I wanted to share highlights from our 22nd Annual Advances in Diagnosis and Treatment of Sleep Apnea and Snoring course in San Francisco. I am admittedly biased as a Co-Director of the course, but I think this is one of the best available, especially for surgeons. The snoring and sleep apnea course program includes lectures in sleep medicine (non-surgical) as well as surgical and dental topics. We again drew about 175 physicians to San Francisco, where I had a chance to connect with long-time friends from my time on the faculty at the University of California, San Francisco.
Atul Malhotra, MD from the University of California, San Diego gave another interesting lecture on the factors that contribute to sleep apnea. Atul has performed excellent research in this area for many years with colleagues both at UCSD and in his previous position at Brigham and Women’s Hospital in Boston. One of the most enjoyable aspects of this sleep apnea course is the opportunity to come together with long-time colleagues and friends and discuss cutting-edge concepts in the field. Atul spoke about the constellation of abnormal anatomy, control of muscles and breathing, arousal threshold (how easily someone wakes up), and some other factors that can be important in individual patients. At the present time, we do not have simple ways to identify the relative importance of these, but it may be that a combination of treatments (for example, surgery and certain medications) may improve outcomes for patients with sleep apnea much better than a single treatment approach.
Richard Schwab, MD from the University of Pennsylvania spoke about his research in upper airway anatomy, especially related to magnetic resonance imaging (MRI). I have written previously about Rich’s most important recent study about how individuals with obstructive sleep apnea may be more prone to depositing fat within their tongue when they gain weight. He reviewed these findings and those of other studies in his thoughtful and interesting presentation.
Sleep Apnea: More than Just the AHI
We know that sleep apnea is not defined entirely by the apnea-hypopnea index or other measures from a sleep study, as this does not mean a wide range of symptoms and health-related impacts that sleep apnea can have. I have written previously in this blog about the importance of looking beyond the apnea-hypopnea index, and Andrew Goldberg, MD, MSCE delivered a provocative talk questioning how we score sleep studies in the first place and asking why we do not include other measures more specifically. Nobody wants to discard the sleep study, but it is odd that we have not advanced beyond our current focus on the sleep study in incorporating these other metrics. In my own practice, I use questionnaires and other questions that evaluate the broader picture of sleep apnea when I see a patient because all patients are different. My thorough new patient assessment provides a deeper understanding of how sleep problems, including sleep apnea, affect their lives. I tell patients that I treat people, not individual numbers like an apnea-hypopnea index, and these assessments are critical to understanding the person.
Atul then spoke about the cardiovascular consequences, outlining the clear evidence that obstructive sleep apnea (particularly moderate to severe obstructive sleep apnea) is associated with development of hypertension and other cardiovascular disease. Treatment has also been shown to lower these risks, with the clearest evidence for CPAP (in patients who can tolerate it) but also with studies supporting the benefits of surgery and oral appliances.
Sam Kuna, MD from the University of Pennsylvania has been a leader in scientific evaluation of home sleep apnea testing. He discussed the available studies that indicate that, especially for patients with a moderate or high chance of having sleep apnea before any testing, the use of home sleep apnea testing, followed by use of auto-adjusting positive airway pressure is as good as in-laboratory studies. Hone sleep apnea testing has some real benefits, whether in improving access to sleep testing or offering testing at lower costs.
Snoring: Does It Matter, and How Do I Choose What To Do?
Snoring is a common and often-complex problem. Jolie Chang, MD from the University of California, San Francisco discussed some of the potential health risks of snoring that we have summarized in a medical journal article. Snoring may contribute to carotid artery narrowing (that would contribute to stroke risk), and of course snoring bothers anyone who has to sleep within earshot of the snorer. There is a wide range of options available to treat snoring, but the challenge is that doing the same thing for everyone is doomed to failure. It is critical to use the latest studies and rely on experience and judgment to evaluate patients and determine what treatments will benefit a specific patient.
Sam then discussed positive airway pressure (CPAP, BPAP, and APAP), emphasizing how helpful it can be in treating sleep apnea as well as the limitations for patients who all too often find it difficult to use it comfortably. Honestly, many patients just hate CPAP. Sam has led some very interesting research exploring the multiple factors that influence CPAP use, including socioeconomic status (patients from poorer areas wear CPAP less) and their tendency to take prescribed medications (patients who do not take other medications also do not wear CPAP). Obviously, every patient is an individual, but his work has pointed to new factors that are associated with CPAP use.
A true sleep apnea course – it is not just all surgery
Peter Cistulli, MD is a pulmonologist (lung specialist) from the University of Sydney is one of the world’s leading advocates for the use of oral appliances to treat obstructive sleep apnea. He has done research related to their ability to treat sleep apnea and argues in favor of their use, as they can be favored by patients instead of positive airway pressure therapy. I somewhat disagree with his opinions that side effects are minor, as a substantial number of patients will develop temporomandibular disturbance or movements of their teeth, especially if you consider that oral appliances require lifelong treatment for most patients and that some of these side effects continue or worsen over time. In my opinion, oral appliances are important treatment options for patients with snoring or obstructive sleep apnea. Like CPAP, they require that a patient is able to sleep comfortably while wearing them at night. For this reason, I refer a number of patients to dentists when my evaluation suggests that they would be helpful. At the same time, I have a number of patients who are dentists and come to see me for surgery because they cannot tolerate oral appliances or experience important side effects.