I don’t know about you, but when I hear
the word “hybrid” it makes me think of a
car. I’ve got a neighbor who has “gone
green” and he drives one of those
unbelievably ugly but fuel efficient Prius
hybrids. He gives me that “you greedy,
gas guzzler” look every time I drive past
his home in my Tundra.
Multiple hybrid therapies exist in
medicine today, from Atrial Fibrillation
treatments, to Heliobacter Pilori treatments, to -- you guessed it -- obstructive
sleep apnea. What is Hybrid Therapy?
And when might you consider utilizing
it?
Hybrid therapy for sleep apnea consists
of combining two popular treatments,
PAP (Positive Airway Pressure) and MRD
(Mandibular Repositioning Devices).
You might also have heard the term
“combination therapy” to refer to this;
either term will do for now.
Let’s start with a patient who shows up in
your office for a consultation:
Jim, 54 y.o. Hispanic male, BMI 29, AHI 49,
LSAT 77%, time below 90% = 9% of the
night.
Would you recommend a dental device for
Jim? It depends! If you’re smart, and I’m
sure you are, then you’d recommend that he
try PAP first. He has, but he didn’t do well
with it. Did he really try it or just give it a
head nod? He tried: three different masks
over three months, then finally gave up. In
this case, I’d make Jim a TAP in a heartbeat
(assuming he has adequate dentition and
ROM). We have treated successfully many
patients like Jim with just an MRD, (success
being getting AHI to less than ten and time
below 90% to less than 1%.) But the higher
the patient’s AHI, then the less likely we are
to treat him successfully with an MRD, and
the more likely we are to utilize hybrid
therapy.
There are times (I’m sure you’ll agree)
when PAP therapy does not work. We
hear about this quite a bit, since many of
our patients have tried and failed PAP
for one reason or another, or the other,
or the other… But if you’ve been doing
dental sleep medicine for more than a
year or so I think you’ll also agree that
there are times when our dental devices
don’t work either. So here we have it,
two scenarios where hybrid therapy
comes into play. When neither therapy
works, you can combine the two, and
together they do work? Precisely!
In Jim’s case, he had tried PAP and failed.
We made him a TAP, and went through
our titration protocol, testing him at two
different positions, about 75% and 100%
of maximum protrusion. Best we could
do with his TAP got him to an AHI of
about 25. At this point I would again
discuss combining his MRD with a
custom mask and PAP. Again, because I
always discuss hybrid therapy with any
severe patient at the consultation
appointment.
It’s a bit of a trick to make a custom mask
for a patient, but certainly something
you should learn how to do. Keith
Thornton and the Airway Management
people have a kit that contains a perforated thermacryl/kevlar saucer that can
be heated and then molded to a
patient’s face, thus creating a custom
tray. A post that attaches to the front of a
TAP and a breathing tube rounds out the
kit and enables you to get an impression
of a patient’s face and the inside of his
nose. The TAP and post are then fitted
into the custom mask and tightened
down.
Jim now has a TAP, backed up to about
50% of his maximum protrusion, a
custom mask, (with NO leaks and NO
straps!), and we combine this to either
Auto PAP or have him go back to a
sleep lab and re-titrate a normal PAP
machine. The reason we need to get a
new titration study or to utilize APAP is
because with a TAP in place with a
custom mask, the pressure needed to
keep Jim’s airway open is considerably
less. Less pressure, no straps, no leaks,
often gets a patient over the hump
with PAP, so the combination therapy
is successful when neither therapy
alone was. Chalk another one up for
the team. Saving lives is wonderful!
Indications for Hybrid Therapy:
Severe OSA patients
PAP not successful / patient intolerant
MRD not successful