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:
Here’s the device:
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.
If you are interested in learning more about sleep studies and CPAP therapy for sleep apnea click here:
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