New York Times article

DR. ELIZABETH WALTON, a 43-year-old internist in Atlanta and the mother of twin 4-year-old boys, has a common, if sometimes embarrassing, health problem. She snores — loudly. And she has tried to fix it with a variety of things, including a machine that blows air down her throat and an oral appliance that looks something like a mouthguard worn by a hockey player.

The appliance works, and Dr. Walton is finally sleeping more easily. (So is her partner.) And because she was told she had obstructivesleep apnea, a more serious disorder than simple snoring, her treatments have been mostly covered by insurance.

Still, she estimates she has spent hundreds of dollars in deductibles, co-payments and fees.

Dr. Walton would have preferred not to go through so much expensive trial and error: “Unfortunately, it’s the nature of this condition.”

Almost half of the adult population snores at least occasionally. Snoring occurs when air flows past relaxed tissues in the throat, causing them to vibrate. Nasal congestion can also contribute to the racket.

“We laugh and joke about snoring,” said Dr. Nancy A. Collop, president elect of the American Academy of Sleep Medicine, “but it can be pretty annoying and disruptive to couples.”

What’s more, while ordinary snoring in itself does not present health problems, it may be a sign of a sleep apnea, as it was in Dr. Walton’s case. Patients suffering from sleep apnea have airways that are so obstructed they stop or nearly stop breathing during sleep.

The lack of oxygen wakens them, usually with a gasp, frequently during the night. “All people with sleep apnea snore,” said Dr. Collop, “but not all people who snore have sleep apnea.”

If you find you suffer from plain old snoring and not sleep apnea, do not expect insurance to cover your treatments. How far you decide to go will depend on a combination of what you and your spouse are comfortable with, what works for you and what you can afford.

Here are a few ways to determine which treatment is right for you or the loud sleeper in your family:

THE GIMMICKS Search for snoring remedies on the Web and you will find dozens of products, including special pillows, mouth and nose devices, special throat exercises and even advice on learning to play the didgeridoo, a wind instrument, to strengthen throat muscles and tissues. By and large, these products are marketed without much evidence of results.

“For the most part, you can save your money,” said Dr. Collop. Instead, she and other sleep experts recommend that most patients start with lifestyle changes that may reduce or eliminate snoring. All are free or low-cost.

Lose weight. Extra weight can restrict throat tissue and cause snoring, so losing weight is often advised for overweight snorers.

Sleep on your side. When you lie on your back, the base of your tongue and soft palate fall to the back wall of your throat, often causing snoring.

Avoid alcohol before bed. Alcohol or sedatives can relax throat muscles and make snoring worse. Avoiding alcohol three or four hours before going to sleep can help, said Dr. Collop.

Clear nasal passages. This is relevant only for people whose snoring starts in their noses. Take a hot shower before bed, or use a saline solution to help clear nasal passages. Check for allergens and dust mites in your bedroom, especially if you are congested only at night. Over-the-counter nasal strips that you put on the outside of your nose before bed may also help. They cost $10 to $12 for a pack of 30.

If none of this eases your snoring, you will need to see a doctor to be evaluated for sleep apnea. About 50 percent of people who snore loudly have the condition. Other symptoms include daytime sleepiness and extensive fatigue.

A SLEEP STUDY To find out if you have sleep apnea, you will most likely need to spend the night in a sleep clinic, where specialists will track your blood oxygen levels, breathing and other movements to see if you are waking frequently at night.

These tests are often covered by insurance if your doctor suspects sleep apnea. They can cost from $1,500 to $3,000, depending on where you live and how extensive your study is.

If you do not have insurance coverage or you cannot afford the co-pay, ask your doctor about performing some of the tests at home with special equipment. If you must go to a sleep lab without coverage, ask for a price similar to what an insurer would pay, not what you would be billed as a private patient.

THE MASK One of the most effective treatments for sleep apnea, continuous positive airway pressure, or CPAP, pronounced SEE-pap, also eliminates garden-variety snoring. But since it is a pressurized mask that forces cold air to the lungs, many patients find it uncomfortable or annoying and end up abandoning the treatment. With a price tag ranging from $1,500 to $2,500 for a CPAP machine, that can be an expensive experiment, especially for uninsured patients.

If you use a CPAP machine, do not give it up without talking to your doctor. He or she may be able to make the device more comfortable by adding a heated humidifier. There are also some newer, more advanced versions that apply less pressure and may be more comfortable.

ORAL APPLIANCES These are form-fitting mouthguards that usually move your lower jaw forward to increase space around your airways. One of these devices finally worked for Dr. Walton.

A dentist who specializes in sleep medicine fits an appliance to your mouth, usually for $1,500 to $3,000. That price should include all follow-up visits and any adjustments that need to be made, said Dr. Sheri Katz, president of the American Academy of Dental Sleep Medicine.

Studies show that custom-fit appliances ease mild to moderate sleep apnea in about 75 percent of patients and snoring in 80 to 90 percent of patients who use them regularly, said Dr. Katz. Dental insurance rarely covers the devices, but medical insurance often will if they are used to treat sleep apnea.

THE LAST RESORT Removal of excess tissue in the throat and nose, whether it is through traditional surgery or newer methods, is a fairly drastic and expensive step. Some procedures can be painful and cause serious side effects.

In a procedure called uvulopalatopharyngoplasty, a surgeon trims and tightens excess tissue in the airway while you are under general anesthetic.

In an outpatient procedure called laser-assisted uvulopalatoplasty, a laser is used to remove your uvula and shorten your soft palate. This procedure has not been proven to improve sleep apnea, but it is used to get snoring under control.

Two newer procedures are available. Somnoplasty relies on radio frequency to remove some of the soft palate. This is also done on an outpatient basis and is generally considered less painful than other snoring surgery. The Pillar procedure involves implanting polyester fibers in the soft palate to stiffen the tissue and decrease vibrations. This is usually done in a doctor’s office under localanesthesia and is less invasive than other surgical treatments.

More data is needed on the long-term effectiveness of the two newer procedures. And like the other treatments discussed, only those surgeries prescribed to help you with a diagnosed case of obstructive sleep apnea will be covered by insurance.

FAQ about Sleep Apnea and various treatment options

Dr. Nancy A. Collop is an associate professor of medicine atJohns Hopkins University and a former president of the American Board of Sleep Medicine.

Q: How long does it usually take a person with sleep apnea to seek medical treatment?

A: Anecdotally, I think it’s a year or two before a patient contacts his doctor. If you snore, suffer from daytime fatigue and have hypertension, it’s certainly worth querying your family physician about the possibility of sleep apnea. Obesity is a risk factor, too, although sleep apnea can occur in people of ideal weight. As the person experiences more sleep deprivation, other symptoms become noticeable, such as weight gain.

Q: Does obesity cause sleep apnea, or vice versa?

A: If you gain weight or become obese, you’re more likely to develop sleep apnea. Conversely, if you lose weight, you’re more likely to get better.

That said, there is some debate in the medical community over which comes first, the apnea or the obesity. One theory is that if you develop sleep apnea, it may change your metabolism or it may make you less active, leading to eventual weight gain. There is more to apnea than weight gain, but we can’t answer that question fully until we have more of an understanding of the natural history of the disease.

Q: Is sleep apnea linked to depression?

A: There’s a very strong link between the two. Many of my patients are taking antidepressant medications. People with sleep apnea often complain of fatigue, lack of energy and poor sleep, all of which are hallmarks of depression. However, sleep researchers don’t know if the depression is due to sleep deprivation, or if it’s a specific manifestation of the sleep apnea itself. When the apnea is effectively treated, the depression often gets better.

Q: How often does sleep apnea adversely affect marriages?

A: I think it’s very common that sleep apnea causes problems in a marriage. Any time I have new sleep apnea patients, I ask that they bring their partners with them. It’s important that both of them understand what the disorder is and how to treat it. It is a big adjustment to see your partner strap on a continuous positive airway pressure, or C.P.A.P., mask every night.

Some bed partners are very accepting of the C.P.A.P. machine, but others, men especially, often find it hard to get used to having a spouse use the device.

Q: The gold standard therapy for treating sleep apnea for the past 25 years has been C.P.A.P. How effective is it?

A: Think of air pressure from the device as a pneumatic splint that keeps the air passages open. In C.P.A.P. treatment, patients wear either a full mask that covers the nose and mouth, or a mask that covers only the nose. Tubes attach the mask to the C.P.A.P. machine.

C.P.A.P. offers a dramatic improvement in sleep apnea symptoms. If a person tolerates the device, those with moderate to severe sleep apnea will notice a difference the first night. They will achieve maximum benefit after a couple of weeks of use.

Research clearly shows that treatment with C.P.A.P. reduces cardiovascular risk, lowers the incidence of motor vehicle accidents and improves quality of life. C.P.A.P., unfortunately, is not curative.

Q: How difficult is it to get patients to try C.P.A.P.?

A: C.P.A.P. compliance ranges from as low as 50 percent of patients to as high as 80 percent. Many patients use the device for four hours a night, on average, every other night. The best predictor of compliance is how much the patient uses it in the first week or two. The other predictor is how educated a person is about sleep apnea and its health implications, and his level of understanding of how C.P.A.P. works.

We can now monitor patient C.P.A.P. compliance through the computer chip in the machine, which gives doctors very accurate information about when the machine was started and stopped. This lets us know if the patient is following through with the therapy. Low compliance offers me a chance to give the patient a pep talk, explaining the health risks of sleep apnea, which can range from chronic daytime sleepiness and weight gain to heart disease, stroke and permanent memory loss.

Q: Why do so many patients eventually stop using the device?

A: Many people complain about having to strap a mask to their head every night. Patients often describe C.P.A.P. as having a “tornado” in their noses. The high flow of air created by the device, which is designed to keep the air passages open, can also lead to sinus congestion or runny nasal passages. Even though newer C.P.A.P. machines are equipped with humidifiers, congestion is still a major complaint and a reason why people give up.

Others complain about irritation of the mask on the bridge of the nose or nostrils. Women often tell me that the headgear that holds the device in place can be bothersome and messes their hair. Some single people are embarrassed by the device and wonder what bed partner would want to sleep with someone wearing that sort of headgear. Occasionally, I’ll have people say that the increased airflow causes them to swallow so much air that they wake up feeling bloated.

Then there are the patients who just don’t think sleep is that important, so they stop using C.P.A.P.

Q: What is the next step for a patient who has tried C.P.A.P. and cannot tolerate it?

A: If a patient still can’t tolerate C.P.A.P., my second-line therapy is a dental appliance. These small plastic devices, similar to orthodontic retainers or sports mouth guards, help prevent the collapse of the tongue and soft tissues in the back of the throat, keeping the airway open during sleep and promoting adequate air intake.  (Dr. Goldman notes that the governing body of Sleep Medicine  officially declared in 2006:

Oral appliances

‘(OAs) are indicated for use in patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP.’

Nearly all appliances fall into one of two categories, classified by mode of action or design variation. Tongue retaining appliances function by holding the tongue in a forward position by means of a suction bulb. This keeps the back of the tongue from collapsing during sleep and obstructing the airway.

Mandibular repositioning appliances help to reposition and maintain the lower jaw in a protruded position during sleep. This opens the airway by indirectly pulling the tongue forward and making it more rigid. Such appliances also hold the lower jaw and other structures in a stable position to prevent opening of the mouth. (this statement is misleading. Mandibular repositioning devices which I utilize, allow free and easy opening of the mouth. One can speak and take a drink of water with no problems while wearing the device. However, they are designed to prevent collapse of the airway while sleeping by positioning the lower jaw in an advantageous, stabilized position.  Dr. Goldman)

Q: Can surgery effectively treat sleep apnea symptoms?

A: Patients who cannot be treated with C.P.A.P. and have failed other conservative measures will often be advised to undergo uvulopalatopharyngoplasty, or UPPP. This is a surgical or laser procedure to remove part of the uvula — the small, fleshy tissue hanging in the back of the throat — and soft palate in an attempt to alleviate snoring and sleep-disordered breathing. Following surgery, a repeat sleep study is needed to determine whether the procedure reversed the sleep apnea.

A small subset of people benefit from UPPP surgery. Over all, however, I’m pessimistic about this procedure, because while it may alleviate snoring, it’s not consistently effective in treating sleep apnea. When we do follow-up sleep studies, we often find the surgery hasn’t really done very much to reduce the number of sleep apnea episodes.

Q: Is UPPP surgery overused?

A: As we’ve gotten to know more about the surgery and its outcomes, I think specialists have gotten less excited about performing UPPP surgery. It’s still overused in some parts of the country, but in general there is less surgery for sleep apnea now than a few years ago.

Q: Why haven’t better treatments been developed?

A: The fact that the disease has not taken seriously by sleep researchers has been part of the problem. From an anatomical perspective, however, airways don’t always collapse at the same spot. C.P.A.P. works so well because it doesn’t matter where your air passage collapses. The air pressure will keep the entire passageway open.

Q: Are drugs being developed for sleep apnea treatment?

A: That’s certainly an area of keen research interest. Experiments have been tried with selective serotonin reuptake inhibitors, or S.S.R.I.’s, but these popular antidepressants have minimal efficacy in reducing the number of times a person’s sleep is disturbed each hour. For example, if a person is typically bothered 40 times an hour, the drug may drop it to 30 times an hour. Granted, that’s not enough to make a significant clinical effect, but it is enough to generate an interest in finding out why there was an effect at all.

Q: Are there ways to prevent sleep apnea?

A: Maintaining an ideal body weight is definitely a plus. We know from studies with men that when the excess weight comes off, the sleep apnea improves or vanishes. In addition, treating underlying nasal problems can also help sleep apnea symptoms. Finally, alcohol worsens sleep apnea because of its depressant effects, so avoiding alcoholic beverages a few hours before bedtime is recommended.

Publish date: 8/30/07