“Sleep Apnea”
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Sleep apnea is a serious, potentially life-threatening condition that is far more common than generally understood, thought to affect between 2 and 4 percent of the adult population.
First described in 1965, sleep apnea is a breathing disorder characterized by brief interruptions of breathing during sleep. It owes its name to a Greek word, apnea, meaning “want of breath.”
There are two types of sleep apnea: central and obstructive. Central sleep apnea, which is less common, occurs when the brain fails to send the appropriate signals to the breathing muscles to initiate respirations.
Obstructive sleep apnea is far more common and occurs when air cannot flow into or out of the person’s nose or mouth although efforts to breathe continue.
Other, milder respiratory events during sleep known as “hypopneas” are defined as periods lasting 10 seconds or longer during which breathing is significantly reduced.
Sleep apnea is characterized by multiple respiratory pauses during sleep. These pauses, or “apneas,” are defined as periods of 10 seconds or longer during which the sleeper stops breathing altogether.
In a given night, the number of involuntary breathing pauses or “apneic events” may be as high as 20 to 60 or more per hour.
Most people with sleep apnea will have periods of abnormal breathing that last between 30 and 40 seconds more than 400 times per night.
So the average person with sleep apnea spends more than 3 hours a night when he’s not breathing normally – or not breathing at all!
These breathing pauses are almost always accompanied by snoring between apnea episodes, although not everyone who snores has this condition. Sleep apnea can also be characterized by choking sensations.
The frequent interruptions of deep, restorative sleep often leads to excessive daytime sleepiness and may be associated with an early morning headache.
Early recognition and treatment of sleep apnea is important because it may be associated with irregular heartbeat, high blood pressure, heart attack, and stroke.
Sleep apnea occurs in all age groups and both sexes but is more common in men (it may be under-diagnosed in women) those over 40, and those who are overweight and possibly young African Americans.
It has been estimated that as many as 18 million Americans have sleep apnea. Four percent of middle-aged men and 2 percent of middle-aged women have sleep apnea along with excessive daytime sleepiness.
People most likely to have or develop sleep apnea include those who snore loudly and also are overweight, or have high blood pressure, or have some physical abnormality in the nose, throat, or other parts of the upper airway. Sleep apnea seems to run in some families, suggesting a possible genetic basis.
Certain mechanical and structural problems in the airway cause the interruptions in breathing during sleep. In some people, apnea occurs when the throat muscles and tongue relax during sleep and partially block the opening of the airway.
When the muscles of the soft palate at the base of the tongue and the uvula (the small fleshy tissue hanging from the center of the back of the throat) relax and sag, the airway becomes blocked, making breathing labored and noisy and even stopping it altogether.
Sleep apnea also can occur in obese people when an excess amount of tissue in the airway causes it to be narrowed. With a narrowed airway, the person continues his or her efforts to breathe, but air cannot easily flow into or out of the nose or mouth.
Unknown to the person, this results in heavy snoring, periods of no breathing, and frequent arousals (causing abrupt changes from deep sleep to light sleep). Ingestion of alcohol and sleeping pills increases the frequency and duration of breathing pauses in people with sleep apnea.
Sleep apnea refers to a breathing problem that can occur during sleep. In sleep, the muscles in the pharynx (the back of the throat) relax, allowing it to constrict. This partial collapse of the pharynx can sometimes lead to inadequate airflow.
The body senses poor airflow and takes a deep breath, which leads to an arousal. These deep breaths and consequent arousals can occur 50-100 times an hour, severely disrupting sleep.
Sleep Apnea is diagnosed by an overnight study of sleep and breathing patterns called a polysomnogram. While there are many treatments for sleep apnea, the most common utilizes a nasal CPAP – a machine that blows pressurized air in through the nose, helping people with this condition get adequate airflow to the lungs, allowing them to sleep well and feel refreshed.
People with sleep apnea report a number of symptoms that they often fail to report as problems, and thus miss detection by healthcare professionals. (A spouse or bed partner often provides helpful information about the sleep and daytime functioning of the sufferer.) Symptoms of sleep apnea include:
• Loud snoring
• Pauses in breathing while asleep
• Snoring interrupted by gasping, snorting, or choking
• Excessive daytime sleepiness, often with the tendency to fall sleep
in inappropriate situations such as while at work, while watching
movies, or while driving
• Trouble with attention, concentration, or memory
• Low mood, depression, or irritability
• Loss of sexual interest, impotence (in men),
• or menstrual irregularities (in women)
• Acid stomach, or heartburn at night
• Dry mouth upon awakening
• Headaches upon awakening
• Nausea upon awakening
• The need to urinate many times at night (without having a
large prostate) or even bedwetting
• Being overweight
• Non-refreshing sleep
It is important to note that many people over the age of 70 may have sleep apnea without snoring.
Sleep apnea is associated with significant health and safety risks.
Because of the serious disturbances in their normal sleep patterns, people with sleep apnea often feel very sleepy during the day and their concentration and daytime performance suffer. The consequences of sleep apnea range from annoying to life-threatening.
They include symptoms suggesting depression, irritability, sexual dysfunction, learning and memory difficulties, and falling asleep while at work, on the phone, or driving. Untreated sleep apnea patients are 3 times (or more) likely to have automobile accidents
It has been estimated that up to 50 percent of sleep apnea patients have high blood pressure. It has recently been shown that sleep apnea contributes to high blood pressure. Risk for heart attack and stroke may also increase in those with sleep apnea
Health risks include:
High blood pressure. One review of the medical literature reports that approximately 6 of every 10 people with sleep apnea suffers from high blood pressure.
Irregular heartbeats. Heart rhythms that are either too slow or too fast, or rhythms that are abnormal (such as premature ventricular contractions, or PVCs) occur in about half of those with sleep apnea.
Stroke is approximately 10 times greater in those with sleep apnea than those without.
Low blood oxygen, a common occurrence in people with sleep apnea, appears to be associated with a number of medical problems. This condition may result in seizure during sleep.
Death rates are higher in those with sleep apnea or untreated than those without.
Excessive daytime sleepiness: Sleepiness is a “hallmark” of sleep apnea, and often results in impaired daytime functioning.
People with sleep apnea may be at greater risk of accidents or injuries due to fatigue. For example, people with sleep apnea are five times more likely to be involved in a fatigue-related motor vehicle accident than healthy individuals.
Sleep apnea treatment
There are many treatments for sleep apnea. Weight loss is a common recommendation for overweight people with sleep apnea.
However, most doctors usually recommend treatment with nasal continuous positive airway pressure (CPAP).
CPAP is delivered using a small bedside machine that is attached to a plastic hose and nose mask worn by the sleeper.
The machine gently delivers air that helps the sleeper breathe normally.
Effective surgical treatments are available, including those offered by Ear, Nose, and Throat specialists, and weight loss specialists.
Mild cases of sleep apnea may benefit from the use of an oral appliance.
Non-specific Therapy
Behavioral changes are an important part of the treatment program, and in mild cases behavioral therapy may be all that is needed.
Overweight persons can benefit from losing weight. Even a 10 percent weight loss can reduce the number of apneic events for most patients. Individuals with apnea should avoid the use of alcohol and sleeping pills, which make the airway more likely to collapse during sleep and prolong the apneic periods.
In some patients with mild sleep apnea, breathing pauses occur only when they sleep on their backs. In such cases, using pillows and other devices that help them sleep in a side position may be helpful.
Weight Loss
Weight loss is a common recommendation for overweight people with sleep apnea.
Most people with sleep apnea are overweight. Excess weight can contribute significantly to the occurrence and severity of sleep apnea. Sometimes weight loss of 5 or 6 pounds can have a significant impact on the problem. Therefore, weight loss is a common treatment recommendation made by sleep specialists.
There is no linear relationship between the amount of weight one loses and improvement in sleep apnea, so it is impossible to predict how much weight loss is needed in order to be helpful. It is most common to find that apnea improves once the patient falls below a critical, “threshold” weight.
Weight loss often is difficult to achieve, and may not result in the therapeutic outcome desired. Therefore, weight loss recommendations often are complemented by recommendations for other treatments.
CPAP/BiPAP
Nasal continuous positive airway pressure (CPAP) is the most common effective treatment for sleep apnea. In this procedure, the patient wears a mask over the nose during sleep, and pressure from an air blower forces air through the nasal passages.
The air pressure is adjusted so that it is just enough to prevent the throat from collapsing during sleep. The pressure is constant and continuous. Nasal CPAP prevents airway closure while in use, but apnea episodes return when CPAP is stopped or it is used improperly.
These treatments deliver room air to the sleeper’s nasal airway through a nose mask at a pressure that is sufficient to keep the upper airway open and facilitate normal breathing.
The machine must be used on a nightly basis, every time the patient sleeps, in order for it to be truly effective. This can be challenging for some people, who find it difficult to use the system regularly.
Others may experience “adverse effects” associated with nasal CPAP use, such as nasal congestion, dryness, or feelings of claustrophobia. The difficulties one has accommodating to nasal CPAP can interfere with treatment compliance. Studies have shown that 20% - 60% of patients abandon the use of nasal CPAP despite the health consequences of doing so.
Variations of the CPAP device attempt to minimize side effects that sometimes occur, such as nasal irritation and drying, facial skin irritation, abdominal bloating, mask leaks, sore eyes, and headaches.
Some versions of CPAP vary the pressure to coincide with the person’s breathing pattern, and other CPAPs start with low pressure, slowly increasing it to allow the person to fall asleep before the full prescribed pressure is applied.
Dental appliances that reposition the lower jaw and the tongue have been helpful to some patients with mild to moderate sleep apnea or who snore but do not have apnea. A dentist or orthodontist is often the one to fit the patient with such a device.
However, most doctors usually recommend treatment with nasal continuous positive airway pressure (CPAP).
Surgery
Some patients with sleep apnea may need surgery. Although several surgical procedures are used to increase the size of the airway, none of them is completely successful or without risks. More than one procedure may need to be tried before the patient realizes any benefits.
There are several physical factors that can contribute to the occurrence of sleep apnea.
Excessive or redundant tissue in the upper airway (the part of the airway between the tip of one’s nose to the base of one’s tongue) can be one important causative factor.
Therefore, some specialists, known as “Ear, Nose, and Throat” doctors have developed several techniques that can be used to effectively treat snoring and sleep apnea.
Somnoplasty is a simple, bloodless procedure that is used to treat snoring by using needle-tip radiofrequency to minimize the soft tissue in the upper airway. Somnoplasty is a procedure that uses radiowaves to reduce the size of some airway structures such as the uvula and the back of the tongue. This technique is being investigated as a treatment for apnea
Uvulopalatopharyngoplasty (UPPP) is a procedure used to remove excess tissue at the back of the throat (tonsils, uvula, and part of the soft palate). The success of this technique may range from 30 to 60 percent.
The long-term side effects and benefits are not known, and it is difficult to predict which patients will do well with this procedure.
Uvulopalatopharyngoplasty (UPPP) and laser-assisted uvulopalatoplasty (LAUP) are two procedures that excise (cut out) or reduce excessive tissue in the back of the throat.
Like UPPP, LAUP may decrease or eliminate snoring but not eliminate sleep apnea itself. Elimination of snoring, the primary symptom of sleep apnea, without influencing the condition may carry the risk of delaying the diagnosis and possible treatment of sleep apnea in patients who elect to have LAUP.
To identify possible underlying sleep apnea, sleep studies are usually required before LAUP is performed.
Tracheostomy is used in persons with severe, life-threatening sleep apnea. In this procedure, a small hole is made in the windpipe and a tube is inserted into the opening.
This tube stays closed during waking hours, and the person breathes and speaks normally. It is opened for sleep so that air flows directly into the lungs, bypassing any upper airway obstruction. Although this procedure is highly effective, it is an extreme measure that is rarely used.
Other procedures: Patients in whom sleep apnea is due to deformities of the lower jaw may benefit from surgical reconstruction. Finally, surgical proced-ures to treat obesity are sometimes recommended for sleep apnea patients who are morbidly obese.
Some of the more common procedures include removal of adenoids and tonsils (especially in children), nasal polyps or other growths, or other tissue in the airway and correction of structural deformities. Younger patients seem to benefit from these surgical procedures more than older patients.
Other surgical procedures such as genioglossus advancement, bimaxillary advancement, also may be attempted during the course of surgical treatment of sleep apnea. Approximately 1/3 of patients who undergo surgical treatment for sleep apnea will realize improvement in respiration during sleep.
The well-documented relationship between obesity (overweight) and sleep apnea has led to the use of certain surgeries for obesity, known as bariatric surgery, used in the interest of treating some cases of sleep apnea.
Patients who are considering surgical treatments for sleep apnea should speak to their primary care doctors and/or Ear, Nose, & Throat doctors. Thorough evaluation in an accredited sleep laboratory is appropriate before and after surgery in order to document the problem and improvement with treatment.
Oral Appliances
Snoring and mild sleep apnea may be treated with the use of an oral appliance. An oral appliance is a device that is worn over the teeth during sleep in order to keep the sleeper’s jaw fixed in a “forward” position.
Some devices also aid in maintaining a stationary position of the sleeper’s tongue. Oral appliances help to open the upper airway and facilitate airflow during sleep. A dental sleep specialist usually must fit these devices.
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