One of the most common questions I get asked by patients is, “what’s the best treatment for sleep apnea.?” In my mind, it’s like asking “what’s the best type of car to get?” Ultimately, it depends. People prefer different cars for different reasons. In the same way, there are various ways of treating obstructive sleep apnea and upper airway resistance syndrome.

I came up with the acrostic COMPASS to describe all the general categories that come to mind. There isn’t one magic bullet, and one option will work better than another for two different people. Many will need a combination of options, and sometimes, all the options. Except for the first and last, they are in no particular order. 

Conservative

I described this in much more detail in a previous blog post under the acrostic SLEEPINESS. These are the prerequisite steps that are needed before considering more formal medical treatment options. 

Oral Appliances

Oral appliances rank high on the list since they can be done through over-the-counter sources or more formally through a trained airway dentist. There are many variations of particular mouth guards that reposition your jaw and/or tongue, but the most common type is what’s called a mandibular advancement device. This is a molded mouth-guard of your upper and lower teeth, where the lower jaw is pushed forward slightly. This pulls your tongue base forward, opening up the airway and helping with snoring and obstructive sleep apnea. 

Over-the-counter models can be found online and are simple to mold and adjust. However, they are not as comfortable or as adjustable compared with formal appliances custom-made by dentists. For mild to moderate obstructive sleep apnea, mandibular advancement devices were found to be equally equivalent to CPAP as first-line therapy.

Myofunctional Therapy

Myofunctional therapy used to be called orofacial myology. It’s now becoming accepted as more mainstream therapy by sleep doctors. This began with the publication of this landmark study from Brazil in 2009, with numerous subsequent supportive studies including a 2015 meta-analysis showing 50% OSA severity drop in adults and 62% in children. Most of the circle of practitioners I worked with used myofunctional therapy as complementary to whatever else they are being treated with. In patients that undergo some kind of dental expansion therapy, tongue exercises are very important. 

Pressure Devices

This includes all the various positive pressure devices including CPAP, APAP, BiPAP, and ASV devices (xPAP devices). Long considered the “gold standard” of treatment for OSA, it’s clear that the vast majority of sleep apnea patients either can’t tolerate or benefit from CPAP long-term. In my experience, one of the most important issues to address before trying one of these devices is to optimize nasal breathing. 

Granted, many people have their lives transformed using CPAP, but many people also struggle with their PAP devices and ultimately give up altogether. The good news is that for the vast majority of people struggling with xPAP, there are helpful ways to make xPAP more comfortable allowing you to sleep better. I lay out a plan to consider all other options if xPAP doesn’t work in my book, Totally CPAP: A Sleep Physician’s Guide to Restoring Your Sleep and Reclaiming Your Life.

Acupuncture 

Around the same time that myofunctional therapy came on the map, acupuncture was also found to help lower obstructive sleep apnea severity by about 50%. Unfortunately, it hasn’t taken off like tongue exercises, but I do find that it helps some people who try it. There is no sleep apnea diagnosis in Chinese medicine. Rather, the entire body and mind are treated, based on your symptoms. I usually have patients take a copy of this paper along with them to their favorite acupuncturist. 

Slim Down

You may have guessed that slimming down means losing weight. However, it’s been shown scientifically that it’s extremely difficult to lose weight if you’re not sleeping well. This is why losing weight can be very challenging for most people. Patients ask me all the time what my recommendations are for how I stay so thin. I usually tell them (jokingly and unofficially since I’m not a nutritionist) that I avoid all foods and drinks with the words non-fat, low-fat, low-calorie, diet, skim, reduced, or 0 calories. I eat organically and avoid sugar to the extreme. I also prioritize sleep, which helps to control hunger in general, as well as cravings for sweet or starchy foods.  

Two very good books that I recommend on this topic are: Why We Get Sick, by Dr. Benjamin Bikman, and Metabolical by Dr. Robert Lustig. The bottom line is that dieting (eating fewer calories in general) induces a starvation state that lowers your body’s metabolism, so it’s hard to lose weight. The key principle is to eat the right (healthy) types of food, without worrying about how much to eat. Of course, eating healthy foods alone won’t work as well without addressing all the areas covered under SLEEPINESS. 

However, some of you with sleep apnea (and especially UARS) are skinny and have no weight to lose. Here you can skip this step and go on to the other options.

Surgery

Most people with sleep apnea find help without needing surgery. But some have no choice to consider surgery, after trying some or all the non-surgical options mentioned above. The problem with recommending surgery is that there are many different options for surgery, in various parts of your upper airway, each with different goals, different techniques used, and different rates of effectiveness.

In young children, tonsillectomy for large tonsils helps very well in most children, but not in all cases. Many children have very severe sleep apnea but very small tonsils. Most adults with sleep apnea also have stuffy noses and surgery is offered if medical therapy doesn’t work. While this surgery does help with congestion, it’s been shown that it doesn’t treat sleep apnea significantly. However, it can make CPAP or mandibular advancement devices much more effective (mainly by keeping the mouth closed).

For more advanced types of surgery, it’s generally divided between jaw bone framework surgery or soft tissue procedures. A complete list of the procedures can’t be described here, since there are too many to list, all with different levels of complexity, potential complications, and effectiveness.

How to Use Your COMPASS

After starting with conservative options, you can try any of the middle 5 categories in COMPASS in any order. As expected, surgery is always reserved for last. The good news is that I’ve seen and interacted with thousands of people who have successfully managed their OSA to the point of being functional again. However, most of these people had to combine many, if not all of the 7 letters in COMPASS to find relief.

COMPASS is a general guide, framework, or checklist of things to try in conjunction with your team of health care professionals. If you are early in the process of managing your sleep apnea, then be persistent and don’t give up. Work with your doctors and formally try the various standard options available. 

But if you’re struggling and not making any progress, you may benefit from a guide or a coach that can evaluate where you are in your journey and point you in the right direction so that you can reach your destination quicker. However, you have to do the leg work and take the needed steps to make progress. It’s OK to hit a dead-end once in a while. Just like when you’re driving and hit a dead end, you turn around, get your bearings by looking at your map, GPS, or compass, and continue in your journey. Don’t give up. Keep moving.

The post Use Your COMPASS to Overcome Sleep Apnea appeared first on Doctor Steven Y. Park, MD | New York, NY.

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