Sweet dreams for sleep apnea patient
Device forces airway to open
Chris DeNardis said he started dreaming again about three months ago, for the first time since he was 11 years old.
“I wake up with more energy. I can’t believe people live the way I used to live,” said DeNardis, who lives in Wallingford and turned 36 on Sunday, just over a year after he had the Inspire device implanted to cure his obstructive sleep apnea. “Now I wake up ready to go. I wake up before the alarm usually,” he said.
Continuous positive airway pressure, or CPAP, is considered the “gold standard” for treating sleep apnea, according to sleep medicine doctors. But for those who can’t tolerate wearing the mask, or who just don’t want to have to deal with it, Inspire’s device may be the best alternative.
It works by sensing when the patient is breathing and stimulating one of the hypoglossal nerves, which forces the tongue forward and opening the airway.
CPAP didn’t work for DeNardis. “I’d wake up and it wouldn’t be on my face anymore,” he said of the mask, which is worn over the nose and mouth (some models just cover the nose). “I just don’t think that it worked for me at all. It didn’t change anything for me.”
Not only did DeNardis snore, but, “I used to choke myself up constantly. … I fell asleep when I was on a trip to Florida with my mom and she was scared out of her mind by the sounds I was making.”
CPAP works by forcing air into the respiratory tract, keeping the tongue, throat or palate from closing. When they do, and a person can’t breathe, he or she wakes up, over and over again.
Dr. Andrey Zinchuk, a pulmonologist and director of the Advanced Apnea Management Program at the Yale School of Medicine, said sleep apnea can cause “poor sleep duration or poor sleep quality.”
“Both of those things are associated with impaired neurocognitive function, sleepiness during the day, fatigue, loss of productivity, irritability … higher rates of car accidents,” Zinchuk said.
Not only that, but as the person keeps trying to breathe, “oxygen levels drop in the lungs, and they drop in the heart, kidneys and brain,” he said. “There’s a release of stress hormones, blood pressure goes up, heart rate goes up.”
Blood pressure also will increase during the day, and hypertension can lead to stroke, he said.
Waking up more than five times an hour is considered abnormal, Zinchuk said. More than 30 times is considered severe sleep apnea, and Zinchuk has seen patients who wake up 120 times an hour.
“Pound for pound, CPAP is the most effective treatment to open up the airway,” he said. “It’s brute force.” It’s also non-invasive.
While CPAP works best, “it’s been pretty well studied that about 40 to 50 percent of patients … don’t tolerate it very well” and stop using the machine, said Dr. Bruno Cardoso, a
specialist in ear, nose and throat surgery at the Yale School of Medicine.
While considered low risk, implanting the Inspire device requires two incisions, “one in the neck, right under the jaw line, typically on the right side, and one incision on the right chest wall under the clavicle” between two ribs, Cardoso said.
One electrode is attached to the section of the hypoglossal nerve that controls the forward movement of the tongue, he said, and “we put an electrode in the rib space in between the rib muscles and the we connect the electrodes to the generator.”
“The sensing lead will sense the respirations and it will send the signal to stimulate the hypoglossal nerve,” Cardoso said.
“The recovery is minimal,” compared to surgeries that remove part of the tongue or palate. Those surgeries also are not as effective, he said.
Dr. Mark D’Agostino, who has worked with Inspire since 2007 — the device was approved by the Food and Drug Administration in 2014 — said of Inspire, “short of CPAP, it’s the highest success rate of anything.”
D’Agostino is section chief of otolaryngology at Middlesex Health and has offices in Middletown, Milford and several in the New Haven area.
Not for everyone
There are limitations. The patient’s body mass index must be lower than 32, according to most insurance companies. As we gain weight, “our tongue gets bigger and the side walls of our throat get bigger and it cuts down the airway,” D’Agostino said. That makes it harder to move the tongue forward.
Also, the apnea must be caused by the tongue falling back, not by the airway collapsing like a wet straw would when sucked. To be sure the patient will succeed with nerve stimulation, “we do what’s called drug-induced endoscopy,” D’Agostino said.
After the surgery, “most patients are back to normal in a day or two,” he said, although the device is not turned on for a month to allow for healing.
The patient turns on the device with a remote control. “The device does not start working until they fall asleep,” D’Agostino said. “We can set the start time whenever we want.”
While insurance requires a patient to fail CPAP in order to get the Inspire device, D’Agostino said, “Failing CPAP is loosely defined. You can say, ‘I don’t want to wear it anymore.’”