CPAP among options to keep breathing regularly during sleep

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

One of the most common treatments for sleep apnea is positive airway pressure. For help understanding this treatment, I'm talking with Dr. Ryan Butzko. He's an assistant professor of medicine at Upstate, and he specializes in sleep medicine.

Welcome to "The Informed Patient," Dr. Butzko..

Ryan Butzko, DO: Hi, Amber. Thank you so much for having me.

Host Amber Smith: Before we get into positive airway pressure, can you please describe sleep apnea, what it is, whom it affects?

Ryan Butzko, DO: Yes. Obstructive sleep apnea is a disease for when you go to sleep, your muscles of your upper airway relax, and it causes either partial or complete blockages to breathing that may or may not be associated with decreases in oxygen throughout the night.

Host Amber Smith: So is it people who stop breathing in the middle of the night?

Ryan Butzko, DO: Yes. Simplified, it is people that stop breathing, and it's due to a blockage in the airway or in the back of the throat that causes the blockage to breathing.

Host Amber Smith: Most times, do people wake up on their own, or is that how people die from sleep apnea?

Ryan Butzko, DO: It's extremely rare to actually die from an apneic event, but it is one of the common causes in obstructive sleep apnea that causes people to wake up in the middle of the nights. Often what'll happen during a partial or complete blockage to breathing is the body will start to increase muscle tone to the upper airway so that it can open up the airway on its own.

And if it cannot do that while you're asleep, the last bailout that it has is to wake you up, and you wake up and kind of gasp for a breath of air.

Host Amber Smith: So how does a person know, or how do they find out, that they have sleep apnea?

Ryan Butzko, DO: The way to get tested is to do a sleep study, and that's the only way that we have right now to diagnose you.

But we do have a fairly extensive amount of sleep studies. The first one that has been done, and the most comprehensive, is something called a polysomnogram, or an in-lab sleep study, where you come into the lab and spend the night. We hook you up to some monitors so that we know when you're sleeping, hook you up to some other monitors, to know when you're breathing and when the blockages to breathing occur, and monitor you throughout the night.

The other tests that we have are something called a home sleep test, of which there are plenty of variety. The best one that we use is a modified version of the in-lab where you take a recording device home that monitors blockages to breathing and your oxygen saturation.

Host Amber Smith: Now, if someone is told that they snore at night, is that something that they need to be concerned with, that maybe they've got sleep apnea?

Ryan Butzko, DO: Snoring by itself does not necessarily diagnose you with sleep apnea, but it is one of the most common markers of sleep apnea. And I'll tell you that it's probably the most common reason that people come to see me in the clinic. If you just have snoring, you may have sleep apnea.

But it really increases the risk if you have other symptoms, like excessive sleepiness during the day. Or when you wake up, you don't feel refreshed at all, or you're waking up frequently during the nights, maybe in a panic or choking and gasping, and you don't know why.

Host Amber Smith: So if someone suspects that they have sleep apnea, they need to get these tests to find out for sure.

Are there simple lifestyle changes that they can do to nip it in the bud?

Ryan Butzko, DO: The biggest association we have with sleep apnea is weight related, so the best lifestyle change that anyone can do is try to lose weight. And when we're talking about weight change, it varies from person to person, but generally speaking, a weight loss of about 20 pounds is usually significant and can sometimes cure people of sleep apnea or at least reduce the severity quite significantly.

Host Amber Smith: Well, let's talk about what positive airway pressure is, and how does it help?

Ryan Butzko, DO: Positive airway pressure -- shortened version of it is CPAP, which stands for continuous positive airway pressure. And what it is, is a machine that provides a little bit of airflow at a certain pressure that we prescribe, that's connected to a tubing and a mask that's connected to your face. The pressure that it provides keeps your airway or the back of your throat open, in order to prevent the blockages, the breathing, that lead to the apneas or the apneic events.

Host Amber Smith: So it's different than putting a mask over your face for oxygen.

This has pressure behind it.

Ryan Butzko, DO: That's correct. So an oxygen mask just provides a little bit of increase in oxygen. This provides an increase in pressure, and it has a mask that has to have a nice, firm seal. Otherwise, the airflow leaks out, and the pressure is gone.

Host Amber Smith: It doesn't sound like it would be very comfortable to have pressurized air going into your throat. Do people just get used to it?

Ryan Butzko, DO: Yes, so that's probably the most common question that I'm asked in my office. most people need a period of time to acclimate to the device. My own father, who uses CPAP religiously and swears by it and cannot sleep without it anymore -- he loves it, and it took him, he told me, about four weeks to get used to the machine.

It's a different sensation while you're sleeping, especially when you wake up, and you have something foreign on your face. So it absolutely takes time to get used to, but once you start to notice the benefits, especially a better quality of sleep, more energy during the day and feeling more rested, it's a lot easier to buy in.

Host Amber Smith: So this is called CPAP, but I've also heard of BiPAP. What is that and how does it differ?

Ryan Butzko, DO: So BiPAP is just a different form of positive airway pressure. It stands for bi-level positive airway pressure, and it's quite simple. Instead of CPAP, which is one continuous pressure, BiPAP is two pressures.

You have one pressure, that's the bottom pressure, that is continuous throughout the night, and then when you take a breath in and the machine senses that you take breath in, it will switch on and kick on to that higher pressure. It can be beneficial for some people with sleep apnea. Some people cannot tolerate higher pressures during the night, and this provides a little bit of a break during the breathing cycle to allow you to have lower pressures when you exhale and just higher pressures when you need them.

It's also a big benefit for people that have something called CO2 retention, or carbon dioxide retention. So if you've ever been told by your doctor or ever been in the hospital and been told that you have elevated carbon dioxide levels, a BiPAP machine can help increase the volume of air that you breathe at night and help you eliminate the carbon dioxide while also providing a modest increase in your oxygen levels at night as well.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Ryan Butzko, who specializes in sleep medicine at Upstate, and we're talking about CPAP machines for people with sleep apnea.

Once you have a patient on the machine who's happy with it, it's working well, are they done seeing you, or do you continue seeing them regularly?

Ryan Butzko, DO: Generally speaking, once they're set up, and they're good to go, and I see that their sleep apnea is well treated, and the way that I can see that they're well-treated is the machine can actually monitor the blockages to breathing through some of the technology that they have in the machine.

It's connected to WiFi, and it sends the data to a website, which I can log in and check on the compliance to make sure that you're using it and see how well you're treated and make sure that the number of blockages to breathing, which is called the AHI number, or apnea-hypopnea index, is within the normal range, which is five or less, during the night.

Once they're well treated, and they're doing OK, I generally just do an annual follow-up. Most of the time the insurance requires just an annual follow-up to make sure that you're using the machine, getting benefit from the machine, for the medical equipment company to keep sending you supplies.

Host Amber Smith: That's pretty interesting that the doctor will know if the patient is using the machine and using it the right way all night long.

Ryan Butzko, DO: Yeah, it's a little bit like Big Brother. So you can't lie in this circumstance because I will know if you're using the machine or not.

But my goal is not to berate anyone for not using the machine. If you're not using it, and you're not comfortable, we work together on a way that you can be comfortable with the therapy.

Host Amber Smith: A variety of CPAP alternatives are on the market, and I'd like to ask your opinion of these products.

Is there anything that you recommend if CPAP just doesn't work for someone? They try it for four weeks, and they just can't get used to the mask or the pressure.

Ryan Butzko, DO: Unfortunately, that is a very true reality of this machine. It is extremely, extremely effective, but even the most effective treatment, if not used, is still a failure.

So we do our best to try to get you used to the machine, try different mask interfaces -- some are more comfortable than others -- and try to improve the comfort settings on the machine to get you used to it. But some people just can't do it. So after that, we try to get a little creative.

For those with more mild sleep apnea, there's something called an oral appliance or a mandibular advancement oral appliance. These devices are made specifically by a dentist that's specifically trained in the making of the devices for sleep apnea, and what the device does, it's like a retainer-type device that's molded to your own teeth that moves the lower jaw slightly forward to give you more room in the back of your throat to breathe and prevent the blockages to breathing.

Again, it's much more effective in mild to low-moderate sleep apnea. If you have high-moderate to severe sleep apnea, it's probably not going to be enough.

One of the second things that I do is, we look and see, on your sleep study, what position that you're sleeping in, the sleep apnea gets worse.

And more often than not, sleeping on your back is the worst position and makes you most susceptible to have the blockages to breathing at night.

Sometimes even a simple positioner device is enough to treat sleep apnea, to get it at least into the mild range or even get rid of it completely, some of which are sold commercially, but even so, I have some do-it-yourself patients that just stick pillows under their back or sew things into the back of their shirt to prevent them from going on their back at night. So for the mild to low-moderate sleep apnea people or someone that's very position dependent, these are some creative options that I sometimes recommend, if they can't tolerate CPAP, that can be fairly effective.

Host Amber Smith: I've seen TV ads for something called Inspire, and it advertises, "no mask, no hose, just sleep." It sounds too good to be true. How does it work?

Ryan Butzko, DO: So I have extensive experience with Inspire. It was a big part of my fellowship and training. So what this is, and what the commercial doesn't tell you -- I think it's intentionally vague for a reason, just to get people talking about it -- it is a surgical implant, and the device is surgically implanted by an ENT (ear, nose and throat) surgeon.

And one part of the device is something very similar to a pacemaker. It's implanted in the right chest, just over the big muscle in the right chest, and that device monitors your breathing and your breathing effort at night.

It also has little wires that are connected to the nerve that controls your tongue, which is called the hypoglossal nerve. That nerve is primarily responsible for tongue movement. When the device is implanted, and it senses that you're taking a breath in, it will send an impulse to the electrodes around the nerve that controls the tongue, telling the tongue to move forward, and thus, theoretically, moving the tongue out of the back of the throat and increasing the area, in order to make you breathe and prevent blockages to breathing.

Host Amber Smith: So are there anatomical reasons that this might work for someone and maybe not be the best thing for someone else?

Ryan Butzko, DO: Yes, absolutely, and during the course of getting you qualified for such a device, the ENT surgeon does something called a drug-induced sleep endoscopy; we shorten it to something called DISE. It puts you kind of in a twilight state, where you get sleepy, and they take a camera and look at the back of your throat and look to see where the back of your throat collapses or where your airway collapses to determine if you have a favorable anatomy for this device.

Host Amber Smith: So how big of a surgery is this to have it implanted? Is it a one-day, kind of in-and-out thing? And then once it is implanted, how soon does it start working, and would someone notice a difference?

Ryan Butzko, DO: It is a same-day surgery. So if you ever had a same-day surgery, you go in, the surgery itself is probably about 90 minutes, on average.

It does require general anesthesia, and it requires you to be on a ventilator for that time, partly because of where they are working and partly because people with sleep apnea are at increased risk for surgical procedures just by the general nature of the anesthesia. Once the device is in, you come out, you generally leave that same day.

Most importantly, you need to wait for the nerve that controls your tongue to heal before we even turn on the device. So you will follow up with a sleep physician four weeks, generally, after the surgery, and at that time we'll assess the nerve healing, and only then will we actually turn on the device.

So in that four weeks, the device is not on and not working. So whatever you were previously using for your sleep apnea, you need to continue before we turn it on.

Host Amber Smith: So someone listening, or someone who sees this on television, they would probably approach their primary care provider, who would perhaps give them a referral to see someone like yourself, someone who specializes in sleep medicine.

And then would you be coordinating with an ear, nose and throat doctor? How does that work?

Ryan Butzko, DO: Generally speaking, at least at my old institution, we had a very close relationship with the ENT surgeon. All of the referrals came to us so that we could screen the patients to make sure that they were appropriate candidates for the device.

Once we determined that they were, we would start the process of qualifying them by having them see the surgeon doing that drug-induced sleep endoscopy that we talked about. And eventually, if they qualified, we would send them for the surgery. We would also usually do a repeat sleep study, just so we have a very recent test of the severity of the patient's sleep apnea.

Host Amber Smith: What happens to someone who has sleep apnea and doesn't do anything for it, doesn't want to deal with the machine, isn't interested in this surgery, just wants to be left alone. Is it dangerous to have sleep apnea go untreated?

Ryan Butzko, DO: It's a good question and something I get asked all the time. So sleep apnea can be dangerous in the same way that you may have heard that high blood pressure is dangerous or diabetes is dangerous over a long period of time.

Sleep apnea can lead to the development of many, many other diseases, and the list is so long and involves so many other organ systems that I can't list them here, but the most dangerous ones are high blood pressure, coronary artery disease or heart disease, heart failure, stroke and arrhythmias, which are abnormal heart rhythms.

Those are the most dangerous complications of sleep apnea. They do take time to develop, but they are highly, highly associated with sleep apnea. If you are untreated, and if your doctor has told you you're in the moderate to severe range, that is the range of sleep apnea that puts you most at risk for developing these complications.

And you should be treated, whether it be with CPAP, whether it be with an oral appliance, whether it be with Inspire, or even really, really trying to lose weight. Any of those things can help.

If you're in the mild range, your risk of developing these things is more or less the same as the general population that doesn't have sleep apnea, so it is not imperative that you need to aggressively treat it. People with mild sleep apnea, I generally only push for more aggressive treatment if they are very symptomatic with regards to their sleepiness or poor functioning during the day or poor quality of sleep at night.

Host Amber Smith: Well, that's important to know. Thank you so much. I appreciate you making time for this interview, Dr. Butzko.

Ryan Butzko, DO: Yes, it was great. Thank you for having me.

Host Amber Smith: My guest has been Dr. Ryan Butzko, a sleep medicine specialist at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

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