My career in sleep apnea surgery is based on the principle that successful surgery should focus on the physical cause(s) of blockage of breathing for each patient. We can determine these physical cause(s) with different evaluations that examine an individual patient’s anatomy that is the source of these physical cause(s). I have focused on the drug-induced sleep endoscopy examination, both in my care of patients and my research. Our international, multicenter cohort studies have shown how drug-induced sleep endoscopy findings before surgery are associated with outcomes of different sleep apnea surgery procedures and, separately, Inspire Upper Airway Stimulation. We have used these same studies to show that some findings of our awake office examination can be combined with drug-induced sleep endoscopy findings to predict outcomes of Inspire Upper Airway Stimulation.

Is there more to sleep apnea surgery than the anatomy?

Because of my research over the past 2 decades, I have had the opportunity to share ideas and learn from colleagues inside and outside the world of sleep apnea surgery. One of my mentors is David White, MD, an incredible person who is also a Professor of Medicine at Brigham and Women’s Hospital and one of the world’s experts in the causes of sleep apnea. Over the past five decades, he has conducted research and trained so many others, showing that factors other than a patient’s anatomy can also play an important role in obstructive sleep apnea.

The factors, also called traits, include anatomy (the most important trait), control of breathing patterns (ventilatory control), how easily someone awakens from sleep with blockage of breathing (arousal threshold), and the ways in which a person has reflex activation of muscles surrounding their throat to improve the space for breathing (muscle responsiveness). Of the non-anatomic traits, ventilatory control and arousal threshold appear to be the most important in sleep apnea surgery patients. Specifically, patients who do not respond as well to surgery are more likely to have abnormalities in these two non-anatomic traits.

Combining surgery and medications to improve

A number of trials have attempted to treat the non-anatomic traits with medications or oxygen as a first-line sleep apnea therapy. The results have not been great, on average, but in almost every study there are a few patients who do respond very well. One important limitation of these studies is that they have not included treatment of the anatomy, so they have overlooked what is clearly the most important cause of obstructive sleep apnea.

During the early stages of the COVID pandemic, because I had some time to dive into research ideas without being able to perform patient care in the same way, I developed a research proposal based on these traits. Ultimately, this led to receiving funding from the National Institutes of Health – one of the few studies of adult sleep surgery they have ever funded – to conduct this work. This research was a key reason for my move from USC to UCLA, and we are now in full swing with the work.

What is my sleep apnea surgery clinical trial at UCLA?

The clinical trial identifies patients who appear to have blockage of breathing at the soft palate, based on their office examination and drug-induced sleep endoscopy. If they agree to undergo soft palate surgery, they can enter the research study. They would get a sleep study (in the sleep lab) before and after surgery to evaluate the results of surgery. If they did not achieve the results we wanted to see with surgery alone, they would then be treated with medications to address the two non-anatomic traits that appear to be most important in surgery patients: ventilatory control and arousal threshold. The idea behind the research is that we would approach anatomy and these two non-anatomic traits to see if the combination could improve results. The study is registered at ClinicalTrials.gov, with more information here.

What to do if you are interested

This work is not secretive, so individuals can be treated with these medications outside of the trial. The important part about the study, however, is that the sleep studies we are running will evaluate these non-anatomic traits, something that is not done with standard sleep studies (at home or in the sleep lab). This makes it important that you be a patient of our sleep surgery team and be scheduled for soft palate surgery here at UCLA. If you are interested in learning more about this, please feel to reach out to me via e-mail ([email protected]).

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