Fig. 12.1
Sleep mechanisms and their connections to obesity
The two commonest sleep disorders associated with obesity are obstructive sleep apnea/hypopnea syndrome (OSAS) and obesity hypoventilation syndrome (OHS) .
Treatment options are available to help with the obesity-related sleep disorders in terms of CPAP, BIPAP, mandibular advancement device, and surgical interventions (Table 12.1).
Table 12.1
Comparison of various apnea treatment modalities in terms of advantages, drawbacks, and cost
Treatments for OSA | Description | Advantages | Drawbacks | Cost | Comments |
|---|---|---|---|---|---|
CPAP therapy | Mask connected to device on nightstand, blows room air into airway to splint airway open. Used to treat all severities of OSA (mild, moderate, severe) | Very effective for mild to severe OSA; robust benefits seen in cardiovascular health, mood symptoms, and numerous other benefits | Inconvenient—e.g. maintenance issues, wearing a mask every night, may induce claustrophobia. Travelling with the device may be inconvenient | $$$ (insurances may cover) | Gold Standard for treatment of OSA. If not effective or not tolerated, APAP or BiPAP can also be tried |
Uvulopalatopharyngoplasty (UPPP), tonsillectomy | Surgical procedure to extract uvula and/or tonsils if obstructing airway. May be helpful for mild to moderate OSA | If effective, may be a cure for OSA. Higher likelihood of success in pediatric population (particularly tonsillectomy) and mild OSA; lower success rate with increasing severity of OSA | Can be painful; high failure rate | $ (often covered by health plans) | Tonsillectomy is often considered the treatment of choice for the pediatric population |
Mandibular advancement device (MAD) | Oral appliance worn at night to protrude lower jaw forward to open airway. Indicated for mild to moderate OSA routinely | Convenient to use, moderate success rate for mild to moderate OSA | Not as effective for treating severe OSA; may damage teeth, aggravate temporomandibular joint problems. Patients can break these devices overnight | $$$ (may or may not be covered by health plans) | Higher efficacy rate in women, patients with positional OSA. Lower efficacy rate in obese patients |
Weight loss | Can be helpful for all severities of OSA, if the patient is overweight | If effective, may be a cure for OSA | Maintenance of weight loss can be challenging | Variable, by mechanism (e.g., surgery, diet, etc.) | |
Maxillomandibular advancement (MMA) | Bilateral osteotomy of upper and lower jaw to open airway | If effective, may be a cure for OSA. High success rate in appropriately selected candidates | May be painful, time consuming, complicated (may require multiple specialists—e.g., orthodontists to align teeth, surgeon, etc.) | $$$$$ | Considered when additional cosmetic benefits are expected, and/or when other options have failed |
Provent | Disposable nasal device worn over nostrils; uses nasal EPAP to maintain airway patency | If effective, can be convenient to treat OSA (e.g., for travel) | High failure rate; expensive with daily use; may be difficult to tolerate particularly in acclimatization period | $ (but cumulative cost can be significant) | Can be combined with modalities (e.g., use CPAP at home, provent for travelling) |
Neurostimulator (hypoglossal nerve stimulator) | Device implanted in upper chest; when stimulated activates key muscles of upper airway to maintain airway patency | If effective, can be convenient to use | Very costly; more research needed to assess optimal patients for this procedure | $$$$$$$$ ($15–30 K, variable) |
Acknowledgement
The authors would like to thank Dr. Judith Leech, Dr. Naomi Spitale and Dr. Sanjeev Chander for their suggested edits and review of this chapter.
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