I am writing from Orlando and the 21st Annual Advances in Diagnosis and Treatment of Sleep Apnea and Snoring course, for which I am a Co-Director. We were so happy to have close to 200 attendees for the 3 day meeting, reflecting the strong interest in sleep apnea and snoring among physicians and dentists from a wide variety of fields: internal medicine, pulmonology, otolaryngology – head & neck surgery, and oral and maxillofacial surgery.
Instead of summarizing all the lectures, I wanted to share some of the key points that I took away from the course, many of them not involving surgery at all. The course combines a wide range of topics important to sleep apnea, snoring, and other sleep disorders, and the first day is not related specifically to surgery–so the highlights are not specifically related to surgery.
Nalaka Gooneratne, MD from the University of Pennsylvania spoke about treatment of sleep apnea in older adults (age 60 years and older). Nalaka reinforced but also added to my understanding of what I think is a fascinating topic. In short, there are a number of studies suggesting that sleep apnea in older adults may be different from that in young and middle-aged persons. It seems that older adults may not need to be treated as aggressively. Any older adult (or any adult) with an apnea-hypopnea index (number of times per hour with blockage of breathing) above 30 should be treated. For those with an apnea-hypopnea index of 5-30 should be treated if they have other signs or symptoms, whether sleepiness, poor sleep quality, memory loss, or medical concerns like hypertension or diabetes.
Nalaka also spoke about melatonin that can be used in treatment of insomnia (especially for those who have trouble falling asleep). While I have always encouraged patients to continue using melatonin if they are already using it, but I have not always had great advice about how to start its use. Because melatonin has minimal side effects, he proposed a very reasonable approach of starting at a melatonin dose of 5-10 mg, using it for a month to see if there is some benefit. The key is to take the melatonin 2 hours before bedtime because it does take some time to be absorbed into the body. If there is benefit, one could then taper down to a dose as low as 1 mg while maintaining the benefit. One last point: melatonin is not regulated by the FDA, and there are various formulations available, none of which has been proven to be superior to the others.
Andrew Goldberg, MD, MSCE from the University of California, San Francisco is another one of the course Co-Directors. He discussed the importance of looking beyond the apnea-hypopnea index when treating obstructive sleep apnea. Basically, there exists a certain tunnel vision in caring only about the apnea-hypopnea index that limits providers and patients who would do better to consider the other effects that matter to patients: health impacts, sleep quality and resulting effects like sleepiness and fatigue, and what may be the most important impact that leads people to seek treatment in the first place–snoring! It reinforces the broader consideration of each patient as more than a single number and is really at the heart of what we do as physicians: caring for people and not just numbers.
Richard Schwab, MD, another course Co-Director from the University of Pennsylvania spoke about his fascinating work related to the anatomy (structure) of the mouth and throat as it relates to sleep apnea. He discussed his group’s research showing that individuals with sleep apnea deposit more fat within their tongue, making the tongue physically larger and likely more prone to contribute to obstructive sleep apnea. It builds on quite a bit of research he has led involving MRI.
Sam Kuna, MD and Ilene Rosen, MD both from the University of Pennsylvania, spoke about advances in telemedicine for treatment of obstructive sleep apnea and insomnia in various studies and the Veterans Administration Medical Centers in this country. I am often contacted by individuals who would like to schedule consultations over the telephone or a video conference system like FaceTime or Skype. The challenge is that there are no formal processes for these to be considered true medical appointments, with all the privacy and legal safeguards and the insurance billing that this entails. I personally think much of what we do can be delivered through the Internet, including the information that I have developed into my videos posted on Youtube. Obviously, a physical examination offers me the ability to look inside a patient’s mouth and perform basic evaluations like a fiberoptic examination. Right now, we do not have great technology to reproduce these, even if a video conference and a flashlight that a person shines into their mouth can be very helpful. I look forward to advances in technology that will enable telemedicine to offer even greater benefits.