CPAP Problems: CPAP intolerance is a Major Flaw In The Treatment Of Obstructive Sleep Apnea And The Practice Of Sleep Medicine

    GURNEE, IL, December 18, 2008 /24-7PressRelease/ -- Sleep apnea is a major health concern that not only increases risks for heart attacks and strokes but robs patients of the quality of life they deserve. Snoring and symptoms of apnea often adversely affect relationships and/or health of the significant other and have been shown to increase marital problems and increase divorce rates. The most common warning signs of sleep apnea are snoring, gasping for breath is sleep and excessive daytime sleepiness or just being tired all the time. Patients with sleep apnea frequently report that they feel tired on awakening and often have dry mouth or morning headaches. The best way to diagnose Obstructive sleep apnea is polysomnography or an overnight sleep test that not only evaluates Obstructive Sleep Apnea but also can evaluate Central Sleep Apnea, Upper Airway Resistance Syndrome,Respiratory Effort Related Arousals (RERA), Snore Arousals, Restless Legs, Parasomnias and sleep stage distribution. Excellent information on the dangers of sleep apnea can be found at: http://www.ihatecpap.com/sleep_apnea_dangers.html

Diagnosis of Obstructive Sleep Apnea leads to an almost automatic referral for CPAP treatment. CPAP is the still considered the Gold Standard of treatment for obstructive sleep apnea and is extremely successful if patient compliance is not considered. There is a small percentage of patients who like their CPAP machines from the day they receive them and never have problems. The majority of patients are not so lucky. There are many variations of the standard CPAP machine all designed to increase patient compliance (ie use of CPAP) but studies have shown that most of these advancements do not increase compliance.

BiPAP is a bi-level air pressure that allows easier expiration, ramping uses a low pressure until the patient falls asleep, APAP is a machine that self adjusts the pressure while the patient is sleeping and humidification can be added to any machine. Unfortunately in spite of many new masks and connections studies have shown that the best predictor of patients success with CPAP is initial patient reaction to CPAP. Additional information about CPAP can be found at: http://www.ihatecpap.com/cpap.html

CPAP Intolerance is a major problem that is best addressed for many patients by utilization of oral appliances or dental devices that are very successful in treating sleep apnea and snoring. They are so successful that the American Academy of Sleep Medicine (AASM) has declared that oral appliances are a first line treatment (the same as CPAP) for mild to moderate Sleep Apnea and an alternative therapy for severe apnea when patients do not tolerate CPAP. Studies have shown that only 23-45% of patients prescribed CPAP actually use it regularly and that most CPAP users average only 4-5 hours a night not the recommended 7 1/2-8 hours per night. Information on some of the more common problems with CPAP can be found at: http://www.ihatecpap.com/cpap-problems.html

The National Sleep Foundation has declared oral appliances "a therapy whose time has come", and the American Academy of Dental Sleep Medicine has endorsed the position of the American Academy of Sleep Medicine. Dr Ira L Shapira, a Chicago dentist and Diplomate of the American Board of Dental Sleep Medicine has formed I HATE CPAP LLC to inform the public about the dangers of sleep apnea and to promote Dental Sleep Medicine and the use of oral appliances to treat sleep apnea.

His website www.ihatecpap.com is designed to help patients learn about sleep disorders and the range of treatments available. He has a find a dentist section to help patients find a sleep apnea dentist in their state which can be accessed at: http://www.ihatecpap.com/directory_listings/main_directories.html and do to heavy international traffic in Australia, Great Britain and other English speaking countries is adding an international listing as well. Thousands of new patient visit the site on a monthly basis and I HATE CPAP LLC will help patients locate a Sleep Apnea Dentist if one is not already listed.

The site has a large section highlighting many oral appliances with pictures and is available at: http://www.ihatecpap.com/oral_appliance.html

There is also a section on surgical alternatives to CPAP found at: http://www.ihatecpap.com/sleep_apnea_surgery.html

Blue Cross - Blue Shield has an excellent description of Sleep apnea and their treatment guidelines that follow. You will note they include CPAP and Orthodontic devices in their non-surgical management. Studies have shown that CPAP and Oral Appliances are more successful than surgey and that surgery is a second line of treatment. See Sleep and Health Journal article comparing Oral appliances to Surgery: http://sleepandhealth.com/modules.php?name=News&file=article&sid=55&tid=22

Obstructive sleep apnea syndrome (OSA) is characterized by repetitive episodes of upper airway obstruction due to the collapse of the upper airway during sleep. In patients with OSA, the normal pharyngeal narrowing is accentuated by anatomic factors, such as a short, thick "bull" neck, elongated palate and uvula, or large tonsillar pillars with redundant lateral pharyngeal wall mucosa. Furthermore, OSA may be associated with a wide variety of craniofacial abnormalities, including micrognathia, retrognathia, or maxillary hypoplasia. In addition, OSA is associated with obesity. Obstruction anywhere along the upper airway can result in apnea. Therefore, OSA is associated with a heterogeneous group of anatomic variants producing obstruction.

The hallmark clinical symptom of OSA is excessive snoring. The snoring abruptly ceases during the apneic episodes and during the brief period of patient arousal and then resumes when the patient again falls asleep. Sleep fragmentation associated with repeated arousal during sleep causes excessive daytime sleepiness that can lead to impairment of almost any daytime activity. For example, patients with OSA-associated daytime somnolence are thought to be at higher risk for accidents involving motorized vehicles, i.e., cars, trucks, or heavy equipment. In addition, excessive daytime sleepiness indirectly affects the cardiovascular and pulmonary systems. For example, apnea leads to periods of hypoxia, alveolar hypoventilation, hypercapnia, and acidosis. This in turn can cause systemic hypertension, cardiac arrhythmias, and cor pulmonale. Systemic hypertension is common in patients with OSA. Severe OSA is also associated with decreased survival, presumably related to severe hypoxemia, hypertension, or an increase in automobile accidents related to daytime sleepiness.

Upper airway resistance syndrome (UARS) is a variant of OSA that is characterized by a partial collapse of the airway resulting in increased resistance to airflow. The increased respiratory effort required results in multiple sleep fragmentations as measured by very short alpha EEG arousals. Snoring may not be a feature of UARS. The resistance to airflow is typically subtle and does not result in apneic or hypopneic events. However, it does result in increasingly negative intrathoracic pressure during inspiration, which can be measured using an esophageal manometer as an adjunct to a polysomnogram. Therefore, this diagnosis rests on polysomnographic documentation of _10 EEG arousals per hour of sleep correlated with episodes of reduced intrathoracic pressures.

Nonsurgical treatment for OSA or UARS includes continuous positive airway pressure (CPAP) or orthodontic repositioning devices, which are addressed in policy #07.01.21, Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome and Upper Airway Resistance Syndrome.
Minimally invasive procedures include laser-assisted uvulopalatoplasty (LAUP), radiofrequency ablation of palatal tissues and the tongue and palatal stiffening procedures. These latter procedures are addressed in a separate policy, #07.01.44 Minimally Invasive Surgery for Snoring, Obstructive Sleep Apnea Syndrome/ Upper Airway Resistance Syndrome.
Traditional surgical procedures include uvulopalatopharyngoplasty (UPPP) and a variety of maxillofacial surgeries such as mandibular-maxillary advancement (MMA). A UPPP involves surgical resection of the mucosa and submucosa of the soft palate, tonsillar fossa, and the lateral aspect of the uvula. The amount of tissue removed is individualized for each patient as determined by the potential space and width of the tonsillar pillar mucosa between the 2 palatal arches. The UPPP enlarges the oropharynx but cannot correct obstructions in the hypopharynx. Thus patients who fail UPPP may be candidates for additional procedures, depending on the site of obstruction. Additional procedures include hyoid suspensions, maxillary and mandibular osteotomies, or modification of the tongue. Fiberoptic endoscopy and/or cephalometric measurements have been used as methods to identify hypopharyngeal obstruction in these patients." The above information was taken from Blue Cross at: http://www.wellmark.com/e_business/provider/medical_policies/policies/osd.htm

Patients looking for comprehensive information on all aspects of sleep will appreciate Sleep and Health Journal that is dedicated to informing the public about all aspects of sleep and is the brainchild or Dr Alex Golbin MD Phd who also wrote the book , The World of Children's Sleep, and the only textbook on Sleep Psychiatry.

Ira L Shapira DDS, FICCMO, DABDSM, DAAPM is an author and section editor of Sleep and Health, President of I HATE CPAP LLC, President Dato-TECH and holds several patents on minimally invasive removal of third molars and collection of stem cells, and has a Dental Practice with his partner Dr Mark Amidei in Gurnee, Illinois. He has recently formed Chicagoland Dental Sleep Medicine Associates with offices in Skokie, Schaumburg, Bannockburn and additional office planned across Chicagoland. Dr Shapira was a charter and Credentialed member of the Sleep Disorder Dental Society which became the American Academy of Dental Sleep Medicine, a Founding member of DOSA, The Dental Organization for Sleep Apnea, a Diplomate of the American Board of Dental Sleep Medicine, a Diplomat of the American Academy of Pain Management, a Fellow and Regent of ICCMO, the International College of CranioMandibular Orthopedics and is their representative to the TMD Alliance representing the most important groups involving diagnosis and treatment of TMJ disorders.

Dr Ira L Shapira is an author and section editor of Sleep and Health, President of I HATE CPAP LLC, President Dato-TECH, and has a Dental Practice with his partner Dr Mark Amidei. He has recently formed Chicagoland Dental Sleep Medicine Associates. He is a Regent of ICCMO and its representative to the TMD Alliance, He was a founding and certified member of the Sleep Disorder Dental Society which became the American Academy of Dental Sleep Medicine, A founding member of DOSA the Dental Organization for Sleep Apnea. He is a Diplomate of the American Board of Dental Sleep Medicine, A Diplomat of the American Academy of Pain Management, a graduate of LVI. He is a former assistant professor at Rush Medical Schools Sleep Service where he worked with Dr Rosalind Cartwright who is a founder of Sleep Medicine and Dental Sleep Medicine. Dr Shapira is a consultant to numerous sleep centers and teaches courses in Dental Sleep Medicine in his office to doctors from around the U.S. He is the Founder of I HATE CPAP LLC and http://www.ihatecpap.com Dr Shapira also holds several patents on methods and devices for the prophylactic minimally invasive early removal of wisdom teeth and collection of bone marrow and stem cells. Dr Shapira is a licensed general dentist in Illinois and Wisconsin.

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