the UPPP procedure (with a historical 40% success rate) had a higher overall survival rate years later compared to people placed on CPAP. Surgical “success” is a controversial topic, and I’ve talked in detail about my logic for offering surgery at all.

It’s clear that there are certain camps that are strong proponents for each of the three major treatment options (CPAP, dental devices, and surgery). Each has it’s advantages and disadvantages. CPAP should always be considered first, but the two other treatments should at least be offered once you’ve exhausted all your CPAP options. Advanced orthodontics is another emerging treatment option but we’ll have to see results from more studies.

One interesting observation is that for people who are happy with their surgery, they forget about the fact that they have obstructive sleep apnea. They just go on with their their normal (and more productive) lives. They’re not reminded every night that they have sleep apnea, as what happens with oral appliances or CPAP. For others, CPAP is a normal part of life, like brushing your teeth before bedtime, and are not bothered at all. Notice how different people deal with their treatment options differently.

In my mind, it’s not about which option is better, but customizing your treatment plan based on a systematic process that starts with CPAP, and making sure to go on to other options if CPAP is not working. Unfortunately, too many people give up after trying only CPAP. Ultimately, there is no gold standard.

What’s your feeling on this admittedly controversial topic?

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

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8 thoughts on “The Gold Standard Treatment For Obstructive Sleep Apnea

  1. The thing you are overlooking is the woeful way in which most patients are handled once given a diagnosis and cpap machine. Patients need to be educated and empowered to take control of their therapy. Providing fully data capable machines and software with which to read the efficacy data will allow users to monitor their therapy and make adjustments as needed. You wouldn’t tell a diabetic to not monitor his blood sugar and take insulin, so why OSA patients are kept in the dark and told they ‘can’t’ monitor or make adjustments is a mystery. Those of us who have taken control of our own therapy find the right pressure(s), learn to adjust masks and environment to allow us to get the best sleep. Using the software to monitor the AI, HI, AHI, and leak rates is essential to compliance and success. Until this is the standard for ALL cpap patients, compliance will be woefully low. Couple that with the system of insurance, DME greed, inadequate education and training, little to no follow-up, and you have a recipe for failure. Until all those factors are changed, the compliance rate will be low.

  2. Emilia, that’s a good point. It’s something that Mike Goldman and all the great people at SleepGuide recommend. I routinely recommend the same. However, what do you do for someone that is fully compliant with minimal to no apneas, no leaks, and feels much worse while on CPAP? What if they tried APAP, CPAP, BiPAP, at various settings and even go through 7 different masks? When is it time to go on to try something else? Perfect compliance doesn’t always lead to good results. Even if you’re successful using CPAP, you have to admit it’s not for everyone and if you’ve exhausted all your options with CPAP, then it’s time to look at other forms of treatment. There are lots of people who are perfectly happy with surgery or with their oral appliances. They’re just not as vocal as the people who didn’t benefit from these options. The good news is that in addition to the three major options (CPAP, dental, surgery), there are other options that are now available, including advanced orthodontics (to widen your jaws to make more space for your tongue), and tongue nerve stimulation implants.

  3. The scenario you present is interesting, and it is one which some have discussed on cpaptalk as well. One thing you don’t factor into the scenario of perfect compliance yet not feeling well is O2 desats. Some folks have wonderful efficacy data as it relates to cpap, but when they do an overnight oximetry test concurrently with cpap they are still getting numerous desats during the night well below 88%. I think before any surgery is considered, O2 levels need to be monitored in these types of patients to see if the addition of an oxygen feed into their hose or mask is warranted.

    As for the other options you mentioned, they are absolutely viable in some instances. But, personally, I would not undergo surgery until all other avenues have been explored and ruled out. And surgery is not always successful, either, with many patients finding themselves back on cpap after going through the pain and suffering of the procedure.

    My understanding of oral appliances is that their efficacy is mostly successful among those with mild OSA. Many complain of the TMJ issues that arise with dental appliance use, but some have no problems.

    I appreciate your response to my post….. nice to know you are monitoring your blog so well!

  4. I used my CPAP for about a year before giving up because the mask, hoses, etc. disturbed my sleep more than the apnea did. When I was able to get through the night with the CPAP, I awoke more rested and alert. After another year of sleeping in another room because my snoring bothered my wife, a friend told me about dental appliances and I’ve been using one (“Noizeless”) for about two years now. I no longer snore, twitch or kick my legs during sleep as I used to do.
    I agree with Dr. Park’s estimates about CPAP use; the friend who told me about the dental appliances also quit using his CPAP. I also agree about the sad state of care for apnea patients; my former Dr. gave me minimal information only after prodding and wouldn’t give me the lab results from my sleep study (I didn’t press her for them, admittedly). Basically all she did was advise proper “sleep hygiene” and give me a referral to a medical supplier for a CPAP. Follow-ups lasted about 5 minutes. I suppose another sleep study while wearing the dental appliance would be good but as long as I’m sleeping well and not sleepy during the day I’m not really motivated to do it.
    I found Dr. Parks website from a comment he made to a NY Times article. Thank you for putting it together–the article on the “Gold Standard” CPAP was very informative and made me aware of alternative treatments I didn’t know about.
    Scot

  5. As both an MD and a sleep apnea patient, I have looked at the CPAP controversy.

    As to the financial considerations, since I’m in Canada, health insurance was not a factor, and my private insurance payed for my CPAP machine.

    Re: education – as a doctor I had the training, and I was highly motivated to keep up to date with new research.

    Unfortunately, I have never felt any improvement after using a CPAP, either short-term or long-term. I’m no more refreshed the next day than after any other night. It is thus difficult to be motivated to overcome the disturbance of the machine itself.

    As I write this, my sister is in a sleep lab having her first night with a CPAP. I sincerely hope that she is among the percentage that feels relief with it!

    ~Deborah

  6. Dr. Park,
    You are right on!
    Gold standard is an interesting choice, and may be great marketing. I think, “most common treatment recommendation” would be more accurate.
    Here is a new solution to Positional Obstructive Sleep Apnea. Our inclined side sleeper mattress is revolutionary and is the first non flat mattress. Please check out our short video. I would be very happy to hear your honest opinion about the sleep system.
    Thanks,
    John Schultz
    CEO SquireSleep.com