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Rested and Refreshed

Technological Advances — Better Breathing Machines and a Revolutionary Surgical Implant — Offer Relief to the Rising Number of Patients With Sleep Apnea

Stephen Allen’s wife had complained about his snoring for years, but he admits that he never took the problem particularly seriously. As the 66-year-old Manhattan resident observes with a rueful laugh: “My father snored. My sister snores. People snore.”

Then one night about seven years ago, his wife woke him from a sound sleep and told him he’d been gasping for air — and made him promise to see a doctor about it right away. His cardiologist referred him to Weill Cornell Medicine’s Center for Sleep Medicine, where Allen underwent an overnight sleep study and was diagnosed with an increasingly common and potentially serious condition: obstructive sleep apnea (OSA).

Sleep medicine expert Dr. Ana Krieger, the physician who diagnosed Allen and has been treating him ever since, calls apnea a “huge” problem, affecting more than 50 million people in America. “It’s highly prevalent,” says Dr. Krieger, medical director of the Weill Cornell Center for Sleep Medicine and an associate professor of clinical medicine, “and because of increased rates of obesity, it’s getting to be even more common.” Apnea occurs when the airway is narrowed or obstructed during sleep, causing breathing to be interrupted. The condition can have severe ramifications, putting sufferers at increased risk of stroke, heart attack and heart failure, as well as fatigue-related accidents. Apnea cases are categorized by how many times per hour breathing is interrupted: five to 15 is considered mild, 15 to 30 moderate and above 30 severe. But in the worst cases, Dr. Krieger says, “it can be as frequent as 130 times an hour” — meaning that people stop breathing more than twice per minute.

Being overweight is a major risk factor for OSA, as fat deposits can narrow the airway. Snoring is the most common symptom, but as Dr. Krieger points out, “not everyone who snores has sleep apnea and not everyone with sleep apnea snores all the time.” Other indications include not feeling refreshed in the morning; having sudden-onset atrial fibrillation or cardiac arrhythmia with no other obvious risk factors; and, in men, waking up repeatedly to use the bathroom, which may be caused by a hormonal imbalance stemming from poor sleep rather than urologic issues. But in general, Dr. Krieger says, “apnea is a silent disease; unless people have someone observing them while they sleep, they’re not aware of it.” In fact, patients with severe cases often fancy themselves excellent sleepers, because they can drop off anytime — which is actually due to the fact that they’re so tired.

For two decades, the primary treatment for apnea has been the use of a portable breathing machine known as a CPAP (for continuous positive airway pressure), which keeps the airway open by forcing air through the nose. While Allen took to his immediately — “the first time I tried my CPAP machine, I fell in love,” he says — many patients have had a tougher time. They’d find the face masks too bulky and uncomfortable, the air pressure disconcerting, and the noise disruptive to bed partners, prompting them to stash the machine in a closet and continue suffering.

Happily, though, the machines have evolved, and technological innovations have made the CPAPs much more user-friendly. Even Allen admits that the large mask on his original contraption made him look vaguely like Hannibal Lechter from Silence of the Lambs; his new one, by contrast, consists of two small nasal pads made of comfortable silicone attached by a single elastic strap. The machine connects to the Internet, allowing him to keep track of his performance — and for Dr. Krieger to monitor his data remotely and tweak the settings as needed. “The new machine clocks your hours, so as soon as I wake up I can see how long I’ve slept,” he says. “My body is not being beaten up by trying to grab air. I wake up rested and refreshed, and knowing I had a good night’s sleep also helps me psychologically.”

But for fellow apnea sufferer Daniel Mittler, even the new generation of CPAP machines didn’t appeal. A 64 year old living on Long Island, he describes himself as a “very heavy snorer” for the better part of a decade. He eventually got diagnosed with OSA and tried the CPAP, but he describes it as “always very uncomfortable.” When his condition worsened three years ago to the point where he was perennially exhausted, a sleep study showed he was waking up as often as 80 times a night — so he grudgingly agreed to give the CPAP another go. “They set me up with a new machine,” he says, “and it was just as awful.”

Then he heard about a brand new surgical treatment that NewYork-Presbyterian/Weill Cornell Medical Center was offering, the first hospital to do so in the New York metro area. It was a pacemaker-like device, dubbed Inspire, that coordinates with a patient’s breathing and stimulates the nerves in the tongue to open up the airway. The first device of its kind approved by the FDA, it’s implanted under the skin in the upper chest, and wires are threaded to the nerves at the base of the tongue and to the chest wall. Mittler underwent the implantation procedure in March, and a month later the device — which is turned on and off by a small remote control and automatically runs for eight hours — was activated. “That first night it was simply fantastic,” he recalls. “I slept through the night and I still do. My snoring had stopped — and I never realized how much the snoring was keeping me up. It was like my life had changed.”

The surgeon who implanted his device, Dr. Maria Suurna, specializes in operating on patients with sleep issues. Until now, she says, the various surgical options for OSA have all consisted of altering the anatomy to widen the airway — sometimes even breaking bones in the jaw to reconfigure them. The Inspire implant has offered an effective and appealing alternative, she says, calling it “the most revolutionary treatment for apnea since the invention of the CPAP.” About a dozen patients have received the device so far, with another 30 or so awaiting insurance approval. “Everybody we’ve implanted so far has done very well,” says Dr. Suurna, an assistant professor of otolaryngology–head and neck surgery. “The outcomes have been great, and our patients are extremely happy.”

- Beth Saulinier

This story first appeared in Weill Cornell Medicine, Vol. 16. No. 1.

 

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