Columbia Patients are ‘Inspired’ by a CPAP Alternative
Obstructive sleep apnea is a common disorder in which a person’s breathing is repeatedly blocked during sleep. It occurs when the muscles around the throat relax, causing the surrounding tissue to compress the upper airway. Loud snoring, gasping for air, and daytime sleepiness are frequent symptoms of sleep apnea, which affects approximately 86 million adults in America.
“The body’s response to the interruption of air flow is to wake itself up repeatedly. You can imagine what that does to one’s sleep quality and ultimately one’s quality of life,” says sleep medicine specialist Yi Cai, MD, who is director of Sleep Surgery at Columbia.
If not treated, sleep apnea can lead to complications, many of which are severe or even life-threatening. Excessive daytime sleepiness can disrupt work, driving, or anything else that requires focus and attention.
In addition to the effects of sleep deprivation, untreated sleep apnea can lead to cardiovascular issues, including arrhythmias, high blood pressure, strokes, heart attacks, and heart failure. “These effects are important contributors to morbidity and mortality,” adds Dr. Cai.
The limits of CPAP: A tale of two patients
CPAP, or continuous positive air pressure, is the first line of defense as treatment for sleep apnea. It requires a sleeping patient to wear a mask, fitted over their nose and/or mouth, connected by a hose to a machine. For some patients, this arrangement works. For some, it does not.
John Evans, DDS, a retired dentist, had been diagnosed with sleep apnea and was prescribed CPAP. He says he recognized the seriousness of his condition and was motivated to treat it. “They showed me how to use the machine and mask and how to keep everything clean.”
But the apparatus was very uncomfortable. “It’s hard to sleep with a mask strapped to your face. It never felt right. So, I tried a nasal attachment, which was more comfortable than a full mask. But I’m a mouth breather, so it didn’t work for me.”
For Amy Stein, a 35-year-old with Down syndrome, “CPAP was never going to work. She has sensory issues and won’t even wear a BAND-AID,” says her mother, Barbara Stein. “There was no way she was going to sleep with a mask and a hose.”
Inspire therapy: A “pacemaker for the tongue”
There are alternatives to CPAP, which have traditionally been three categories of surgery for the treatment of sleep apnea. They included “skeletal” or jaw surgery, “soft tissue” or throat surgery, and nasal surgery. “Nasal surgery doesn’t address sleep apnea directly, but for some patients, it can optimize their nasal airways for better CPAP results,” Dr. Cai explains.
In recent years, sleep specialists and ENTs have added a fourth category: hypoglossal nerve stimulation therapy, or ‘Inspire’ therapy. Inspire Medical Systems received FDA approval for the device and the procedure in 2014.
When talking to her patients, Dr. Cai describes Inspire therapy as “a pacemaker for the tongue.” One component, implanted in the upper right chest, detects breathing and houses the battery. A second component, implanted under the right neck, delivers stimulation to the tongue.
“Frequently in sleep apnea, the tongue falls back into the airway, blocking airflow,” Dr. Cai says. “Inspire sends a signal at a regular interval to stimulate the nerve controlling the tongue, which moves the tongue forward. This clears the blockage and allows breathing.”
A third component is a remote control, which is held and activated by the patient. “This is a nice feature. We can program the device to delay as the patient prepares to fall asleep. Then it starts,” says Dr. Cai. “In the morning, the patient wakes up and uses the remote to turn off the device.”
Pursuing a possible solution
Dr. Evans was open to trying this approach. “I was on a Zoom call with two cousins, and it was kind of funny, because we all have sleep apnea! We were talking about CPAP, and one of my cousins, a physician, mentioned that some of her friends had a surgical procedure called ‘Inspire’ that changed their lives. That was the first I had heard of it.”
Eventually, through a referral from his neurologist, Dr. Evans met Dr. Cai. “She was very thorough. I completed a questionnaire; we spoke several times; she reviewed the data from a previous sleep study and my months of CPAP; and she scoped my windpipe to make sure my throat’s shape and structure would accommodate the Inspire therapy.”
For Amy and her mom, the introduction to Dr. Cai, who had just arrived at Columbia, was refreshing. “We talked about the challenge of Amy using CPAP, and Dr. Cai was very understanding,” says Ms. Stein. “She said we just needed to try it, and if Amy refused, okay; at least we tried.”
Ms. Stein also appreciated Dr. Cai’s optimism. “She’s a very glass-half-full type of person,” Ms. Stein recalled. “So, in the end, we decided to go through with Inspire therapy.”
Personalized care, excellent outcomes
Before Dr. Evans’s surgery, he shared with Dr. Cai that he was taking low-dose aspirin due to a stroke he had suffered. “I put Dr. Cai in touch with my neurologist, and they talked all about my situation. They figured it out. If I recall correctly, I stayed on the aspirin, but Dr. Cai took additional precautions to prevent excess bleeding during the surgery.”
Dr. Evans had the procedure in 2024, and he is delighted with the results. “It’s amazing. I don’t snore anymore. I don’t bother my wife adjusting the CPAP machine. And I have more energy during the day because I sleep much better. It really is a life-changer,” he says. “The device is really impressive. It doesn’t come on until you have fallen asleep, so you’re not even aware of it.”
Amy’s surgery presented her mother and Dr. Cai with a different challenge: managing the difficulties Amy can experience after general anesthesia. “Dr. Cai remembered that Amy likes ABBA,” says Ms. Stein. “So, Dr. Cai set up an ABBA playlist in the recovery room.”
Since Amy’s procedure in 2024, Ms. Stein has been very pleased with her daughter’s progress. “We did a home sleep study, and it showed something like 90% improvement. Amy can sleep quietly without thrashing around. Her mood is better, and she seems more willing to socialize.”
This summer, Amy was able to attend sleep-away camp for one month. According to Ms. Stein, “Amy loves it and looks forward to it. Everybody there knows her and her quirks. They’re lovely and the camp is lovely.”
Obstructive sleep apnea therapy research
Dr. Cai is a physician and a scientist. She and her team are currently recruiting participants for a study of the cardiovascular and metabolic effects of sleep apnea surgical therapies, including Inspire.
“There’s a gap in the medical literature,” she says. “The symptomatic benefits of Inspire therapy are well-documented: for example, ease of breathing and quality of sleep. But we think there are additional positive health effects that warrant study.”
Studies like this can lead to enhanced care. “It’s exciting to be part of academic medicine,” Dr. Cai says. “Surgical sleep apnea therapies can help our patients, and patients can help us advance our understanding of these therapies.”
Yi Cai, MD, is an assistant professor of Otolaryngology—Head and Neck Surgery at the Vagelos College of Physicians and Surgeons and director of Sleep Surgery at Columbia. She and her team are currently recruiting participants for a study of the cardiovascular and metabolic effects of sleep apnea surgical therapies.