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Sleep Disorders

Sleep Apnea

06/23/2009

Question:

Several months ago, to rule out sleep apnea as a cause for afib, my husband had a sleep study done. It was determined that he had mild apnea and a CPAP machine was prescribed. He could never go to sleep with the machine. It was further determined that since his oxygen level didn`t drop that it was not the cause of his afib. He has since had a PVI Ablation. Since his ablation he has needed to urinate every hour - day and night. The urologist feels it is caused by the sleep apnea. He has since tried and is still unable to go to sleep with the machine. He`s explored the dental appliance. Is there any other treatment other than surgery that he can try? He is unable to sleep more than 2 consecutive hrs. per night and sometimes none. He is 5`8" and 155 lbs. so obesity isn`t an issue.

Thank you for your help.

Answer:

Thank you for your question. It sounds like your husband is having quite a bit of trouble and it’s a good idea to look into the matter further. However, without knowing the specific details of your husband case, I cannot provide you with a definitive answer, but I can speak to the issues in general.

The terms mild, moderate, and severe obstructive sleep apnea (OSA) reflect the number of apnea- type events (apnea-hypopnea index or AHI) measured per hour of sleep and is a reflection of one aspect of the severity of OSA. Another indication of severity of OSA is the degree of sleep disruption and daytime sleepiness caused by the sleep apnea. So it’s possible to have a relatively low AHI (mild OSA) but still have significant symptoms related to it. If we accept that your husband has significant OSA, then he should be treated.

The primary treatment for OSA is the use of CPAP, which is very effective at keeping the airway open during sleep. It does this by “pressurizing” the airway to prevent it from collapsing. In a large number of well-done studies, CPAP therapy has been shown to improve a number of measures of quality of life, including daytime alertness, improved concentration and improved mood. In addition, growing data suggest that CPAP may reduce some of the medical consequences associated with sleep apnea. The main problem with CPAP is that many individuals, such as your husband, have trouble adapting to sleeping with this type of device. Most of the time, with patience, perseverance, and appropriate trouble-shooting, individuals can learn to sleep with CPAP (or one of its versions) and do quite well. I am often surprised by how many patients have not been made aware of other mask options and different types of devices that may help improve their tolerance of CPAP. Despite best efforts, some individuals are unable to use CPAP and thus alternative therapies must be considered.

Alternative treatments for OSA really fall into 2 main categories: oral appliances and surgery. Oral appliances generally work to advance the lower jaw, hoping to open space in the back of the throat. They tend to work best in individuals with more mild to moderate OSA and in those who may have a small or more posterior sitting jaw. Individuals who use oral appliances during sleep often tolerate them, though they can have some annoying side effects (jaw achiness, pain with chewing in the morning, headaches, drooling). In addition, if there is a history of temporomandibular joint (TMJ) disease, then these devices should be used with great caution as they put considerable stress on the TMJ and can worsen problems.

For some individuals, surgery is a reasonable option. Surgery tends to be most effective in those with clear anatomic problems that are amenable to surgery (such as large tonsils, deviated septum), have more mild to moderate sleep apnea and who are not obese. There are a variety of surgeries that can be considered, though they are generally tailored based upon an individual’s anatomy. A tracheotomy (surgical tube placed in the neck) is usually curative for OSA, but because it is somewhat disfiguring, is reserved for severe cases that fail other treatments.

Other treatments that have been mentioned in the literature included weight loss for those who are overweight (in some cases, this can be curative), positional therapy (avoiding sleep on your back for those with a significant positional component to their sleep apnea) and medications. Unfortunately, aside from treatment to help alleviate nasal congestion, almost all other medications hoped to significantly impact OSA have failed when well-studied. Primary medication treatment for OSA is not recommended at this time. Elevation of the head of bed may have some ameliorating effect on the sleep apnea, although there are no studies to support this at this time.

I would accept that there is not strong evidence that mild OSA would be responsible for triggering his atrial fibrillation. The available studies do indicate a role for untreated OSA in the recurrence of atrial fibrillation after cardioversion (a treatment different from ablation, which may be a more effective treatment for the atrial fibrillation), but this is a different situation. It is not clear to me why the recurrent hourly awakening started after the ablation. If he had not been able to use CPAP, and was not using it before the ablation, then why did he start having the interruption to his sleep only after the ablation? Was awakening every hour always a symptom of his sleep apnea? Could this be related to medication he is on or is there another cause to his awakenings? These relations will need to be further explored. In addition, not being able to sleep at all on some nights is unlikely to be related to his OSA and suggests another possible problem leading to insomnia. However, if the multiple awakenings are only due to OSA and this has always been a symptom of his OSA, then his OSA is probably more significant that reflected by the sleep study report.

As you can see, the situation may be complex and will require input from a specialist in sleep medicine. I think that your husband’s sleep physician should be able to sort out the contribution of the OSA to his nighttime symptoms and whether this is enough to warrant treatment. If treatment is indicated, then a number of options may be available, depending on the specifics of your husband’s case.

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Response by:

Rami N Khayat, MD Rami N Khayat, MD
Clinical Assistant Professor of Pulmonary, Allergy, Critical Care & Sleep
College of Medicine
The Ohio State University