Open Access
Feature Article

Obstructive sleep apnoea – navigating the system

Open Access
Feature Article

Obstructive sleep apnoea – navigating the system

CLAIRE M. ELLENDER, CERYS JONES, CRAIG HUKINS

Figures

© chameleonsey/ istockphoto.com Models used for illustrative purposes only
© chameleonsey/ istockphoto.com Models used for illustrative purposes only
Dr Ellender is a Respiratory and Sleep Physician at the Princess Alexandra Hospital, Metro South Hospital and Health Service, Brisbane; and Senior Lecturer at the Faculty of Medicine, Princess Alexandra Southside Clinical Unit, University of Queensland, Brisbane. Dr Jones is a General Practitioner at Eastbound Medical Clinic, Bentleigh East, Melbourne, Vic. Dr Hukins is a Respiratory and Sleep Physician at the Princess Alexandra Hospital, Metro South Hospital and Health Service, Brisbane; and Associate Professor at the Faculty of Medicine, Princess Alexandra Southside Clinical Unit, University of Queensland, Brisbane, Qld.

Mandibular advancement splints are indicated in mild to moderate OSA in the absence of significant oxygen desaturation and in patients who are intolerant of CPAP therapy.19 

The advantages of mandibular advancement splints are that they are more portable than CPAP machines and they are associated with fewer nasal side effects than CPAP therapy. Their disadvantages include their cost, the potential long-term changes to the wearer’s bite and the requirement for adequate dentition. Mandibular advancement splints generally cost between $1200 and $2500 and full payment before use is usually required.

Surgery

Surgery as a treatment for OSA remains largely a last resort, and is only indicated in patients with mild symptomatic OSA where reversible risk factors (e.g. obesity) have been optimised, or for other OSA patients who cannot tolerate alternative therapies, following a sleep specialist opinion.16 The procedure involves debulking of the uvulae, palate and tongue with radiofrequency tissue ablation (known as a modified uvulopalatopharyngoplasty and coblation channelling of the tongue). 

The advantage of surgery is that there is no ongoing requirement for device use; disadvantages include the risks of surgery and the limited longevity of efficacy as people age and gain weight. 

Advertisement

Positional therapy

Positional therapy can be used for sleep apnoea where upper airway obstruction is present only in the supine position. Several forms of positional therapy are available, including vibro-tactile electronic devices, tennis balls sewn into a nightshirt and pillows with straps to prevent supine sleep. These are available for purchase through local CPAP retailers. 

Positional therapy is indicated in mild to moderate OSA where there are infrequent events in the lateral position (e.g. lateral AHI less than 15 events per hour).

The advantage of positional therapy is that it has fewer side effects than other treatments; a disadvantage is that long-term adherence is poor. 

Advertisement

Weight loss

Weight loss of more than 10% body weight can improve the severity of OSA; however, even surgical weight loss has been shown to result in persistent OSA in most patients.20 Thus, weight loss in isolation is not likely to be sufficient treatment for patients with moderate or severe OSA. 

PAP treatment

Accessing CPAP treatment

Following confirmation of the diagnosis of OSA, some patients can commence APAP treatment immediately and others will require in-laboratory CPAP titration (Table 3). This can be done by GPs in primary care, via local CPAP retailers and without a sleep physician consultation if the patient is able to self-fund therapy.  See Table 3 for a guide to which patients are suitable for auto-titrating CPAP and which patients require in-laboratory CPAP titration studies. 

Patients are generally encouraged to rent an APAP machine for at least three nights and then rent a fixed pressure CPAP machine for two months prior to purchase of a CPAP machine to ensure tolerability. In most capital cities, rental of an APAP or CPAP machine costs about $100 to $200 each month. Masks cost about $120 to $300 and usually require replacement of head straps and silicon seals every 12 months.

Advertisement