Obstructive sleep apnea, with its often raucous snoring, can place a severe strain on a romantic relationship, driving partners into separate bedrooms.
It can also take a dramatic physical toll, leading to high blood pressure, stroke, cardiac arrhythmia, and coronary-artery disease.
Problem is, most sufferers can't tolerate the first line of apnea treatment.
Nearly half of all patients prescribed a CPAP machine give up on it within a year, said Maurits Boon, an ear, nose, and throat specialist who focuses on sleep medicine at Thomas Jefferson University Hospital. CPAP, or continuous positive airway pressure, uses mild air pressure administered through a mask to keep the airways open. Some users (and partners) say it sounds like Darth Vader breathing.
"I think patients become very sad and upset when CPAP doesn't work for them," Boon said. "The good news is that there are a whole host of options available."
Oral appliances and an implantable nerve stimulation device, jaw and weight-loss surgery are all options to reduce or eliminate sleep apnea. Other treatments - met with less enthusiasm by local specialists - include throat surgery, a new bedside device, nasal inserts, and a "sleep positioning" collar.
Obstructive sleep apnea (OSA) is caused when the throat repeatedly collapses on itself. The blockages starve the body of oxygen, rousing the sleeper who gasps for air. In serious cases, the apneas (breathing interruptions) can occur more than 40 times an hour.
For the majority of OSA patients, CPAP provides immediate results. They sleep better and wake up feeling rested. But about 40 percent grow to hate their CPAP machines and stop using them. Masks leak, hoses become tangled around their necks, and the headgear that keeps it all in place can be uncomfortable.
"I've tried it. I cannot use it," said Karl Doghramji, director of the Jefferson Sleep Disorders Center at Thomas Jefferson University Hospital. "I put the mask on my nose and I get a sense of claustrophobia."
Snoring is often the first sign of OSA. Other symptoms include daytime drowsiness, poor concentration, depression, and even impotence.
As for the cardiovascular-disease link, "we don't totally understand how it happens," said Richard J. Schwab, director of the Penn Sleep Center at the University of Pennsylvania. "It may be linked to hypoxia [the lack of oxygen getting to tissues] or it may be related to the arousals which cause a sympathetic surge in the nervous system."
Even mild cases can be cause for concern, according to the American Sleep Apnea Association.
"About 104 Americans die every day from a cardiovascular event associated with sleep apnea," said association director Tracy Nasca. "Mild cases can leave the brain deprived of oxygen up to 19 times an hour."
Before the introduction of CPAP in the early 1980s, the most effective treatment for sleep apnea was a tracheostomy, a procedure that bypassed the obstructions by cutting a hole into the neck to open a passage to the windpipe, Doghramji said.
Though apnea is linked with being overweight, "weight loss wasn't often effective" as a treatment, Doghramji said. "People couldn't achieve the loss needed to treat the apnea."
Many have found relief using a dental appliance, Schwab said. Similar to a mouth guard, a mandibular repositioning device opens the airway by pushing the lower jaw forward. It can be pricey, starting at about $1,500, and is often not covered by insurance, Schwab said.
When CPAP and dental appliances fail, the next step may be surgery.
Last year, Penn and Jefferson began offering hypoglossal nerve stimulation, marketed under the name Inspire. Boon and Schwab said it's effective in 70 percent of those who have it. Doctors implant a pacemakerlike device under the collarbone. From the device, a lead runs up the neck to the back of the nerve under the tongue. When the device senses an interruption in breathing, it sends an electrical pulse that causes the tongue to push forward, clearing the airway.
Inspire is pricey, though Medicare will cover it, Boon said. If your insurance doesn't, costs can reach $100,000. But specialists are enthusiastically promoting it.
"It's been a game-changer," Boon said. "Many patients see the number [of apnea episodes] reduced to zero."
Throat surgery to treat sleep apnea, including the removal of the uvula, is often not effective. It also has another downside: "namely a miserable recovery," Boon said.
More extreme is maxillomandibular advancement surgery, which requires breaking the upper and lower jaws and repositioning them to open the airway. It requires four months of recuperation at home while the jaw is wired shut. It's very effective, Doghramji said, but it's also expensive, running up to $270,000.
For patients who don't relish machines or invasive surgery, an aboriginal instrument from Australia may hold some hope.
Though few have taken him up on it, Doghramji has suggested patients learn to play the didgeridoo. It's inexpensive, starting at $30, and practicing the instrument has been shown to strengthen the throat muscles, leading to a decrease in apnea episodes, he said.
"There's a couple of published papers that show if you have any level of apnea, there was an improvement with playing it," Schwab said. It requires dedication - namely, practicing an hour a day, five days a week.
Singing, too, is also effective for some people, Schwab said.
"Playing the didge or singing may not make your apnea totally go away, but you're going to see some benefit from it," he said.
Schwab said the worst thing you can do is ignore apnea.
"Not treating it, doing nothing, is a really poor decision," he said. "Sleep apnea may not be something that will make you die in your sleep tomorrow. But it might down the line."
Continuous positive airway pressure (CPAP)
Considered the "gold-standard" in treating obstructive sleep apnea, CPAP uses pressurized air sent through a mask to keep the air passages open. But about 40 percent of users can't tolerate the device. The face mask can leak and the pads can irritate the face. Some who quit say it's like sleeping with a vacuum cleaner. The device is about $700 and is covered by Medicare and most private insurers.
A mouthpiece called a mandibular advancement device (MAD) pushes the lower jaw forward to open the airway at the back of the throat. Available with a prescription from qualified dentists, a custom-fit MAD can cost $1,500 to $3,000. Cheaper boil-and-bite devices are not considered effective, doctors said.
Hypoglossal nerve stimulation (Inspire device)
Approved by the FDA in 2014, the Inspire device - similar to a pacemaker - is surgically implanted near the collarbone. Two leads run from the device. One monitors breathing, another runs up through the neck to the muscle behind the tongue. When it senses a halt in breathing, it sends a mild electrical pulse to the tongue, causing it to move forward and opening the airway. Sleep specialists say it's very effective but costly. It's sometimes covered by Medicare and the VA but often resisted by private insurers.
Oral pressure therapy (Winx)
Winx, a bedside device, uses a principle similar to CPAP. A mouthpiece attached to a machine generates a slight vacuum and pulls the soft palate forward. Richard Schwab of the Penn Sleep Center said the $700 device has worked only about 30 percent of the time; the manufacturer says 50 percent. Some insurers cover the cost.
Maxillomandibular Advancement (MMA) surgery
The most extreme surgical treatment for moderate to severe obstructive sleep apnea requires breaking the upper and lower jaw and repositioning them to open the airway. It's very effective, said Karl Doghramji of the Jefferson Sleep Disorders Center, but it's also expensive, running up to $270,000. Some private insurers cover the cost.
Surgery to remove tissue from the throat to treat sleep apnea has fallen out of favor. Most often, doctors detached the uvula. Other procedures involved removing the tonsils, sections of the soft palate, and even parts of the tongue. Private insurance often covers the cost if the patient can't tolerate CPAP.
An outpatient procedure, pillarplasty stiffens the palate by inserting tiny woven implants. Schwab is not a fan. "There's insufficient evidence to show Pillar works long term or short term," he said. "In addition, the implants can extrude to outside the soft tissue. I advise people to stay away." Usually not covered by private insurance.
EPAP (Provent device)
A low-tech approach to treating sleep apnea uses two single-use disposable devices that stick to the nostrils like Band-Aids. EPAP (short for "expiratory positive airway pressure") allows air to enter the nose through a tiny valve. When a patient breathes out, the device slows the air as it leaves the nostrils, theoretically holding the airway at the back of the throat open. Schwab said his patients have found EPAP "very difficult to tolerate." Monthly cost runs $69 to $99 and is not covered by insurance.
Night Shift device
A "sleep positioner," the Night Shift device is a collar that buzzes when it senses a patient is sleeping on his or her back. A prescription is required for the $350 device. "If you want to go that route, it's just as easy to use tennis balls sewn into a night shirt," Schwab said. "You don't have to spend a lot of money."