Other Therapies for Obstructive Sleep Apnea

Zack Freeman

Saad S. Ahmad

Positive airway pressure (PAP) is the treatment of choice for obstructive sleep apnea (OSA) regardless of severity (1). However, other therapies are available that may be offered depending on the severity of the OSA, the need for alternative therapy due to intolerance, or the need to provide adjunctive therapy to supplement the primary treatment method. Oral devices and surgical interventions are clinically validated alternative therapies, each detailed in other chapters. This chapter will familiarize the sleep technologist with therapies other than PAP, oral devices, or surgical intervention. Validated treatment options at the time of this writing will be reviewed, as well as popular options that need more research and available options that have been found not to be effective.

WEIGHT LOSS

Obesity affects nearly 38% of adults in the United States (2). Obesity is a significant risk factor for OSA, with prevalence statistically increasing with body mass index. OSA has been shown to exist in approximately 9% of women and 24% of men. Of the morbidly obese, OSA is known to be present in approximately 55% of women and 80% of men. Obesity is known to associate with OSA in a number of ways. Obesity contributes to OSA by altering the upper airway’s structure and function. Upper airway collapsibility is increased, as fat deposits narrow the upper airway and abdominal fat masses reduce tracheal tension (3). Obesity also affects the physiologic balances required for normal respiratory function (4). Weight loss is not only a viable option for the treatment of OSA but is also significantly beneficial toward a person’s health and quality of life (5, 6, 7). Although no specific result can be guaranteed for any patient, decades of accumulated data can lead the practitioner to some perception of possible expected outcomes.

Methods of Weight Loss

There are multiple methods of weight loss, each with different applicable attributes to sleep apnea treatment. When approaching weight loss, the patient must review his or her options and decide which is best for him or her. Health care professionals must be able to assist the patient with information, so that the patient can make the best choices. Weight loss can be achieved by either dietary and lifestyle modification or surgical procedures. As surgery results in a more drastic reduction of weight loss, it accordingly results in a more drastic reduction of apnea-hypopnea index (AHI) (3). When choosing a weight loss program, it is recommended that the patient first consult a health care professional. It may be difficult for health care professionals to assess the patient’s interest in engaging with weight loss discussion without the patient expressing interest or asking specific questions; however, it is beneficial for the health care provider to assess the patient’s interest and readiness for weight loss (7).

Diet and Lifestyle Changes

Commercial weight loss programs have shown better success with initial weight loss and lower relapse rate than primary care-managed diet or informal diet (8). Many commercial diets come and go, leaving the patient with many to choose from. In 2014, Americans spent approximately $2.5 billion on commercial diet programs (8). A 2015 study published by the U.S. Department of Health and Human Services studied 141 commercial diets and found Weight Watchers and Jenny Craig to give the most evidence for both promising weight loss and long-term outcomes from all the programs (8). It is noted that this study met criteria for recommendations set forth by the U.S. Preventive Services Task Force (USPSTF). The USPSTF is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine that makes recommendations about the effectiveness of specific clinical preventive services for patients without related signs or symptoms. Table 54-1 shows data from this study giving a summary of characteristics and updated costs for commercial programs that had eligible randomized controlled trials available.

Surgical Weight Loss

Bariatric surgery is a term that includes a variety of surgical procedures that reduce the amount of food the stomach can hold and cause malabsorption of nutrients. Bariatric surgery is recognized as one of the most effective treatments for obesity and therefore becomes an effective weight loss method for treating OSA. Bariatric surgeries are shown to be more effective in reducing AHI than intensive lifestyle changes or dieting. The most common bariatric surgery procedures are Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, laparoscopic adjustable gastric band (LAGB), and biliopancreatic diversion with duodenal switch (BPD/DS). Each surgery has its own advantages and disadvantages. Table 54-2 is a summary of the advantages and disadvantages according to the American Society for Metabolic and Bariatric Surgery (ASMBS). The ASMBS is the largest medical organization in the world dedicated to obesity-related diseases and conditions and metabolic and bariatric surgery. Studies have shown LAGB and BPD/DS to be the most effective types of bariatric surgery to reduce AHI, with recent evidence showing BPD/DS to be the most effective within these two (9).

Weight Loss Outcomes

Even modest weight loss, described as 10% loss of total body weight, can result in a significant reduction of AHI (5). That is not to say that weight loss is an easy cure for sleep apnea. It has been shown that most patients who undergo bariatric surgeries have significant sleep apnea that requires PAP treatment 1 year after surgery, notably at lower pressures than before the weight loss (6). This information validates the importance of proper evaluation after significant weight loss, as well as the effectiveness of weight loss as an adjunctive treatment.

POSITIONAL THERAPY

Whether a patient with OSA has positional sleep apnea is a significant consideration when reviewing treatment options. Positional sleep apnea is defined as supine AHI two times the nonsupine AHI. Reports on the prevalence of positional sleep apnea vary, but it is estimated that approximately 56% to 75% of patients with OSA exhibit an increase in severity in the supine position (10).

Indications for Positional Therapy

Positional therapy for OSA refers to the implementation of a strategy to keep the patient in a nonsupine position while sleeping. Positional therapy is recommended as a secondary therapy. It is also considered a suitable alternative therapy, but only if the patient has been shown to have positional sleep apnea where the AHI normalizes in a nonsupine sleeping position. The American Academy of Sleep Medicine (AASM) guidelines state that when positional therapy is implemented, a positioning device should be used, an objective positional monitor should be considered, and outcomes should be monitored. Methods to monitor outcomes may be self-reported compliance, objective position monitoring, and symptom resolution (1).

Methods of Positional Therapy

Perhaps the most well-documented method of positional therapy is known as the “tennis ball technique.” As the name implies, this method originated from the use of a tennis ball. A tennis ball would be sewn into the front pocket of a t-shirt and then the patient would wear the t-shirt backward to bed. When the patient would attempt to move to the supine position, the discomfort from the tennis ball would prompt the patient to roll off the back. The term has since been associated with any device that includes a mass strapped to the patient’s back, causing him or her to not lay supine. Although this method is effective in efficacy, compliance is unsatisfactory. Compliance is estimated to be 40% to 70% in the short term, but as low as 10% in the long term (10).

Newer devices exist with promising results to date, but there are limited data on long-term compliance. These devices strap to a person’s chest or neck and give off vibrations or auditory alarms when the patient moves to the supine position (10). When considering a device, one should consider whether it has Food and

Drug Administration (FDA) approval and clinical studies showing effectiveness.

Table 54-1 Summary of Commercial Weight-loss Programs

Programs	Intensity^a	Nutrition	Physical Activity	Behavioral Strategies	Support	Costs	May Meet USPSTF Criteria^b
Weight Watchers	High	Low-calorie conventional foods, point tracking	Activity tracking	Self-monitoring	Depending on membership level: group sessions, online coaching, online community forum	$19.95-$54.9/mo depending on membership level	Yes
Jenny Craig	High	Low-calorie meal replacements	Encourages increased activity	Goal setting, self-monitoring	One-on-one counseling	$15-$26/d for meals. Membership is $20 for 10 wk, or $359 yearly.	Yes
Nutrisystem	High	Low-calorie meal replacements	Exercise plans	Self-monitoring	Depending on membership level: one-on-one counseling, online community forum	$10.18-$13.93/d depending on membership level	Yes
HMR	High	Very-low-calorie or low-calorie meal replacements	Encourages increased activity	Goal setting	Group sessions, telephone counseling, medically supervised	$301.95/3 wk kit, +groceries needed	Yes
Medifast	High	Very-low-calorie or low-calorie meal replacements	Encourages increased activity	Self-monitoring	One-on-one counseling, online coaching	$443.60-$557.30/mo depending on membership level	Yes
Optifast	High	Very-low-calorie or low-calorie meal replacements	Encourages increased activity	Problem solving	One-on-one counseling, group support, medically supervised	$150/wk	Yes
Atkins	Self-directed	Low-carbohydrate conventional foods or meal replacements	Encourages increased activity	Self-monitoring	Online community forum	Can be free, meal kits and plans up to $200/wk	No
Lose It!	Self-directed	Calorie tracking	Activity tracking	Self-monitoring	Online community forum	$0 to $39.95	No
SlimFast	Self-directed	Low-calorie meal replacements	–	Self-weighting	Online nutrition support, coaching text messages	$75/mo	No
Prices were updated per program web sites in 2018. Two programs were removed as they are no longer available (24, 25, 26, 27, 28, 29, 30, 31, 32).
^aHigh-intensity programs recommend more than 12 sessions per year; low-intensity programs recommend less than 12 sessions per year or are self-directed. ^bAssessment of whether the programs may potentially meet U.S. Preventive Service Task Force criteria for intensive behavioral counseling for obesity. HMR, health management resources; USPSTF, United States Preventive Services Task Force.
Information presented in this table was extracted from Gudzune, K. A., Bleich, S. N., & Clark, J. M. (2015). Efficacy of commercial weight-loss programs. Annals of Internal Medicine, 163(5), 399.