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With Sleep Apnea, Find a Treatment and Doctor Willing to Fine Tune It

NEW YORK (Nov 1, 2013)

Obstructive sleep apnea, a condition in which breathing repeatedly stops during sleep because of repeated closure of the upper airway, is increasingly prevalent in the United States. Estimates suggest that one in every 15 Americans suffer from the affliction, with many unaware they have it. This is problematic as untreated sleep apnea can be life-threatening.

Amy Atkeson, M.D., a pulmonary and sleep specialist at the Cardiopulmonary Sleep and Ventilatory Disorders Center at NYP, spends her time researching, diagnosing and treating patients with sleep apnea. It is easy to understand why sleep apnea is underdiagnosed, she noted. "If a patient is not experiencing a restful night's sleep, there are a lot of other factors that he/she might blame besides breathing. It is important to receive a proper evaluation with a sleep specialist." An overnight sleep study can be performed, if indicated, to determine whether sleep apnea is present.

Dr. Atkeson attributes the increase in sleep apnea to the increase in obesity. "Until we get the obesity epidemic under control, sleep apnea is here to stay. Being overweight or obese is the No. 1 risk factor for sleep apnea," she said. Dr. Atkeson encourages nearly all of her patients to try to lose weight.

There are several types of sleep apnea, but the most common type is obstructive sleep apnea. A frequent sign is loud snoring during slumber. Upon waking, a patient may describe his/her sleep as light or unrefreshing. Symptoms may also include increased sleepiness, irritability, problems with memory and concentration, as well as dry mouth and morning headaches. Obstructive sleep apnea is strongly associated with increased lifetime risk for high blood pressure, and may also put sufferers at increased risk for cardiovascular and cerebrovascular events such as a heart attack, irregular heart rhythms and stroke.

The mainstay of treatment for patients with obstructive sleep apnea is continuous positive airway pressure (CPAP) therapy. It consists of a small machine that delivers pressurized air through a mask that is placed over the patient's nose and/or mouth (depending on the mask) during sleep. Air pressure in the CPAP machine is greater than the surrounding air and helps to keep the upper airway passages open, treating the obstructive sleep apnea and also resolving snoring. Invented in the late 1970's, CPAP therapy remains the most tested and effective method to treat sleep apnea. However, some patients find the device cumbersome or uncomfortable. Common problems include air leak from the mask, claustrophobia and a dry mouth or nose.

"I have yet to meet someone who is excited about wearing a CPAP mask," said Dr. Atkeson. "About 50% to 60% of patients are compliant with CPAP over the long-term. Someone who is very symptomatic is more likely to stick with it, but someone without a lot of daytime symptoms is less likely to be compliant," she explained. "Some of our younger patients find it socially embarrassing," she added.

Dr. Atkeson and her colleagues strive to develop solutions to make the device more comfortable for patients and ultimately increase compliance. They employ various methods to tweak CPAP therapy including adjusting the fit of the mask, checking patient positioning and encouraging weight loss.

"Finding the right mask often makes all the difference. With a correctly fitting mask, we can often improve a person's subjective experience such that that patient will continue therapy," she said. Humidification of the pressurized air can help, and today's CPAP machines permit lower levels of CPAP to be delivered initially, so that patients can fall asleep at a lower, more comfortable pressure setting and then ramp up to the therapeutic level.

Other options for mild to moderate sleep apnea are oral devices such as the mandibular advancement device (MAD). A MAD is custom-fitted by a dentist or orthodontist and worn in the mouth at night (similar to a retainer). "It works by moving the lower jaw forward, creating more space in the back of the airway. MADs work well for patients with small or recessed lower jaws and patients with a strong positional component to their obstructive sleep apnea (worse supine). A large randomized trial showed that MADs compare fairly well with CPAP and are mildly better tolerated, but they are not as effective as reducing breathing events," said Dr. Atkeson.

Doctors at NYP also check body positioning during slumber. "For many patients, obstructive sleep apnea is worse on the back and better, or even resolved, on the sides. Sleeping exclusively on one's side is a low-tech, simple way to treat OSA for some patients," she said.

Dr. Atkeson stressed that the best way to decrease the obstructive sleep apnea disease burden is to fight the obesity epidemic. "Weight reduction is the best thing most people can do to improve sleep apnea," she said.

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