Inspire Medical’s Upper Airway Stimulation technology is a powerful (no pun intended) addition to the array of options for individuals suffering from obstructive sleep apnea. As a surgeon who implants this therapy, I see patients (whether my own or those coming for a second opinion) where Upper Airway Stimulation is not working well. While there are no magical solutions, it is clear that a careful, thorough approach can often lead to major improvements. Here are some of the steps to take when patients have persistent obstructive sleep apnea after being treated with Upper Airway Stimulation:
1. Do Not Give Up
Treatment with Upper Airway Stimulation is a process. The process takes a few months, starting with the preoperative evaluation and including the implant surgery, activation and adjustment of the system. It can be frustrating to go through this processand not have a perfect result. The important thing is not to give up. Improving results requires everyone to keep moving forward, figuring out why the therapy is not working and coming up with a plan to address the issues.
There are a number of reasons why Upper Airway Stimulation may not be working well enough. The first step is to collect data from the patient, bed partner, device itself, and the sleep studies done with the system activated. Identify the source of the problem and develop a plan to address it or learn more. When I have encountered unusual issues, I have reached out to the Inspire team. I have been so impressed with their dedication and insight that has helped to resolve issues or overcome obstacles that patients are facing.
3. Awake or Sedated Titration
Often everything is functioning properly and the patient is tolerating therapy without not having resolution of their sleep apnea. In these cases, a change in the electrical settings of the device can be helpful. Upper Airway Stimulation includes a stimulation lead that has 3 electrical contacts placed on a portion of the nerve that controls tongue movement (hypoglossal nerve). The system typically delivers the electrical stimulation in a certain manner, using the three electrical contacts with a specific combination of positive and negative settings on the contacts to produce an electrical field for nerve stimulation. Some patients benefit from an adjustment in these settings to modify the electrical field of stimulation if this can move the tongue forward in a more favorable way. The goal is to open the space for breathing not only in the Tongue Region but also in the Palate Region; sometimes a change in the electrical configuration is all that is needed. This exploration of changes is often first done while a patient is awake in the office but can be done under sedation using the technique of drug-induced sleep endoscopy.
4. Consider Additional Treatments, Including Surgery
Treating obstructive sleep apnea often requires a combination of therapies. While the majority of patients have excellent results with Upper Airway Stimulation alone, in many cases another treatment can be added. The other treatment can be something as simple as positional therapy (avoiding sleeping on the back), or it can be another surgery.
The surgeries that can be combined with Upper Airway Stimulation range from a revision of the Inspire system (generally to move the stimulation lead) to adding surgery for the Nasal Region or Palate Region. I have written previously about work presented at the 2018 International Surgical Sleep Society meeting in Munich about good results for soft palate surgery performed in patients treated with Inspire who had incomplete resolution of their sleep apnea. Currently, I have a couple of patients who are considering soft palate surgery and another who would benefit from repositioning of the stimulation lead cuff.
The Bottom Line
The bottom line is that whenever something does not work as well as we would like…find out why and develop a plan to address it.