A Multidisciplinary Team Approach Improves Care for Patients with Sleep Disorders
The Department of Otorhinolaryngology at McGovern Medical School at UTHealth Houston and UTHealth Houston Neurosciences have teamed up to help patients with obstructive sleep apnea (OSA) through expert diagnosis and, for those who qualify, hypoglossal nerve stimulation using Inspire® upper airway stimulation. People who suspect they have obstructive sleep apnea may access multidisciplinary care either through an otorhinolaryngologist or a sleep medicine specialist.
“We diagnose OSA as mild, moderate, or severe with symptoms that range from snoring to gasping for air or cessation of breathing for more than 10 seconds,” says Xiaoyang Hua, MD, PhD, an associate professor of otorhinolaryngology. “The underlying causes of OSA vary and may include enlarged tonsils, nasal polyps, a deviated septum, excessive soft tissue in the throat, a narrow jaw structure, or decreased muscle tone. Because of this complexity, effective treatment often requires a multidisciplinary approach involving specialists in otorhinolaryngology, sleep medicine, pulmonology, oral surgery, internal medicine, and weight management. We work together to develop individualized treatment plans tailored to each patient’s anatomy, medical history, and lifestyle.”
People with severe OSA may have 30 or more episodes per hour of apnea (no breathing) and hypopnea (shallow breathing), creating a systemic response linked to cardiovascular disease, hypertension, diabetes, cognitive decline, heart attack, stroke, and increased risk of motor vehicle accidents, all of which dramatically affect quality of life and life expectancy. “Symptoms of OSA include loud snoring, excessive daytime sleepiness, difficulty concentrating, and morning headaches caused by low blood oxygen levels and disrupted sleep. The first-line treatment is noninvasive ventilation – continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) – but about 50 to 60% of people with sleep apnea diagnosed by a sleep study are unable to tolerate these interventions for physical or lifestyle reasons,” Dr. Hua says. “Some of these people may qualify for hypoglossal nerve stimulation using Inspire.”
In addition to being unable to tolerate CPAP or BiPAP machines, candidates for Inspire must not have a circumferential blockage of the soft palate. They must be age 18 or older, have moderate to severe OSA with an apnea-hypopnea index (AHI) greater than 15 on a diagnostic sleep study, and not be significantly overweight. To confirm their eligibility for the procedure, candidates must undergo a sleep study with a sleep medicine specialist and a drug-induced sleep endoscopy (DISE) procedure, a powerful tool for studying the airway in a sleeping patient in real time, with an otorhinolaryngologist. Inspire also has been approved to treat OSA in children with Down syndrome ages 13 to 18.
“If patients weigh more than the target body mass index, we discuss strategies to lose weight before surgery so they can achieve more benefit from the device,” says neurologist Aparajitha Verma, MD, MBA, clinical assistant professor in the Vivian L. Smith Department of Neurosurgery and medical director of quality and patient experience for UTHealth Houston Neurosciences. “If people concerned about sleep apnea come to me first, I talk with them and then refer them to Dr. Hua, who will schedule a drug-induced sleep endoscopy procedure, which helps Dr. Hua determine the level and pattern of airway obstruction. I ask my patients who qualify for Inspire to alert me the day he surgically implants their device. Then we schedule a clinic visit for six weeks later to activate it and set a minimum stimulation level.”
Sudha Tallavajhula, MD, professor of neurology at McGovern Medical School and medical director of the Neurological Sleep Medicine Center at TIRR Memorial Hermann, also works with patients with OSA, including those who qualify for Inspire. “After surgery and assessment for proper wound healing, Inspire patients come to my clinic for device activation,” Dr. Tallavajhula says. “We set parameters for how long the device should be turned on, based on the number of hours a patient wants to sleep, and provide further education on how to use it. The device’s start delay time is usually set at 30 minutes but can be adjusted to allow the patient to fall asleep before the stimulator is activated. We give them the remote control and show them how to slowly escalate the device to titrate between efficacy and tolerance. Then we see them in about six weeks. If they’ve been using it every night and are at a good level of stimulation, we schedule an in-lab device fine-tune sleep study two to three months after activation.”
“During the fine-tune study, our sleep technologists work with an Inspire technologist to adjust the stimulation to get the best possible sleep result,” Dr. Verma adds. “We also follow the patient periodically afterwards, usually every four to six months.”
Although obstructive sleep apnea is the most common sleep disorder, both neurologists treat patients with central sleep apnea, in which the brain fails to send the proper signals to the muscles that control breathing, causing pauses or shallow breaths that lead to fragmented sleep, daytime sleepiness, and other health problems. “The sleep medicine specialist’s No. 1 job is to diagnose the type of sleep apnea and assess its severity, keeping in mind coexisting health problems and other variables,” Dr. Tallavajhula says. “Patient selection and education are crucial to the success of the Inspire program, as is ensuring that patients are aware of the limitations of the device. Many come in thinking Inspire will help them sleep. It will treat obstructive sleep apnea – although some patients have residual issues with apnea after activation – but it will not help you turn off your mind and fall asleep. We collaborate closely with Dr. Hua on patient education and selection of the best candidates for the procedure. If patients have other sleep issues, we address them to make sure they get the most out of their hypoglossal device therapy.”