Treatment

I. Continuous Positive Airway Pressure (CPAP)

Benefits of CPAP

The CPAP pump operates by maintaining a constant pressure of air through a nose/full face mask whilst the patient is asleep. This results in splinting the throat open and preventing its closure whilst asleep (the cause of sleep apnoea). Partial throat closure during sleep results in snoring and this is also alleviated by a CPAP pump
Use of the CPAP pump will allow free breathing during sleep to allow for a normal sleep pattern and a restful sleep. Regular use of the CPAP pump will result in other positive long-term effects including improved mood, memory, concentration and better quality of life. There is increasing evidence that CPAP also improves blood pressure and helps to prevent heart attacks and strokes.
CPAP education
Prior to undergoing an overnight CPAP trial, all patients thought to require CPAP are invited to attend a session of CPAP education. Attendance of a partner or housemate together with the patient is strongly encouraged. CPAP education is generally carried out by one of the sleep specialist nurses and allows each patient individually to adjust to the idea of CPAP. The education session takes place in the sleep lab and normally runs for about an hour. It involves:
This will involve:
Watching a DVD about sleep apnoea and CPAP (which has been produced by the Dept of Sleep Medicine). There should be adequate time for questions and discussion with the sleep nurse afterwards.
Having a mask fitting to ensure the most appropriate and comfortable mask is used during the CPAP trial.
Using the CPAP machine whilst awake.



During the night, measurements will be recorded by the CPAP machine that will enable us to determine what pressure the CPAP pump will need to be set at. This will ensure that any breathingproblems can be effectively corrected.
In the morning after the CPAP trial, the machine will be downloaded to a computer, which will show the optimal pressure and any potential problems with mask leak etc.
The sleep nurse specialist will then set the optimal pressure for the CPAP machine which the patient then takes home.
Every patient will be given an appointment for review in OPD1 (Outpatient Dept 1, Ground Floor). This will be in approximately six months from the date of the CPAP trial.
Patients are encouraged to contact the nursing staff before then if they are having any problems using CPAP



II Mandibular repositioning splint

If you are diagnosed with simple snoring, or mild sleep apnoea, you may be treated using a mandibular repositioning splint, or MRS (sometimes also referred to as a mandibular advancement device, or MAD).
This is a dental appliance, similar to a gumshield, which is worn over the teeth while you are asleep. It acts by holding the lower jaw and tongue forward, which in turn increases the space at the back of the throat, reducing the narrowing of the airway which can lead to snoring.
The MRS is made individually for you by an orthodontist using impressions made of your teeth and jaw.
An MRS may not be suitable for you if you have none or very few of your own teeth.


III  Weight loss

Symptoms of sleep apnoea are generally worsened in people who are overweight and studies have shown that weight loss reduces the degree of sleep disordered breathing at night.
It is therefore very important that weight is kept within the normal range. Consultation with a dietitian may be necessary to assist in safe and sensible weight loss.


IV  Surgical treatment.

Several surgical procedures may be used for the treatment of OSA. These include: uvulopalatopharngeoplasty (UP3), geniotubercle advancement, hyoid myotomy and resuspension, Maxillo mandibular advancement, and tracheostomy.
In children, where the cause of OSA is usually tonsil and adenoid enlargement, surgical removal of the enlarged tonsils and adenoids is the treatment of choice for OSA.

Overall, uvulopalatopharneoplasty (UP3) is the most common surgical procedure for treating OSA. This involves removing the uvula and some of the surrounding soft palate. The idea behind UP3 is to eliminate the area of obstruction or to widen the airway so it does not occlude completely
There is significant discomfort after the surgery for about 1 weeks UP3 is very effective for eliminating snoring. Because snoring is generally the most easily measured sign of OSA, patients undergoing UP3 are advised to undergo another sleep study 6 months after surgery to verify its effectiveness.

Geniotubercle advancement and hyoid myotomy and resuspension are sometimes done in conjunction with a UP3 or if a UP3 has proven ineffective. The geniotubercle advancement is done by making a small cut into the midline of the mandible (jawbone) and repositioning a small piece of bone. This bone, the geniotubercle, attaches to the tongue muscles. As the geniotubercle is pulled forward, the tongue is also pulled forward, potentially relieving any airway obstruction caused by the base of the tongue.

A hyoid myotomy is often performed in conjunction with the geniotubercle advancement. The hyoid is a bone in the anterior upper neck. This surgery is felt to advance the base of the tongue as well. Complications from hyoid myotomy are rare but include dental nerve anesthesia and mandibular fractures extending into the root system of the teeth. A combined success rate of approximately 70% has been reported where UP3 has been combined with geniotubercle advancement and hyoid myotomy.

Maxillo mandibular advancement consists of fracturing each side of the face in the region of the upper jaw and both sides of the lower jaw, then essentially pulling the face forward a few millimeters. Metal spacers are then placed in the mid-face and the lower jaw to fill the gap between the bones. This surgery is reserved for patients with significant apnea untreatable with the other surgeries mentioned or CPAP. It has been reported to be highly effective in eliminating obstructive sleep apnea.

Tracheostomy is the oldest surgical treatment for OSA still in existence. It is done by making an incision in the lower neck and penetrating the trachea. A plastic or metal tube is then inserted through the skin into the trachea. This procedure is curative for OSA essentially in 100% of the patients. The tracheostomy site bypasses the area of obstruction during sleep. The tracheostomy can be covered during the day and opened at night. Because newer treatments have proven their effectiveness, tracheostomy is now rarely used for OSA.