Treatment

Question 1

What do physicians expect of us when they send a patient for OAT (what are the treatment goals)?

Answer 1

Reduce AHI
Increase SpO2 to normal
Reduction of symptoms (fatigue, morning headache that goes away with ambulation, bruxism [can cause mroning headaches that worsen], snoring, RLS, impotence)

Question 2

What is considered a successful AHI outcome?

Answer 2

AHI<10 with no symptoms (partial response)
AHI reduced by ≥50% in severe cases with improvement in symptoms (partial response)
Discuss with physician what he perceives as success before treating

Question 3

What is considered a successful outcome in terms of SaO2?

Answer 3

Depends on the group:
Nadir >85%
SaO2 <1 minute
Nadir ≥90% (most widely accepted and probably the most accurate)

Question 4

Somnomed pros, cons

Answer 4

Pros: lightweight, easy A/P adjustment, high compliance, can be used in edentulous patients
Cons: dorsal fin breakage, no lateral movement (not good for brux/clench), high cost for Somnomed brand (other brands of dorsal fin are available)

Question 5

EMA (elastic mandibular appliance) pros, cons

Answer 5

Pros: thin (tongue space, gaggers), lower cost, lateral movement, tongue space, A/P movement. Roubal recommends for all patients AHI<15, and for all that do not respond with TAP (he says 70% of TAP non-responders will respond with EMA)
Cons: in bruxers the bands only last a couple of weeks (bands must be replaced frequently), bands lengthen over time (decreases protrusion); appliance life expectancy 2 years

Question 6

TAP pros and cons

Answer 6

Pros: easily adjustable, lateral movement
Cons: tongue rests on mechanism; difficult to adjust vertical

Question 7

Oasys pros and cons

Answer 7

Pros: both a mandibular repositioner and a nasal dilator, excellent for allergy patients
Cons: no lateral movement, molar advancement tubes strip easily, impression of vestibules is critical for nasal buttons

Question 8

Full Breath pros and cons

Answer 8

Pros: no mandibular advancement needed (good for TMJ); single arch
Cons: very difficult to titrate (posterior tongue restrainer); bd for gaggers; can make swallowing difficult

Question 9

SilentNite pros and cons

Answer 9

Pros: good tongue space, inexpensive, good trial appliance
Cons: only FDA approved for snoring, breaks easily, not good for bruxers

Question 10

Tongue retaining device (TRD) pros and cons

Answer 10

Pros: inexpensive, good for edentulous, good for those who can’t tolerate mandibular advancement
Cons: lingual frenum sensitivity

Question 11

What is the most critical consideration when choosing which appliance to use?

Answer 11

Only use an appliance that has FDA approval

Question 12

Do all patients physiologically respond positively to mandibular repositioning appliances?

Answer 12

No. Some people simply will not see an increase in their airway.

Question 13

What is Dr. Weaver’s protocol for titration?

Answer 13

Acclimate for 1 week
If symptoms are better, HST
If symptoms are not reduced, advance .5mm every day until symptoms improve
If TMJ symptoms arise, revert back to last comfortable size, wait 1 week and advance .5mm weekly
If TMJ symptoms prevent good outcome, treat the TMJ (daytime orthotic)
Final HST or PSG scored by physician – report success to physician – inform patient that decision about final sleep study is the physician’s decision

Question 14

Follow up appointment protocol per Dr. Weaver

Answer 14

Review chief complaints (same, gone, or new) – fatigue (Epworth), snoring, headache, TMJ, comfort of appliance
Review medical hx
TMJ check, ROM, muscles
Changes in occlusion
Check appliance for wear, damage, etc.
HST every year (he says – I think only PRN)
Report to physician

Question 15

How many OSA patients have TMJ?

Answer 15

30%

Question 16

What is the way to treat TMD in OAT patients?

Answer 16

1. Diagnose the TMD prior to OAT therapy & inform the patient
2. If no TMD prior but it arises during OAT, treat the TMD (daytime orthotic)
3. If TMD is present prior to OAT, give patient options: inform of the TMJ issues, talk about daytime appliance and OAT

Question 17

Clinical goals of TMD treatment?

Answer 17

Reduce or eliminate pain
Improve ROM
Recapture dislocated discs (uncommon)
Eliminate inflammation
Restore correct swallow
Reduce parafunctional activity (generally improves when airway and/or pain improves)

Question 18

TMD treatment modalities?

Answer 18

Splint therapy (daytime and/or nighttime)
Physical therapy
Chiropractor
Trigger point therapy
Myofunctional therapy

Question 19

EPAP (Provent)

Answer 19

Shows significant improvement in AHI. Probably a very good adjunct to OAT in nasal breathers who are unable to achieve optimal results with OAT alone.

Question 20

OAT and CPAP combo therapy advantages

Answer 20

Reduce PAP pressure by 4-5 cwp
Effective in preventing mouth leaks
Can hold nasal pillows instead of using head straps
Can be ‘bulked out’ in the cheek area to limit air leaks if flaccid tissue.
Augment Efficacy of OAT with Adjunctive Air Pressure
More Stable/Comfortable Mask Fit

Question 21

How effective is A&T alone in the treatment of OSA in children?

Answer 21

AT largely improves the AHI of children with OSA • Residual OSA in children undergoing AT is likely in the context of children with severe underlying OSA and/or obesity
Older children and obese children are particularly increased risk for residual OSA • Similarly non-obese children with either severe OSA or with asthma are at an increased risk for residual OSA.

Question 22

Which treatment modality is better in insomnia: CBT-I or pharmaceuticals?

Answer 22

They were comparable in all measures except sleep onset, in which CBT-I was better
(Smith et al. 2002)

Question 23

What are the common components of CBT-I?

Answer 23

Stimulus control & sleep restriction (overwhelming empirical support)
Sleep hygiene (ineffective as a monotherapy)
Relaxation therapy (not as effective as SCT and SRT)
Bright light therapy
Cognitive therapy

Question 24

What is the theory behind stimulus therapy (in CBT-I)?

Answer 24

Minimize activities in the bedroom to sleep and sex.
No other activities (condition the mind to expect only 2 possibilities)
No eat, read, lie awake, worry, work, TV in bed(room)

Question 25

What are the stimulus control instructions (CBT-I)?

Answer 25

Decondition Arousal & Re-associate Bed With Sleep • Do not use your bed or room for anything but sleep or sex • Go to bed only when sleepy • If not asleep in 15-20 mins get out of bed • Return to bed only when sleepy • Repeat as often as necessary • Get up at the same time every day! • No napping

Question 26

What is the theory behind sleep restriction therapy (CBT-I)?

Answer 26

Uses Sleep Debt to Consolidate Sleep

Question 27

What are the sleep restriction instructions?

Answer 27

1) Fix Rigid wake time
2) Curtail Sleep Opportunity to match TST
3) Titrate 15 min. weekly bedtime advances contingent of SE = 95% benchmark
Example: insomniac in bed from 11-10, TST of 5 hours, with delayed sleep onset and 3 awakenings plus lying in bed before getting up in the morning – Week 1 stay up until 2, get up at 7, Week 2 to bed a 1:45 and up at 7, etc.

Question 28

What are the published success rates of OAT?

Answer 28

Overall 50%
Mild/Mod = 75%
Severe = <50%, unpredictable

Question 29

Is OAT (TAP-1) or CPAP more effective, according to a 2 year randomized clinical study published in Sleep?

Answer 29

The results of this study indicate that, regarding treatment success, there is no significant difference between oral appliance therapy and CPAP in treating mild to severe OSAS in a 2-y follow-up. CPAP, however, showed a tendency toward a higher (nonsignificant) overall success rate than oral appliance therapy. This tendency was most pronounced in patients with severe OSAS. Both therapies had positive effects on polysomnographic variables during follow-up but CPAP therapy was significantly more effective in improving the AHI and the lowest oxyhemoglobin saturation levels at 1- and 2-y follow-up. (Vol 36 issue 9, http://journalsleep.org/ViewAbstract.aspx?pid=29087)

Question 30

For whom is OAT recommended, according to a 2013 Sleep article?

Answer 30

the current literature increasingly supports MAS as an effective alternative to CPAP except for extremely and morbidly obese persons. Future studies focused on long-term comparative effectiveness outcomes that include objective measures of adherence as well as the consideration of informed patients’ preferences for treatment are required for the comparisons between CPAP and MAS treatment.(Almeida FR. Long-term effectiveness of oral appliance versus CPAP therapy and the emerging importance of understanding patient preferences. SLEEP 2013;36(9):1271-1272.)

Question 31

What should be the most important factor in deciding between OAT and CPAP?

Answer 31

Patient choice of treatment. “the recent crossover study by Phillips et al. gives some insight into the impact of such an approach in OSA.11 They found that in retrospect, nearly half of patients preferred MAS and importantly, adherence to both CPAP and MAS were higher in patients who preferred the corresponding options” (Almeida FR. Long-term effectiveness of oral appliance versus CPAP therapy and the emerging importance of understanding patient preferences. SLEEP 2013;36(9):1271-1272.)

Question 32

What is the “magic number” on the pharyngometer?

Answer 32

120

Question 33

What should you do when the pharyngometer only shows improvement at 16mm?

Answer 33

Phonetic bite. We’ve had great results with it; let the patient know that because the airway showed no changes with pharyngometer, our odds of success are diminished. However, we have had great results when using the phonetic bite.

Question 34

Patients will often initially feel more fatigued when apnea treatment is successful, but if they keep at it they will turn the corner and start feeling better. We don’t know why, but what are some of the theories?

Answer 34

 “Sleep debt” needs to be repaid?
 Feeling more energy, patients accomplish more, leading to fatigue?
 Mouthful of acrylic leads to arousals? Mouthful of acrylic leads to arousals?
 The body craving this newfound, healthful sleep?

Question 35

How often does fatigue remain in successfully treated CPAP patients?

Answer 35

55%. In other words, we can’t expect that every fatigued apnea patient will feel more rested or energetic, nor should we base our HST on that.