What is the problem? Please specify the negative outcomes (what would ideally be avoided) and who cares about these negative outcomes.
Obstructive Sleep Apnea (OSA) is a common, chronic health condition characterized by repetitive breathing obstructions while asleep, causing daytime fatigue and sleepiness, and are associated with serious health consequences such as hypertension, heart failure, motor vehicle accidents and premature death.While continuous positive airway pressure (CPAP), the gold standard treatment, can prevent these breathing obstructions, 30-50% of OSA patients cannot tolerate it leaving OSA patients untreated or undertreated.
Tell a story of a specific instance that illustrates the problem.
Mr J. is a patient I follow in the Cardiology outpatient clinic for heart failure and poorly controlled hypertension. He was diagnosed with severe OSA but has been unable to tolerate CPAP and currently is not on any OSA therapy. He says he is now used to poor sleep which means he just naps more during the day. He is unwilling to try CPAP again. He states that CPAP “is not designed for a human” and describes a feeling of claustrophobia from the tight-fitting mask and an inability to find a comfortable position when sleeping because of the tubing from the mask. After trying a few different masks types he gave up and sent the machine back.
How do the current approaches to address this problem fall short?
CPAP requires a tight-fitting mask, tubing and a bedside pump to keep the airway open using continuous pressurized air. Many patients do not tolerate this approach primarily related to discomfort from the mask (feeling of claustrophobia, harder to breath against forced air, frequent mask dislodgement) and the tubing and pump limiting sleeping positions and negatively impacting the sleep environment for the user and potentially the bed partner. A common alternative to CPAP, the mandibular advancement device (MAD), is poorly tolerated by many due to jaw pain and changes to dentition. A newer alternative is a hypoglossal nerve stimulator that increases the muscle tone of the tongue preventing tongue-related throat obstruction. Currently it has limited use as it requires surgery and relies on expensive pacemaker technology.
Key References:
Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9):1006-1014.
Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg. 2016;45(1):43.
Truong KK, De Jardin R, Massoudi N, Hashemzadeh M, Jafari B. Nonadherence to CPAP Associated With Increased 30-Day Hospital Readmissions. J Clin Sleep Med. 2018;14(2):183-189.
Deane SA, Cistulli PA, Ng AT, Zeng B, Petocz P, Darendeliler MA. Comparison of mandibular advancement splint and tongue stabilizing device in obstructive sleep apnea: a randomized controlled trial. Sleep. 2009;32(5):648-653.
