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MESSAGES TO

Sleep Apnea

A DxD Session with Dr Lynne Lim


Ended on Mon Mar 25 2019
Ended

Top Answers


There are so many types of CPAP machines on the market and internet, it can be bewildering. The most important consideration should be that it is something tailored to your specific type and severity of sleep apnea.

The mask choice, fitting, fine tuning of settings, type of CPAP, even the size and portability of the machine is important to optimise use and effectiveness.

The after sales support is very important too. For that reason, I do not advise that the CPAP be bought on the internet, as your doctors will not be able to support you in the use of the CPAP after that.

Machines do break down and mask fits do need updating along the way as your condition may change too. Without proper and hands-on, timely support and trouble-shooting, many patients end up not using what they have bought, with risk to their health.

When using a CPAP, it continues to be important to have some follow up with your doctor. For example, if the nose continues to be blocked, you would have to use the CPAP at high pressures and may not be able to tolerate it and thus become non- compliant with it.

The doctor may then need to help identify the source of block and some simple medications may help. If it is a structural obstruction, sometimes, a surgical procedure is needed to allow comfortable use of the CPAP.

If you go with a vendor or brand recommended by the doctor, that would be safe. The doctor liaises closely with the vendors to support the patient, and would choose only proven CPAP brands and models that have worked well. As you have identified, Philips and ResMed are well known brands, but there are others too, something to meet every need.

19 Aug 2018

Non-invasive, non-CPAP treatments are only considered for occasional or mild OSA, and if these are relevant:

  • Your mom should avoid alcohol and smoking if there is the off chance she is on them.
  • Your mom can try a change of sleep position to sleep on her side instead of on her back if there is no discomfort.
  • If she is overweight, losing help can help. If there is a nose block from allergy or infection, medications, nasal rinses and allergen control may help.

The European patent office lists more than 2000 devices which the public is tempted often to use to self-manage.

However, it is better to seek an ENT, sleep physician or neurologist’s consult first. For example, many of my patients try to use nasal splints or external nasal stickers to widen the nasal passages.

However, the level of block in their nose may not be at the nose, and those extra cost and discomfort would then not be helpful.

Mandibular Advancement Splints (MAS) worn at night may help advance the lower jaw in sleep. They are better prescribed by sleep dental specialists, as there can be discomfort in the temporomandibular joints and dentition otherwise.

There are tongue retainers which are used, but few patients have tolerated those well long term.

Unfortunately, continued sleep apnea will worsen dementia and cognitive decline, so treatment for your mom’s sleep apnea is very important. Anaesthesia comparatively, when expertly done, will not worsen her cognitive decline.

It is important to work with your vendor and doctor to see why the CPAP tolerance is low, as there is likely a simple solution to increase the CPAP tolerance.

19 Aug 2018

Thanks for the D2D. Here are some cost estimates for sleep apnea treatment in Singapore:

The initial cost would be the consultation (from $150) and possibly a flexible nasoendoscopy cost (from $250) to determine the levels of obstruction and medical issues that need to be managed holistically.

A sleep study is usually needed (from $500 depending on type needed). The costs thereafter would really depend on what type of treatment is, depending on the cause and severity of sleep apnea. Example, medications, CPAP machines, surgery – the cost would differ widely. The prices of CPAP machines and masks usually start from $1,000 for good quality ones.

However, the total cost would really depend on what the cause of the sleep apnea is eventually. 

Medisave and insurance coverage for the consult, nasal scopes to identify sites of airway blockage and medications is not a problem.

For sleep study and CPAP machines, different insurers and Medisave coverage can be patchy, so do check for your specific coverage entitlements first, as the individual would have signed for different coverage.

Surgery for the various sites of obstruction have been covered usually, but it would still be wise to clear with your specific insurer first.

20 Aug 2018

Many spouses do suffer chronic fatigue themselves if they are not able to sleep due to their spouse’s snoring. Some wear ear plugs to sleep. However, it is important to remember that your husband may be snoring out an SOS for help. Snoring is not just noise, but may be a sign that there is also sleep apnea.

To help your husband stop snoring and avoid complications of sleep apnea, do bring him to a doctor first to determine the anatomical or medical conditions causing the snoring. Only if the correct diagnosis is first made, and the management individually targeted, can the snoring be reduced or stopped.

Please refer to my reply to the question “What are my options to treat sleep apnea, and how effective is sleep apnea treatment?” for proven methods to address snoring and sleep apnea.

20 Aug 2018

 thanks for the D2D.

Please refer to my reply on “How to treat sleep apnea without CPAP or surgery?” for conservative first line measures to treat sleep apnea. Additionally, surgical measures may be needed when these conservative modalities do not suffice, or if the patient cannot tolerate the CPAP mask or prefer a surgical option.

What I have found to be most importantly, is to tailor treatment for each patient’s medical and anatomical condition, preferences, needs and comfort level. A multidisciplinary and multilevel approach is often needed. There is really no one best treatment, with even patients having the same severity of sleep apnea and sites of obstruction needing different treatment.

Surgery may be needed to correct a deviated nose septum bone, reduce inferior turbinates by actual trimming or radiofrequency or coblator reduction of size; or strengthen weak and collapsible nasal valves.

Even if a CPAP still needs to be used for severe sleep apnea post nasal surgery, establishing an open nasal airway is important to reduce mouth breathing, as mouth breathing inevitably allows the tongue to fall backwards in sleep and further obstruct breathing. A nasal surgery is sometimes needed thus, to allow CPAP ease of use.

If very large tonsils are the only cause of the sleep apnea, tonsil removal surgery is a simple surgery that will cure the sleep apnea. If the soft palate is low lying or medialised, it may require realignment through a uvulopharyngopalatoplasty (UPPP) surgery.

Nowadays, there are many modifications to UPPP that allow less complications and better results (like uvulopalatal flap and lateral pharyngoplasty). Should the base of tongue and its lymphatic tissue be bulky, radiofrequency or coblation reduction surgery may be helpful, but these procedures may need to be repeated several times to be effective.

Other surgery are usually 2nd line, as there are more complications. Careful selection of the patients after comprehensive counselling of pros and cons would be important.

For example, to reduce a large base of tongue prolapse, tissue removal of the midpart of the tongue may be needed (like median glossectomy), or skeletal advancement methods to prevent the tongue from falling backwards in sleep is needed (like inferior saggital mandibular osteotomy and genioglossus advancement and hyoid surgery).

Patients with receded lower jaw and midface may need skeletal maxillomandibular advancement surgery. This would require dental reorganisation too, and a more morbidity. If the CPAP is able to treat the OSA, most patients nowadays do not opt for the more complex surgical interventions.

Ongoing research into an implantable hyperglossal nerve stimulator for moderate to severe sleep apnea is ongoing for patients that have failed CPAP therapy. This maintains upper airway patency by augmenting the neural drive supplying the throat pharyngeal dilator muscles. It is not approved for use in Singapore yet.

20 Aug 2018

Thanks for the D2D. Snoring is not just noise. Not all who snore have sleep apnea, but snoring is a sign that you may have sleep apnea. In Singapore, a recent study found that 90% of those with already moderate to severe sleep apnea did not know that they had sleep apnea!

Sleep apnea happens when there is a block in the airway that results in significant oxygen desaturation in the blood. To differentiate snoring from sleep apnea, a definitive sleep study is needed.

People who snore loudly, stop breathing during sleep, have sleepiness and fatigue in the day, and have structural obstructions in the nose and throat, low lying soft palate and large tonsils, less developed chin and prolapsed base of tongue will have increased risks of sleep apnea.

Compared to Malays and Indians, Chinese have the highest sleep apnea rates, despite them having the lowest obesity rates. This is likely due to their craniofacial proportions that predispose to a narrower airway.  

Many of my patients seek treatment for sleep apnea late, when they already have hypertension, heart disease and diabetes that are hard to control despite medications and lifestyle changes, partly due to an undiagnosed sleep apnea.

20 Aug 2018

Thanks for the D2D. In sleep apnea, there is reduced oxygen in the blood from obstruction or collapse of the nose-oral-pharyngeal- laryngeal airway in sleep.  This reduced oxygenation leads to highly significant long term side effects, and can be thought of as a silent killer really. No one pays much attention to it till it is late or too late, as it seems like just harmless snoring.

Adults can have daytime sleepiness, irritability, depression, impaired concentration/ memory, fatigue and morning headaches. At night, there is choking or stopping of breathing episodes, grinding and wearing down of or cracked teeth, increased urination and poor libido.

Regular snorers are 5 times more likely to have hypertension, cholesterolaemia , diabetes, heart attack and stroke than occasional snorers. For all these reasons, many society guidelines now recommend a sleep study early for patients with hypertension and stroke.

Even as you look out for your uncle, it is important to spread to word to friends and family that snoring in children can be just as harmful. For children, instead of snoring, many have open mouth breathing as their nose passages are tiny.  The child is restless, tossing and turning in sleep with mouth open and often bed wetting. The child often wakes up irritable, hyperactive, may be misdiagnosed as attention deficit.

Unlike adults, many kids do not have sleepiness. These kids may not be obese, and may even fail to thrive. Long term complications similarly include heart, hypertension and memory problems. There can be long narrow facies, dental overbite and reduced lower jaw growth – these all predispose them to become adult snorers.

Another group in which snoring is often underestimated is women. Of women with preeclampsia blood pressure problems in pregnancy, 50% have sleep – it is important to seek treatment for snoring before pregnancy as medications and surgery may present problems for the fetus.

20 Aug 2018

Thanks for the D2D,

Losing weight will help to control sleep apnea if the patient is overweight. As it is a lifestyle and dietary change, the patient should always use it first line and it is also good for general health. It cannot completely cure sleep apnea if there are other causes of sleep apnea.

Bariatric surgery for some severely obese patients may be helpful if they have been carefully evaluated before surgery.

20 Aug 2018

For starters, please refer also to my answer for “How does one differentiate normal snoring from sleep apnea?"

However, the only way to diagnose definitively if there is sleep apnea is with a sleep study. The sleep study is important not only to diagnose if there is sleep apnea, but also to quantify its severity so as to guide management.

A sleep apnea study would monitor your sleep overnight, including your breathing pattern, blood oxygen level, blood pressure, brain activity, heart rhythm, limb movement, snore loudness levels, sleeping positions are monitored. There is no pain, and no needles are used.

Your doctor will decide if you need an attended sleep study with a technician watching and checking whilst you sleep, or an unattended one.

Patients may find it difficult to sleep initially or all night in a new environment with sticky surface electrodes on their face, chest and limbs hooked up to equipment and monitors. Thus, for more straight forward cases of sleep apnea, a home-based sleep study works sufficiently and well too.

The WatchPAT is an example of a portable home sleep study device, providing the option of a cheaper, more natural experience in the patient’s home.

For cases where it is more likely to be due to obstructive sleep apnea and not neurological system or complex sleep disorders, the WatchPAT is sufficient and has high accuracy. Your doctor will help advise on which type of sleep study is appropriate after the consult.

20 Aug 2018

Hi Quen Sang, thanks for the D2D!

People get sleep apnea if a block in the airway passage results in significant oxygen desaturation in sleep. In sleep apnea, there is reduced oxygen in the blood from obstruction or collapse of the nose-oral-pharyngeal- laryngeal airway. 

The most common causes in children are allergic rhinitis, adenoid and tonsils enlargement. For adults, the common causes are nose block from allergic rhinitis, deviated nose bone, hypertrophic turbinates, polyps; soft palate redundancy and medialisation; receded lower jaw, prolapsed large tongue base, poor muscle tone and obesity.

Both obesity and aging are on the rise in Singapore, resulting in rising incidence of sleep apnea too. Just by virtue of being Chinese, with more restricted facial and head proportions, there is also increased risk of sleep apnea.

In Singapore, there is still a lot more that needs to be done to increase awareness amongst the population wrt snoring and sleep apnea. The Singapore Health Study 2012 noted that 31% of the population had moderate to severe sleep disordered breathing. Amongst those affected, 90% were undiagnosed.

20 Aug 2018

thanks for the D2D! 

That is a tough question! “The best ENT doctor” would depend on what the patient specifically needs, prefers and feels comfortable with. Some patients do not get to choose outside their insurance panels.

Thus, there will not be one doctor who is best for everyone.

Many patients rely on word of mouth recommendations from doctors or fellow patients they trust. You can also look up the individual websites of the clinics, and take time to read carefully to see if the way the doctor practices and if the services match your needs.

For example, if you are looking for a diagnosis and simple measures to manage your sleep apnea, that would be very different from if you need a complex surgery.

20 Aug 2018