Obstructive sleep apnea (OSA) can cause long-term health problems, such as raising the risk of cardiovascular, cognitive and mental health conditions as well as poor quality of life. While continuous positive airwave pressure (CPAP) therapy is the recommended first-line treatment, it isn’t effective for all patients. This was true for a 47-year-old man with sleep apnea who came to UCSF Health seeking alternatives to his CPAP device, which he was unable to tolerate.
“When it comes to OSA, treatment tolerance and adherence is so important,” said otolaryngologist Jolie L. Chang, MD, FACS, chief of the UCSF Division of Sleep Surgery. “If a patient’s CPAP is sitting in the closet, our ability to treat their OSA is essentially zero.”
Patient-centered decision-making
The patient consulted with UCSF Health’s team of sleep disorder experts, including Chang; pulmonologist and sleep medicine specialist Katherine Malcolm, MD, MPH; and otolaryngologist Megan Durr, MD, FACS, who specializes in surgery for sleep apnea.
The patient described his symptoms, which included daytime sleepiness and difficult-to-control hypertension, and discussed his sleep habits and other health concerns. Chang explained treatment options and advised the patient to review educational videos developed by the UCSF team that help patients evaluate and compare various medical and surgical treatments.
“A lot of our patients don’t know about all the evidence-based treatment options,” Chang said. “So we created short informational videos, and we encourage patients to watch them to best prepare for their visit.” She and other UCSF researchers recently published a study showing the use of such videos prior to sleep surgery consultation improves the treatment decision-making process for patients.
With advice from the team, the patient decided on a hypoglossal nerve stimulation implant, which delivers electrical impulses to keep the airway open during sleep. The implant can be an alternative for patients who can’t or won’t use CPAP. UCSF Health is a specialty center for this procedure.
Chang performed a drug-induced sleep endoscopy to determine whether the patient’s type of upper airway obstruction could be effectively treated with the implant. She found that the patient didn’t have a complete circumferential collapse – which showed, along with other findings, that he was a good candidate for his treatment choice.
Chang and the surgical team successfully implanted a hypoglossal nerve stimulator in the patient. He was discharged the same day.
One month after surgery, at a follow-up visit with Chang and Malcolm at the multidisciplinary clinic, the patient’s implant was activated. The team instructed him to turn it on every night before sleep and explained how to use the remote to adjust the settings weekly and acclimate himself to the therapy. During a series of follow-up appointments, the team worked with the patient to titrate the settings to the optimal level for his symptoms. After three months, the patient underwent a sleep study, which showed that a comfortable implant setting was working effectively and he was experiencing restful sleep. The patient reported a significant decrease in daytime sleepiness, stabilization of blood pressure and improved quality of life.
OSA treatment goes beyond surgery
Durr, an expert in sleep surgery at UCSF Health and Zuckerberg San Francisco General Hospital and Trauma Center, explained how effective OSA treatment goes beyond surgery. “Sleep is complicated,” she said. “Our patients require support from our multidisciplinary team of specialists to optimize all aspects of sleep. For example, weight management can significantly improve surgery outcomes, and insomnia treatment improves sleep symptoms overall. Partnerships with our colleagues across UCSF Health are vital and enhance the quality of care we can deliver to each patient.”
This collaborative effort includes specialists from the UCSF Snoring and Sleep Apnea Surgery Clinic, UCSF Sleep Disorders Center, UCSF Neuro/Psych Sleep Clinic, UCSF Oral and Maxillofacial Surgery Clinic, UCSF Sol Silverman Oral Medicine Clinic and UCSF Osher Center for Integrative Health.
Top experts improving patient outcomes
Chang is lead author and co-editor, with Andrew N. Goldberg, MD, MSCE, FACS, of the International Consensus Statement on Obstructive Sleep Apnea (ICS:OSA), which serves as a resource for OSA evidence-based practice and future research needs. The document contains contributions from more than 130 international experts in various specialties, including neurology, pulmonology, sleep medicine, otolaryngology, oral and maxillofacial surgery, dentistry, anesthesiology, psychiatry, cardiology and sleep physiology.
“The ICS:OSA brings together diverse expertise to provide a comprehensive resource for understanding and treating OSA, enabling clinicians to make evidence-based decisions for their patients," Chang said.
Updates on OSA management are presented in the annual CME course, Advances in Diagnosis and Treatment of Sleep Apnea and Snoring, directed by Goldberg; Chang; David M. Claman, MD, director of the UCSF Sleep Disorders Center; and faculty from UCSF, UCLA and the University of Pennsylvania. Sleep disorder experts, including Malcolm, Durr and the course directors, discuss complex OSA cases and weigh in on treatment recommendations.
The UCSF team also conducts research on using wearable consumer sleep technologies to track and understand changes in patients’ sleep patterns as they’re being treated for OSA. In one study, participants used a smartphone app to track snoring during up-titration of hypoglossal nerve stimulation therapy. Increased voltage was associated with a 50% reduction in snoring frequency and intensity.
In another study, patients on hypoglossal nerve stimulation therapy used both wearables and patient-reported outcome measures (PROMs) to track sleep-related metrics. Stimulators were turned off for one week during the eight-week study. The wearable data correlated with the PROMs, indicating that sleep metrics collected from wearables may have value for assessing and managing titratable OSA therapies.
Durr, Chang and other UCSF specialists recently published a study looking at patients for whom CPAP therapy had failed. The researchers identified several sociodemographic and health care system factors associated with decreased use of CPAP alternatives and concluded that more work needs to be done to reduce or eliminate barriers to care for these populations. Possible ways to expand treatment access and improve outcomes include expanding sleep testing options and providing comprehensive education on both medical and surgical treatment options.
“Our multidisciplinary approach is ideal for patients with complex OSA diagnoses who seek alternatives to CPAP therapy,” Chang said. “We focus on shared decision-making so patients feel well-informed and comfortable with their treatment choice.”
To learn more
UCSF Snoring and Sleep Apnea Surgery Clinic
Phone: (415) 353-2757 | Fax: (415) 353-2603
Phone: (415) 885-7886 | Fax: (415) 885-3650
