Treatment Options for Obstructive Sleep Apnoea (OSA)
Who should be treated?
The decision about whether you need treatment must
be made in consultation with your doctor. Obviously
if you suffer from the classic symptoms of sleep apnoea
with daytime sleepiness and alterations in your mental
function or personality, then treatment will be of great
importance to you. But some people with sleep apnoea
are surprisingly unaware or free of symptoms.
Even asymptomatic patients may be at risk for the cardiovascular
complications of obstructive sleep apnoea. You may be
at risk of developing hypertension or other medical
complications, even if you do not have severe apnoea
or marked drops in oxygen levels at night. The decision
should therefore be based on both symptoms and signs
of sleep apnoea after review with your physician.
Medical Treatment Options
Sometimes relatively simple measures can help sleep
apnoea. Some patients may only have apnoeic episodes
when sleeping on their backs. If they can stay on their
side apnoea may be reduced or eliminated. Unfortunately
this is more difficult to achieve than it would seem.
One suggestion has been to sew something such as a tennis
ball into the back of the pyjama top. Another suggestion
by a patient was to use a pinecone! In addition to the
lateral position, elevation of the head of the bed by
about 30° will also substantially decrease apnoea
in some patients.
The severity of obstructive sleep apnoea is also
related to weight in many though not all patients. Even
modest weight loss may significantly decrease apnoea.
In general a 10-15% weight loss will decrease the severity
of apnoea by half.
Most agents that cause sedation will somewhat worsen
OSA. Clearly, however, alcohol is the most important.
Alcohol results in a decrease in upper airway tone and
often leads to marked worsening of OSA. Avoidance or
at least decreasing the amount of alcohol, especially
close to bedtime, is of great importance in managing
sleep apnoea medically. If the patient is on treatment
such as CPAP, then modest amounts of alcohol may be
Hypothyroidism (low thyroid hormone)
Untreated hypothyroidism has been associated with
OSA. This may be due to the body changes, the size of
the thyroid gland or the effects of low thyroid hormone
on breathing pattern. Treatment may help, but usually
the improvement is not enough to completely treat OSA
and eliminate the need for other treatment.
Electrical Stimulation of the Upper Airway
Since OSA occurs when the muscle tone in the throat
(pharynx) is not strong enough to hold the airway open,
it would seem logical that if the muscles were stimulated
the apnoea would be corrected. There is promising research
in this area, which does suggest this may be the case.
Unfortunately, no device is readily available for clinical
Since resistance to airflow in the nose increases
airway collapse in OSA, reducing nasal obstruction would
seem likely to help. Several devices that dilate the
nose, both internal and external, are available. While
they seem to help some snorers, no significant consistent
benefit for sleep apnoea has been seen.
Antidepressants have been tried for sleep apnoea.
None has proven to consistently or completely treat
OSA though some improvement is sometimes seen in the
severity of apnoeic episodes. There is ongoing interest
in finding a medication that would help but no immediate
choice is available now.
Continuous Positive Airway Pressure (CPAP)
CPAP involves the delivery of air (not oxygen) under
pressure to the pharynx. This pressure acts as an air
splint, holding the airway open and preventing the partial
or complete collapse that is the main event in OSA.
Usually this is delivered through a mask that fits over
the nose only. In almost all cases this eliminates the
signs and symptoms of OSA as well as the snoring. Most
patients get relief quickly, some the first night they
use it. In others it may take 1-2 weeks to adapt to
the sensation of using the machine.
CPAP was first used in Australia in 1981. The major
difficulty then, and now, was devising a mask to fit
comfortably but snugly over the nose. Since the first
masks a great deal of research has gone in to finding
comfortable masks. There are now a variety of masks
of different designs and different materials. Most still
fit over the nose but some are designed to fit into
the nasal opening. These are particularly helpful if
you have any degree of claustrophobia. Because some
patients cannot adapt to nasal breathing, masks that
fit over both the nose and mouth are also available.
There are also newer units, which actually adjust the
amount of pressure as needed throughout the night. For
some people this is more comfortable. Another choice
for difficult cases, particularly for those with more
severe OSA, is BIPAP or bi-level CPAP where the pressure
during inspiration can be different than during expiration.
This too can be more comfortable for some, especially
when high pressures are needed.
CPAP is considered the single most successful treatment
For more information on our CPAP Services, please
Surgical Therapy for OSA
For some patients CPAP is not an acceptable choice.
This may be because of their inability to tolerate it
or just unwillingness to use it. Many of these patients
are candidates for surgery.
Surgery for sleep apnoea focuses on correcting the
obstruction of the upper airway. The goal of surgery
is cure of sleep apnoea, which means relief of the obstruction.
Obstruction of the upper airway can occur at several
levels including the palate, the base of the tongue
or both. Surgery is aimed at correcting whichever obstruction
is present. Nasal obstruction may also be present and
contribute to the tendency for the airway to collapse,
even though it is rarely the sole cause of OSA. Overall
there is success with surgery alone in 20-50% of all
patients. The surgery is not complicated or dangerous,
but is quite painful.
Oral Appliances for OSA
In the last several years, many devices, which can
be worn inside the mouth, have been tried for sleep
apnoea. The goal is generally to hold the mandible (lower
jaw bone) in its normal position or to pull it slightly
forward. This prevents the jaw and tongue from falling
backward during sleep and causing obstruction. There
have been as many as 55 devices tried with largely the
same goal. More recent ones allow some adjustability
of the jaw position. The devices are generally well
tolerated if the patient has no major tooth or jaw problems
to begin with. They seem most helpful in mild to moderate
cases but some success has occurred in more severe cases
as well. The success is not like that with CPAP but
offers an alternative to those who cannot use CPAP and
may not want or be candidates for surgery.