Airway and diagnosis

[Paula McCabe]

Hello,

Can't someone have a normal airway volume and still have apnea?

Background: I've always thought airway examination was not a lot of help in diagnosing apnea.
I remember a doctor showing me an x-ray of someone WITHOUT apnea who had a very narrow airway and another who had a normal airway but had apnea.

However, I saw another doctor recently who is saying most of his apnea patients have a narrow airway based on his 3-D reconstruction of airway volume.

My AHI is around 5.6 and my 3-D airway reconstruction is normal while awake but my blood oxygen drops into the 80's for hours during sleep studies and two sleep endoscopies showed airway collapse.

I am an MMA candidate. I KNOW that I have a breathing problem because my symptoms are profound and some past airway treatments had markedly improved my condition. The only thing I am wondering is, if my airway is normal and I still have a problem, will opening it more even help? My guess is that it will but, it's a big surgery that will change my face so I need to know what's going on.

Thank you,
Paula

[Sleeprider]

Apnea can be either or both obstructive or central in nature, so airway anatomy is not necessarily predictive, particularly of non-obstructive sleep disordered breathing. I'm also not sure where upper airway resistance syndrome (UARS) might fit into this. The viewpoint raised in your post seems like it would be more prevalent amongst specialists seeking surgical and PAP correction to OA. Airway anatomy has been extensively explored. There are a number of articles exploring the relationship of anatomy and apnea. Here is some articles that explores the issues you raise. Whether these are applicable to you or not, there is no way to know. Good post and welcome to the forums.

http://www.medscape.com/viewarticle/584505_2
http://jap.physiology.org/content/116/1/3
http://www.ncbi.nlm.nih.gov/pubmed/18497601

[Paula McCabe]

Apnea can be either or both obstructive or central in nature, so airway anatomy is not necessarily predictive, particularly of non-obstructive sleep disordered breathing. I'm also not sure where upper airway resistance syndrome (UARS) might fit into this. The viewpoint raised in your post seems like it would be more prevalent amongst specialists seeking surgical and PAP correction to OA. Airway anatomy has been extensively explored. There are a number of articles exploring the relationship of anatomy and apnea. Here is some articles that explores the issues you raise. Whether these are applicable to you or not, there is no way to know. Good post and welcome to the forums.

Thank you. Maybe there is no easy answer.

[TyroneShoes]

There is one easy answer, which is if you have the insurance or the cash on hand, you are a candidate. And that may have nothing to do with whether is is the best course of treatment for you.

My recommendation based on nothing is to save that for a last resort. XPAP is pretty effective and non-invasive. Nothing else really is.

[trish6hundred]

Hi Paula,
WELCOME! to the forum.!
Hang in there for more answers to your questions and much success to you.

[Paula McCabe]

There is one easy answer, which is if you have the insurance or the cash on hand, you are a candidate. And that may have nothing to do with whether is is the best course of treatment for you.

My recommendation based on nothing is to save that for a last resort. XPAP is pretty effective and non-invasive. Nothing else really is.

Thank you Tyrone! xPAP does not keep my airway open and the problem is to the point of disabling me. For 25 years now I have been battling this and I am all out of fight and sick of living a lesser life.

I've had several surgeries and somnoplasty and tried all the devices, techniques, etc. About the only thing I have tried is sleeping on my stomach, acupuncture or airway exercises, none of which I am hopeful enough to try unless someone told me it really works.

---

Hi Paula,
WELCOME! to the forum.!
Hang in there for more answers to your questions and much success to you.

Thanks Trish!

[me50]

we don't know enough about your diagnosis, etc. when did you have a sleep study or your last sleep study? do you have the results of that sleep study? if so, can you post it here without your personal information?

If you don't have a copy of your sleep study, you should get it. What was your diagnosis? How many events and what type of events did you/do you have? How long have you tried the machine? What issues do you have with the machine? Have you been diagnosed with Central Apnea?

What all surgeries have you had and what was the purpose of those surgeries? Obviously the end result has not been a good one.

How have you determined that by using the machine that it doesn't keep your airway open?

I agree with TyroneShoes

[Paula McCabe]

we don't know enough about your diagnosis, etc. when did you have a sleep study or your last sleep study? do you have the results of that sleep study? if so, can you post it here without your personal information?

If you don't have a copy of your sleep study, you should get it. What was your diagnosis? How many events and what type of events did you/do you have? How long have you tried the machine? What issues do you have with the machine? Have you been diagnosed with Central Apnea?

What all surgeries have you had and what was the purpose of those surgeries? Obviously the end result has not been a good one.

How have you determined that by using the machine that it doesn't keep your airway open?

I agree with TyroneShoes

Thank you for your reply.

Dr. Steven Park said essentially, that the airway needs to be examined when lying down and mine was not. I find this amazing that most doctors don't do this. Dr. Park is so awesome! But I think that explains why my airway appears normal when upright. The sleep endoscopy however, shows collapse.

Reliance on sleep studies has made this journey very long because of my low scores for Apnea. Dr Park said he sees lots and lots of patients like me. It's a shame doctors don't know more.

[TyroneShoes]

He is a doctor, and I am not. So his opinion would (and should) carry weight with you. Assuming he is a good doctor.

But although I am not a doctor, I can still offer a different opinion, and then consider it if you wish.

IMHO, the "airway" does not need to be examined at all.

At all.

The 3D modeling is a gimmick, and has no value other than to raise the whoop-dee-doo factor of impressing potential candidates. It's a sales tool, that boosts sales by leading you away from your own common sense. A seduction technique. Pay no attention to that man behind the curtain.

And who needs gimmicks? That man behind the curtain, who has no legitimate argument to present to you, that's who. People trying to persuade you to part with your cash when you might not need to, and sometimes this is done at the expense of the negative ramifications that it can cause for the patient. Your issues from that are considered collateral damage.

What is important is whether you have SA events or not. Whether you have OSA events or not will tell you indirectly but positively and without question, whether the airway is "open" or not. A PSG study can do this, and even a data-capable xPAP can examine the wave-shape of your breathing and tell whether there are obstructions or flow limitations in any breath you take, and report that to you.

A 3D model adds nothing, no value at all, to the diagnosis. It might add an expensive line item to the final bill. A dentist does not need to know the precise architecture of a cavity in order to fill it, and no one needs to have a 3D model of their airway in order to treat breathing disorders properly.

I assume your AHI of 5.6 is without xPAP treatment. But either way, this is a very mild case of SA, and is virtually on the borderline of a negative diagnosis for SA.

What you need to know is whether the events are OSA events or not, because xPAP really does not treat CA and hypop and other sorts of disordered breathing events all that well. OSA events are the most common, and it treats that typically at 100%.

The only negative issue is a perception issue: OSA is so common among breathing disorders, and xPAP treats that so well, that a generalization that xPAP is all you need and will fix you is the common misperception. The way to get beyond that is to understand what sort of issues you have and whether xPAP is the right fit. It is for most, but not for all. But it is important to understand this very thoroughly before looking at alternatives, because the alternatives are pretty ineffective and grim, while xPAP is a miracle.

What you also need to know is whether "keeping the airway open" is the goal. Of course that is everyone's goal, but this sounds like issues (non-OSA events) that will not even be addressed by doing that.

So if xPAP, which is typically always effective at keeping the airway open, is not doing that (which seems almost impossible if not preposterous), then how will MMA do this? And is "keeping the airway open" really the goal here? It is very possible that your particular issues will not be addressed by keeping the airway open, or only partially addressed by doing that.

You have a lot of significant questions that need answering. My advice is to find a doctor that is not so oriented towards providing MMA as a solution. At least one, maybe more than one. Get to the bottom of this. I am not dismissing MMA out of hand, but were it me, I would really be looking at alternate explanations to what is possible to address my issues.

Question authority. Assume nothing. Take charge. Refuse to be preyed upon. Dig relentlessly until you have real answers.

[TyroneShoes]

...Can't someone have a normal airway volume and still have apnea?
...

My AHI is around 5.6 and my 3-D airway reconstruction is normal while awake but my blood oxygen drops into the 80's for hours during sleep studies and two sleep endoscopies showed airway collapse....

Lets look at this part of what you are saying.

An apnea refers to an apneic event, or an interruption in respiration, typically during inhalation. OSA does not coexist with "normal airway volume" for the moment an OSA event occurs. But "normal airway volume" is not a static thing. It is dynamic; it changes from moment to moment.

CA and other breathing issues can certainly coexist with normal airway volume, because CA events have little or nothing to do with the airway, and are mostly driven by CNS issues.

Those are not guesses; they are facts. But this is a guess: the fact that you have a very low diagnosed (or treated, not sure which) AHI seems incogruent with low 02 sat levels. IOW, it seems like the apneas are not really the entire story behind that. I think that is a burning question I would want my sleep doc to answer for me.

You have an AHI of 5.6, which means that you had on average 5.6 apneic events per hour in this sleep session. Some of those could be OSA events. So endoscopic reports of airway collapse confirming that should not be unexpected, and that may indicate that some of these events are OSA events. SleepyHead, which you have, will tell you whether you are having OSA events when using xPAP, so there really is already an answer waiting for you regarding that. You don't need endoscopic evidence to determine that.

OK, facts and guesses are over. Now, opinion. Mine is that endoscopy is an invasive procedure not commonly necessary with sleep studies. Certainly there may be a legitimate reason to do this, but I would be alarmed by a doc that wants to pull every arrow out of the quiver at the drop of the hat, including this, 3D modeling, and suggesting MMA when you still have many unanswered questions. There is a fine line between this sort of medical excess and Dr. Mengele.

And by the way, it would be criminal to do anything that might change that face.