Mini-Series on Obstructive Sleep Apnea (OSA): Diagnosis, Prevention and Treatment
Finally, the last part of our Obstructive Sleep Apnea (OSA) mini-series (whew)! In this section, I will dig a little deeper and discuss OSA diagnosis, prevention and treatment. Please check out Parts 1 and 2 for a background and overview on adult and pediatric OSA.
OSA Diagnosis:
Are you worried that you or a loved one may have OSA? To start off, taking a sleep questionnaire may be helpful to see if you’re at risk. The Epworth Sleepiness Scale (ESS) is one of the most common ones used. Here are a few questions you may want to ask yourself:
Have you been told that you stop breathing during sleep?
Has anyone said that you snore?
Are you feeling tired in the daytime?
Do you feel like you have no energy?
Do you nap or fall asleep easily?
Do you have morning headaches?
Do you see yourself saying “yes” to a lot of these questions? If you think you are at risk of having OSA, a sleep study is required for a formal diagnosis. This is important if you would like your insurance to cover treatment. Sleep studies have been traditionally performed overnight at a sleep lab; however, home sleep tests (HSTs) have become popular recently. HSTs are convenient, comfortable and less costly. A sleep physician analyzes and makes a medical diagnosis for both. The AHI/RDI indices that I discussed in parts 1 and 2 are used to determine OSA severity.
In case you were curious, here are the components of a sleep study: a polysomnogram (PSG) measures brain, eye, and muscular activity by looking at “electrical” activity. Electrical activity?! To keep it basic, sensors are placed on your head! Simultaneously, inspiratory effort is analyzed as well as blood-oxygen saturation, heart rate, blood pressure, and sleep position. All of these components are required to get a complete understanding of your sleep behavior. In case you’ve forgotten, please review OSA consequences on the body in Part 1.
3-D imaging of the airway itself via cone beam computerized tomography (CBCT) offers supplemental information. This can be done in a dental office. Looking at airway anatomy may show the specific sites of airway constriction. There are also devices that conduct dynamic (4-D) airway assessments.
OSA Prevention:
Prevention is the best medicine! How may we avoid developing OSA? As mentioned in Part 1, OSA is often a disease of obesity. Weight loss and abdominal muscle toning may help directly tackle and/or prevent OSA. However, please keep in mind that this may not be effective if the OSA is resultant of an underlying skeletal structure imbalance.
In addition, eliminating activities that may cause airway inflammation or muscle laxity will be helpful. Smoking is highly irritating to the airway. Drinking alcoholic beverages may also negatively affect airway muscle tone. Some other “sleep hygiene” activities include avoiding heavy meals in the evening, sleeping on one’s side, head elevation, and nose strips.
If we really want to be preventative, let’s start from the beginning... of life! Interestingly, breastfeeding allows for optimized musculoskeletal facial growth and prevents a tendency towards developing mouth-breathing or a tongue thrust habit. I discussed these in Part 2 if you would like a refresh!
OSA Non-Surgical Treatment:
Okay, so you’ve been officially diagnosed with OSA. Now what? Continuous positive airway pressure (CPAP) machines are the gold standard of treatment. Basically this machine is a mask that surrounds the nose and mouth connected to the machine via a tube, which pushes a constant stream of airflow. This keeps the airway open. Sounds great, doesn’t it? The main issue is that patients poorly tolerate these machines. You may imagine it is not the most comfortable and using the machine itself has a stigma.
For this reason, oral appliances such as mandibular advancement splints (MAS) have increased in popularity. An appliance is much less invasive. They are highly effective for mild-moderate cases or for those who cannot tolerate CPAP. There are many different kinds of oral appliance designs. A dentist would choose a design based on a detailed exam and history. MAS treatment may not work for those with periodontal disease, many missing teeth, worn out dentition, temporomandibular joint disorder (TMD), severe jaw asymmetries, or ongoing dental work. Furthermore, if one’s OSA is a result of nasal constriction, an oral appliance will most likely not work! I will mention that there are side effects to oral appliances. These may include TMD symptoms, movement of teeth, a jaw protrusion tendency, dry mouth, excessive salivation, and soreness. However, in many cases OSA is a life or death issue! The health and lifestyle benefits will likely outweigh these side effects.
So how do the oral appliances work? By protruding the lower jaw and related soft tissues, the airway is expanded. Based on my own research, this form of treatment is especially appropriate for those whose OSA and decreased airway volume relates to a facial skeletal disharmony (versus obesity) and upper airway constriction. Please do not hesitate to contact me if you’d like more in-depth info on this!
Finally, I mentioned in Part 2 that rapid palatal expansion is a great orthopedic treatment/prevention option. This procedure may be performed non-surgically in a pediatric/adolescent population.
OSA Surgical Treatment:
Surgery is often reserved for more severe cases wherein non-surgical intervention is not effective. Advancing both the upper and lower jaw is the most common surgery. The forward advancement of facial muscles and soft tissues widens the airway. Other less common soft-tissue surgeries include tongue resection or resection of the uvula/soft palate tissues. These, as you can imagine, are extremely uncomfortable procedures. Most patients do not come out happy afterwards.
Adenotonsillectomy (T&A) surgeries are resurging in popularity with the pediatric age group. Removing these soft tissues helps eliminate a physical airway blockage.
In the most severe cases tracheotomies may be indicated. This may be compared to a CPAP-like machine that directly connects to the trachea to ensure oxygenation to the lungs and vital organs.
Take Home Messages:
OSA is a serious medical condition not to be messed around with! The ability to breathe is essential to one’s health, quality of life, and ideal growth and development in a pediatric population. OSA events trigger stress responses in the body, and in severe cases these episodes may occur hundreds of times in one night. Over time, untreated OSA will likely decrease longevity. Hopefully this overview has helped you become more aware of OSA signs, symptoms, and the necessary directions towards diagnosis and treatment.