Featured patient of the week #107 is a classic example of the difficulty that many patients have in finding out options for the management of their sleep apnea.  This patients is a physician who had been diagnosed with sleep apnea quite a few years ago and who had been prescribed CPAP therapy.  I have been very clear throughout this website that CPAP is a godsend for untold hundreds of thousands of sleep apnea patients.  However, there are huge numbers of patients that absolutely cannot tolerate CPAP.  

There is a belief in much of the medical community that if you merely educate the patient about the need for therapy and try enough different CPAP masks, that the patient will soon tolerate CPAP.  This physician needed no education about the need for his therapy.  As a doctor, he well knew the danger of sleep apnea coupled with his heart condition.  He tried every possible CPAP combination before abandoning that treatment.  Luckily he heard my interview on “Sound Medicine“, the National Public Radio program sponsored by the Indiana University School of Medicine and quickly scheduled an appointment.  Patients do best in dealing with any medical condition when they have information about the options for the management of their disease!

The photo at right shows Patient #107′s dental condition showing the deep overbite so common in many patients with sleep apnea.  This dental condition represents less room for the tongue making it easier for the tongue to block the airway during sleep with the muscles in the base of the tongue are relaxed.

Sleep apnea puts a great deal of stress on the cardiovascular system, making this disorder particularly important to manage with Patient # 107.  Shown below is a chart documenting the tremendous improvement is maintaining appropriate oxygen levels throughout the night that were obtained with oral appliance therapy use in this patient.  Before using oral appliance therapy, this patient 68 times during the night when his oxygen levels dropped between 4 and 9% and 24 times when O2 levels dropped between 10 and 20%, a significant stress on the heart!  Using his oral appliance no significant oxygen desaturations were noted.

Featured patient is a wonderful example of blending therapies that, by themselves, would not provide optimum results.  This patient is also an example that initial diagnostic tests may not give the correct information.

This patient came to see us for help with his “horrible snoring”.  He frequently traveled with friends and no one ever wanted to share a room with him.  He had recently had a sleep study at a local hospital and received the following diagnosis, “The patient was a very loud snorer……..Mildly abnormal sleep apnea with no desaturation and preservation of REM sleep.  The patient does not require treatment.”

Surprisingly, this diagnosis was given despite the patient’s uncontrolled blood pressure of 154/95 while being on blood pressure medication  (those people with drug resistant hypertension have an 80% chance of having obstructive sleep apnea).  This patient had worked with his primary care physician for some time in an unsuccessful attempt to get his blood pressure under control.  In addition to his concern about his uncontrolled blood pressure, this patient reported a significant amount of daytime sleepiness with an Epworth Sleepiness score of 16.

Given the significant daytime sleepiness as well as the presence of drug resistant hypertension, a Watch PAT home sleep study was ordered.  The sleep data gathered from this report suggested the presence of severe sleep apnea.  Even though the diagnosis from the hospital sleep study indicated that no treatment was needed, the wording “mildly abnormal sleep apnea” provided the opening for this patient’s medical insurance company to approve treatment.  Oral appliance therapy was chosen by this patient because he regarded himself as being “severely claustrophobic” and knew he could not tolerate a CPAP mask.

Oral appliance therapy provided patient #106 immediate relief from much of his daytime sleepiness, taking Epworth score from 16 to a more normal 9. However, over the first several months of treatment there was no change in his drug resistant hypertension.  A follow-up home study to assess treatment effectiveness indicated that he was obtaining a significant increase of REM sleep, indicating a much more restful sleep.  In addition, the number of hourly respiratory events had been dramatically reduced but not eliminated.  

This situation shows clearly the disadvantage of oral appliance therapy.  CPAP therapy when used full time would almost always completely eliminate any residual respiratory events while oral appliance will not always completely normalize sleep breathing as in this case.  However, for those patients who will not or cannot wear CPAP full time, oral appliance therapy can usually accomplish identical or better results.  For this patient, a comparison between weekly unmanaged respiratory events with oral appliance therapy and for average CPAP compliance is shown in the chart below.

This chart shows clearly that oral appliance therapy used in this patient exceeds the benefits that he would derive from CPAP used with average compliance.

However, even though patient #106 was doing better with oral appliance therapy than CPAP used with average compliance, it was reasoned that the remaining unmanaged respiratory events were contributing to his still uncontrolled hypertension.  Patient #106 was still unwilling to use CPAP due to his claustrophobia but was willing to consider surgery.  Patient #106 was sent to a local ears, nose and throat physician for a consultation.  When presented with the surgical options this patient decided against surgery.

This decision to avoid surgery allowed us to try again to get patient #106 to consider CPAP.  It was decided to deal with his feelings of claustrophobia by combining the oral appliance with a CPAP nasal interface as shown below:

In this photo, the upper part of the oral appliance is shown joined to the CPAP nasal pillow.  When worn with the lower part of the oral appliance, the patient receives the benefits of BOTH therapies at the same time.  The oral appliance moves the lower jaw and tongue base forward which helps lower CPAP air pressure necessary to eliminate the remaining airway obstructions.  In addition, since the CPAP nasal pillow is joined firmly to the oral appliance there is no need for head straps and the patient is free to turn from side to side during sleep without the mask being pulled away from the face causing sleep disturbing air leaks.

Patient #106 was seen for follow-up a month after joining the oral appliance and CPAP together.  Happily, his previously uncontrolled hypertension was now completely under control and his primary care physician was in the process of reducing the medication.  In addition the CPAP compliance card was downloaded and it was seen that patient #106 was easily able to wear his hybrid PAP full time.

Patient #105 demonstrates the enhanced level of health that results when a patient has their sleep breathing more normalized.  Our initial home sleep monitoring showed him with an oxygen desaturation index of 23, a significant amount of sleep apnea.  Initially, his daytime sleepiness was very significant with an Epworth Sleepiness Scale number at 15.  This level of daytime sleepiness is significant enough to put him and others at severe risk if he were to drive a motor vehicle a significant distance.  In addition, his fatigue level as measured by the Fatigue Severity Scale was 40, indicating a high level of fatigue. 

Six months later, his sleep breathing was almost normalized with his oxygen desaturation index at 7, his Epworth score was a normal 4 and his daytime fatigue score a greatly improved 25.  During this time he had lost 21 pounds with his neck size has decreasing from 17″ to 16.25″.  

Patient #105 is an example of someone who was too fatigued to exercise and, yet, was unable to tolerate CPAP therapy.  However, he was easily able to use an oral appliance to help manage his problem.  Once he started using his oral appliance, he immediately started feeling better.  This renewed feeling of alertness and energy inspired him to start light exercise.  With the light exercise came the weight loss.  With the weight loss, came the reduction in neck size.  With less fatty tissue in the neck, more room was available for the upper airway.  

It is impossible to diminish the importance of a good night’s sleep!

Featured patient #104 came with her husband to our office for a consultation regarding her snoring which was interfering with her husband’s sleep. She had been to see an ENT physician who had referred her to the hospital’s sleep lab to rule out sleep apnea.  The result of the sleep study indicated “loud snoring but otherwise unremarkable polysomnography”.  In other words, this was medical terminology for “Other than the fact that you snore loudly, you don’t have a problem.” In further consultation with the ENT, she had ruled out a surgical approach to snoring relief.

At the initial consultation, patient #104 denied any daytime sleepiness or fatigue.  However, when asked how she felt when she awakened in the morning, she replied, “Waking up is hell.”  Her husband indicated that once she had her shower, she was fine for the rest of the day, but that he often had to go the bedroom several times to get her out of bed.

Since it had been several years since she had her sleep study, we did a home sleep study to verify that she did not have obstructive sleep apnea.  The result of the home sleep test agreed with the hospital test, but indicated a significant amount of upper airway resistance which is often overlooked by hospital sleep evaluations.

An oral appliance was fabricated for patient #104 and her immediate response at our follow up appointment was “Waking up is wonderful”  I no longer hit the snooze alarm 3-4 times before getting up.”  Follow up home sleep evaluation revealed that her pulse rate during sleep dropped 7 beats per minute with her oral appliance in place indicating a much more restful sleep.  In addition the Watch PAT home sleep monitor indicated a dramatic increase in REM sleep from a sub-normal 10% to 30%.