New treatment options for patients with obstructive sleep apnea who are intolerant to positive airway pressure therapy

July 31, 2021

Before the 2020 COVID-19 pandemic, Mayo Clinic Sleep Medicine added capabilities for connected care and in-home testing for obstructive sleep apnea to reduce barriers to diagnosis. "That timing proved an example of fortuitous foresight; we were in a position to pivot swiftly to provide virtual consults and established care," says Timothy I. Morgenthaler, M.D., Pulmonary and Critical Care Medicine at Mayo Clinic in Rochester, Minnesota. "The department was able to provide many home sleep apnea tests to patients in their hometowns. They didn't ever need to travel to Mayo Clinic's campus."

Many patients still require or benefit from full in-lab polysomnography. Mayo Clinic Sleep Medicine can provide the full range of sleep medicine services. New treatment options for patients with obstructive sleep apnea who are intolerant to positive airway pressure (PAP) therapy continue to be a focus and priority for patients. "Many patients do benefit from use of PAP therapy, but it is not the best for every patient. An individualized approach is best, and through very close collaborations, Mayo Clinic Sleep Medicine can offer many alternatives," says Dr. Morgenthaler.

Sleep surgery specialist broadens treatment alternatives

In 2018, Otolaryngology (ENT)/Head and Neck Surgery, in collaboration with Sleep Medicine at Mayo Clinic in Minnesota, recruited Michael D. Olson, M.D., a dedicated sleep surgeon to broaden its already established surgical expertise and provide a consolidated approach to the care of patients considering surgical alternative treatment options for obstructive sleep apnea. The collaboration ensures that patients are offered a full spectrum of surgical approaches, including:

  • Soft tissue surgery such as uvulopalatopharyngoplasty and glossectomy
  • Orthognathic surgery (maxillomandibular advancement)
  • Upper airway stimulation therapy

"Our goal is to reduce the friction patients experience when seeking alternative therapies by reducing the time and effort they need to expend obtaining multiple opinions and a personalized treatment plan," says Dr. Morgenthaler. "Having a consolidated approach to these surgeries has allowed streamlined scheduling for patients between their evaluation in Sleep Medicine and referral to the sleep surgeon. Furthermore, pivoting our practice to virtual care delivery during the COVID-19 pandemic allowed us to triage patients traveling from a distance, visiting with them upfront virtually to determine candidacy for surgical alternatives, and ultimately saving time and travel through consolidation of itineraries when they arrive."

Upper airway stimulation therapy

In recent years, the surgical landscape in the treatment of obstructive sleep apnea has changed: In 2014, the U.S. Food and Drug Administration approved the first upper airway stimulation therapy for the treatment of patients with obstructive sleep apnea who are PAP intolerant. "This therapy has opened treatment options for a variety of patients who perhaps would not otherwise have been able to tolerate other surgical modalities, such as soft tissue surgery or jaw advancement," says Dr. Olson. "Furthermore, given the mechanism of action, the device provides a minimally invasive option for management of lower airway obstruction (the tongue base), which has been difficult to manage outside of significant tongue base reduction techniques or via advancement of the jaw."

Outcomes of surgical alternatives are an important priority for Mayo Clinic Sleep Medicine, which participates in the Acute Decompensated HEart Failure National REgistry (ADHERE) of patients implanted with this therapy. "The outcomes of our first 50 cases have mirrored previously published data, with reductions of obstructive sleep apnea severity to the mild range in 76% of patients. Of those patients, 31% obtained an apnea-hypopnea index of less than five per hour," says Dr. Morgenthaler.

Oral appliance therapy

Since 2010, oral appliance therapy has evolved as a distinct alternative treatment approach for the management of obstructive sleep apnea. The clinical guidelines for oral appliance therapy, jointly published by the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine in 2015, recommend its use for patients who are intolerant to PAP therapy or seeking alternatives to PAP therapy.

Customized oral appliances fabricated by a qualified dentist are more efficacious than noncustom oral appliances for physiological sleep-related outcomes. "From the dental perspective, the clinical and laboratory processes involved with the fabrication of custom oral appliances have also been evolving to be more streamlined, consistent with our goals to reduce friction for patients seeking effective therapy," says Subha Giri, D.D.S., M.S., with Dental Specialties at Mayo Clinic in Rochester, Minnesota. "Traditional dental processes are being replaced with end-to-end digital processes rendering precision designs for custom oral appliances that aim to improve patient comfort, compliance and overall sleep-related outcomes. Leveraging virtual resources since 2020, dentists providing oral appliance therapy, in collaboration with sleep medicine specialists nationwide, have been able to enhance much needed access for this treatment alternative."

Multidisciplinary PAP-intolerance clinic planned

Mayo Clinic Pulmonary and Critical Care Medicine is in the early stages of developing a multidisciplinary PAP-intolerance clinic, where a team of sleep medicine physicians, a dental sleep specialist and a sleep surgeon can collaborate to provide patients who are PAP intolerant with a consolidated evaluation and collaborative treatment plan to deliver the most ideal individualized treatment plan to patients.

For more information

Sleep Medicine. Mayo Clinic.

Acute Decompensated Heart Failure National Registry (ADHERE) Algorithm. MDCalc.

Ramar K, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: An update for 2015. Journal of Clinical Sleep Medicine. 2015;11:773.