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Posted by sleepsurgeon on July 15, 2009 at 06:16:12:

Sleep apnea is a very complex process. It is an anatomic (airway) problem as well as a neurological problem. The brain responds to the airway collapse, causing all kinds of symptoms. The increased respiratory effort contributes to cardiac and metabolic stresses. There is so much we don’t know about the complex interplay between the airway, brain and the organ systems. Currently, all we can do is to address the anatomic problem, which is the airway. The goal is simple-make it bigger, whether it is with CPAP, oral appliance or surgery (you can add Provent, which also increases the airway).

Although we anatomically compartmentalize the airway-palate, tongue, lateral wall, epiglottis, etc., it is a tube, a compliant and tortuous tube to be exact. A movement of part of the tube is going to cause secondary impact on the other part of the tube because it is all connected. Collapse of the epiglottis is usually due to the collapse of the tongue since it is attached to the tongue base. Collapse of the tongue base narrows the airway, increases the negative pressure, leading to collapse of the lateral wall, soft palate, and vise versa. I have never been a fan of sleep endoscopy-YOU ARE GOING TO SEE TONGUE COLLAPSE AND PALATE COLLAPSE IN EVERY PATEINT. If you don’t see them collapsing, it is because you are not mimicking the actual physiological process. The airway collapses differently during different period and stage during sleep. Sometimes the palate collapse dominates, sometimes the base of tongue collapse dominates, but most of the time, the whole tube collapses. To put it in very simply-people don’t always produces the same sound when they snore. Sometimes it is loud, sometime not so loud, sometimes the breathing is just a bit noisy but no snoring, sometimes there is choking sound, sometimes there is no sound at all and the patient is not breathing because the tube is shut off! Sleep endoscopy DOES NOT give you any additional information and DOES NOT change treatment recommendation. I do not like to do procedures that do not help in terms of treatment. I have done many, many sleep endoscopies, but they all have been at the time of surgery to get myself familiarized to the individual’s airway, not an additional procedure to determine treatment.

The most frustrating aspect of treating sleep apnea is that occasionally, no matter what you do, some patients just don’t respond as well as others. I wish all my patients respond greatly. The phrase-Dr. Li, you have changed my life or Dr. Li, you have saved my life is what I want to hear. Thankfully, it is what I often hear, thus spoiling me to expect it. But we all know it doesn’t always happen. One needs to remember that not one treatment works on everyone and surgery is no exception, and this includes tracheotomy-yes, tracheotomy doesn’t eliminate sleep apnea in many patients (some have RDI in the 20s afterwards based on published results), but all are significantly improved, which is the aim of all treatment. MMA is the most successful procedure besides tracheotomy, but it does not result in dramatic improvement in all patients. I am in the process of going over almost 600 MMA that I have done for sleep apnea and it looks like the success rate is around mid to high 80s%. I am also sorting out unfavorable factors influencing the MMA results and will publish them in the future.

In evaluating successful surgery means that patients need to feel much improved and the sleep study results such as RDI is much improved. One of the greatest problems with surgery is comparing RDIs-I know I will probably confuse many on this topic which I will address later. In patients that did not achieve significant improvement often still get some improvement most of the time, which may facilitate better results with other treatments.

At the end of the day, the doctor and the patient are in the same boat, working together to try to make things better. I know sleep apnea is really impairing people’s lives. I also know that the road to getting better can be long and discouraging. All I can say to all of you is to try to hang in there. Medicine is continuing to progress and advances are being made. A great deal of interest is in sleep apnea as reflected in the amount of private money being invested in new technologies for diagnoses and treatment. Another treatment option may be just around the corner.

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