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Sleep Disordered Breathing (SDB) is a condition that ranges in the devastation it can inflict. In its simplest form, it can present itself as just the annoyance of snoring. Snoring is the oscillation of soft tissue in the back of the throat as a person breathes. Usually this occurs as the air passageway from the mouth and nose to the lungs begins to constrict. This slight constriction causes the air to pass through faster. It is this fast passing air that causes the redundant soft tissue of the oral cavity to ruffle in the breeze, i.e. snoring. If the snoring is associated with a slight drop in oxygen levels, due to the increased effort associated with breathing, and daytime somnolence, being tired during the day; then the combined symptoms are grouped together in a condition called Upper Airway Resistance Syndrome (UARS).
Obstructive Sleep Apnea (OSA) is the condition where the air passageway becomes completely blocked. The tongue falls back and the muscles on the sides of the throat collapse in creating an obstruction of the airway. At this point, the patient is no longer passing any air despite a progressive increase in respiratory effort. The ribs expand and the diaphragm contracts in an effort to breathe but no air is exchanged. In the blood, oxygen levels drop and carbon dioxide levels climb. The brain senses the emergency and sends adrenaline out to the entire body, awakening the patient. This causes a flexing of the muscles and the stereotypical resuscitative gasp often heard. This is the typical description of OSA, snoring with pauses, no breathing at all, followed by a snort.
The severity of obstructive sleep apnea is categorized by how often the obstructions (or partial obstructions) occur. A mild OSA case is on in which the patient obstructs less than 15 times per hour (120 times in 8 hours of sleep). A moderate case is one in which there is less then 30 obstructions per hour (240 events in an 8 hour sleep night). Severe OSA is when there is more then 30 obstruction per hour. The hourly average of the events is called the Respiratory Disturbance Index (RDI). The RDI lets us know exactly how bad the condition is.
Research has shown a direct link to Obstructive Sleep Apnea and increased likelihood of heart attacks, strokes and an increase auto accident occurrence. There are also links between obstructive sleep apnea and metabolic disorders (diabetes). The importance of detecting and treating sleep disordered breathing is reflected in the tens of millions of dollars that the government is granting toward research.
Treatment alternatives include weight loss, positional sleeping, surgery, c-pap (constant positive air pressure) and oral appliance therapy. Weight loss can have a noticeable change in the respiratory disturbance index. A 10 % loss in ones weight will reduce the RDI by 26%. Conversely, a gain of 10% in ones weight will increase the RDI by 32%. Additionally, we all know that weight loss and the maintenance of that weight loss is very difficult. In some cases, a change in the position you sleep (staying off your back) can improve your sleep and there are means by which you can train yourself to sleep in a desired position.
There are several surgical approaches that have been tried to resolve obstructive sleep apnea, some with more success than others. At this point, the only two surgeries I recommend for the resolution of obstructive sleep apnea are the orthagnathic surgery (jaw advancement surgery) and tracheotomy. Both surgeries have been proven to resolve the condition on a long term basis. Both surgeries are, however, rather invasive and would need to be considered only after other treatment alternatives have not worked. I do not consider the other surgical options a primary treatment option due to the mixed result they produce. The treatment option that is prescribed the most is c-pap (constant positive air pressure). With c-pap, ambient room air is pumped through the nose via a mask and inflates the air passageway in an attempt to prevent any obstruction from occurring. While c-pap can be very effective, the limitation of its usefulness is patient compliance. Reports of 50% compliance after 4-6 months are common in studies.
Oral appliance therapy is the treatment of choice in this office. There are two basic types of appliances; mandibular advancement appliances (MAA) and tongue retaining devices (TRD). The mandibular advancement appliances work by holding the jaw in a slightly forward position. This position works by three means: first, it does not let the mandible fall back and obstruct the airway; second, by holding the mandible forward, the appliance indirectly holds the tongue in a forward position not allowing it to fall back and obstruct the airway; and third, the forward position creates a new muscular baseline for the muscles at the side of the neck, not allowing them to collapse the airway. The tongue retainers directly hold the tongue forward through the use of a bulb. Success rates for oral appliance therapy are not as high as that of c-pap; however, when taking compliance into consideration, the overall success rates for both treatment modalities are comparable. There are limitations to every treatment option as well as side effects, which should be reviewed prior to treatment.
Please feel free to contact the office to schedule a sleep consultation.
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