The Inspire Upper Airway Stimulation System is a new FDA-approved treatment for obstructive sleep apnea in patients who are unable to tolerate or do not receive benefit from positive airway pressure. Studies published in major scientific journals, including the New England Journal of Medicine, showed that 2 out of 3 patients who received the Upper Airway Stimulation system achieved a dramatic improvement or resolution of their sleep apnea. There were major improvements in sleepiness and other effects on daily activities. In addition, 85% of patients had no or soft snoring.

This treatment involves a surgical procedure to place the system inside the body, and patients receive a remote control to turn on the device when they go to bed and turn it off in the morning when they wake up. It does not require a mask or anything to wear at night.

Dr. Kezirian is one of the world’s leaders in sleep apnea surgery, including Upper Airway Stimulation, and he has worked with this approach to treating sleep apnea for the past 10 years. Dr. Kezirian has treated many patients who have had tremendous benefit from Upper Airway Stimulation and the team at Keck Medicine of USC with Upper Airway Stimulation. This patient has wanted to share his experience with other patients with sleep apnea that are struggling with positive airway pressure therapy (such as CPAP). A video of Brian’s story is available at the Keck Medicine of USC Otolaryngology–Head & Neck Surgery website.

KCBS Television in Los Angeles featured a story that featured this same patient. The story includes a brief discussion from Dr. Kezirian about the effects of sleep apnea and how Upper Airway Stimulation works. The story is shown below:

Dr. Kezirian has also developed the video below to answer the most common and important questions related to Upper Airway Stimulation.

 

How does Upper Airway Stimulation work?

The tongue can play a major role in obstructive sleep apnea because during sleep, when the muscles in the body relax, the tongue can fall back to block breathing in the throat. There are 3 components of the Upper Airway Stimulation system that are placed inside the body during a surgical procedure. There is a pulse generator placed on top of the chest (pectoralis) muscle and two leads. When the system is turned on during sleep, the pulse generator sends a gentle stimulation signal through a stimulation lead to move the tongue forward and open the space for breathing in the throat.

 

How do I know if Upper Airway Stimulation is right for me?

There are 3 steps involved in determining whether you are a good candidate for the Upper Airway Stimulation therapy. First, you must have obstructive sleep apnea and have been unable to tolerate positive airway pressure therapy. Second, you would have an office evaluation with Dr. Kezirian to discuss whether it would be helpful. The third and final step is a short evaluation procedure called drug-induced sleep endoscopy. Dr. Kezirian is an international expert in drug-induced sleep endoscopy and has written on his blog about drug-induced sleep endoscopy and its use in selecting ideal candidates for the Inspire II Upper Airway Stimulation System.

Why should I come to see Dr. Kezirian for Upper Airway Stimulation?

Dr. Kezirian is the only surgeon in Southern California with a primary clinical and research focus in the surgical treatment of obstructive sleep apnea.  Keck Medicine of USC was the first center in Southern California offering the Inspire II Upper Airway Stimulation System to those suffering from obstructive sleep apnea. This is based on Dr. Kezirian’s substantial experience with this approach, his understanding of selection of ideal candidates, and the commitment of the Keck team to achieving the best outcomes. One of the tests required before receiving the Upper Airway Stimulation system is drug-induced sleep endoscopy; Dr. Kezirian is one of the world’s experts in this evaluation technique that is so important to determining whether patients should expect a good outcome from Upper Airway Stimulation.

To schedule an appointment with Dr. Kezirian, please call the Patient Access Center at 323-442-5790.

Inspire Medical has developed a brochure that provides additional information about the treatment and the published results. Here is another brochure from Inspire Medical that describes the consistent benefits that patients achieved through the first 3 years after receiving the device. Recent results were presented showing consistent outcomes for Upper Airway Stimulation through 5 years after implantation, but there is no specific brochure available.  The brochures are slightly more technical and designed for physicians, but many patients can understand these as well as many physicians.

 

Inspire Upper Airway Stimulation system for treatment of sleep apnea

 

Inspire Upper Airway Stimulation system in the body after sleep apnea surgery

 

RISKS

Bleeding

As with any procedure, there is a risk of bleeding. Bleeding in this area can be serious and life-threatening. Fortunately, this is uncommon, and usually there is only minor bruising. A major factor in preventing serious bleeding is to avoid the use of aspirin, NSAIDs (such as ibuprofen, Advil®, Motrin®, naproxen, or Aleve®), vitamin supplements, or herbal medications for at least two weeks before and after surgery.

Infection

To reduce the risk of infection, patients receive intravenous antibiotics prior to the procedure. The risk of infection with this precautions is low, but infections can be serious and require removal of the entire Upper Airway Stimulation system.

Tongue weakness or trouble swallowing

This procedure requires dissection of the nerve responsible for tongue movement: the hypoglossal nerve. The hypoglossal nerve can be injured during the procedure, but there are important precautions taken during the procedure to minimize those risks. Tongue movement is important for swallowing, and nerve injury or the swelling that can occur after this procedure can present some difficulty with swallowing. Damage to the hypoglossal nerve can recover over the course of days or weeks, but the damage can take months to recover or be permanent. Studies have shown that stimulation of this nerve during treatment with Upper Airway Stimulation should not cause damage to this nerve or other nerves.

Tongue numbness or tingling

There is a nerve (lingual nerve) that is responsible for the senses of touch and taste for the tongue. This procedure involves dissection in the general area of this nerve, although it is typically not encountered during the surgery. If nerve damage or these symptoms do occur, usually the damage is temporary with recovery over the course of days or weeks, but the damage can take months to recover or be permanent.

Facial weakness

The neck incision can be close to a branch of the nerve that controls facial movement. There are a number of precautions taken to avoid injury to this nerve. If nerve damage or facial weakness does occur, usually the damage is temporary with recovery over the course of days or weeks, but the damage can take months to recover or be permanent.

Change in voice

Damage to the hypoglossal nerve can cause changes in voice. If a change in voice occurs, they will typically resolve soon after surgery. However, permanent changes are possible.

Pneumothorax (collapsed lung)

The sensing lead is placed between muscle layers of the rib cage. There is a low risk of entering the space around the lung or injuring the lung. This can cause a collapsed lung, which requires treatment but should heal without long-term problems.

Need for additional procedures

Upper Airway Stimulation may not be effective in accomplishing the goals of surgery. Another procedure—either performed on the Tongue Region or on another area—may be necessary.

 

POSTOPERATIVE INSTRUCTIONS

NOTIFY DR. KEZIRIAN IMMEDIATELY IF YOU HAVE ANY TROUBLE BREATHING OR IF ANY BLEEDING DEVELOPS!

Pain control

Like most surgeries, there is pain in the recovery period. Most patients experience mild to moderate pain for 1-3 days. THe pain should improve after the first 2 days. If there is a second spike up in pain, especially if there is any trouble in breathing or swallowing, contact Dr. Kezirian. You will receive a pain medication to take as you need it. Some people try to “hang in there” or suffer without taking pain medications. Controlling your pain is important for breathing, healing, and being able to swallow enough to maintain your nutrition.

Nutrition and fluids

It is very important to have good nutrition and avoid dehydration after surgery. This procedure has less difficulty with pain and swallowing after surgery than some others that are performed for sleep apnea, but it is possible that you will only be able to tolerate a liquid diet for the first 1-2 days after surgery.

Antibiotics

Most patients receive an antibiotic after the procedure. This can be useful for preventing infection and decreasing swelling. Take the antibiotics as directed. If you develop a rash or diarrhea (possible risks of antibiotics and other medications), stop the antibiotics and contact Dr. Kezirian immediately.

Avoid strenuous physical activity for 4 weeks

Most patients will return to normal, non-strenuous activity in 1-2 weeks. However, strenuous physical activity increases heart rate and blood pressure, raising the risk of bleeding. In addition, it is important that all components of the Upper Airway Stimulation system heal in place. Strenuous physical activity can result in movement of the components of the system, resulting in possible additional procedures to place them in the correct position.

Walking and Breathing

Walking and taking deep breaths after surgery is important. Patients should walk at least 3 times a day starting the day after surgery. Taking 10 deep breaths every hour while awake is also very important. Walking helps prevent blood clots from forming in your legs. Taking deep breaths and spending more time out of bed (walking or in a chair) than in bed is helpful because your lungs fill up with air, lowering the risk of fevers and pneumonia. Not walking enough is a major cause of fevers after surgery, so please do remember to walk at least 3 times every day.

Do not use mouthwashes, lozenges, or throat sprays

Patients should not use mouthwashes, lozenges, or throat sprays following surgery because many of these contain alcohol that can irritate the lining of the mouth or numbing medication that can expose you to a serious complication when used for more than a couple of times.

Sleep with head elevated (at 45 degrees) for at least three days

Elevating your head during sleep decreases blood flow to the head and neck regions. Therefore, it decreases swelling and the associated pain. Elevating the head during sleep may also improve breathing patterns in other ways. Therefore, we recommend elevating your head during sleep at 45 degrees for at least three days following the procedure.

Nausea and constipation

Nausea and constipation can occur after any surgery. The anesthetic medications that you receive during surgery and the narcotic pain medication you receive after surgery can cause these. You will receive medications after surgery to decrease nausea and constipation, but please notify Dr. Kezirian if you feel constipated or have not had a bowel movement in any 3 days after surgery.

Postoperative appointment

Dr. Kezirian likes to see his patients about 1 week after surgery. If a postoperative appointment has not been scheduled, please contact the office at 323-442-5790 to schedule this when you return home after your surgery.

Additional questions

For any emergencies, please call 911.  For other questions, please contact Dr. Kezirian at eric.kezirian@med.usc.edu.  If you would like to speak with someone, please call the Call Center at 323-442-5790 and ask to speak to Dr. Kezirian or whomever is answering calls for his patients.

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