Answers to Your Questions About Inspire Upper Airway Stimulation Therapy

In this guest post, Dr. Eric Kezirian answers your questions about upper airway stimulation therapy with the Inspire device. 

Positive airway pressure therapy (whether CPAP, BPAP, APAP, or another form) is the first-line treatment for obstructive sleep apnea (see the image of an obstructed airway to the right). 

However, some patients cannot tolerate or sleep comfortably while wearing it.  If you are having trouble with positive airway pressure therapy or if it is not helping you, you may want to consider alternative treatment options, including surgery.

Inspire Upper Airway Stimulation is an exciting new treatment that was approved by the United States Food and Drug Administration in 2014 for patients with obstructive sleep apnea who do not tolerate or do not benefit from positive airway pressure therapy.  I was the first surgeon in the Western United States to offer Inspire Upper Airway Stimulation and have many years of experience with this approach to treating sleep apnea. 

The Upper Airway Stimulation system works somewhat like a pacemaker for the tongue.  There is a main unit (called a pulse generator) that sends a signal to the nerve controlling tongue movement (hypoglossal nerve) through a stimulation lead as well as a sensing lead that allows the system to send that signal only when the patient is breathing in and not through the entire night. 

Upper Airway Stimulation is different from other treatments for sleep apnea in many ways, including the fact that it combines surgery and non-surgical treatment.  Here are answers to some of the questions I receive about it.

How do I know if I’m a candidate for this therapy? Can my doctor order it or do I need to see a specialist?

Surgery for sleep apnea is not one-size-fits-all.  Different people have different causes of their sleep apnea, and this is true when it comes to surgery.  Specialists in sleep surgery are familiar with the wide range of procedures that I describe at sleep-doctor.com.  Evaluation techniques like drug-induced sleep endoscopy allow a sleep surgeon to understand what procedures may work best for an individual patient, and drug-induced sleep endoscopy is actually required before receiving Upper Airway Stimulation because it shows whether someone has a good chance to benefit from this therapy. 

Do I have to use CPAP for three months before I’m eligible?

There is no defined period of time for using CPAP before you consider alternative treatments.  Some patients are completely unable to tolerate CPAP in spite of our best efforts, while some patients take some time to become fully comfortable with it.  The key is making the right decision about whether you can or cannot tolerate and sleep comfortably with CPAP, whether it takes 3 days, 3 months, or 3 years.

What is the surgery like? Is it implanted near my heart? Will the device be visible beneath my skin?

All components of the system are placed inside the body during a surgical procedure that typically lasts 2 ½ hours. The surgery is performed under general anesthesia, and patients typically resume a normal diet on the night after surgery. The system is generally placed on the right side, opposite from the heart.  By far the most visible portion of the system is the main unit that is placed on top of the pectoral muscle, the main muscle of the chest.  This is covered by the skin and by the layer of fat that we all have underneath the skin that camouflages the device a little bit.  The result is that there is definitely a bulge that can be seen, but the device is not right underneath the skin, allowing others to see every edge of the device clearly.

How does the system know I’m having sleep apnea? Does it change the signal based on the severity of my sleep apnea?

Somewhat like with CPAP, every patient has a sleep study where we determine the best settings that treat a patient’s sleep apnea.  Then a patient goes home with their remote control to turn the device on at night and then turn it off in the morning, with the ability to change the strength of the stimulation signal they are receiving.  When the system is turned on using the remote control, the system moves the tongue forward on every breath.  The system does not wait until someone is having sleep apnea to send signals, as it wants to prevent them from happening in the first place.  The remote control can be used to adjust the signal before it is turned on, but the system does not adjust the signal itself while someone is sleeping.

Here’s the remote:
Inspire Remote

Here’s the device:  
Inspire Generator

Can the device shock me or misfire? Will I get hurt?

Because the device is placed entirely inside the body, there is no electric shock feeling and no injury from the stimulation.  The system provides gentle electrical stimulation to the nerve that controls tongue movement, moving the tongue forward without waking up a patient.

Is the system secure? Can someone hack the control to turn it on or off?

The system works with radiofrequency communication that requires a controller placed directly over it.  This is similar to many medical devices.  It would be extremely complicated to hack medical devices, and to my knowledge it has never occurred—for this device or other similar devices.

Can I use it while I’m flying on an airplane?

Yes.  You would just want to bring your remote control with you on the airplane.

How long does the device last and do I need to get it replaced? How about the batteries?

The device has a battery, like a pacemaker for the heart.  The battery lasts 8-10 years.  Replacement involves an outpatient procedure to remove and then replace the main unit.

What if I don’t like the device? How do I have it removed?

Removal of the device is possible and has been done.  It does require another surgical procedure.

What are the differences in the types of devices available now?

There is another device in clinical trials that is not yet widely available in the United States.  We do not know how well it works.  It has some different features, including the fact that it delivers constant stimulation through the entire night instead of just when a person is breathing in.

Will my insurance cover this? What should I expect to have to pay? Do you expect changes in coverage in the near future?

Insurance often covers this, but like any new procedure or device, at first there is a process for obtaining insurance coverage.  The key is to have a thorough evaluation to make sure someone is the right kind of patient that would benefit from Upper Airway Stimulation and then to send information for preauthorization to the insurance company.

To learn more about the Inpsire Upper Airway Stimulation device, please visit the website www.inspiresleep.com. You can reach out to Dr. Kezirian directly with any questions at www.sleep-doctor.com.

Dr. Eric Kezirian MD

If you are interested in learning more about sleep studies and CPAP therapy for sleep apnea click here:

Request sleep study

Request CPAP appt.

Other posts you may find interesting:

Comments

  1. Bob Edwards Reply

    Is it possible to disable the initial pulse when the device is first turned on before going to bed? I find it very uncomfortable

  2. Eric J Kezirian, MD, MPH Reply

    I do not think it is, but you should definitely check with Inspire Medical Systems or the team that manages your care. It is there to make sure someone knows the device has been turned on, and most people love it.

  3. Joyce Vince Reply

    I dislike the feeling when it is turned on, I was told it is milder than what happens when you are asleep. Unfortunately, I feel the zaps in the middle of the night, I pause the remote, finally turning it off.

  4. Leslie Reply

    Joyce,

    I had the same issue and reducing the level of stimulation was the ticket. Thus far, I’m very happy now. Have you done a sleep study since your device was implanted? It’s a marathon, not a sprint and does take time.

  5. Eric J Kezirian, MD, MPH Reply

    Slow and steady definitely wins the race, and anyone who finds themselves waking up due to the stimulation should turn it down for at least a few days before turning it back up gradually. The key with Upper Airway Stimulation is to use it at a level that is comfortable. The large majority of patients have found it very comfortable, often waking up much less than before they started the therapy because they are now having treatment of their obstructive sleep apnea. That being said, patients with difficulty falling asleep and/or staying asleep during the night (types of insomnia) can have an especially difficult time getting used to Upper Airway Stimulation.

  6. Olivier Van Glabeke Reply

    Hi everyone,
    It’s very hard to find comments about people who had a Upper Airway Stimulation surgery! As I am about to have the surgery in January, I’m very curious to hear comments of people who have been treated with it. Please help and share your experience. Thank you!
    Kind regards
    Olivier Van Glabeke
    Belgium

  7. Stewart Reply

    I shoot in skeet tournaments would I will be able to shoot once the device is implanted?

  8. Eric Kezirian, MD, MPH Reply

    For patients who fire guns with a barrel placed against the chest, we would want to implant the device on the opposite side. The device can be placed on either side of the upper chest, so it would not limit your ability to continue skeet shooting.

  9. Dina Reply

    My husband had the Inspire device implanted two years ago, and it no longer works for him as a viable means to control his sleep apnea. He went in for a wet endoscopy a couple of weeks ago, so they could take a look at his throat while he was sleeping and the Dt’s are now telling him to go back on the CPAP again. He will likely go back into surgery to have the Inspire device removed in a few months. So not worth the surgery or expense for him to have this device implanted.

    • Luther Scott Reply

      Why does the device no longer work for your husband? Did your husband undergo the sleep endoscopy prior to having the device implanted?

    • Eric James Kezirian Reply

      There are reasons that people do not respond to Inspire therapy, whether right away or over time. Typically, the next step is not just to remove it. I have written previously about a common approach to understanding why someone has not responded and how to resolve issues, if possible. You can see my blog post at https://sleep-doctor.com/blog/inspire-upper-airway-stimulation-not-working-for-your-sleep-apnea/.

  10. Nicole Reply

    Please call me my name is Nicole Peller my phone number is 6146250079

  11. Chester Fisher Reply

    Does Inspire have any beneficial effect on Central Sleep Apnea besides its effect on obstructive sleep apnea?

    • Eric James Kezirian Reply

      There is no benefit for central sleep apnea. In fact, having substantial central sleep apnea can interfere with Inspire therapy’s ability to treat obstructive sleep apnea.

  12. Geoffrey Halberstadt Reply

    Can you have an MRI after inspire is placed

    • Eric James Kezirian Reply

      You cannot have an MRI of the chest, abdomen, or pelvis. However, you can undergo 1.5 Tesla MRIs of the head and neck as well as the arms or legs. Different MRI machines have different magnet strengths, and 1.5 Tesla machines are commonly used, although 3 Tesla machines and other magnet strengths are also seen commonly. For further questions, you will want to discuss this with an Inspire team.

  13. Jeffrey A Fortezzo Reply

    I am thinking about having the operation for Inspire. Can you give me some data on what results your patients have had? I would like to know how often a problem has occurred during surgery? How many patients have had problems using the device? Also wondering how effective Inspire is after 6 months, one year, two years of use etc. Thanks, Jeff

  14. Jessica Weigle Reply

    My dad just got inspire in March 2020, he was set to go have it turned on a month later when all this COVID stuff occurred and docs offices were closed. In the meantime he had to have a pacemaker put in on May 4. When he went to get the inspire turned on May 8, they wouldn’t do it without a cardiologist present bc they don’t know how it will act with the pacemaker….I’m searching for someone who has both a pacemaker and an inspire to ask if there are any issues…

  15. Jerry Ceppos Reply

    I would think twice—no, make that three times—before implanting the Inspire device. I wish I had. Immediately after one was implanted in me last summer, most of my body shut down. I was in critical condition with acute pulmonary edema and many other serious problems. I was on a respirator for about a week and in the ICU for three weeks. After-effects continued for at least five months. I missed work for the entire second half of 2019. Beware.

  16. Nicole Peller Reply

    Could someone explain to me how I was able to get the inspire while I had pneumonia still inside me ?Also I have had so many problems .i decided to find a professional sleep doctor to help me does not know anything about me.After doing his sleep study he says YOU DONT HAVE SLEEP APNE AT ALL so my question is am I the only person that this is happened to you or somebody else got the Inspire put in and then found out they don’t have sleep apnea? Thankyou

    • Eric Kezirian MD MPH Reply

      You should not have had the Inspire device placed if you do not have obstructive sleep apnea. There is the possibility of what is called night-to-night variation in sleep study results, but it should not be so substantial that you would go from having moderate to severe obstructive sleep apnea to having no sleep apnea at all. However, anything is possible. If you had weight loss or a difference in your body position during sleep, that could definitely affect your obstructive sleep apnea.

  17. Nicole Peller Reply

    Has anybody had the Inspire put inside their body and then one year later find out they never had sleep apnea?

  18. Christopher T. Jenkins Reply

    I have sleep apnea and use a ResMed AirCurve 10. It often blows so strong it comes out my mouth. I use air pillows because I cannot tolerate a mask. I already have an implanted spinal stimulator in my back for spinal stenosis and neuropathy pain. When it was implanted I had some very painful problems that eventually went away. Can a person have both kinds of stimulators implanted? I assume no more M.R.I. can ever be done after implantation. I can’t have one anyway. Can both types of stimulators be implanted in the same person?

    • Eric Kezirian, MD, MPH Reply

      You can likely have both kinds of stimulators implanted, but you should speak with the Inspire team when you obtain an evaluation. MRIs are OK with the Inspire device for certain common types of MRI machines (called 1.5T or 1.5 Tesla) and many areas of the body (head, neck, arms, and legs but not chest, abdomen, or pelvis).

  19. DAVID LABORDE Reply

    How significant are the pulses to the tongue nerve? I’m concerned about getting to sleep during the stimulation.

    • Eric Kezirian, MD, MPH Reply

      They are noticeable while you are awake because your tongue moves. They should not wake you up from sleep. The system is set up to come on after you are asleep because you tell the system how long to wait until it starts working, choosing the time based on how long it typically takes you to fall asleep and then adding 10 minutes

  20. Robert Vines Reply

    After 18 months with Inspire…

    This is what I read about Inspire before I had my own: “The Inspire therapy works inside your body with your natural breathing process to treat obstructive sleep apnea. It continuously monitors your breathing patterns while you sleep. Based on your unique breathing patterns, the system delivers mild stimulation to key airway muscles which keeps the airway open while you sleep.”

    From that description, I assumed there would be stimulation when my breathing paused causing an apnea event. The way mine actually works is that there is an initial pause in stimulation to allow you to fall asleep then the initial start-up can be a real jolt. My mouth is propped open by my tongue thrusting forward followed by a constant thumping of my tongue against the roof of my mouth. Only one side of my tongue is fully stimulated which causes the tongue to thrust out and to the side. Each stimulation is instant causing the tongue to jerk very fast. It also causes my tongue to buzz somewhat like it was AC current or chopped DC.

    My tongue thrusts out for 3 seconds and then repeats after a one-second pause causing the constant thumping noise against the roof of my mouth. However, after 30 minutes to one hour, the tongue movement seems to settle down to a less aggressive and less jarring thumping. This may be simply a tiring of my tongue muscles rather than a change in the stimulation. The stimulation cycle of three seconds on and one second off eventually changes but never seems to have any coordination with my breathing. Sometimes it becomes quite rapid, and sometimes it lengthens enough to allow a complete breath.

    I also noticed that it will not work at all if my electric blanket is turned on. And, I noticed that sometimes my electric shaver will turn on the stimulation. Experiencing this, makes me want to carry the remote with me everywhere in case the system turns on. I have also found the Patient Manual on the internet (which I now wish I had seen before having the surgery) which states that stimulation can initiate if you are near a CB Radio, electric welder, other electrical devices, dental drills, or near our induction stovetop. This is not so bad for me because I have an excuse not to help my wife in the kitchen, but bad news for not being able to use the handheld 2way CB radios that I use hiking or the welder in my shop. I will also need to remember to take control with me when I go to the dentist.

    Before having the Inspire device I used a mouthpiece that holds my lower jaw forward as well as a BIPAP unit set at a fairly low pressure. I have to use a low pressure because raising the pressure results in severe gas pains for me as air flows into my stomach. The plus with using the BIPAP even at low pressure, however, is that I have online access to the daily report of the previous night’s sleep. I average 17.5 apnea events per hour using these two together.

    I found if I use the Inspire device without the mouthpiece or the BIPAP, I wake in the night with a headache. Using the BIPAP, the mouthpiece, and the Inspire device solves the headache problem but does not change the average number of events per hour. It does add two inconveniences. First, frequently when the Inspire initiates the stimulation I wake up. This is almost always the case if I have it set on one of the highest values. The second is that I have always experienced sinus drainage, especially when I lie down. When this drainage is in my throat, I swallow reflexively. Using the Inspire device, I cannot swallow. A third problem is that the sensor pokes painfully in my ribs if I try to sleep on my right side.

    My summary is that the device has been a disappointment for me. Because I still use the BIPAP on low pressure and can access a daily report on events per hour, I have repeatedly experimented with using Inspire and not using Inspire to see if it helps. My repeated data shows events per hour is the same using the Inspire or not using Inspire. In other words, the Inspire does not help me. I am also surprised to see a device being marketed with such a susceptibility to EMC/EMI interference. UL approval of the device would have revealed these problems. There should be a ramp of the initial stimulation over a period of minutes to prevent the initial jolt of full stimulation that wakes me up. There should also be a ramp of each stimulation to allow a more gentle tongue movement. And, of course, the sensitivity to electronic interference needs proper filtering. And finally, there should be an on/off switch on the control to keep the battery from going bad while you are carrying it with you.

    • Shari T Reply

      Hi Robert…I’m scheduled to get inspire today….after reading ur post I’m feeling affraid. I hope I’m making the right decision. My dad also has sleep apnea and his drs have said some, perhaps most of his dementia symptoms are related to his uncontrolled condition. My dads condition is a possibility for me too. Which also scares me. The device turning on by itself is especially concerning. The pain u mentioned is likely to cause me not to use it as directed… right now I dont know what to do. My email is Sharit2015 (AT) aol.com if u get notice of my reply and u want to reply.

  21. Ele T Reply

    Shari, what did you end up deciding?

    Also, it seems Inspire comes out with a new device model every 3 years. Being right at the milestone for a new one, has anyone heard if they have a new model coming out soon? Debating whether to hold off or not. Thank you

  22. Craig Van Anne Reply

    Dr. Kezirian — I have undergone a drug-induced sleep endoscopy which shows complete palate obstruction with the tongue 100% in contact with boths sides of the throat. My AHI is 17, intermittent; RDI 34. I am approved for Inspire therapy, but recently have become aware of Radio Frequency Ablation. I am intrigued with RFA being much less intrusive and avoiding the MRI-ban of Inspire. Your thoughts on RFA, please. I live in the SF Bay Area. Thanks!!

  23. Harry Reply

    I’m Harry from Brooklyn and I just completed level 4 of my Inspire Sleep.
    My 1st panic was acceptance of my Metro plus insurance, which was accepted. I was disappointed that the VA isn’t part of the inspire program as yet. My surgery performed by MD Steven Parks @ Montifeur Hospital in the Bronx went very well. Just a little discomfort at first (no real pain). Just rest and heal for approx 30 days. The consult to activate the remote was very informative. It was strange feeling my tongue being controlled by the Inspire device. I do get up after a few hours of sleep to urinate and drink water, therefore, I pause the remote ((15 minutes), then it automatically resumes. By that time I’m back in bed asleep. I still have a ways to go but I’m very encouraged!!! All I can say is: Get rid of your CPAC NOW machine
    THE STORY CONTINUES

    • Tim D Reply

      The VA covered my Inspire through care in the community.

  24. BECKY HUTCHENS Reply

    ARE MAJOR CARRIERS COVERING THE DEVICE ITSELF? I KNOW THE PROCEDURE CODES ARE COVERED BUT JUST WONDERED ABOUT THE DEVICE.

  25. David R Wells Reply

    I’m scheduled to have the device implanted on Sep 29. I have been doing research and now, after the comments here, I am seriously considering cancelling the surgery. I’ve struggled with apnea for many years and it has really taken a toll on me. Tried CPAP multiple times and have had all the surgeries possible to correct the problem, except a tracheotomy. To make things worse, I have other serious health problems, most noticeably chronic Adult On-Set Still’s Disease. Getting to sleep is a chronic problem due to pain and staying asleep is just as bad. I would appreciate any additional comments on experiences that could assist me in deciding whether to go forward next week. Thank you.

  26. Eric Kezirian, MD, MPH Reply

    You should speak with your doctor about this. It can be complicated to become comfortable with Inspire if you have substantial troubles falling asleep, but your individual situation should be discussed with them.

    • David R Wells Reply

      I have a superb physician and we have a great relationship. I trust that he would not suggest if the benefits did not out way the negatives. So all I really have left is this therapy or a perm opening. The comments above have me concerned, but I say you’re right … work with my physician.

  27. Eric Kezirian, MD, MPH Reply

    It can be difficult for some patients to get comfortable enough with Inspire if they have substantial difficulty falling asleep. However, this is really something for you to discuss with your own physicians.

  28. Margaret McCarthy Reply

    I am 75 have recently been diagnosed with normal pressure hydrocephalus and may need to have a shunt put in my brain. My GP and Cardiolist want me to take care of my sleep apnea Problem and have suggested the Inspire. I definitely cannot use any CPAP masks with my clastrophobia problem. Have tried all the masks over years. I am worried about the MRI problems and I can only sleep well enough on my right side. What do you suggest? I live in Scottsdale Arizona.

  29. Frank Cook Reply

    I had the Inspire surgery on September 21. Since then I have had several pain on the right side(same side where the device is installed) of my head, it is exacerbated with the movement of my tongue. The pain is in my right eye, ear, and throat. When I move my tongue as when eating it is severe pain. It seems like when the device leading to my tongue was attached that there was not enough length to allow the tongue to move about freely.
    Has there been anyone else had any similar experience? I need more info before I complain to the surgeon.

  30. Frank Cook Reply

    I had the Inspire surgery on September 21. Since then I have had several pain on the right side(same side where the device is installed) of my head, it is exacerbated with the movement of my tongue. The pain is in my right eye, ear, and throat. When I move my tongue as when eating it is severe pain. It seems like when the device leading to my tongue was attached that there was not enough length to allow the tongue to move about freely.
    Has there been anyone else had a similar experience? I need more info before I complain to the surgeon.

  31. James Reply

    Dr. – Shortly after having the Inspire Stimulator implanted & activated, I developed bilateral tinnitus, which had gotten extremely distrissing. The percieved ‘sound’ is louder at night(high pictched screeching, sometime a forest full of crickets) than in the daytime(low hissing).
    Are you aware of any other reports of tinnitus developing directly after activation?

  32. James Reply

    Dr. – Shortly after having the Inspire Stimulator implanted & activated, I developed bilateral tinnitus, which had gotten extremely distressing. The perceived ‘sound’ is louder at night(high pitched screeching, sometime a forest full of crickets) than in the daytime(low hissing).
    Are you aware of any other reports of tinnitus developing directly after activation?

  33. Mike G. Reply

    I am considering the Inspire implant. I’m confused by the sleep study reposrt and the docs haven’t been all that helpful. During my home sleep study my overall AHI was 75, but it also said that I had 289 Obstructive events, 80 central events and 153 mixed events. It also says my obstructive apnea index was 37, my central apnea index 10 and mixed apnea index 19.

    I have been using an Auto Pap for 10 weeks. During that time my AHI has averages about 30 despite numerous pressure adjustments. The Neurologist in the sleep clinic has basically declared the APAP ineffective. Next steps being BiPap or surgery. I have seen two surgeons in the sleep clinic., an ENT and an oral maxillofacial surgeon. The two surgeries discussed have been a Maxillomandibular advancement (very scary) and an inspire implant. the oral surgeon says try Bipap first because the presence of the central apnea will mean continued sleep apnea even after surgery. The ENT says BiPAP will likely be ineffective as well and that its benefit over cpap/apap is one of comfort and not necessarily effectiveness. he is enthusiastic about Inspire and I have scheduled me for the DISE. I sent him an email today asking if I should be concerned about the central apnea. One of the first things that crossed my mind when first told about Inspire was comfort i.e. will it wake me up, keep me up or keep me from falling asleep. After reading the posts above I admit I am concerned, however, I recognize that these posts represent a very small sampling of Inspire patients and also that people who have a negative experience with a product of any type are more likely to write a negative review than someone who is please writing a positive review. I think my bigger concern is whether my central apnea will have a negative effect on the efficacy of the device such that I still have to use some type of PAP device.

    • Erika Reply

      Mike- The Inspire will not be effective for your central sleep apnea at all. BIPAP typically makes central sleep apnea worse. CPAP/APAP and BIPAP will not fix your central and mixed events either. I am shocked that no one has mentioned ASV to you (aka VPAP)!!!! That is the gold standard for complex sleep apnea, which is what you have. However, the use of it depends on your cardiac ejection fraction, which can be obtained via echocardiogram. I would consider this route FIRST before any type of surgery! (I am an registered sleep technologist of 19 years). Good luck!

  34. Tim Reply

    After three failed CPAP attempts over the years, I had Inspire surgery in June 2019. It is pretty common to return to the office with the Inspire rep to adjust the device, which they can do from a computer. I think they eventually want you up around 7,8,9 level. I am at a level 3 right now and have no issues with snoring and am sleeping all night. I’ve tried to go up to a level 4 but when the device turns on after 30 min, it’s pretty powerful and wakes me up. It takes about a minute to settle down to a calmer level. So I just stay at a 3. It definitely works better for apnea than the cpap, for me anyway.

  35. E Mares Reply

    Going on 9 months since surgery. Had 2 adjustments and settled on level 6. Considerable reduction in snoring and more sound sleep. The device takes some time to get used to but I am not dealing with CPAP anymore. Had I had to pay for copays I don’t know if I would elect to have implant. VA picked up the cost.
    This is evasive surgery so be prepared for recover time and pain associated with it.
    If you get pain meds be aware that will cause constipation so drink lots of fluids or you’ll have some issues.

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