Thinking about surgery...

[sleephelp888]

This forum has been an amazing resource so, first of all, thank you all!

I have been snoring for as long as I can remember. I finally did something about it this year as I turned 40. I was diagnosed with sleep apnea and was put on CPAP in April. I am normal weight but turns out I have a deviated septum, a huge tongue and uvula which is all affecting my breathing (doc said I have the trifecta of sleep apnea).

I had a rough few months with the CPAP but stuck with it as it is recommended all over this forum. I feel like I have finally adapted to the CPAP and I have some good nights. However, I feel like there is room for improvement. My AHI has improved slowly over the year but it seems to be stuck at an average of 4. And I almost never sleep more than 6 hours. I review my data using Oscar and my apple watch and I have noticed a trend. My first 2 - 2.5 hours of sleep are amazing. Then it seems I move around and things get worst through the night. Like I said, I am usually done by the 5th or 6th hour of sleep. I still don't know the feeling of getting 7-8 hours of uninterrupted sleep.

I am seriously considering surgery. The doctor made it clear that the goal of the surgery would be to improve the CPAP experience and I am ok with that. The surgery would be to remove the uvula and take care of the deviated septum. I've seen a lot of negative posts on here about surgery.

Are there any success stories with surgery and the continued use of CPAP?

Thank you!

[greatunclebill]

there's a reason there are many negative and not many positive comments. think about that. deviated septum may work to make it easier to breathe. it may and may not get you out of a full face mask into some of the nose things, but will do northing as far as cpap is concerned. you should go to a pulmonologist for apnea and an ent for ent things. ent's eventually all want to cut because that is their training but it seldom helps apnea. pulmonologists however think cpap which is the gold standard apnea treatment, any pulmonologist will normally tell you what we are saying about surgery.

[Okie bipap]

Back around 1997, I had UPPP surgery to remove the uvula and reshape the soft pallet. I also had a deviated septum corrected and turbinate reduction at the same time. From my own personal experience, I would recommend only the deviates septum correction and turbinate reduction if they are enlarged. I do not recommend the uvula removal and soft pallet surgery. Recovery from the uvula and soft pallet was slow and painful. It took several years before I was able to eat spicy foods, and I am really fond of Mexican food. I will admit the surgery fixed my immediate problem. I had just been diagnosed with sleep apnea, and the only mask the lab could offer me was a nasal mask. I was a mouth breather at that time, and continue to do so when sleeping. Also, the CPAP machines then were much larger than they are now. My job required frequent air travel and I was already carrying a nebulizer machine with due to asthma. The surgeries relieved my symptoms for several years. I no longer snored, and my wife did not mention that I would quit breathing while sleeping until I started having problems again around 2012. One of the side effects of the surgery is I now have a big problem with post nasal drip that runs directly down into my throat. This gets worse during allergy season, but never really goes away. My nephew had the same surgery done about the same time I did, and he got very little relief in his sleep apnea and continued to use the machine as soon as his throat healed enough he could stand to use it.

As a side note, I was not retested for sleep apnea until 2014, and then only because I had knee replacement surgery. While I was in the hospital, the nurses noticed my blood oxygen would drop when I slept. The doctor who did the morning rounds was a pulmonologist who specialized in sleep apnea saw the notes from the nurse and scheduled me for a sleep study. My oxygen levels dropped enough when I slept that he also prescribed oxygen when sleeping until I could be tested. I used the oxygen concentrater until I finally got a bi-level machine several months later.

[chunkyfrog]

The uvula is there for a reason.
Once it is gone you will understand why---
FOR THE REST OF YOUR LIFE.

[Miss Emerita]

Could you post an Oscar chart? It'd be great if you could get that AHI down below 4 prior to reaching a decision about (irrevocable) surgery. People here might be able to help.

A few other things: how often do you get out into sunlight, and during what times of the day? And how much alcohol do you consume in an average day, and at what times?

[sleephelp888]

Could you post an Oscar chart? It'd be great if you could get that AHI down below 4 prior to reaching a decision about (irrevocable) surgery. People here might be able to help.

A few other things: how often do you get out into sunlight, and during what times of the day? And how much alcohol do you consume in an average day, and at what times?

This is a pretty typical night. Sunlight? I am outside at least once during the day. I don't consume much alcohol. I will have 1 beer or wine with dinner, twice a week at the most. I posted my equipment as well. I sleep on my stomach but never wake up on my stomach.

[Pugsy]

I wonder if your OSA is worse in REM stage sleep. That second half of the night is where we have more REM sleep.
It's common for OSA to worsen and need more pressure during REM and/or when sleeping on our backs.
I have REM worse OSA....like 5 times worse in REM than in non REM sleep and sometimes need a lot more pressure.

I wonder if your sleep would improve if you used a higher minimum pressure to prevent the airway collapses that you see in the second half of the night. I had to do this for my REM related pressure needs. The minimum of 8 did a good job when not in REM but I needed a minimum of 10 to better prevent the REM related events.

Did your sleep study measure sleep stages at all?

Respironics machine that auto adjust the pressure tend to be slower in their responses than the equivalent machine in the ResMed brand.
So we help them out a bit with an increase in the minimum to give things a better head start in an effort to prevent the airway from collapsing in the first place.

Before I did the surgery (and BTW the only thing I would consider surgery on is the deviated septum thing and I would NOT cut on the uvula or tongue) I would consider just increasing that minimum pressure a bit and see what happens. I am thinking around 10 minimum.

[chunkyfrog]

I would definitely try to find a more optimal pressure range before pulling the trigger on surgery.
With everyone sensible wearing masks in public, one might think you could cover up post-op bruising;
but vanity is a poor excuse for rushing into more aggressive measures--
when less invasive actions could help just as much.

[Miss Emerita]

Thanks for posting the chart. Please do give Pugsy's suggestion a try. After you see how that goes, an additional experiment would be to try using a soft cervical collar, in case the clusters of events are partly due to tucking you chin down toward your chest, which can tend to restrict the airway somewhat.

Your alcohol use (sparing and well before bedtime) does not seem to be the culprit. (Drinking closer to bedtime and/or more can cause wakefulness during the second half of the night.)

You don't mention the time of day for your one outing. Spending more time outdoors can help to regulate your circadian rhythm. With your difficulty staying asleep as long as you would like, you might consider sunglasses if you are outdoors in the morning, and you might also benefit from exposure to sunlight in the mid to late afternoon. Some people benefit from using a light box in the evening, but be aware that this can lead to a later bedtime.

If you want to try these adjustments in light exposure, I would recommend waiting until you first try Pugsy's suggestion and then perhaps a cervical collar. It's good to make one change at a time so you know what is contributing to improvement and what isn't.