Sleep disordered breathing (SDB) is a growing problem in our fast-paced, high stress, nutritionally challenged society. SDB includes the various types of sleep apnea and snoring. Sleep apnea may be central, obstructive, or mixed. Snoring may be primary and may not be associated with SDB or other health conditions. It may also be a symptom of SDB, such as obstructive sleep apnea; or fall under the category of Upper Airway Resistance Syndrome (UARS), which is characterized by:
- Daytime fatigue and sleepiness;
- Nocturnal decreases in esophageal pressures that may occur with or without snoring and do not result in oxygen desaturation;
- Absence of airway obstruction or apneic events.
Historically, Speech-Language Pathologists (SLPs) have not played a major role in the treatment of SDB. The concept of applying our education, experience, and training to assist people with SDB is relatively new to us but growing. It might be helpful to answer a few basic questions delve into this further.
What is sleep apnea?
Sleep apnea is a disorder characterized by repeated episodes of breathing stops/starts while sleeping. There are different types of sleep apnea:
- Central Sleep Apnea occurs when the brain’s regulation of respiration is disordered.
- Obstructive Sleep Apnea (OSA) occurs when oral and pharyngeal muscles weaken and collapse to block the airway during sleep.
Complicating this issue further is the existence of mixed forms.
Is snoring also sleep apnea?
No. Snoring may or may not be present in OSA, and just because one snores does not mean s/he has apnea events. Objective assessment and diagnosis via polysomnography (sleep study) may be ordered by a physician if deemed necessary based on individual patient signs and/or symptoms.
How is sleep apnea diagnosed?
Sleep apnea is a medical condition. Assessment, diagnosis, and treatment of sleep disorders is outside the Speech-Language Pathology Scope of Practice as defined by ASHA11. Evaluation by a physician and referral for polysomnography is required to objectively identify, characterize, and quantify the severity of a sleep disorder.
How is SDB treated?
Several established treatments for SDB are currently recognized and reimbursed by third party payors. They include:
There are multiple types of airway pressure treatment options. Continuous Positive Airway Pressure (CPAP) is probably the most familiar and is considered very efficacious2. It is highly effective, but rate of non-compliance is high, averaging 54% and ranging from 29% to 83%.
Intraoral dental appliances
Mandibular advancement devices and tongue-retention devices are two dental appliances that may be used to treat SDB2. One study found that intraoral devices are efficacious in approximately 67% of SDB patients and adherence was 62% four years after initiating treatment.
Surgical intervention is the only accepted option offered after relatively non-invasive airway pressure and dental appliance options have been tried unsuccessfully. Several different procedures are available, but all are highly invasive. Rate of success is low, and patients report significantly negative impact on voice and swallowing.
This is Dysphagia Café. What does OSA have to do with dysphagia?
OSA is caused by collapse of the musculature of the oropharynx and/or hypoglossus. Our SLP education and professional experience are heavily concentrated in this area of the human anatomy. Any condition that compromises the muscles and structures involved in the speech/swallow mechanism is of concern to SLPs who treat dysphagia. Breathing powers verbal communication, but it must also be coordinated to protect the airway during deglutition. Schindler et al. found that people with characteristics consistent with OSA also demonstrated signs and symptoms consistent with sub-clinical dysphagia.
SLPs have the education, training and potential to play an important role in the management of certain forms of sleep disordered breathing
Research regarding the use of OPE to treat OSA has increased markedly over the past several years. One of the most familiar and frequently cited examples is the 2009 study published by Guimarães et al. The results of their randomized controlled trial demonstrated improvement of approximately 40% in the Apnea Hypopnea Index scores of an OPE treatment group following a 12-week protocol. Published evidence from multiple research sources has continued to grow robustly from that point.
It must be noted that ASHA published a 1993 opinion on the topic, stating that diagnosis and direct treatment of sleep disorders is outside the SLP Scope of Practice. This is ASHA’s most recent opinion, and it is not found when searched on the organization’s website. It is not mentioned in the 2004 Preferred Practice Patterns for the Speech-Language Pathologist. However, a change may be coming, as evidenced by increasing:
- Topic-related presentations and posters accepted for presentation at ASHA’s annual conventions.
- Research studies published in the past 10 to 15 years supporting inclusion of SLP-provided, non-invasive orofacial exercises to the list of treatments options for SDB.
The treatment of sleep disorders has become a hot topic over the past several decades. Established, reimbursable treatments currently include airway pressure, intraoral devices, and numerous surgical interventions. The relatively non-invasive treatments are efficacious but less than effective because patient compliance and adherence are low. Invasive surgical interventions are risky and demonstrate less than optimal success rates.
A collaborative team of healthcare professionals is required to assess, diagnose, and treat sleep disordered breathing. The process has not traditionally included SLPs. Adding appropriately trained SLPs to teams of professionals treating SDB is a reasonable consideration because:
- SLPs are heavily educated and trained in the anatomy, physiology, disorders, and treatment of the speech, voice, resonance, and swallow mechanism. Respiratory disorders impact structures and functions that are solidly within the SLP Scope of Practice.
- Oropharyngeal and hypoglossal anatomy and physiology is critical to speech, voice, resonance, and deglutition. It also happens to be the anatomical geography most often compromised in people with SDB.7 It may be further damaged by surgical interventions.6
- Lifestyle and medical factors contribute to the development of sleep disordered breathing, and patient compliance and adherence to established treatments is less than optimal. SLPs have a long history of educating and training patients to modify behavior to meet their goals. Adding those skills to the SDB treatment team could potentially improve patient compliance, adherence, and outcomes of other non-invasive treatments.
SLPs have the education, training and potential to play an important role in the management of certain forms of sleep disordered breathing. The evidence base is building, but like most areas in the field of communication sciences and swallowing disorders, further research is needed. It is my hope that we will soon begin to play a more prominent role as members of collaborative, multidisciplinary teams treating individuals with sleep disorders.
Links of Interest
- Sleep Apnea Pathogenesis, Diagnosis, and Treatment, 2nd edition
- YouTube Video of Oral Pharyngeal Exercises in OSA from Guimarães et al 2009
 Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, & Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiology, 2013;177(9):1006–1014.
 Garcha PS, Aboussouan LS, & Minai O. (2013). Sleep-disordered breathing. Retrieved 19:03, June 25, 2016, from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/sleep-disordered-breathing/
 Wolkove N, Baltzan M, Kamel H, Dabrusin R, Palayew M. Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea. Can Respir J 2008;15(7):365-369.
 Zancanella E, Haddad, FM, Oliveira LAMP, Nakasato A, Duarte BB, Soares CFP, Cahali MB, Eckeli A, Caramelli B, Drager L, & Ramos BD, Nobrega M, Fagondes SC, Andrada NC. (2014). Obstructive sleep apnea and primary snoring: treatment. Brazilian journal of otorhinolaryngology, 80(1), 17-28.
 Sutherland K; Vanderveken OM; Tsuda H; Marklund M; Gagnadoux F; Kushida CA; Cistulli PA; on behalf of the ORANGE-Registry. Oral appliance treatment for obstructive sleep apnea: an update. J Clin Sleep Med 2014;10(2):215-227.
 Franklin KA, Anttila H, Axelsson S; Gislason T, Maasilta P, Myhre KI. Rehnqvist N. Effects and side-effects of surgery for snoring and obstructive sleep apnea – a systematic review. Sleep 2009;32(1):27-36.
 Ahmed MM & Schwab RJ. Apnea: Insights from upper airway imaging studies. In: Pack AI, ed. Sleep Apnea Pathogenesis, Diagnosis, and Treatment, 2nd edn. Philadelphia: Informa Healthcare, 2012.
 Schindler A, Mozzanica F, Sonzini G, Plebani D, Urbani E, Pecis M, Montano N. Oropharyngeal dysphagia in patients with obstructive sleep apnea syndrome. Dysphagia 2014;29:44-51.
 Guimarães KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2009; 179:962-966.
 American Speech-Language Hearing Association. (1993). Orofacial Myofunctional Disorders: Knowledge and Skills. Quoted by Robert M. Mason, DMD, PhD, CCC/SLP at http://orofacialmyology.com/QuestionableClinicalPractices.html; retrieved at 20:36, June 25, 2016.
 Camacho M, Certal V, Abdullatif J, Zaghi S, Ruoff CM, Capasso R, Kushida CA. Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis. Sleep 2015;38(5):669–675.