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Obstructive Sleep Apnea


Weight loss, sleeping on one's side, and decreasing alcohol consumption can help


Obstructive Sleep Apnea (OSA)

OSA is a sleep disorder that is associated with the repetitive collapse of the upper airway during sleep, which results in fragmented sleep, recurrent arousals, and intermittent periods of hypoxia and hypercapnia.

Airway obstructions may be described as hypopneas or apneas, depending on their severity. When airflow is reduced by at least 30% for 10 seconds or more, the episode may be called a hypopnea. If airflow is reduced 90% or more for at least 10 seconds, it is described as an apnea.

Prevalence of Obstructive Sleep Apnea

Obstructive Sleep Apnea (OSA) affects around one billion adults worldwide, and between 2% and 9% of adults in the United States. Though, actual prevalence may be much higher because the majority of cases go undiagnosed.

European countries with the highest prevalence are:

  • Russia, 40 million
  • Germany, 26 million
  • France, 24 million
  • Ukraine, 13 million
  • Spain, 9 million
  • United Kingdom, 8 million

It has been receiving increasing attention in the past decade, largely because of the growing research linking OSA to cardiovascular disease, metabolic disorders, and a decline in neurocognitive and behavioral functions.

Risk Factors

Although the pathophysiology of the disorder is not well established and a multifactorial origin is suggested, previous epidemiological studies pointed out that OSA is associated with aging, the male gender, craniofacial anatomy, and obesity (body mass index or BMI). However, there is mounting evidence for post-menopausal women having a higher risk of developing OSA.

  • 83% of people with drug-resistant hypertension have sleep apnea
  • 77% of people with obesity
  • 76% of people with chronic heart failure
  • 72% of people with type 2 diabetes
  • 62% of people with a prior stroke
  • 49% of people with atrial fibrillation

Certain physical features can also make a person more likely to develop OSA, such as:

  • A lower jaw that is small or positioned farther back
  • A tongue that is enlarged at its base
  • Large tonsils
  • A neck size larger than 17 inches
  • Excess fat surrounding the throat

Cigarette smoking can increase the risk of OSA by as much as three times compared to people who have quit or who have never smoked.

How is Obstructive Sleep Apnea Diagnosed?

Also called polysomnography (PSG), a sleep study involves an overnight stay at a specialized sleep laboratory, often located within a sleep center or hospital. Sometimes, a sleep study can be completed at home with a portable sleep monitor.

Portable sleep monitors (PM) should, at a minimum, record airflow, respiratory effort, and blood oxygenation. The type of biosensors used to monitor these parameters for in-laboratory PSG are recommended for use in PMs and include an oronasal thermal sensor to detect apneas, a nasal pressure transducer to measure hypopneas, oximetry, and, ideally, calibrated or uncalibrated inductance plethysmography for respiratory effort.

During a sleep study, trained and certified technicians will place sensors on the head and other parts of the body. They may also place several belts around the chest and position a small tube beneath the nose. These devices take measurements of various body functions during sleep, such as breathing, movements, heart rate, and how long it takes to enter different stages of sleep.

The systems analyze, display and summarize Electrocardiogram (ECG) or Plethysmogram (PLETH) data, typically collected during sleep, then generate the Apnea Hypopnea Index (AHI) or respiratory disturbance index (RDI), to aid in the evaluation of sleep disorders, diagnose obstructive and central sleep apnea, and the management of sleep disorder treatment.

The severity of sleep apnea is defined as follows:

No sleep apnea

AHI < 5 per hour sleep.

Mild sleep apnea

AHI 5–15 per hour sleep.

Moderate sleep apnea

AHI 15–30 per hour sleep.

Severe sleep apnea

AHI ≥ 30 per hour sleep.

When considered in combination with a person’s symptoms, the number of breathing events per hour found during a sleep study can help doctors determine the severity of OSA.

Most of the PSG devices are compatible with and use a Software as a Medical Device (SaMD), which is cleared by the U.S. Food and Drug Administration (FDA).

Treatments of Obstructive Sleep Apnea

The primary treatment of choice for mild, moderate, and severe OSA is positive airway pressure (PAP) therapy, and should be offered as an option to all patients.

PAP therapy involves the use of pressurized air through a mask, which is pumped by a bedside machine and into the nose and/or mouth to keep the airway open during sleep. This therapy may be provided using continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP or BPAP), or auto-titrating positive airway pressure (APAP). BiPAP may be prescribed when CPAP is not well tolerated, or low oxygen levels persist at night despite the use of CPAP.

Your prescription will specify the type of therapy needed and your therapeutic pressure, as well as accessories such as mask types, chin strap, or humidifiers, which are essential to the proper delivery of positive airway pressure.

It takes time to adjust to sleeping with PAP therapy, often several weeks to few months. When adjusting to your new machine, you may experience nasal congestion, headaches, skin irritation or stomach bloating. Most of these side effects are temporary and can be reduced by changing the mask style or using a heated humidifier to add moisture to the air.

Obtaining Durable Medical Equipment (DME)

CPAP device prices range from $250 to $1000 or more (frequently run in the thousands of dollars), not including the cost of necessary accessories such as filters and masks.

Furthermore, most insurance providers require that you fulfill the following, in addition to meeting your annual deductible:

▪ First, you must have a prescription for CPAP therapy from your healthcare provider.

▪ Second, you must successfully complete a compliance period with the CPAP machine, to demonstrate that you are using the treatment regularly. Typically, at least 4 hours per night, on 70% of nights, in a consecutive 30-day period.

More recent PAP devices record your use via an app on your phone, while others use an SD card reader to collect the data. If you are unable to meet these requirements during the first 3 months, you may have to start the process again, or stop the treatment altogether.

There are supplies that need to be replaced over time, including:

  • Masks
  • Mask components
  • Tubing
  • Filters
  • Chin straps
  • Headgear
  • Water chamber

You will need to contact a DME vendor in order to get your prescription filled and obtain the equipment. Once chosen, the vendor requires insurance information, prescription, authorization forms, and sleep study report.

The vendor will then get insurance approval for DME coverage, before shipping the apparatus to your home with further instructions. In some cases, the DME vendor may request additional information, such as a Letter of Medical Necessities.


You might be able to find direct-to-supplier PAP manufacturers with lower prices than those available through your insurance plan. However, make sure to check if these devices are cleared by the FDA.

When you choose to buy your PAP equipment without insurance, you avoid the requirements of treatment compliance, eliminate the possibility of restarting the process of getting a sleep test and prescription from your doctor. Paying for your equipment directly gives you the opportunity to compare products and choose the PAP equipment you find most suitable.

Don’t forget to budget the ongoing costs of tubes, filters, and other replacements, as well as additional accessories for more comfortable sleep and easier travel:

▪ Pillows.

▪ Cleaners.

▪ Mask liners.

▪ Hose holders.

▪ Batteries.

▪ Travel bags.

Alternatives to Positive Airway Pressure (PAP) Therapy

Alternative therapies may be offered depending on the severity of the OSA and the patient’s anatomy, risk factors, and preferences.

Implantable Device

Inspire is the only FDA approved obstructive sleep apnea treatment that works inside your body to treat the root cause of sleep apnea with just the click of a button, and without mask, hose or machine.

It’s a small device placed under the skin of the neck and chest during a same-day, outpatient procedure that takes about two hours. When you’re ready for bed, simply click the remote to turn Inspire on. While you sleep, Inspire opens your airway, allowing you to breathe normally and sleep peacefully.

Each patient will have one incision under the chin and one below the collarbone. Some patients will also have one on the side of the rib cage. The battery in Inspire is designed to last for approximately 11 years.

You can expect to pay any deductible for the year, along with any copay or coinsurance fee for a surgery.

Oral Appliance For Sleep Apnea

Oral appliance therapy (OAT) is a clinically proven treatment for millions of patients with obstructive sleep apnea (OSA). OAT is far less cumbersome than traditional CPAP therapy because oral appliances are easy to use, comfortable, noise-free, portable, and do not require electricity or distilled water.

If you and your doctor decide that an oral device is a good option, you will need a referral to a dentist for evaluation, impression of your teeth and fitting. This device helps keep the airway open during sleep.

It is recommended to have another sleep test to see how the appliance is working for you. Further adjustments may be necessary. The risks of oral appliance therapy include:

  • Bite changes.
  • Pain in the jaw, teeth, and temporomandibular joint (TMJ) pain.
  • Loose teeth.
  • A need for dental work replacement.
  • Excessive drooling.
  • Mouth dryness.
Lifestyle Changes

▪ Weight loss and exercise. Exercise itself is associated with significantly improved apnea hypopnea index (AHI) (mean change -6 events/hour), sleep efficiency, subjective sleepiness, and cardiorespiratory fitness with minimal change in body weight.

▪ Not drinking alcohol before bedtime. Alcohol relaxes throat muscles, which can trigger snoring. If you want to enjoy an evening cocktail, be sure to stop drinking at least three to four hours before bedtime.

▪ Sleeping on your side. When you lie on your back, your tongue falls backward, blocking your airways.

▪ Elevate your head. Propping up the head of your bed by four or more inches can take pressure off your airway so that it’s easier to breathe while you sleep.

▪ The American Academy of Sleep Medicine states that “medical cannabis and/or its synthetic extracts should not be used for the treatment of OSA due to unreliable delivery methods and insufficient evidence of effectiveness, tolerability, and safety”.

When people think of sleep apnea, they picture an obese male who snores, but that’s just a stereotype.

The treatment pressure is measured in centimeters of water (cm H2O) and most devices can be set by the provider to deliver pressures between 4 and 20cm H2O.

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