Lung Function and Sleep Disordered Breathing Treatment with OAT
Oral appliance therapy for sleep disordered breathing is not new. The practice hit its stride in the 1990’s and the number of appliances has increased dramatically since that time. Recent estimations of the number of appliances for the treatment of snoring and sleep apnea is at 104 appliances. I am sure that as trends change the appliance usages also change. The appliances that have the strongest foot print are the Sleep Herbst, The TAP, Somnomed and EMA. The Narval appliance by Resmed.
The question remains however that whichever appliance is chosen the patients outcome may be preordained by their preexisting physiologic lung condition. Sleep Disordered Breathing and COPD are the most common breathing disorders and often coexist. It is critical to a good outcome that lung function be tested before sleep apnea care is initiated if for no other reason that to frame the patients expectations.
The PulmoLife™ chronic obstructive pulmonary disease (COPD) screening monitor quickly checks lung function for the early detection of COPD. It also provides a practical approach to screening smokers. Click here for information on CPT reimbursement for FEV1 testing in your region.
“This is one of the biggest concerns that has remained present within the sleep treatment field. Qualifying patients simply based on AHI, implies the positive pressure and mandibular advancement are equal alternatives to one another leaves out a fundamental requirement. This requirement is adequate lung function.” says Dr Bradley Eli DMD, MS from Sleep Treatment Specialists. The article below was previously published on the www.sleeptreatmentspecialists.com website and is posted here with permission
Successful Sleep Treatment Requires Good Lung Function –
Dr Bradley Eli DMD, MS
The Journal Respiratory Care has reported that “Sleep-disordered breathing (mainly obstructive sleep apnea [OSA]) and COPD are among the most common pulmonary diseases, so a great number of patients have both disorders; this “overlap syndrome” causes more severe nocturnal hypoxemia than either disease alone.
Sleep disordered breathing (SDB) affects 23 % of the general population. The American Thoracic Society reports that From 1980 to 1990, the number of office visits in the United States resulting in a diagnosis of sleep apnea increased from 108,000 to 1.3 million. In spite of this rise in awareness it is estimated that there remain 22 million people who are unaware they have the condition.
Sleep disordered breathing is a condition generally ranging from simple loud snoring to sleep apnea which describes the obstruction of or absence of respiration during sleep. It is very clear that the conditions of respiration during sleep are very different from those in the awake patient. This is why patients who may have SDB are tested asleep and in a sleep lab. Symptoms of SDB include
- sleepiness and fatigue during the day
- observed pauses in breathing while asleep
- disturbed sleep
COPD is a term used to describe a group of lung diseases including emphysema, chronic bronchitis and asthma among others. COPD affects 24 million people in the United States and over half of them have symptoms but remain undiagnosed. The COPD foundation describes the symptoms of COPD as:
- Increased breathlessness
- Frequent coughing (with and without sputum)
- Tightness in the chest
In spite of how common these two conditions are and how often they occur in the same patient it is rare when a patient is screened for both conditions on their annual follow up. It is possible this is simply a result of the way medical care is funded or because the conditions are so common that the path to care is varied leaving the patient in charge of their condition.
Sleep apnea patients who have difficulty with CPAP therapy often are left unaware that the treatment they are receiving can be enhanced by further diagnostic testing to evaluate the possibility that they are also suffering from COPD. Often this testing is left until the patient has found themselves unable to tolerate CPAP or the patient has gone untreated for a time until their symptoms force them to seek alternatives.
“This is one of the biggest concerns that has remained present within the sleep treatment field. Qualifying patients simply based on AHI, implies the positive pressure and mandibular advancement are equal alternatives to one another and leaves out a fundamental requirement. This requirement is adequate lung function.” says Dr Bradley Eli DMD, MS
Dr Bradley Eli DMD, MS a San Diego sleep therapy specialist has made COPD screening and monitoring a new standard of care for patients in his practice. Dr Eli has respiratory therapists employed, at the Sleep Treatment Specialists clinic in San Diego, delivering CPAP and monitoring compliance with care. In addition these clinicians perform spirometry tests and use FEV1 to establish candidacy for alternative sleep therapies such as oral appliance therapy.
CASE PRESENTATION BY DR BRAD ELI DMD, MS
Patient a 34 year old male with and initial AHI of 54, and a family history of Cardiovascular disease refused CPAP and after being untreated for 6 months presented for treatment options. After history and discussion of treatment options with an emphasis on CPAP compliance revealed an inability for reinitiating CPAP.
CPAP was reviewed and was open to be reinitiated if OAT was not adequate to resolve his condition. The Sleep Herbst was fabricated and delivered and the patients initial bite position from his class 1 occlusion was edge to edge. At 2 mm advancement, patient reported 100% compliance. Objective improvements included resolution of sleepiness from ESS baseline 8 to post OAT 0, snoring cessation and normalized Blood Pressure were also reported and documented. follow up efficacy sleep studies were ordered and completed by Sleep Data, a local independent home sleep testing company, and results are in table below.
Although all key indicators suggest dramatic improvement in objective and subjective complaints, the patient’s perception of overall well being remained below our objective measures.
Clearly in this case all of the recommended standard measures of success were being met however the patient’s report of fatigue remained in a range of concern and were inconsistent with measured values.
Spirometry testing was added to our protocol in 2014. In this case the ATS recommended protocol for spirometry was conducted and the patient was found to have an FEV1 values of Trial #1, 53 % predicted, Trial #2, 45% to predicted and Trial #3, 52% to predicted using NHanes III predicted set which is included as part of the Pulmolife chronic obstructive pulmonary disease (COPD) screening monitor.
Recommendation was immediately made to the primary physician and authorization supporting documentation provided. We expect that a full Lung Function test will be ordered for this patient. This patient will be monitored as a COPD patient under the care of his physician, in combination with his SDB care which will continue to be provided by Dr Bradley Eli’s team at sleep treatment specialists.