New efforts to treat sleep apnea open up at UCH

A fellowship-trained sleep surgeon, therapy and construction of a sleep lab beef up options for patients.
September 28th, 2016
Katherine Green, MD, says the Inspire device is one of many options for patients with obstructive sleep apnea who have not found relief from CPAP.

University of Colorado Hospital is set to open eyes with an aggressive approach to tackling one of the nation’s most persistent sleep problems.

The Center for Lungs and Breathing at UCH recently brought on board Katherine Green, MD, an otolaryngologist and fellowship-trained sleep medicine specialist and surgeon. Green has experience with new and more advanced procedures for the soft palate and tongue, the primary culprits in obstructive sleep apnea (OSA), a condition that affects an estimated 18 million Americans. She is also available to help patients at UCH with Inspire therapy, an alternative to traditional surgery.

Also in the works for UCH is the UCHealth Stapleton Sleep Clinic, now under construction in the building that houses the A.F. Williams Family Medicine Clinic and The Center for Integrative Medicine. The four-bed unit will join those already in use at UCHealth Northern Colorado and Colorado Springs. It is currently slated to open in March 2017, said Tim Wimbish, director of the Center for Lungs and Breathing.

Open discussion

People afflicted with OSA have nightly periods of sleep disruption that occur when the muscles in the upper throat relax and collapse, blocking the upper airway and neck. That restricts the flow of oxygen to the lungs. The result: periodic snoring and gasping for air.

 

Alternatives to CPAP seminar

For those who are unable to use CPAP, a seminar led by Dr. Katherine Green, medical director of the UCHealth University of Colorado Hospital Sleep Center, will cover treatment options like Inspire therapy and sleep surgery.

February 27, 2019
5:30 – 6:30 pm
University of Colorado Hospital
Bruce Schroffel Conference Center
RSVP here: https://www.uchealth.org/events/events/alternatives-to-cpap-seminar/

Those sounds are annoying for bed partners, as many people can attest. But OSA is far more than a harmless inconvenience. It has been linked to a host of medical problems from cardiovascular issues to chronic fatigue and poor cognition, Green said.

The standard therapy for OSA patients is CPAP (continuous positive airway pressure). Patients put a mask over the face and nose or place prongs in the nose. A machine forces positive pressure down the airway, preventing the airway from collapsing. It’s low-tech, relatively inexpensive and very effective for many people at keeping the airways open.

“CPAP is our first-line therapy, and it can be life-changing,” Green said.

Surgical fixes

There is a hitch, she added. For CPAP to be effective, patients must use it every night. Only about 40 to 50 percent of patients are comfortable wearing the mask. For many others, the machines go into the closet, leaving patients to struggle with an untreated condition and its serious health consequences. It’s those patients Green aims to help through surgery and, now, Inspire.

The traditional surgical alternative to CPAP was the tongue-twisting uvulopalatopharyngoplasty, or UPPP, which involves removing part of the soft palate, the uvula and the tonsils, if they are still present.

While it was effective for some, UPPP often offered plenty of pain without the desired pay-off, Green said. “In the old model we cut things out,” as she put it, “but we didn’t have a great success rate.”

Green received training in alternative procedures during her fellowship at the University of Southern California. These include reconstructing and repositioning the soft palate, rather than removing parts of it, and shrinking or stiffening the tongue with controlled cuts to make it less of an obstruction. If the patient’s condition warrants it, she will also perform more than one surgery to treat multiple OSA-causing issues.

Palatable planning

The key to successful treatment is developing a treatment plan tailored to each patient’s needs, Green said. To do that, she makes an evaluation with a drug-induced sleep endoscopy in the OR. The patient is lightly sedated to produce a state that is close to normal sleep.

Inspire
The Inspire device, which is implanted under the patient’s skin, looks and functions something like a pacemaker for the heart.

“We will actually hear loud snoring during the procedure,” Green said. “We can figure out what happens during sleep.”

With the patient sedated, Green uses an endoscope to look at the back of the patient’s airway and examine the anatomical obstructions. She videotapes the procedure and watches it with the patient to help him or her make a treatment decision. The evaluation moves away from giving a one-size-fits-all approach to patients who are candidates for a procedure, Green said.

“It gives us a lot more information and confidence in picking a surgery that will be most effective for the patient,” she said.

Green said that with careful pairing of the patient to the newer procedures, she has achieved success rates of 80 to 85 percent in treating OSA. But she acknowledged that surgical procedures of the palate and tongue are not easy on patients and that patients typically need two full weeks to recover.

New inspiration

For those who shy away from more traditional surgery and have not gotten relief from CPAP, Inspire offers another option. It’s an FDA-approved device that looks like a pacemaker and uses similar technology. In a minimally invasive procedure, the surgeon implants the small, battery-powered device under the skin and over chest muscles. The device has two wires; a stimulator cuff is implanted in the neck around the nerve that controls movement of the tongue, and a sensing wire placed between the muscles of the ribcage.

Before bed, the patient turns on the Inspire device with a remote control, then goes to sleep. With every breath, the lead in the ribcage sends a signal that gently stimulates the tongue, pulling it forward so that it doesn’t obstruct the airway.

The procedure typically lasts 90 to 120 minutes, said Green, who implanted the Inspire device during her fellowship. Patients usually go home the same day or the next day and generally have less post-operative pain than those who have traditional surgeries for OSA. She said the success rate thus far is comparable to or better than other procedures.

She stressed, however, that Inspire is not for everyone. For example, patients must have a body mass index (BMI) of 32 or less. Batteries wear out and must be replaced, requiring another procedure, something some patients might not want.Some might simply not want a device implanted in their bodies.

Green said she also recommends it to patients only after she does the endoscopic airway evaluation, as the device has been shown to be most effective with particular patterns of airway collapse. Inspire Medical, the device manufacturer, identified other patterns of collapse as contraindications for the therapy.

“We’re going to be careful about who gets Inspire,” which is also available at UCHealth Northern Colorado’s Poudre Valley Hospital, Wimbish said. “Our goal is to offer a breadth of surgical options and identify what will be most successful for each patient.”

The expansion of the sleep program offers opportunities for providers to collaborate, Wimbish added. For example, the hospital might help a patient whose BMI is too high to qualify for the Inspire procedure with nutrition, exercise and weight-loss services, he said. The connection between OSA and hypertension, arrhythmias, stroke and other cardiovascular problems makes involvement with the hospital’s Cardiac & Vascular Center a natural.

“In the past we’ve helped to diagnose patients with obstructive sleep apnea, but we haven’t had a great method for addressing it,” Wimbish said. “We’re now expanding on what we’ve been able to offer and will be able to manage it with more success.”

Click here for more information or call 855-LUNG-UCH to make an appointment with Dr. Green.

About the author

Tyler Smith has been a health care writer, with a focus on hospitals, since 1996. He served as a writer and editor for the Marketing and Communications team at University of Colorado Hospital and UCHealth from 2007 to 2017. More recently, he has reported for and contributed stories to the University of Colorado School of Medicine, the Colorado School of Public Health and the Colorado Bioscience Association.