Treatment of Obstructive Sleep Apnea PART 2

Nitin K Sethi, MD, MBBS, FAAN

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In this blog post, I shall discuss various treatment options for obstructive sleep apnea (OSA). Good news is that nowadays there are a number of very effective treatment options available for OSA. Let us discuss these one by one:

Positional Sleepers: This is the simplest treatment available for snoring and at times OSA. As the name suggests, a positional sleeper helps a person sleep on his/her side as against the back. Since snoring and OSA is frequently worse on the back, sleeping on the side is helpful (the tongue falls on the side and does not obstruct the flow of air). There are many different positional sleepers available on the market. Many of my patients design their own positional sleeper by using pillows or tennis balls sewn into their T shirt/PJs.

COMMERICALLY AVAILABLE POSITIONAL SLEEPER: THIS ONE IS CALLED ZZOMA (Source: sleep education blog) no copyright infringement is intended and the image has been included for purely educational purposes.

Mandibular Advancement Device (MAD): MAD is like a mouth guard. The patient puts the MAD into his/her mouth at night before sleeping. As the name suggests the device “helps to advance the mandible/lower jaw”. The tongue is attached to the lower jaw. So the device by pulling the jaw and tongue forward helps to make more room in the back of the throat for air to flow in and out more easily. There are MADs which are available over the counter. These devices while cheaper as compared to custom made device (made by a dentist) have one problem. They usually are not well fitting. As a result they are not comfortable and are not effective. The best MAD is one which is made by a dentist. The dentist measures the patient’s teeth and makes a device which fits well, is comfortable and effective. Most dentists make MADs so please talk to your dentist about this. There are dentists who are certified by the American Academy of Dental Sleep Medicine. In my opinion these dentists are the best in MADs and I frequently refer my patients to one.

Mandibular Advancement Device (Source: no copyright infringement is intended. Image has been included for purely educational purpose.

Nasal Continuous Positive Airway Pressure (CPAP): Nasal CPAP is the most effective treatment for OSA around the world. CPAP has no side effects-it is a simple machine which helps to “force” the air into the narrowed airway. The patient sleeps with a mask over the nose (nasal mask) or over the nose and mouth (full face mask). The mask is attached to the CPAP machine with the help of a long hose. In the night when the patient is about to sleep, he/she puts the mask on and turns on the machine. The machine sucks in room air, filters it (the machine can be fitted with HEPA filters), humidifies it (the machine has a small humidifier and the patient can change the setting to his/her comfort level) and then blows the air with force in to the patient’s nose. The machine does this throughout the night. In the morning when the patient gets up, the machine is turned off. Indeed a simple and effective solution to OSA. While nasal CPAP has no side-effects, there is one problem. That problem is that majority of patients initially find the CPAP uncomfortable to use. In my experience this is very common. I have patients who come back and tell me they hate the machine, they cannot sleep with the machine and that they will not use it. There are others who come back and say they love the machine and it has changed their lives. So, I tell my patients not to get dejected and upset when initially they are struggling with CPAP use. Finding the most comfortable mask, adjusting the CPAP pressure and humidifier settings wells and most patients over time begin to get used to sleeping with the machine and start to like it. The correct CPAP pressure (the pressure needed to make the OSA go away) is calculated in the Sleep Lab (patient sleeps in the Sleep Lab and while asleep the correct CPAP pressure is determined by the Sleep Medicine technician). There are numerous CPAP machines (different models made by different vendors) and many different types of masks. The trick in my opinion is to find the right mask for the patient and the correct CPAP settings. Once that is done, most patients like CPAP. I usually instruct my patients to try to use the CPAP as much as possible (goal is to get the patient to use the CPAP every night and throughout the night as many patients go to sleep with the CPAP on but then take it off during the night).

Source: CPAP. Wikipedia (no copyright infringement is intended. Image has been included for purely educational purpose).

Do you snore? It could be Sleep Apnea PART I

Many people snore. Do all snorers (people who snore) also suffer from sleep apnea? Is snoring harmful to health? Is sleep apnea harmful to health? What are the signs and symptoms of someone who has sleep apnea? How is sleep apnea diagnosed and treated? These and other questions shall be discussed in this blog post and the one that follows.

SNORING: simply defined snoring is noisy breathing which occurs when a person is sleeping. It is a very common condition. Many people snore when they fall asleep on their backs (supine position). Some snore softly, others snore loudly disturbing the sleep of their bed partner. Hence snoring can be of mild, moderate and severe intensity. A common cause of snoring is obstruction to the flow of air in the nose. Deviated nasal septum with or without turbinate hypertrophy is a common cause of snoring. Snoring at times can also occur when there is obstruction to airflow in the upper part of the throat. In these cases, the soft palate vibrates giving rise to the snoring sound. When snoring occurs on its own it is referred to as simple snoring.

Simple snoring is not considered to be harmful to the health of the snorer. Hence simple snoring does not need to be treated in all cases. Simple snoring though disturbs the sleep of the bed partner. It may be so loud that the bedpartner is forced to sleep in a separate room! At times patients snore so loudly that their snoring wakes them up! In these cases snoring may warrant treatment.

TREATMENT FOR SIMPLE SNORING: There are many treatment options for simple snoring. These include simple interventions such as weight loss (we are more likely to snore as we put on weight so weight loss frequently alleviates snoring), sleeping on the side (lateral position) rather than on the back (supine position) also helps. Snoring occurs most commonly when one sleeps on his/her back. Sleeping on the side with the head elevated may at times alleviate snoring completely. This can be accomplished by a number of ways. Use of POSITIONAL SLEEPERS is recommended in these patients. There are a number of positional sleepers available on the market. Many of these are over the counter and do not require a doctor’s prescription. These BUMPER BELTS all attempt to treat snoring by “forcing” the snorer to sleep on his/her side than on the back. One can also make one’s own positional sleeper with the help of pillows or a ball tied around the upper back. There are surgical treatments for simple snoring. A commonly performed surgery (done by ENT surgeons) is SEPTOPLASTY AND TURBINATE REDUCTION SURGERY. In this surgery the ENT surgeon corrects the deviated nasal septum and reduces the size of the enlarged nasal turbinates.

SNORING ALONG WITH SLEEP APNEA: When someone stops breathing while asleep it is referred to as sleep apnea (SA). Sleep apnea can either be obstructive (referred to as obstructive sleep apnea or OSA) or central (referred to as central sleep apnea or CSA). OSA is far more common than CSA and as the name suggests it is due to OBSTRUCTION to airflow. The obstruction occurs due to narrowing of the airway at the level of the oro-pharynx. Behind the tongue lies the airway. It is hollow tube which goes down, becomes the trachea and takes air to the lungs. In people who are overweight, the upper part of this airways gets obstructed by the tongue, “excess” soft tissue and enlarged tonsils. When these overweight people lie down on their back to sleep, the tongue falls back narrowing and obstructing airflow through the upper airway. The excess soft tissue around the neck also contributes to upper airway narrowing. The airway then collapses leading to OSA. It is important to remember that people who have OSA frequently have no complaints. They are NOT bothered by their snoring or by the episodes of sleep apnea. Their complaint (if any) is that the next day they wake feeling tired (not rested). These people feel sleepy during the day (this is referred to as EXCESSIVE DAYTIME SLEEPINESS) and may fall asleep (or struggle to stay awake) during meetings and while in class.

By Credits to Habib M’henni / Wikimedia Commons – Own work based on:, Public Domain,

Many people thus do not realize they suffer from sleep apnea. They only seek medical attention when their bedpartner is bothered by their snoring or complains about their excessive daytime sleepiness.

As compared to snoring, OSA is harmful to the patient’s health. Nowadays OSA is considered to be a risk factor for hypertension (elevated blood pressure), diabetes (elevated blood sugar) and there are studies that indicate that untreated OSA increases the risk for heart disease and strokes.

While OSA is common in people who are over weight, have a thick (increased fat and soft tissue) neck and enlarged tonsils/adenoids, it can also occur in people who have normal weight and body mass index (BMI). In these people the cause of OSA is different (anatomically they may be predisposed to OSA due to the structure of their face/jaw and upper airway which predisposes to airway collapse while asleep).

Nitin K Sethi, MD, MBBS, FAAN

Sleep apnea syndrome: how to identify it and what to do?

Sleep apnea syndrome or SAS is a relatively common sleep disorder. As the name suggests patients who have SAS have episodes of apnea during sleep (meaning they have episodes where in they stop breathing as they sleep). Usually patients who have sleep apnea are obese (overweight), have a large neckand snore during sleep. It is usually their sleeping partners who notice that the patient stops breathing during sleep. The patients themselves may not be aware of the fact that they stop breathing at night. They however do complain of feeling sleepy during the day (we refer to this as excessive daytime sleepiness or EDS) and of feeling tired and fatigued. Patients with SAS may frequently fall asleep while watching TV, sitting by themselves and reading or at times even while driving.

SAS has in the recent past gained more attention from the medical community. Studies have shown that patients who have SAS especially that which remains untreated have increased incidence of elevated blood pressure, coronary artery disease and even strokes. As these patients are overweight, this too adds to the risks of both CAD and strokes.

SAS can be of two types. Obstructive sleep apnea (OSA) and central sleep apnea (CSA). The difference between them is quite technical but clinically they both present in the same way.

So who all should be evaluated for SAS. A person who is overweight, has a thick short neck, who snores loudly at night and complains of feeling sleepy during the day should be evaluated for SAS. SAS can occur in children too but here the causes are slightly different. One important cause which needs to be ruled out in a child is enlarged tonsils or adenoids (enlarged tonsils and adenoids obstruct and narrow the air passages).  Some people may also have an enlarged tongue or their facial structure is such that the structures inside their mouth are all crowded. These patients too are predisposed to SAS.

Diagnosis of SAS: so how is the diagnosis of SAS made? Well a good clinical history and examination shall suggest the diagnosis to the doctor. To confirm and grade the degree of SAS we ask for what is called a sleep study. You come into the lab for an overnight sleep study. I call it a lab but it is more like a bedroom in your own house. We place electrodes on your head to look at your brain waves, electrodes to measure the air as it moves in and out of your nose, a device to detect when you snore, a device to detect if you have limb movements at night etc.  Then you are allowed to fall asleep and it is while you are asleep that we detect if you indeed do have apneic spells at night and we grade how severe your apnea is (there are standarized grading scales available for this purpose).

A report is generated and your doctor then tells you what kind of SAS you have: is it OSA or is it CSA and how severe it is.


Treatment of SAS: so you have SAS. What to do about it? Depending upon the severity of the SAS, the treatment varies. If it is mild, all your doctor may ask you to do is to try to lose weight and change the position in which you sleep (SAS is worse if you sleep on your back, as the tongue falls back obstructing the air passages, on the other hand if you sleep on your side, the tongue falls to one side and your air passage remains open). We actually tie a small tennis ball on the patients back so that he does not roll back onto his back. If the SAS is moderate to severe, your doctor may recommend what is called a CPAP machine. CPAP stands for continuous positive airway pressure. This is a small device which is placed besides the patient’s bed at night and through a tight fitting mask it blows air into the patients mouth and nose. This keeps the air passages patent preventing them from collapse and thus abolishes SAS. It takes time to get used to a CPAP machine as sometimes the mask is too tight and patients cannot sleep as the machine keeps making a little noise and blowing air into them. That said and done a CPAP machine is the treatment of choice for moderate to severe SAS. What pressure to set the machine at, is determined during the sleep study by the technician. We use the minimal pressure which would abolish all the apneic events.

Some surgical options are also available but these need to be discussed with your doctor. There is a specific subgroup of patients who gain benefit from surgery.


Nitin Sethi, MD