Michael Morgenstern, MD
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Michael Morgenstern, MD

About the author: Dr. Michael Morgenstern is double board certified in Neurology and Sleep Medicine and the founder of the American Sleep Apnea Society. He is the Director of the Morgenstern Medical in Lake Success, NY, where he treats patients with sleep disorders and other neurological conditions.
Michael Morgenstern, MD
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Most people don’t like hearing that they will need to use continuous positive airway pressure (CPAP) forever. Thankfully, this isn’t always the answer. The answer generally depends on the severity of the apnea, its cause and whether alternative treatments can be tried.

Obstructive sleep apnea (OSA) is a chronic condition. It is not much different than diabetes or high blood pressure. Like diabetes and high blood pressure, there are mild forms and severe forms of OSA. More severe OSA can have bad consequences. It can cause significant disability and even death. It usually requires lifelong treatment.

This isn’t the answer most people want to hear, but it really isn’t that bad. First of all, unlike most medications, some people absolutely love CPAP. They notice a 360 degree, 100%, complete turnaround, a home run type difference in their life. Has anyone ever come up to you and said that their blood pressure medication was the best invention since sliced bread? (maybe it was, but did they ever tell you this?). Probably, not. Not only because you aren’t their doctor. I can tell you as a physician that no one has ever told me that about any of their medications. But several patients have told me this about CPAP. Some people I meet could easily be mistaken as spokespersons for CPAP. But they aren’t paid by anyone. Why shouldn’t they be happy? They have tried CPAP. They have seen real great results. They actually love their CPAP.

But after having it prescribed, most people still want to know if they will need to use it for life. At least that is before they discover that it is the next best thing since sliced bread. There are several variables that may impact whether common alternative treatments or lifestyle changes may help.

Weight loss

As with other chronic conditions, diet and exercise contributing to weight loss can often help. Since OSA is caused by airway narrowing during sleep, and fat depositing around the airway sometimes contributes to airway narrowing, weight loss can help improve OSA.  In some people, weight loss helps more than in others. If airway narrowing in an overweight individual was caused by weight gain, then losing weight may have a significant benefit. If, however, genetics and the anatomic structure of the upper airway was the predominant cause for apnea then weight loss may accomplish little.  Losing weight is always a good thing. But it is difficult to achieve and even harder to sustain. Therefore, weight loss is recommended as an adjunct to CPAP treatment. In morbidly obese individuals, bariatric surgery can be effective for weight loss and to improve OSA severity. Individuals with OSA should undergo a sleep study if significant weight is lost. This may reveals that sleep apnea is no longer present or that lower CPAP pressures are required for treatment.

OSA severity and alternative treatments

OSA that is mild or moderate may be treated with an oral appliance. These devices advance the jaw forward changing the airway shape during sleep. In patients with good dentition, this can provide an alternative to CPAP that can successfully treat their apnea. Surgery is also a possibility in mild and moderate forms of apnea, if one cannot tolerate CPAP but still benefits from treatment. In more severe cases of apnea surgical options diminish. The problem with surgery, in general, is that it has the potential for serious consequences including death. In my book that means it should only be used as a last resort. Alternatively, if OSA is mild and a person is not benefiting from CPAP treatment, then stopping treatment might be reasonable. However, as individuals age and/or gain weight, the severity of apnea tends to worsen, therefore, if treatment is stopped then patients should be monitored for symptoms of sleep apnea and another sleep study should be considered as time passes, weight is gained or symptoms of OSA emerge. Another caveat, is that if the severity of apnea was identified using a home sleep study (HST), stopping treatment without an in-lab study might not be prudent. The reliability of distinguishing between mild and moderate OSA is diminished in HST. HST tends to underestimate sleep apnea and should not be relied upon to rule out a more severe form of sleep apnea for the purpose of discontinuing treatment.

CPAP is an effective, well tolerated and well liked treatment for OSA. It is the first line treatment, which means we usually try it out before other treatments. Many people love it. Some don’t like it, but use it. For others, they hope there is an alternative or that they don’t have to use it forever. When they ask if CPAP needs to be used forever, sometimes the answer is yes. Yes, you don’t have to use CPAP forever. Other times, it is yes, you should probably use it forever. But before worrying about using CPAP forever, I tell people to just try it out once. Take it one step at a time. See if you like it. See if you can get used to it. You never know you may actually come to love it and be telling others about how it is the best invention since sliced bread.

About the author: Dr. Michael Morgenstern is a board certified Neurologist, expert in Sleep Medicine and  founder of the American Sleep Apnea Society. He is Director of the Cedarhurst Sleep Center in Long Island, New York and also sees patients with neurologic conditions.