Have you been diagnosed with obstructive sleep apnea (OSA) and are trying to find out how to cure it for good? Our board-certified sleep doctor explains how you can beat OSA.
OSA is a sleep disorder characterized by repetitive collapse of the upper airway during sleep and is the most common form of sleep apnea. After being diagnosed with the condition through a sleep study, people with sleep apnea are often not immediately ready to think about starting treatment options like continuous positive airway pressure (CPAP), which is the gold-standard treatment or wearing an oral appliance for sleep apnea. Even if they are willing to start CPAP, the idea of using it for the rest of their lives may be offputting. Patients often ask me, "Is there is a cure for sleep apnea?" The answer is, "It's complicated."
What Do We Mean By Curing Sleep Apnea?
First, let's define what constitutes a sleep apnea "cure." The best definition would be achieving an apnea-hypopnea index (AHI) <5. You could also think about a dramatic reduction in the AHI or moving your AHI from moderate (15-29 events/hour) or severe (≥30 events per hour) to mild sleep apnea (5-14.9 events/hour) as a win. The medical research is less conclusive in showing that mild sleep apnea has the deleterious long-term effects on your health that moderate and severe degrees have. What can you do to significantly move the needle on your OSA? I'm going to discuss strategies that have been shown to have the potential to dramatically improve or cure the issue. I'm going to refrain from commenting on things that have only been shown to slightly mitigate the sleep apnea like learning how to play the didgeridoo or throat muscle exercises.
Some of the very biggest factors causing sleep apnea are being overweight (body mass index or BMI of 25-30) or obese (BMI ≥30) and having a big neck (neck circumferences of 17” or more in men and 16” or more in women). Keep in mind that neck circumference is typically dependent on weight.
The American Academy of Sleep Medicine’s guideline is, if you are heavy and diagnosed with OSA, it is reasonable to retest you if you lose at least 10% of your total body weight. In my experience, this often leads to unnecessary sleep tests. I recommend losing the weight and then taking a few nights off of using your CPAP or other treatment. If you start sleeping poorly again, feel tired during the day, or your bedpartner says that you are snoring like crazy or having apneas, then you’re not ready – keep losing weight and reassess. Let's be honest here though, it is really, really hard for most people to lose significant amounts of weight and keep it off.
Weight loss surgery is an interesting prospect. Research shows that weight loss surgery can cure a number of obesity-related medical problems such as high blood pressure and type 2 diabetes. What about sleep apnea? The research we have suggests that many patients who have bariatric surgery will still have some degree of sleep apnea after their weight loss stabilizes. The current hypothesis is that there may be a “kindling” effect whereby having OSA for a long period of time leads to dysfunction within the brain’s centers that control the upper airway muscles, potentiating OSA despite having a more patent airway.
Quitting smoking and alcohol use, or at least keeping them away from bedtime, can have a profoundly positive impact on your sleep apnea. Tobacco smoke irritates the epithelium, or inner lining, of your upper airway, causing edema (fluid) to accumulate and narrow the airway, predisposing it to collapse during sleep. On a side note, questions about marijuana use are becoming increasingly common amongst my patients due to the relaxing of marijuana-related laws in many jurisdictions. I do not hold myself out to be a cannabis expert by any stretch of the imagination but it seems logical that smoking marijuana could have the same deleterious effects on your upper airway as cigarette smoking. Eating the THC, or at least using a "vaporizer," seems like a better strategy.
Alcohol has muscle relaxant effects that can make your airway more prone to collapse. It also is a central nervous system (CNS) depressant that can prevent your brain from waking up from the warning signals it is getting from your body as a result of the abnormal breathing events, leading to your body potentially suffering more physiological stress and damage. Sedatives, muscle relaxants, and narcotic pain medications can have the same effect. Make sure to discuss with your prescribing physician before attempting to make any changes to your medication regimen.
A Surgical Cure?
The Roto-Rooter AKA The UPPP Surgery
Historically, the most common surgery for sleep apnea has been an upper airway surgery performed by ENTs known as the “UPPP,” short for uvulopalatopharyngoplasty. Unfortunately, the long-term data revealed that this surgery was only about 40-50% effective in significantly improving the degree of OSA and the benefits tend to abate with time. There is some evidence that many years later, patient’s who have had UPPP surgery may end up with worse OSA than they started with before the surgery.
Other ENT Surgeries
Despite patients’ wishful thinking, nasal surgeries such as septoplasty (correction of a deviated septum) and turbinate reductions have minimal effects on OSA. Glossectomy, partial removal of the tongue, does have good evidence showing that it can improve OSA but it is very painful and seldom done in clinical practice.
The BiMax: The Atomic Bomb of OSA Treatments
There is one surgery that can be curative for OSA and it is known as the “BiMax” for bilateral maxillomandibular advancement surgery. This surgery is performed by an oral and maxillofacial surgeon and involves your maxilla (cheekbones) and mandible (lower jaw) being broken, advanced about 1 cm, and fixed in place with hardware. Your jaws will need to be restrained through wires or a splint for 4-6 weeks after the surgery. You will look different after the surgery but most people feel like their appearance is improved due to a better jawline. Research shows that, in the right patient, this procedure is 90% effective over the long-term in getting the AHI <5, i.e., curing the sleep apnea. The best candidates for this surgery are non-obese people with severe obstructive sleep apnea. The surgical complication rate is relatively low. The most common long-term adverse effect is numbness on the cheeks.
If you're really motivated, there is a decent chance that you can best sleep apnea through weight loss and quitting smoking and drinking, if those are contributing factors for your case. For lazier people looking for a cure, the BiMax is the best solution. However, most patients that I discuss the BiMax with shudder at the thought of such an extreme surgery. If you fall into that camp, maybe treating sleep apnea with CPAP therapy is beginning to sound more appealing?
Joseph Krainin, M.D., FAASM is the founder of Singular Sleep, the world's first online sleep center. He is a Fellow of the American Academy of Sleep Medicine and board-certified in both sleep medicine and neurology. He has been practicing medicine for over 10 years.