Obstructive sleep apnea (OSA) is a sleep disorder marked by repeated interruptions in breathing due to relaxed throat muscles blocking the upper airway. These interruptions can drastically lower blood oxygen levels, causing the brain to trigger brief awakenings to restore normal breathing.
Erin Gurski, RN, FNP-C, Nurse Practitioner in the Division of Pulmonary Critical Care and Sleep Medicine, says patients with OSA may struggle with fragmented sleep, excessive daytime sleepiness, and health issues. Additionally, subtle signs of OSA, like emotional irregularity, morning headaches, memory loss, difficulty concentrating, frequent nighttime urination, drowsiness while driving, and decreased libido, can significantly impact quality of life and employment. Symptoms include loud snoring with silent pauses, choking, snorting, or gasping sounds.
“The signs of OSA are sometimes absent or unnoticed, especially in the absence of a bed partner to observe them. This often leads to 80 to 90 percent of adults with OSA being underdiagnosed,” Gurski says. “Diagnosis often occurs only after significant health issues, such as increased blood pressure, diabetes, or stroke, arise.”
The primary treatment for OSA is Positive Air Pressure (PAP) Therapy, using CPAP (continuous) or BPAP (bi-level) devices that keep the airway open during sleep. Second-line treatments include oral appliances, sleep position therapies, surgery, and hypoglossal nerve stimulation, known as Inspire. Lifestyle changes, such as avoiding alcohol and sedatives and promoting weight loss, are also recommended.
"I strive to help patients acclimate to their chosen therapy, most often PAP therapy, and to motivate them to continue using the device," Gurski says.
She addresses reasons for non-compliance, such as pressure intolerance, dry mouth, mask discomfort, or lack of motivation, by reminding patients of the symptoms that led them to seek treatment and reassessing symptom severity and sleep quality.
For some patients, CPAP titration may be necessary to fine-tune PAP settings for optimal pressure and comfort. Annual visits are typical for those using the device effectively, but for those still struggling after six months with moderate to severe sleep apnea, discussions about hypoglossal nerve stimulation (Inspire) may begin.
Inspire is a second-line therapy involving outpatient surgery to implant a device that stimulates the hypoglossal nerve to keep the airway open during sleep. The device, developed by Inspire Medical Systems and FDA-approved in 2014, is controlled by the patient via remote control. The patient turns it on when ready to sleep, can pause it if they wake up, and turns it off in the morning.
"There are numerous configurations that the Sleep Medicine physician and I can change to adjust how the stimulation affects the tongue to ensure comfort," says Gurski.
Inspire technology became available to UTMB patients around 2020, with implementation picking up post-COVID-19 pandemic. The interdisciplinary process at UTMB involves Sleep Medicine, Oral and Maxillofacial Surgery, and ENT specialists, all of whom have extensive training and certification. Close communication enhances collective knowledge and patient care. Patients can be referred to Sleep Medicine for therapy discussions or directly to surgeons. After surgery, ongoing care is managed by Gurski or Rizwana Sultana, MD.
Gurski shares that Inspire therapy is not suitable for everyone; factors such as apnea severity, BMI, and reasons for discontinuing PAP therapy are considered. PAP therapy is generally attempted first, and insurance criteria may vary, so it is recommended to consult a specialist.
Candidates undergo an initial consultation followed by a Drug Induced Sleep Endoscopy (DISE) to assess appropriate anatomy for the stimulation to be effective, then proceed with implantation. Activation occurs six weeks post-surgery. Side effects are rare and minor, with patients recovering well overall.
National data from the ADHERE Registry, which includes over 5,000 patients, shows high satisfaction with Inspire therapy. The Epworth Sleepiness Scale (ESS) decreased by five to six points, and apnea-hypopnea index (AHI) results indicated significant reductions. Among UTMB patients, 100 percent had an AHI of less than 15, with a median treatment AHI of 4.6. Compliance averages six to seven hours per night, with 80 percent using the device for more than four hours each night, compared to the national median CPAP use of 4.7 hours and a compliance rate as low as 50 percent.
"I love to tell patients to 'Give yourself the gift of sleep!'" Gurski emphasizes.
While Inspire is a proven therapy, it remains a second-line alternative to CPAP, which is the gold-standard treatment for OSA. However, for patients with moderate to severe sleep apnea, excessive daytime sleepiness, and cardiovascular risk factors, Inspire therapy is worth exploring.
For more information and studies, providers can visit Inspire Sleep Publications.
Learn more about Pulmonary Critical Care and Sleep Medicine at UTMB Health.
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