Maxillary Expansion (DOME) to enable effective CPAP treatment?

[fireyoni09]

Hi,

I have been on CPAP for > 8 months, and while the treatment has been successful on-paper (in-terms of AHI reduction, I am consistently at AHI <= 1, verified by follow-up sleep study w/ my CPAP), I don't feel better at all. My doctor claims that this is because I breathe from my mouth during sleep instead of from my nose, and recommends surgery for maxillary expansion (DOME / Distraction Osteogenesis Maxillary Expansion).

1. Why would breathing from my mouth instead of from my nose render CPAP ineffective? Can anyone point me to literature backing this up?

2. Before I commit to surgery, I want to be sure that breathing from my nose during sleep will actually help me feel better. To test this, I am looking into using a chin-strap or taping my mouth during sleep, plus clearing my nasal passage as best I can without surgery, at least for long enough to reach some sort of conclusion.

If anyone could offer advice on this I would appreciate it greatly! Thanks very much.

[LSAT]

Investigate all other avenues before contemplating surgery. Taping, chinstraps and full face masks.

[fireyoni09]

Thanks for your reply. I've been using a full-face mask since I started treatment. I will start using a chin-strap tomorrow night. Do you have any more advice on how I can confirm that mouth-breathing is the problem?

[kteague]

I'll leave the technicalities to others. My understanding is that a full face mask accomodates mouth breathing. There's even oral masks available for mouth breathing only, so it's hard for me to get that mouth breathing alone is unacceptable. Now, I am thinking if there is an obstruction causing air to blow out the mouth instead of opening the airway, I can see that being an issue, but your low AHI doesn't point to that. If you are able to nose breathe when awake, I would agree that experimentation with preventing mouth breathing would be preferred to going straight to surgery. How did your doctor determine that this particular surgery would be helpful? Surely there is something besides a shot in the dark explanation for why you aren't feeling better. What other things have already been investigated? Medication side effect? Other medical conditions? Other sleep disorders, for instance, limb movements? I would encourage you to post your machine data to see if anything jumps out at some of the astute data folks here.

[ChicagoGranny]

I don't feel better at all.

CPAP treatment can be effective and the patient still not feel energetic. Do an honest evaluation of your habits against this checklist -

Good Sleep for CPAPers

- Practice good sleep hygiene (Google it and read several sources; ignore extreme advice.)
- Eat a good diet
- Have a regular, moderate exercise program
- Try to avoid daytime naps
- Practice total abstinence of caffeine including sources like chocolate (sigh)
- Review all medicines, vitamins and supplements you are taking to make sure none are interfering with sleep
- Use the bedroom for sleeping (and sex) only, and make sure the bedroom and bed are comfortable.
- Learn to appropriately handle emotional stress in your life
- Do not listen to your breathing or the sound of the machine as you are falling asleep. (Some people, including me, actually find listening to their breathing and the sound of the machine to be relaxing.)
- Distract your mind by thinking of a pleasant, relaxing activity that you enjoy.
- If you are awakening at night, do not be too concerned. It is actually a normal part of sleep. (It does become a problem though for people who, when they awaken, become frustrated and have difficulty returning to sleep.)
- Use CPAP software, such as the free OSCAR (or the free SleepyHead), to make sure your therapy is optimized
- If you still don't feel or sleep well, make sure you have regular medical checkups to confirm there are no other medical problems

This is a checklist. Some of the things you already do. Some are easy and can be done right away. Others you can work at over time.

CG

[squid13]

One thing about surgery is if it doesn't work for you it can't be undone so I would think real hard before I went down that route. I would also seek a second opinion from another Doctor. This looks like a dental procedure from a Orthodontist.

[rosie1231]

I had non-surgical maxillary expansion with ALF appliances. There are a few other non-surgical options as well offered by airway-focused dentists. The effects aren't as extreme as surgery, and slower of course, but less invasive.

[ChicagoGranny]

This looks like a dental procedure from a Orthodontist.

Rare. Usually a dental surgeon.

[fireyoni09]

I had non-surgical maxillary expansion with ALF appliances. There are a few other non-surgical options as well offered by airway-focused dentists. The effects aren't as extreme as surgery, and slower of course, but less invasive.

I am 23. Is this something that can still be done at my age?

[ChicagoGranny]

I am 23. Is this something that can still be done at my age?

Yes, but it would take as much as a couple of years depending on your anatomy. And, you would need to ask an orthodontist if it would achieve results as good as DOME procedure.

[fireyoni09]

I'll leave the technicalities to others. My understanding is that a full face mask accomodates mouth breathing. There's even oral masks available for mouth breathing only, so it's hard for me to get that mouth breathing alone is unacceptable. Now, I am thinking if there is an obstruction causing air to blow out the mouth instead of opening the airway, I can see that being an issue, but your low AHI doesn't point to that. If you are able to nose breathe when awake, I would agree that experimentation with preventing mouth breathing would be preferred to going straight to surgery. How did your doctor determine that this particular surgery would be helpful? Surely there is something besides a shot in the dark explanation for why you aren't feeling better. What other things have already been investigated? Medication side effect? Other medical conditions? Other sleep disorders, for instance, limb movements? I would encourage you to post your machine data to see if anything jumps out at some of the astute data folks here.

Thanks for your reply, I appreciate it. My doctor determined that this surgery is appropriate since I am a chronic mouth-breather, and have nasal obstruction and a narrow, high arched palate. I did a MSLT test which did not find any evidence of Narcolepsy or anything else.

The question that remains is why CPAP would be more effective breathing through my nose.

[ChicagoGranny]

The question that remains is why CPAP would be more effective breathing through my nose.

Are you using OSCAR to monitor your CPAP performance nightly?

[fireyoni09]

The question that remains is why CPAP would be more effective breathing through my nose.

Are you using OSCAR to monitor your CPAP performance nightly?

I was using SleepyHead for the first few weeks when I started, but I had little to no difficulty getting down to an AHI of 1, and my Resmed machine reports a very low AHI every morning when I wake up. Is there anything more I can do in-terms of CPAP settings, if it seems like the treatment is successful already?

[Julie]

It's not the inhalation that's the problem, it's when you exhale through your mouth and lose therapy air... though you did say you've used full face masks.

I would not do surgery - certainly not at your age yet until you've really given all other methods a try. Don't forget that surgeons get paid for surgery... ahem.

[sephiro499]

Hi,

I have been on CPAP for > 8 months, and while the treatment has been successful on-paper (in-terms of AHI reduction, I am consistently at AHI <= 1, verified by follow-up sleep study w/ my CPAP), I don't feel better at all. My doctor claims that this is because I breathe from my mouth during sleep instead of from my nose, and recommends surgery for maxillary expansion (DOME / Distraction Osteogenesis Maxillary Expansion).

1. Why would breathing from my mouth instead of from my nose render CPAP ineffective? Can anyone point me to literature backing this up?

2. Before I commit to surgery, I want to be sure that breathing from my nose during sleep will actually help me feel better. To test this, I am looking into using a chin-strap or taping my mouth during sleep, plus clearing my nasal passage as best I can without surgery, at least for long enough to reach some sort of conclusion.

If anyone could offer advice on this I would appreciate it greatly! Thanks very much.

Hi I'm getting double jaw surgery myself, because I've exhausted all othjer options over 10 years. Basically after everything failed (for me) I read this book by Steven Park MD (ENT). You might want to check it out.

I got my entire nose done (functional rhinoplasty) but it didn't change my sleep. I think there are (and probably always will be) complications for people on cpap. Just the nature of having a mask and hose maybe just doesn't work for you.

But even as someone who has already decided on surgery I have given cpap 10 years. I agree surgery should be choosen as a last resort.

Have you had a CBCT or a volumetric xray of your upperairway? Have you considered sleep endoscopy? -They put you to sleep to see what/where your airway is failing.

You may also want to consider facial growth orthodontics. I do know that the maxilla can be widened to a point with special orthodontics.