Adherence to CPAP Improves Quality of Life, Oral Appliances are as Effective as CPAP but show Higher Compliance.

A recent study in Sleep and Breathing Journal,"Adherence to CPAP therapy improves quality of life and reduces symptoms among obstructive sleep apnea syndrome patients"showed significant improvement in patients who used CPAP for 6 months.

A more careful look at the study also shows the major problem with CPAP.

This study looked at 50 patients, 41 men and 9 women who were "compliant" with CPAP usage. This means that they wore CPAP an average of 4-5 hours/night. It is well established that 7-7.5 hours/night is ideal CPAP usage. Standardized tests showed subjective improvement in quality of life but a large group of patients still reported "excessive fatigue" (54.5%), and "decreased energy" (55.3%).

The real danger to using CPAP for 4-5 hours a night is the risk of cardiovascular events including heart attack and stroke. Patients with untreated sleep apnea have an enormous and dangerous increased risk of myocardial infarction and cerebral vascular accidents in the early morning hours, usually between 3 and 5 AM. Patient who wear CPAP for only 4-5 hours are no longer utilizing it during the hours of greatest risk!

The danger of unacceptably low CPAP use (4-5 hours /night) was well documented by an article in Sleep (2011 Jan 1;34(1):105-10.) "Reliable calculation of the efficacy of non-surgical and surgical treatment of obstructive sleep apnea revisited."

The article concludes "Using a mean AHI in CPAP therapy is more realistic than using arbitrary compliance rates, which, in fact, hide insufficient reductions in AHI." Clearly stating 4-5 hour compliance is a poor measure of success.

Compare this information to a recent article in Chest (2011 Jun 2) "Efficacy of An Adjustable Oral Appliance and Comparison to Continuous Positive Airway Pressure For the Treatment of Obstructive Sleep Apnea Syndrome." Where they found high effectiveness of Oral Appliances. Oral Appliances are utilized by most patients for the entire night.





Sleep Breath. 2011 Jun 11. [Epub ahead of print]
Adherence to CPAP therapy improves quality of life and reduces symptoms among obstructive sleep apnea syndrome patients.
Avlonitou E, Kapsimalis F, Varouchakis G, Vardavas CI, Behrakis P.
Source

Sleep Laboratory, Henry Dunant Hospital, Athens, Greece.
Abstract
PURPOSE:

The aim of the study was to asses quality of life and symptoms of obstructive sleep apnea syndrome (OSAS) patients after adhering to 6 months of continuous positive airway pressure (CPAP) treatment.
METHODS:

A group of 50 patients (41 men and 9 women) were diagnosed by polysomnography and treated with CPAP therapy for 6 months. Their symptoms and health-related quality of life were assessed by administering a validated and translated version of the sleep apnea quality of life index (SAQLI). Sleepiness was measured using the Epworth Sleepiness Scale (ESS) and through electronic monitoring of CPAP usage per night of sleep.
RESULTS:

Mean CPAP usage was 4.5 ± 0.5 h per night. Comparisons between quality of life indexes before and after CPAP treatment showed an improvement in the total SAQLI score (3.8 ± 0.9 vs. 5.8 ± 0.8 after CPAP, p < 0.01), in daily functioning (4.2 ± 1.4 vs. 6.0 ± 0.9, p < 0.01), social interactions (4.8 ± 1.3 vs.6.3 ± 0.7, p < 0.01), emotional functioning (4.4 ± 1.4 vs. 5.7 ± 1.0, p < 0.01), symptoms (1.6 ± 0.8 vs. 5.8 ± 1.2, p < 0.01), and in the ESS (13.7 ± 6.5 vs. 3.9 ± 3.8, p < 0.01). Regarding the patients' symptoms, improvement was noticed for "sleepiness while watching a spectacle" (96%), "reading" (95%), "carrying on a conversation" (95%), "driving" (92.9%), "restless sleep" (87.8%), and "urinating more than once per night" (84.8%). Smaller improvements were observed for the reported "dry mouth-throat upon awakening" (36.1%),"excessive fatigue" (54.5%), and "decreased energy" (55.3%).
CONCLUSION:

We conclude that OSAS patients who adhere to nighttime CPAP therapy show significant improvement of their quality of life, daytime sleepiness, and other symptoms after 6 months of treatment with CPAP. The article explains mathematically the problems of considering 4-5 hours as "success. "The more severe the AHI, the more percentage of total sleep time (TST) CPAP must be used to significantly reduce the AHI. Patients with moderate OSA reduce the AHI by 33.3% to 48.3% when using CPAP 4 h/ night (AHI 0-5, respectively). The required nightly percentage use rises as one reduces the AHI target to < 5. CPAP must be used 66.67% to 83.33% per night to reduce the AHI below 5 (AHI of 0 while using CPAP). By using these definitions most CPAP usage of 4-5 hours a night is actually only partial treatment leaving the patient at risk.



Sleep. 2011 Jan 1;34(1):105-10.
Reliable calculation of the efficacy of non-surgical and surgical treatment of obstructive sleep apnea revisited.
Ravesloot MJ, de Vries N.
Source

Sint Lucas Andreas Ziekenhuis, Department of Otolaryngology/Head Neck Surgery, Amsterdam, the Netherlands. m.ravesloot@slaz.nl
Abstract
BACKGROUND:

Various treatment methods exist to treat obstructive sleep apnea (OSA); continuous positive airway pressure (CPAP) is considered the gold standard. It is however a clinical reality that the use of CPAP is often cumbersome. CPAP treatment is considered compliant when used ≥ 4 h per night as an average over all nights observed. Surgery, on the other hand, is regarded as successful when the apnea hypopnea index (AHI) drops at least 50% and is reduced below 20/h postoperatively in patients whose preoperative AHI was > 20/h. The effectiveness of CPAP compliance criteria can be questioned, just as the effectiveness of surgical success criteria has often been questioned.
STUDY OBJECTIVES:

The aim of the study was to compare non optimal use of optimal therapy (CPAP) with the continuous effect (100%) of often non optimal therapy (surgery).
DESIGN:

Using mathematical function formulas, the effect on the AHI of various treatment modalities and their respective compliance and success criteria were calculated.
RESULTS:

The more severe the AHI, the more percentage of total sleep time (TST) CPAP must be used to significantly reduce the AHI. Patients with moderate OSA reduce the AHI by 33.3% to 48.3% when using CPAP 4 h/ night (AHI 0-5, respectively). The required nightly percentage use rises as one reduces the AHI target to < 5. CPAP must be used 66.67% to 83.33% per night to reduce the AHI below 5 (AHI of 0 while using CPAP).
CONCLUSION:

Using a mean AHI in CPAP therapy is more realistic than using arbitrary compliance rates, which, in fact, hide insufficient reductions in AHI.

PMID:
21203364
[PubMed - indexed for MEDLINE]
PMCID: PMC3001787
[Available on 2011/7/1]

Chest. 2011 Jun 2. [Epub ahead of print]
Efficacy of An Adjustable Oral Appliance and Comparison to Continuous Positive Airway Pressure For the Treatment of Obstructive Sleep Apnea Syndrome.
Holley AB, Lettieri CJ, Shah AA.
Source

Pulmonary, Critical Care, and Sleep Medicine, Walter Reed Army Medical Center.
Abstract
BACKGROUND:

We sought to establish the efficacy of an adjustable oral appliance (aOA) in the largest patient population studied to date, and provide a comparison to CPAP.
METHODS:

Retrospective analysis of patients prescribed an aOA. Results of overnight, PSG with aOA titration were evaluated and compared to CPAP. Predictors of a successful aOA titration were determined using a multivariate logistic regression model.
RESULTS:

A total of 497 patients were prescribed an aOA during the specified time period. The aOA reduced the mean AHI to 8.4±11.4, and 70.3%, 47.6%, and 41.4% of patients with mild, moderate, and severe disease achieved an AHI<5, respectively. Patients using an aOA decreased their mean Epworth Sleepiness Score (ESS) by 2.71 (95% CI: 2.3-3.2; p<0.001) at follow-up. CPAP improved the AHI by - 3.43 (95% CI: 1.88-4.99; p<0.001) when compared to an aOA, but when adjusted for severity of disease, this difference only reached significance for patients with severe disease (-5.88 (95% CI: -8.95 - -2.82; p<0.001)). However, 70.1% of all patients achieved an AHI < 5using CPAP, compared to 51.6% for the aOA (p<0.001). On multivariate analysis, baseline AHI was a significant predictor of achieving an AHI < 5 on aOA titration, and age showed a trend toward significance.
CONCLUSIONS:

In comparison to past reports, more patients in our study achieved an AHI < 5 using an aOA. The aOA is comparable to CPAP for patients with mild disease, while CPAP is superior for patients with moderate to severe disease. A lower AHI was the only predictor of a successful aOA titration.

Grinding (Bruxism )appliances and Sleep Apnea: Can a grinding appliance make Sleep Apnea Worse? The answer is a definite maybe.

A recent article inthe Journal of Oral Rehabilitation examined the question as to whether a grinding appliance could make sleep apnea aworse. ( of 18 patients showed increases in AHI when their bites were opened without mandibular advancement but only 2 were significantly changed. The article considers whether the vertical opening is responsible for increasing AHI but it is also possible that grinding and/or clenching habits may be protective of the airway and the utilization of these appliances may reduce that activity that is protective against sleep apnea.

It has been previously reported that bruxism appliances can increase sleep apnea in some patients.


J Oral Rehabil. 2011 Apr 5. doi: 10.1111/j.1365-2842.2011.02221.x. [Epub ahead of print]
The effect of raising the bite without mandibular protrusion on obstructive sleep apnoea.
Nikolopoulou M, Naeije M, Aarab G, Hamburger HL, Visscher CM, Lobbezoo F.
Source

Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), Research Institute MOVE, University of Amsterdam and VU University Amsterdam, Amsterdam Department of Clinical Neurophysiology and Center for Sleep-Wake Disorders, Slotervaart Medical Center, Amsterdam, The Netherlands.
Abstract

Summary  It has recently been suggested that wearing a maxillary occlusal splint (i.e. a hard acrylic resin dental appliance that covers the occlusal surfaces of the maxillary dentition and that is being indicated for the treatment of, e.g. temporomandibular pain) may be associated with a risk of aggravating obstructive sleep apnoea (OSA). The present study tested the hypothesis that raising the bite without mandibular protrusion in OSA patients is associated with an increase in the apnoea-hypopnoea index (AHI). Eighteen OSA patients (13 men; 49·5 ± 8·1 years old) received a mandibular advancement device in 0% protrusion of the mandible (0%MAD). The MAD caused a bite rise of 6 mm as measured interincisally. Polysomnographic recordings were obtained at baseline and with the 0%MAD in situ. No statistically significant difference in AHI was noted between the baseline night and the 0%MAD night. However, nine patients had an aggravation in AHI during the night they used the 0%MAD. Taking into account the previously established smallest detectable difference of 12·8 in AHI, the AHI increased in only two of the patients. The outcomes of this study suggest that an increased jaw gape without mandibular protrusion might be associated with a risk of aggravation of OSA for some, but not for all OSA patients. Dental practitioners should be aware of this possible association when treating patients with oral devices that raise the bite.

© 2011 Blackwell Publishing Ltd.

PMID:
21463349
[PubMed - as supplied by publisher]

Inland Empire Sleep Solutions offers alternatives to CPAP for Patients in Washington State and Idaho. Live a Better Life Through Sleep!

Reprinted information from 24/7 Press Release
Inland Empire Sleep Solutions: The Best Sleep Apnea Treatment: CPAP vs. Oral Appliances. A Question of Compliance and Effectiveness. Oral Appliances Win the Compliance Award. Snoring Can Be Cured!

CPAP is considered the gold standard for sleep apnea treatment but poor compliance issues with CPAP often make oral appliances the best sleep apnea treatment. For the morbidly obese patient, CPAP is the best first line treatment.

What is the best sleep apnea treatment? It is not CPAP, according to a recent study that showed 60% of patients abandon CPAP use. At least it is not the best treatment for the 60% of patients who abandoned it. This does not mean CPAP is not the most effective treatment, what it means is no matter how effective a treatment may be, it is a poor treatment if it is not used. Oral appliances are an extremely effective treatment for mild to moderate sleep apnea but less effective for morbidly obese patients and those with severe sleep apnea.

Oral appliances are the "Best Sleep Apnea Treatment" because patients actually use them. Compliance issues have always been the biggest problem with CPAP. Studies have shown most patients quit CPAP completely but even patients who use CPAP average only 4-5 hours/ night 4-5 nights a week. That is not the best treatment but it is better than no treatment. The best site for information on oral appliance therapy and dental sleep medicine is http://www.ihatecpap.com.

Dr Ira L Shapira is a Diplomate of the American Board of Dental Sleep Medicine. He is the president of I HATE CPAP LLC. He is proud to announce a new resource for Washington State and Idaho to help patients with sleep apnea and snoring find solutions. Inland Empire Sleep Solutions http://www.inlandempiresleepsolutions.com/ is bringing the best information on Sleep Apnea Treatment to the Inland Empire region.

Medicare recognized how poor CPAP compliance was and now has minimum usage schedules for CPAP that will save Medicare millions of dollars because such a small percentage of patients actually utilize their machines on a regular basis. Inland Sleep Solutions will feature dental offices where there has been training in Dental Sleep Medicine.

CPAP is the "best treatment" for the 25% of patients who love their CPAP, and use it all night, every night.

Oral appliances may be less effective across a range of all patients at eliminating sleep apnea but they are much more effective at achieving patient compliance. A treatment that is used will always be superior to a treatment that is not used.

Oral appliance success can be greatly improved by titration of appliances in the sleep lab. When an appliance eliminates sleep apnea based on a sleep study it is effectively equivalent to CPAP. The issue of compliance almost always favors oral appliances but objective monitors for oral appliance use are not yet available. They probably will be available in the very near future making oral appliances a leading choice of sleep medicine physicians who care about patients desires.

The best treatment is one that works and is used. For most patients with mild to moderate sleep apnea the best treatment is an oral appliance due to much higher compliance. If compliance is equal and CPAP or appliances are equally effective than both would qualify as the best treatment. The patient can chose their desired treatment. Studies have shown the majority of patients offered a choice prefer a comfortable oral appliance over CPAP.

Some severe sleep apnea patients refuse CPAP, for those patients an oral appliance is superior to "no treatment".

CPAP is almost always the best treatment for the morbidly obese patients but an oral appliance is still better than no treatment if CPAP is refused.

There are patients who are severe and/or morbidly obese and the "best treatment" is actually combination treatment of an oral appliance and CPAP combined. A mask retained by the teeth instead of straps may be considerably more comfortable for many patients and lower pressure from combined use makes CPAP easier to tolerate.

The best treatment may be CPAP but with a custom made nasal mask that is made from an impression of the patients face similar to how dentures are made. Custom masks combined with oral appliances are a new entry in the field coming from airway management.

Cleanliness is of major importance with both CPAP and oral appliance treatments. Dirty masks and hoses can lead to sinus infections, bronchitis and pneumonia while poor oral hygiene with an oral appliance can lead to periodontal disease. Dr Shapira advise all patients to keep their masks and hoses scrupulously clean. It is vital to be just as thorough in cleaning oral appliances and in maintaining oral hygiene care when wearing an oral appliance. They are not well suited for patients who do not regularly brush their teeth.

What is the best CPAP mask for patients who utilize CPAP? Studies have shown that different masks and machines usually do not increase patient compliance but they do increase comfort for patients who actually use CPAP. Other studies have shown that patients' usage of CPAP initially predicts long term compliance with CPAP. Patients who reject CPAP initially rarely embrace CPAP use in the long term. What is the best CPAP mask? A mask the patient actually uses. This will be very patient specific.

What is the best type of CPAP machine? There is standard CPAP machines that come in many styles and shapes. The industry has done a good job of making CPAP machines quieter and smaller. BiPAP machines have lower pressure during expiration that reduces claustrophobic feelings in some patients and often eliminates the sensation of drowning on air. Ramping is a gradual increase in pressure allowing patients to fall asleep prior to pressure increasing. Humidification and heated hoses are also increasing patient comfort. Unfortunately all of these advances have not been shown to increase overall patient compliance.

Servo-ventilation machines are more efficient and effective in treating central sleep apnea, which is a neurological condition where the brain "forgets" to breathe.

The best sleep apnea treatment is always patient specific. The 60% of patients who do not tolerate CPAP will likely find comfortable oral appliances are the best treatment.

A small minority of patients do not tolerate CPAP or oral appliances. The best treatment for these patients may be surgery.

What is the best sleep apnea surgery? The morbidly obese and extremely severe sleep apneics may find that a tracheotomy is the best treatment. Patients breathe through their throat bypassing the pharyngeal blockages. Most patients do not want a trach.

Soft palate surgery is almost never the best sleep apnea treatment. UP3 or Uvulopalatopharyngealplasty is painful and has very high morbidity but more importantly rarely eliminates sleep apnea and patients still require CPAP or oral appliance therapy. Pillars, somnoplasty, LAUP or laser-assisted uvuloplasty are less painful but still ineffective in treating most apnea patients completely.

Maxilo mandibular advancement is extremely effective but is major surgery where the upper jaw (maxilla) is cut loose from the skull and often split in pieces, the lower jaw (mandible) is sectioned into 3 pieces and the hyoid bone is sectioned in pieces and then the patient is wired shut for six weeks. This surgery is often very successful. A geniohyoid surgery is less invasive only splitting the lower jaw in pieces and advancing the chin and tongue. While it is effective in patients with severely recessed lower jaws (weak chin) in most patients it is the "Jay Leno" surgery creating his unique profile.

For severely obese patients with severe sleep apnea bariatric surgery may be the best sleep apnea treatment.

It is also possible to do several tongue reduction surgeries that vary in effectiveness. Dr Shapira suggests that patients attempt CPAP and/or Oral Appliances before considering surgery. Patients with blocked nasal airways frequently improve with partial turbinectomies and correction of deviated septums but while helpful this will usually not eliminate sleep apnea.

Dr Shapira reminds patients of the famous quote: "There is no disease or disorder known to man that can't be made worse by sticking a knife in it." This does not mean to avoid surgery cautions Dr Shapira but rather to approach any surgery with caution and consider the possible problems associated with surgery.

Information on the dangers of sleep apnea, sleep apnea treatment and comfortable oral appliances is available at http://www.ihatecpap.com.

We are currently looking for Dentists with training in Dental sleep Medicine in the following communities. Dentist wishing to become part of the program can contact Meg at meg@hamiltonsaunderson.com

Washington State
Clarkston
Colfax
Ellensburg
Ephrata
Kennewick
Moses Lake
Pasco
Pullman
Richland
Ritzville
Spokane
Spokane Valley
Walla Walla
Washougal
Wenatchee
Yakima
Idaho
Coeur d'Alene
Lewiston
Moscow
Priest Lake