Inspire Hypoglossal Nerve Stimulator Surgery for Sleep Apnea Treatment

If you have obstructive sleep apnea, you may be interested in exploring surgical treatment options. One such option is the hypoglossal nerve stimulator, called Inspire.

What is Inspire? Who should consider using it? And what are the side effects? These are all good questions. Learn about the Inspire upper airway stimulator and whether it might be the right therapy for you.

A woman peacefully sleeping in bed
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Indications for Inspire Placement

Inspire is an alternative to continuous positive air pressure (CPAP). The device works inside your body while you sleep. Placed during a same-day, outpatient procedure, the device activates the hypoglossal nerve to tighten the muscles of the tongue and upper airway during sleep, improving airflow and reducing sleep apnea. When you’re ready for bed, all you have to do is click the Inspire remote to turn on the device.

Inspire is approved for use by people with:

  • Moderate to severe obstructive sleep apnea with an apnea-hypopnea index (AHI) of greater than 15
  • Non-compliance with CPAP therapy after a trial
  • A body mass index (BMI) of less than 32, excluding those with morbid obesity

Age Requirements Have Changed

Inspire has the official endorsement of the U.S. Food and Drug Administration. Originally, in 2014, the FDA approved the device for people who were at least 22 years old. In 2020, the FDA reduced the minimum age requirement to 18.

Contraindications

There are a few relative contraindications to the use of Inspire therapy. Contraindications are symptoms or conditions that can make a treatment risky. In this case, if the obstruction contributing to sleep apnea is occurring within the nose, due to allergies or a deviated nasal septum, Inspire will be ineffective. Similarly, certain skeletal anatomy (such as a small or recessed lower jaw) may be a reason to not pursue the treatment.

If tonsils are enlarged, surgery targeting these tissues may be more appropriate. Certain neuromuscular conditions that affect the ability to swallow or that contribute to slurred speech may also be contraindications.

If frequent magnetic resonance imaging (MRI) is needed for other medical conditions, the device is not safe for use. The treatment is also not open to children.

Heed the Limitations

Most people who undergo Inspire surgery have moderate to severe sleep apnea and have failed CPAP therapy, despite their best efforts. They continue to have symptoms and may be desperate for an effective solution. Surgery may be appealing as a more permanent fix to a problem that may otherwise linger or not go away.

Questions to Ask Your Sleep Surgeon

It's important to have a comprehensive understanding of the role of this treatment in your condition. The first choice for the treatment of obstructive sleep apnea is the use of continuous positive airway pressure (CPAP). Success with this treatment requires proper mask fitting and optimal device settings.

In some cases, alternatives such as weight loss, bilevel therapy, an oral appliance, or positional therapy can be pursued. Once you have exhausted treatment options with your board-certified sleep physician, you may wish to consider the Inspire hypoglossal nerve stimulator. Consider some questions to ask your surgeon:

  • Am I a good candidate for this surgery?
  • If you couldn't do this surgery, what would you recommend as a treatment for me?
  • How often have you done this procedure?
  • What is your success rate in resolving sleep apnea (AHI greater than 5)?
  • How many of your patients have complications from this procedure?
  • How will I know if the therapy works well for me?
  • Will I have testing after the device is placed to determine settings and my response to therapy?
  • Who will I follow up with once the surgery is complete?

You may have additional questions based on your specific situation.

Recap

Asking questions of your surgeon may help put your mind at ease. Take notes as you go along; you may wish to refer to them later to jog your memory. If you can, bring a trusted friend or family member with you to the session. They may think of questions you hadn't thought of or ask follow-up questions that will save you time later.

Determining Good Candidates

After a consultation with a sleep surgeon, you will likely have a procedure called a drug-induced sleep endoscopy to assess your anatomy. In a controlled environment, a medication will be administered that causes unconsciousness and muscle relaxation.

This procedure helps to determine whether your airway collapses completely from all sides. If it does, surgery may not be effective and the procedure would not be performed. On the other hand, surgery is usually scheduled if a patient passes this "anatomy test."

Placement Surgery for Inspire

Inspire is implanted during a same-day, outpatient procedure. The stimulation wire is placed leading to the hypoglossal nerve and wraps one of its distal branches. A second sensing wire is placed along the rib cage to detect breathing so the tongue muscle and airway can be stimulated as breaths are drawn in. Then the stimulator itself is placed within the right upper chest wall and connected to the sensors. The entire procedure takes about two hours.

After the surgery, patients usually go home if there have not been any complications. Most do not require the use of narcotic pain medications. Doctors often recommend that patients avoid strenuous activity for two to three weeks following surgery. A regular diet can be consumed without any necessary modifications.

Effectiveness

Inspire airway stimulation is a relatively effective treatment for moderate to severe obstructive sleep apnea. Studies have shown that at 12 months, it reduces the AHI from 29.3 to 9.0 events per hour, on average. This represents a 68% reduction. It should be noted that the residual AHI still qualifies as mild sleep apnea. The number may improve as the therapy is optimized.

Excessive daytime sleepiness seems to improve as well. Scores on the Epworth sleepiness scale improved from 11 to 6 with treatment, suggesting a reduction in daytime sleepiness. When the device is turned off, sleep apnea usually returns.

Complications

There are few complications to the placement of the Inspire device. About 25% of patients complained of relatively modest pain. About one-third of patients complained of tongue discomfort or abrasion. Both issues appear to resolve in a short time.

About 1% of patients developed a skin infection or irritation (cellulitis) from the surgery. Another 1% had to undergo another surgery to correct the placement of the device.

Side Effects and Risks

The treatment is generally well-tolerated once healing from the surgery is over. Some people find the sensation within the tongue is uncomfortable when the device is activated during sleep. But this rarely requires intervention. Additional side effects include:

  • Allergic reaction or rejection of the implanted materials
  • Bleeding
  • Coughing
  • Damage to the nerve
  • Difficulty swallowing or speaking
  • Dry mouth
  • Headaches
  • Infection
  • Insomnia
  • Persistent pain at implant site
  • Scarring or fibrosis around the implant
  • Tongue movement restrictions
  • Tongue soreness or weakness

Respond Promptly

If any of these symptoms persist beyond a few days, contact your surgeon.

Follow-Up and Device Use

After the surgery, patients return to see their surgeon for a post-operative check within seven to 10 days. The device is officially turned on at one month. It is recommended to schedule an in-center sleep study at two months to assess the effectiveness of the device and to adjust the settings, if necessary.

Once placed, the Inspire stimulator can be activated before going to sleep. There is usually a delay of 30 minutes before the stimulation begins. If you wake at night, the device can be paused. It is often set to turn off after eight hours.

Costs of Inspire Surgery

According to the Inspire website, the treatment is covered by "most major insurance providers." Out-of-pocket costs will depend on your insurance plan.

Summary

People with obstructive sleep apnea often try several treatment options (including continuous positive airway pressure, or CPAP) before turning to a hypoglossal nerve stimulator called Inspire. The Inspire stimulator is surgically implanted so that it can nudge the hypoglossal nerve to tighten the muscles of the tongue and upper airway during sleep, thereby improving airflow and reducing sleep apnea. Inspire must be placed during surgery with general anesthesia. The procedure takes about two hours. But the procedure isn't available to everyone. You have to be deemed a good candidate for it first.

A Word From Verywell

If you're interested in Inspire, reach out to your healthcare provider or sleep surgeon. But be prepared for a common response: They probably will ask that you try other treatments first.

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