EFFECTS OF TREATMENT

Weight Loss

This patient lost 28.7 kgs (63 pounds) over a 4 month period through diet and exercise. During this time, he was on treatment with CPAP at a pressure of 10.

In comparing the endoscopic findings at the 2 weights, the following changes in the upper airway have occurred as a result of the weight loss:

• The lateral dimension of the velopharynx has increased.
• Jaw thrust results in greater airway dilation.

The airway continues to show excessive lateral collapse on Muller's maneuver.

These findings support the hypothesis that increased mass loading of the upper airway by adipose tissue promotes obstructive sleep-disordered breathing.

1. Shelton KE, Woodson H, Gay S, Suratt PM. Pharyngeal fat in obstructive sleep apnea. Am Rev Respir Dis 1993; 148:462 - 466.
2. Mortimore IL, Marshall I, Wraith PK, Sellar RJ, Douglas NJ. Neck and total body fat deposition in nonobese and obese patients with sleep apnea compared with that in control subjects. Am J Respir Crit Care Med 1998; 157:280-283.

The Effect of CPAP and Weight Loss on the Upper Airway

This patient showed findings consistent with Severe Obstructive Sleep Apnea on oximetry. He was placed on auto - CPAP at a base pressure of 10 and he was instructed to sleep with his trunk propped up at 30 degrees by a foam wedge. He also lost 23 kgs (51 pounds) over 4 months through diet and exercise.

In comparing the endoscopic findings at the 2 body weights, the following changes in the upper airway have occurred as a result of the weight loss and CPAP use:

• The lateral dimension of the velopharynx has increased.
• Jaw thrust (advancing the mandible) results in greater airway dilation and the soft palate no longer sags in the middle.

The airway continues to show excessive lateral collapse on Muller's maneuver.

The weight loss from the head and neck reduces the pressure on the pharynx and results in an increase in the lateral dimension. Elimination of snoring by the CPAP allows recovery of the neuromuscular function in the soft palate. As a result, the soft palate no longer sags when the mandible is advanced.

With further weight loss and use of the CPAP, there will be sufficient improvement in the upper airway to allow the patient to safely use a dental appliance in place of the CPAP.

More Examples...

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Case Study 1
34 year old man - loud snorer, observed apneas, BMI of 22.6, wakes up with dull headache, increasingly tired, sleepy, and forgetful. Epworth score of 8.

Case Study 2
54 year old man, truck driver, snorer, observed apneas. License revoked due to excessive daytime sleepiness. Referred to UBC for investigation.

Case Study 3
53 year old man, loud habitual snorer, observed apneas, waking up several times a night with a dry throat, increased lethargy, poor short - term memory, close to falling asleep behind the wheel when driving home from work in the evening.

Case Study 4
48 year old man who was diagnosed to have Severe OSA (AHI of 78, mostly hypopneas) with PSG at UBC 5 years ago and who did well for the first 3 years with CPAP. In recent years, he consumed excessive amounts of alcohol and gained substantial weight. He began to complain of increasing fatigue and cognitive dysfunction. An overnight oximetry showed clusters of desaturation while on CPAP of 10. The CPAP was increased to 11 and he was advised to abstain from alcohol, exercise and he was referred for dietary counselling. He weighed 156 kgs and his BMI was 48. His Epworth score was 8.

Case Study 5
50 year old man with excessive daytime sleepiness that prevented him from accepting a promotion at work, snoring but no observed apneas, BMI of 34.3. Polysomonography at Victoria General Hospital did not show findings consistent with OSA. Mild nocturnal myoclonus was recorded. He was placed on Sinemet with no improvement.

Case Study 6
47 year old man investigated at UBC at age 43 and found to have Severe OSA (AHI of 75.5). PSG performed on "Smart CPAP" showed incomplete response with AHI of 30.1. A third PSG with CPAP titration showed elimination of obstructive events at a pressure of 7. He declined CPAP and had a UPPP with minor improvement in symptoms. PSG was not performed to determine if AHI was improved. He was then fitted with a dental appliance that he wore nightly for 3 years. He presented for evaluation because of continued excessive fatigue and sleepiness. He continued to snore, even while wearing the dental appliance. BMI of 27.5. Epworth score of 11.

Case Study 7
21 year old Negro woman, complained of excessive daytime sleepiness and waking up frequently at night since childhood. Not known to be a snorer. Suffers chronic rhinorhea. All female members of the family are similarly affected. BMI of 25.1 and Epworth score of 16.

Case Study 8
64 year old woman, loud habitual snorer with observed apneas. Excessive daytime fatigue. Severe acid reflux symptoms. BMI of 26.7. Epworth score of 6.

Case Study 9
60 year old man, 8 year history of NIDDM requiring escalating doses of Insulin to control (340 units daily at presentation), morbidly obese with BMI of 35.8, chronic heartburn controlled with Ranitidine 150 mg bid. Epworth score of 18.

Case Study 10
41 year old woman, habitual snorer, waking up 5 or more times a night, excessively tired and sleepy during the day, wakes with a dull headache. BMI of 30.7. Epworth score of 9.