Sleep Newsletter

Fall/Winter 2011

We are committed to providing the latest treatment options for Obstructive Sleep Apnea.  Continuous Positive Airway Pressure (CPAP) is the gold standard therapy for sleep disordered breathing.  As an alternative to CPAP therapy we are offering Somnoguard, a Mandibular advancement device.

We encourage open communication to optimally treat your patients.  Please contact us if there is any topic of interest you would like more information about.

Warmly,

Elizabeth A. Lynch, MD

Non-positive Airway Pressure Modalities: Mandibular advancement devices/positional therapy

Chan ASL, et al. Proc the Am Thorac Soc, 5: 179-184

Although positive airway pressure is the most efficacious treatment for obstructive sleep apnea (OSA), its clinical effectiveness is limited by its obtrusive interface. Two alternative treatment modalities used in clinical practice are mandibular advancement devices (MADs) and positional therapy.

The goals in treatment of OSA are to prevent obstructive apneas and hypopneas, to improve symptoms, and to modify the increased cardiovascular risk.  MADs achieve this by mechanically protruding the mandible, thereby increasing the dimensions of the upper airway and reducing its collapsibility. By avoiding supine sleep, positional therapy improved the patency of the upper airway in those with positional OSA.

There is now a relatively strong evidence base to support the use of MADs in clinical practice, with research studies assessing there impact of treatment on a range of healthy outcomes. The revised clinical practice parameters of the American Academy of Sleep Medicine recommend their use for mild to moderate OSA; or for patients with severe OSA who are unable to tolerate or refuse treatment with positive airway pressure.

Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults

Epstein LJ, et al. Clin Sleep Med, 5 (3): 263-276, 2009

Available practice parameters provide evidence based recommendations for addressing aspects of care. Questions regarding OSA should be incorporated into routine health evaluations. Suspicion on OSA should trigger a comprehensive sleep evaluation.  The diagnostic strategy includes a sleep-oriented history and physical examination, objective testing, and education of the patient.

The presence or absence and severity of OSA must be determined before initiating treatment in order to identify those patients at risk of developing the complications of sleep apnea, guide selection of appropriate treatment, and provide a baseline to establish the effectiveness of subsequent treatment.

Once diagnosis is established, the patient should be included in deciding an appropriate treatment strategy that may include positive airway pressure devices, oral appliances, behavioral treatments, sur gery, and/or adjunctive treatment. OSA should be approached as a chronic disease requiring long-term, multidisciplinary management. For each treat- ment option, appropriate outcome measures and long-term follow-up are described.

Adherence to Continuous Positive Airway Pressure Therapy:  Th Challenge to Effective Treatment

Weaver TE, et al. Proc Am Thorac Soc, 5:173-178, 2008

Despite the high efficacy of continuous positive airway pressure (CPAP) to reverse upper airway obstruction in sleep apnea, treatment effectiveness is limited by variable adherence to prescribed therapy. When adherence is defined as greater than 4 hours of nightly use, 46-83% of patients with obstructive sleep apnea have been reported to be nonadherent to treatment.

Evidence suggests that use of CPAP for longer than 6 hours decreases sleepiness, improves daily functioning, and restores memory to normal levels. The decision to embrace PAP occurs during the first few days of treatment. No single factor has been consistently identified as predictive of adherence.

Critical elements associated with continuous positive airway pressure adherence with treatment initiation are phone call/follow-up the first week of treatment, accessing CPAP use and associated outcomes, assessment of a patients perception of treatment and symptom-related response, trouble shooting problems immediately, retitration as necessary, among others.

One of the most dramatic immediate effects of any medical treatment is the ability of CPAP treatment to reverse the repetitive upper airway obstruction of sleep apnea and associated day time sleepiness. Patients will describe the effect as emerging from a daytime fog and being able to live a productive and healthy life.

The Sleep Institute of New England

1 Little River Road, Kingston, NH  03848

Tel: (603) 347-8810

Fax: (603) 347-8811