Treatment of OSDB
History
Until the early 1980’s, the medical
community erroneously attributed the cause of most sleep disordered
breathing (“SDB”) to be neurological in nature.
With the introduction of modern diagnostic techniques, the
medical community was able to determine that the vast majority of SDB
cases (over 95%) were a result of an anatomical / physical problem,
related directly to constriction of the airway.
Modern techniques, such as
polysomnography give physicians the tools to define and categorize
OSDB and to differentiate the conditions of OSA, UARS and snoring from
neurologically-based disorders such as narcolepsy.
Previously, many patients suffering from the less critical and
more treatable conditions were misdiagnosed with narcolepsy or other
neurologically based conditions, the treatments for which, in many
cases, worsened the apnea conditions.
Treatments, introduced during the
1980’s, designed to alleviate constrictions of the airway fall into
two categories:
- Surgery to remove excess tissue
from the airway, and,
- Devices to open the airway using
air pressure (Continuous Positive Airway Pressure, CPAP).
The surgical treatment,
uvulapalatopharyngeoplasty (“UPPP”), was first described by Dr.
Fujita et al in 1981. At
the same time the first use of CPAP in the treatment of OSA was being
pioneered by Dr. Colin Sullivan of Sydney, Australia.
With the development of laser surgery came the laser-assisted
uvulopalatoplasty (“LAUP”) popularized following a report by Dr.
Y.V. Kamami of the Marie-Louise Clinic, Paris, France.
Throughout this period various types
of oral appliances were introduced.
However, during the 1980’s, physicians generally concurred
that CPAP was the one and only treatment alternative to surgery.
Research projects conducted during
the early 1990’s indicated the efficacy of mandibular advancement
devices (oral appliances or airway dilators) by opening the airway. This resulted in a major review and focus on treatment
alternatives and protocols. The
effects of this review are best illustrated by the 1995 American Sleep
Disorders Association Review titled
“Oral Appliances for the Treatment of Snoring and Obstructive Sleep
Apnea”, and the report “Practice Parameters for the Treatment of Snoring and Obstructive Sleep
Apnea with Oral Appliances”.
The review stated that comparison of the risk and benefit of
oral appliance therapy with the other available treatments suggested
that oral appliances (or airway dilators) presented a useful
alternative to CPAP for patients with all but the most severe cases of
OSA and, especially for those who cannot tolerate CPAP therapy. As well, the review determined that airway dilators were an
effective treatment for those with less severe forms of OSDB,
including snoring and UARS. Since
1995, studies have continued to reinforce oral appliances as first
line treatment for patients with snoring
and mild to moderate sleep apnea.
Medical diagnosis and treatment
protocols traditionally develop from identification of the simple
leading to the more complex. The
simple signs and symptoms being first described, and eventually the
more complex symptomatology being revealed.
The development of diagnostic and treatment protocols for
obstructive sleep disorders has been the reverse of this established
principal in medicine. Complex
diagnostic systems have been established to deal with the overall
problems in OSDB. As these
systems become more adept, it is evident validated screening can
allow the diagnosis to be tailored to the level of severity of
the conditions. The
introduction of ambulatory sleep screening devices, oximetry, and
pharyngometry are examples of this trend.
Together with the relaxation of the
demands for high level diagnostics has come the
realization that the less debilitating and life threatening conditions
of snoring and the milder forms of obstructive sleep apnea may be more
effectively treated with less invasive and complicated treatment
modalities such as oral devices.
We believe that these recent
developments in sleep screening, and the growing medical acceptance of
oral appliance therapy indicate that universal acceptance of oral
appliances as first line treatment for snoring and mild to moderate
sleep apnea will be achieved within the next several years.
This belief is supported by evidence of considerable enthusiasm
within the sleep diagnostic community and primary health care
professionals. It is
further supported by an increasing level of interest in these products
and services by major health care product suppliers and insurers such
as Blue Cross/Blue Shield.
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Treatment Solutions for OSDB
Virtually
all obstructive events occur in the area of the airway that is
surrounded by collapsible, often inadequately supported tissue.
This collapsible airway tissue starts
at the front of the soft palate and extends to the top of the voice
box or larynx. The soft
palate, tongue and side and back walls of the throat may intrude on
the airway individually or in concert with one another, causing the
tissue to vibrate or seal off the airway during normal breathing.
Different therapies attempt to address all or some of these
collapsible airway tissues by their own unique methods.
Parts
of the Airway
The simplest therapies for treating
OSDB include weight loss and behavioral changes such as the avoidance
of alcohol and heavy meals after 8 p.m.
Interventional therapies for more severe cases of OSDB include:
The following table summarizes common
treatments available for the varying levels of severity of OSDB.
|
|
CPAP
/ BiPAP
|
Surgery
|
Airway Dilators
|
Home
/ Herbal Remedies
|
| Intermittent
Snoring |
|
x
|
x
|
x
|
| Persistent
Snoring |
|
x
|
x
|
x
|
| UARS |
x
|
|
x
|
|
| OSA
- mild |
x
|
|
x
|
|
| OSA
- moderate |
x
|
|
x
|
|
| OSA
- severe |
x
|
|
x*
|
|
*Where patient refuses to use CPAP or to complement CPAP performance.
