Friday, September 16, 2011

An alternative to CPAP or another wannabe?

          Legend has it that it all started one night when an Australian professor, physician, and soon to be inventor was watching his friends bulldog sleep. As Colin Sullivan MD sat there and watched his friends bulldog choke and gasp for air, he suddenly realized that higher air pressure could keep the dog's airway open! By 1980 Colin had invented the first ever CPAP (Continuous Positive Airway Pressure) device. Although the first machines were loud and the masks were crude; they were effective. Ever since CPAP has became the dominate clinical solution to treating sleep apnea.

                                                           A patients airway after surgery
          But although CPAP remains the dominate solution, there have been many different approaches to treating OSA that have sought to overtake or replace CPAP. There is the Uvulopalatopharyngoplasty surgery or UPPP. This surgery removes tissue from the upper airway. As a clinician I can tell you that I have seen many patients undergo this surgery who then return to the sleep clinic who's sleep apnea is unchanged or even worsened in some cases. Although it does work on some, in my opinion the results are not very promising or consistent.


          I know at this point your probably thinking that this post is getting a little strange. But a recent study in the British Journal of Medicine has spawned a small movement of patients and entrepreneurs dedicated to using the giant horn featured above to treat sleep apnea.(1) It actually makes sense. Blowing this large horn requires a lot of respiratory drive. This respiratory effort along with the vibrations the horn makes will strengthen the patients upper airway if the horn is played regularly enough. How permanent is this change? Do I need to keep using the horn? What if I have severe OSA? These are all good questions that will likely be unanswered until the device is used rigorously by a large number of patients. Below is a video that explains the process.

          The idea of strengthening the airway by exercising it is a very good idea. Instead of just using the CPAP to band aide your apnea, people are actually able to restore their airway back to normal with this form of treatment. But I don't think that this horn will ever REPLACE CPAP. I just can't imagine clinics issuing horns for people to use at home. Most of the places that offer these horns tend to have more of an alternative medicine feel. Can you imagine doctors prescribing giant horns? I can already picture the look on a patient's face when they hear they are about to be given a giant horn. It just does not have a clinical feel and does not really fit into most people image of health care. Also it likely would not fit into many peoples lifestyles. People have families, have to travel, are really busy, and just don't have great environments to play a loud horn in. Although strengthen the muscles in the airway I believe could have a lot of potential for the future of sleep medicine; I do not believe the didgeridoo is the appropriate way of achieving it.

          The newest approach that I have heard is featured above. The Provent nasal valves claim to "reduce" the effects of OSA and are supposedly backed by double blind studies. The way that these plugs work is actually pretty smart. They completely cover each nostril. When the patient breathes in the valves lets them pull air through each valve unrestricted. But then when they breathe out their nose, the valve partially restricts the flow of air flowing out. This builds up pressure in the airway which serves as the famed nasal splint that CPAP also uses to keep the airway open. A patient who uses these plugs would not need a mask, tubing, a machine, etc. (Below is a not-so-impressive video of how the device works).

          But there are a few issues that I have already identified with this type of therapy. First of all is that once you have the nasal plugs in it is very difficult to breathe out through your nose. Provent states that patients wearing Provent at night have to get used to breathing through their mouth while they are falling asleep. This could be uncomfortable for some. This made me wonder "What about mouth breathers who are unable to breathe through their nose? Or those who can brethe through their nose but for whatever reason also breathe their mouth?" Provent reps claim that patients naturally breathe through their nose at night, unless it is blocked. As a sleep technician I have seen hundreds of people who have no nasal blockage who breathe through their mouth at night, even on CPAP. This is not even counting those with deviated septums, chronic congestion problems, skin irritation, chronic nasal bleeding, etc. But like everything Provent is obviously not for every patient. But this does not mean that it does not have its place in sleep medicine.

         The second issue I have with the Provent nasal valve is in its claim to "reduce" the effects of OSA. A reduction of OSA in my opinion should NOT be the desired end result. A complete reduction should be. If a patient's OSA get reduced by half, that patient could still be waking up constantly, they could still be having breathing events that will likely cause health problems down the road, and still possibly be bothering their bed partners with snoring. In my opinion more research needs to be done that specifically states how often it can cure OSA. If this research does exist I would certainly like to see it.

          Although there are issues that need to be worked out I must say that this therapy does have its place. Lets face it, no matter how skilled and persuasive of a clinican or physician you are; there are those who will never adapt to CPAP. These patients could just not care, be unable to adapt, not want to pay their co-payments, and/or believe that CPAP is just a money making scheme. These patients could benefit from Provent. If you cannot cure them with CPAP then reducing their OSA becomes much more attractive. It also can bring in revenue for Providers on patients that would be lost otherwise. People who do not like CPAP also find Provent to be attractive since it is much less cumbersome than CPAP. Also for people that it can cure, perhaps this could be a more desired method of treatment than CPAP.

          Ventus Medical, the organization that created and sells Provent has done a really good job bringing its Product into the market. They have hired a sales force that understands the business and all the different players. They are currently pursuing a HCPC code for their product so that insurances will cover its usage, and most importantly it does not seem like they are not attempting to replace CPAP. They are approaching providers with an alternative to CPAP that providers can attempt to use to treat the percentage of their patients that have failed CPAP. Recently the product was even shown on the hit daytime show The Doctors. It will be interesting to see how the products performs in the market. As always I will keep you posted on my experiences with it.

-Sleep Guy

(1). Puhan M et al. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomized controlled trial. British Medical Journal. 2006. 332:266-270.

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