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The Gold Standard Treatment For Obstructive Sleep Apnea

Posted Oct 22 2010 1:17am

In the sleep community, CPAP is consistently mentioned as the “gold standard” treatment option for obstructive sleep apnea. I find this odd, since the overall success rate for CPAP is disappointing, especially if you look at overall acceptance and compliance numbers. Some people may take exception to what I have to say, but here are the facts:

Theses are only rough estimates, but if you take 100 people who are newly diagnosed with obstructive sleep apnea, only about 1/2 are willing to even try it. Of the people who give it a try, maybe about 1/2 end up using it regularly, and of those who use it regularly, perhaps 1/2 continue to use it for more than 1-2 years. Even if you’re using it regularly, not everyone feels any significant improvement in their symptoms.

As you can see, out of all the possible people who are candidates for CPAP, only a small fraction ever end up benefitting at all. It’s shocking how many CPAP machines sit in the closet after only a few weeks use. In controlled research studies, compliance can be quite high, even up to 60 or 80%, but in the real world, it’s probably more like 20-30% long-term.

Despite the grim statistics, CPAP is still the best option that we have. Millions of people benefit from its’ use significantly, and in many cases, it’s a life-saver. There’s also so much more that can be done to educate and support new CPAP users so that more people are able to use and benefit from it.

The frustrating thing is that there are alternative forms of treatment that can be just as good, if not better than CPAP. But in most cases, they’re simply dismissed as being not effective.

The first treatment option that’s available that should be considered the real “gold standard” is tracheotomy. This is where a hole is surgically made just below your voice box into your windpipe, essentially bypassing your entire upper airway. This has essentially a 100% cure for obstructive sleep apnea.

The two other major options for sleep apnea are oral appliances and surgery. The criticism by certain sleep doctors against these two options is that it never gets the AHI down to normal levels. But even a 50% drop in the severity of your breathing pauses is much better than not using your CPAP at all. This was borne out in one Veterans Administration study that showed that the UPPP procedure (with a historical 40% success rate) had a higher overall survival rate years later compared to people placed on CPAP. Surgical “success” is a controversial topic, and I’ve talked in detail about my logic for offering surgery at all.

It’s clear that there are certain camps that are strong proponents for each of the three major treatment options (CPAP, dental devices, and surgery). Each has it’s advantages and disadvantages. CPAP should always be considered first, but the two other treatments should at least be offered once you’ve exhausted all your CPAP options. Advanced orthodontics is another emerging treatment option but we’ll have to see results from more studies.

One interesting observation is that for people who are happy with their surgery, they forget about the fact that they have obstructive sleep apnea. They just go on with their their normal (and more productive) lives. They’re not reminded every night that they have sleep apnea, as what happens with oral appliances or CPAP. For others, CPAP is a normal part of life, like brushing your teeth before bedtime, and are not bothered at all. Notice how different people deal with their treatment options differently.

In my mind, it’s not about which option is better, but customizing your treatment plan based on a systematic process that starts with CPAP, and making sure to go on to other options if CPAP is not working. Unfortunately, too many people give up after trying only CPAP. Ultimately, there is no gold standard.

What’s your feeling on this admittedly controversial topic?

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