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CPAP therapy 3

What to know: CPAP vs Surgery for OSA

Should you have surgery for sleep apnea?  In some cases, yes, but I will share my personal approach to treating sleep apnea as a board certified sleep specialist who can also offer surgery, as opposed to the other medical-only sleep specialties.

 

First, despite being a surgeon, I recommend CPAP therapy (which might end up as CPAP, BiPAP or AutoPAP) to all my sleep apnea patients as a first line.  CPAP is the only “guaranteed” cure (along with surgical tracheostomy).  That is, of course, if you use it all the time for the rest of your life.  There is often a great deal of help that a physician can offer to help adherence with CPAP both medically and also potentially surgically.  I believe more efforts should be made at this junction for patients beginning treatment and having difficulty.  Even if you are planning to have surgery to attempt to rid your life of CPAP, it is in your best interest to start with this device.  Eliminating sleep apnea presurgically and allowing the body to heal is actually safer for you.  Also, many surgeons recommend CPAP use after surgery initially before results to improve your OSA have begun.

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Second, other non-invasive options such as oral appliance therapy/ mandibular advancement devices or Provent, a special nasal sticker for sleep apnea can be explored next.  These should be entertained unless contraindicated, as they are the last options before more aggressive treatment is sought.  Both of these may not fully treat your sleep apnea even if you are wearing them all night, so it is of utmost importance if you are treated with one of these that you have another sleep test with the therapy in place to determine efficacy!

Provent OSA Therapy

Lastly, I recommend surgery to patients only after they have made tried and failed these attempts.  Often I will help them medically to try CPAP one more time.  Often, nasal congestion issues can be the downfall of a new CPAP user, and aggressive medical management may be able to get them some success in the face of past failure.  As far as surgery goes, I will not list all the many different procedures but speak to them in general.  While nasal surgery often has little impact on sleep apnea severity, I do perform it often with great success in returning patients to CPAP.  Besides helping with nighttime compliance with CPAP, the daytime benefits of breathing well last well after the mask has been removed.  Thereafter, those who can not or will not use CPAP may wish to alter the anatomy of the palate or tongue to improve their disease.  Given the possibility of residual sleep apnea and/or need for multiple procedures to achieve the desired result, I prefer a patient who has at least tried or can’t tolerate CPAP since further treatment may be necessary if surgery is not curative.

On a final note, here are some other concerns regarding CPAP and surgery:

  1. I think it should be noted that “real world” CPAP usage is not ideal.  Many CPAP users with low adherence have only partly treated sleep apnea. While improved, it would be like residual apnea after surgery.  I find many patients being followed for OSA with poor adherence which isn’t appropriately improving their disease.  If you are not using the machine more than 6.5 hours per night, you may have significant residual disease that is slowly worsening your health.  Now, some of the CPAP machine manufacturers actually have smartphone apps that will allow patients to be more involved in the compliance.  Patients need to take an active role in their treatment, and hopefully these technologies will help with public awareness.
  2. “Sleep apnea surgery” is a more recently developing area of medicine.  Many surgeons still perform the “UPPP” of yesterday, an over 30 year old procedure that has not had great success in helping patients despite minor variations through the years and is the reason many medical sleep specialists do not recommend surgery.  It is my personal belief that the uvula should not be cut off entirely as is the standard with this “older” procedure.  Newer procedures such as anterior palatoplasty and expansion sphincter pharyngoplasty are reconstructive of the palate and throat rather than ablative or destructive of these tissues.  Ask your surgeon about what “type” of surgery they perform and choose wisely as the “older” techniques may not only not improve your disease, but may leave you with other symptoms and make it more difficult to wear certain types of more comfortable CPAP masks.
  3. My personal approach to surgery is always less invasive before more invasive.  Less invasive options should always be considered before other more risky and invasive options.  Always ask your surgeon about less invasive options and understand the risks of surgery for the procedure offered as well as the increased risk to sleep apnea patients in general.  The perioperative use of CPAP is strongly encouraged.  You will be safer for it!

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