A reader writes:
I am respiratory therapist and set people up on CPAPs all the time. It truly is amazing how many people are diagnosed with obstructive sleep apnea and find some benefit from CPAP therapy. The main problem that I encounter is that during their sleep study they are told that they will sleep much better as soon as they get their CPAP. I tell all of my patients that it take a minimum of 6-8 weeks before they will truly be comfortable with the CPAP and sleep with it on all night. Some never get used to it, and for them, surgery is an option. But as Americans, we want relief right away.
I'm an otolaryngologist and head/neck surgeon, and I just read the post "The Dish At Ten: The View From Your CPAP" and there were some potentially misleading statements.
The first reader stated that his/her sleep study found 150 disturbances per hour (the correct term for that is respiratory disturbance index, or RDI. The apnea-hypopnea index, or AHI is actually used more often to assess the severity of sleep apnea). The reader found relief from a dental appliance (that's the term for intra-oral devices that put gentle traction on the lower jaw or the tongue). I find it hard to believe that someone with an RDI of 150 could be treated with a dental appliance alone; the sleep apnea is just too severe. It would be important to get a sleep study with the dental appliance in place to see how much it actually helped.
The second reader described a common operation called septoplasty, usually done because the thin bone and cartilage separating the right and left nasal passages are crooked. He/she was incorrect to say that we "don't use general anesthesia because it's too dangerous". In fact most septoplasties are done under general anesthesia (I do all my septoplasties under general) unless the patient is really sick and cannot tolerate it.
It is also incorrect to say that nothing can be done about the soft palate. In fact, most surgery for sleep apnea involves some sort of surgery on the palate, and septoplasty alone is usually not that effective. The back of the tongue is also a common site for obstruction in sleep apnea, and there are some techniques used there as well.
The big problem with surgery for sleep apnea is that it is difficult to determine who will improve. If someone has huge tonsils, we can usually be confident that they will do better if we do a tonsillectomy, but for most others it still is a challenge to predict the outcome. CPAP, when tolerated, is almost 100% effective. Weight loss helps too.
My Dad's sleep apnea almost killed him. Over the last few years he had put on a significant amount of weight. In the Fall of 2009 he literally started to swell up. I finally convinced him to go to the hospital on Valentines Day 2010.
He was suffering from congestive heart failure and pneumonia. Within a day of being in the hospital he went into cardiac arrest and was put on a ventilator. Two months later - two bouts of respiratory arrest as they weaned him off the ventilator and a kidney failure chaser - he was out of the hospital. He was discharged 100 lbs lighter and with a CPAP machine.
The entire episode was brought on by 30 years of undiagnosed sleep apnea. Now he's the picture of health thanks to his CPAP.
I've been puzzled by the absence of "conservatism" in the discussion of remedies for sleep apnea. The more conservative remedies would be weight loss, dietary change and exercise, wouldn't you say?
Ok, I'm thinking sleep apnea is another self inflicted wound of fat America. If readers differ, please send pictures of skinny apnea patients wearing masks. I know the fatter I get, the more I snore - partners alert me. Just like every other damn part of our body, as we gain weight it sticks and we expand. In the case of the throat, it narrows the airway and creates loose flesh. I'm no doctor, so correct me if the painfully obvious ain't so.
I am tired of wasting medical dollars treating self-inflicted health conditions. Lung cancer from smoking. Heart disease from smoking and eating. Diabetes from a sugar diet. We all have to take financial responsibility for our actions and be held accountable by our health insurance. I don't want to contribute to smokers lung cancer care. I have a few habits I need to contribute a bit extra for too.
There is a connection between some sleep apnea and being overweight. But it's by no means the only cause. It can be caused by too muscular a neck, rather than too fat a one, as well as large tonsils, obstructed sinuses, or more than usual soft tissue in the throat and soft palate. The risk increases a lot if you have diabetes. And I think it's just hard to take a position that all behavioral-related illnesses should not be covered by insurance and others should be - because the judgment is often hard to make and sick people are still sick. Heart disease is by far one of the biggest health problems, for example, and is obviously connected in many cases to lifestyle - but may also be genetic or caused by other factors. But we cannot determine who is helped based on moral judgments. Ditto diabetes, which can be caused by many things, including a sugary diet.
The cost of treating sleep apnea, of course, is small compared with most diseases.
(Photo by Flickrite baslow)