UH Clinical Update - September 2017
As the new System Director of Sleep Medicine for University Hospitals, Ambrose Chiang, MD, faces a challenge familiar to sleep specialists: Patients with obstructive sleep apnea (OSA) often consider the CPAP “cure” to be as bad as the condition it treats. 
“Obstructive sleep apnea affects at least 15 percent of men and 5 percent of women in the general population,” Dr. Chiang says. “It’s a very important disorder with significant consequences for cardiovascular health. However, patients often have difficulties following the prescribed treatment. About 50 percent of CPAP users fail to tolerate and comply with CPAP use.”
For UH providers who have patients like this, Dr. Chiang encourages referral so that their patients can be reassessed. UH has 10 full-service sleep labs for doing so, from UH Geneva on the Eastside to UH Elyria on the Westside and UH Samaritan to the south.
“My sleep medicine colleagues and I would be more than happy to see those patients,” he says. “CPAP therapy, though difficult to tolerate for many, remains the standard first-line therapy for patients with moderate to severe OSA. CPAP therapy has evolved so much since 1981, and we now have numerous masks, gadgets, and various kind of devices available to our patients. In addition, there are many treatment options available to those who previously failed CPAP.”
One treatment option for OSA, Dr. Chiang says, is dental appliance therapy, which is now reimbursed by Medicare, Medicaid and most insurance companies.
“We’re working with the Case Western Reserve University School of Dental Medicine to provide dental appliance therapy, which advances the lower jaw to open up the airway in sleep,” he says. “This usually works in patients with mild to moderate OSA.”
A hypoglossal nerve stimulation device, known as Inspire therapy, is a new innovative therapeutic option for patients with moderate to severe OSA who have failed CPAP therapy, Dr. Chiang says. UH was the first health care provider in Northeast Ohio to offer the therapy.
“Inspire therapy requires a minimally invasive surgery, and the device is implanted like a pacemaker, which delivers mild stimulation to the key airway muscle to keep the airway open during sleep,” he says. “Dr. Mark Weidenbecher, our UH ENT colleague, has done over 30 cases in the past few years with very impressive results.”
Another option for patients with OSA is an oral pressure therapy system called Winx. The Winx system gently suction air out of the oral cavity, draws the soft palate forward and stabilizes the tongue to actively open the airway for uninterrupted breathing during sleep. A sleep positioning device called Night Shift can also be helpful in treating positional OSA, Dr. Chiang says. Worn on the neck, Night Shift begins to vibrate when the patient starts to sleep on his or her back. The vibration slowly increases in intensity until the patient changes positions.
Another option is bariatric surgery.
“For some of the morbidly obese patients, bariatric surgery can eliminate OSA, and our sleep team works closely with Dr. Leena Khaitan and the UH Bariatric Surgery weight loss program,” Dr. Chiang says.
Although Dr. Chiang provides clinical expertise to UH patients with all sleep disorders, he is most experienced with complex sleep-disordered breathing, including central sleep apnea and obesity hypoventilation syndrome. Dr. Chiang has been treating sleep apnea patients for over 20 years and established and led the Pulmonary Sleep Apnea Program at Duke University Medical Center for the past 12 years. He left Duke to join UH in May 2017. He completed his medical degree in 1981 at Taipei Medical University and his pulmonary and critical care medicine fellowship in 1991 at Duke University Medical Center.
Dr. Chiang currently sees patients at UH Cleveland Medical Center (Bolwell-6), UH Chagrin Highlands Health Center, UH Mentor Health Center, and UH Twinsburg Health Center. He will soon start a sleep medicine clinic at UH Medina Health Center.
He and his sleep medicine colleagues are eager to serve UH patients at risk for OSA and other sleep disorders. Symptoms that should trigger a referral for a sleep study for assessment of OSA, he says, may include loud irregular snoring, excessive daytime sleepiness, fatigue, witnessed apneas, nocturnal choking or gasping in sleep, morning headaches, nocturia of unknown etiology and other sleep complaints.
“Also, those with morbid obesity, congestive heart failure, atrial fibrillation, chronic kidney disease, particularly if they have the other OSA symptoms, may need to be evaluated for OSA,” Dr. Chiang says.
He’s also eager to find solutions for patients who have failed CPAP therapy.
“Those are the ones who need to come in for reassessment. We have many different ways to help them out. Whoever fails CPAP, we want to see them and figure out a way to help them so that they don’t develop long-term cardiovascular consequences.”