Sleep Apnea


SLEEP APNEA

Description:

Sleep apnea is a disorder characterized by a reduction or cessation (pause of breathing, airflow) during sleep. It is common among adults but rare among children.

Sleep apnea is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep. Breathing pauses can last from a few seconds to minutes. They often occur 5 to 30 times or more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound.

Sleep apnea usually is a chronic (ongoing) condition that disrupts your sleep 3 or more nights each week. You often move out of deep sleep and into light sleep when your breathing pauses or becomes shallow.

This results in poor sleep quality that makes you tired during the day. Sleep apnea is one of the leading causes of excessive daytime sleepiness.

There are three different types of sleep apnea: obstructive sleep apnea (OSA), central sleep apnea, and mixed sleep apnea. These types differ in their causes and potential treatments. In all the types of sleep apnea, some part of the respiratory system narrows, impairing the amount of oxygen a person takes into his or her lungs.

Obstructive Sleep Apnea: This is the most common and severe form of sleep apnea. A typical person with this form of sleep apnea is an overweight male between 35 and 50 years old who usually has a small jaw, a small opening to the airway at the back of the throat, and a large tongue or tonsils. During sleep, the muscles of the soft palate, the muscles at the base of the tongue, and the uvula (the tissue that hangs from the middle of the back of the mouth) relax and sag, blocking the airway, which then collapses.

As breathing stops, the diaphragm and chest muscles strain until the block is literally uncorked, and a noisy gasp -- the snore -- is made. When breathing stops, blood oxygen levels fall, forcing the heart to work harder. As a result, blood pressure rises, and the heartbeat may even become irregular.

Obstructive sleep apnea is made worse by drinking alcohol or taking tranquilizers, antihistamines, or sleeping pills.

Central Sleep Apnea: In this rarer form of the disorder, the airway remains open, but the diaphragm and chest muscles temporarily fail. The dropping blood oxygen levels signal the brain, which prompts the person to awaken and gasp in a breath. Because the airway is typically open, this apnea sufferer does not snore loudly but does have daytime sleepiness.

Central sleep apnea is more common among people over 60, and is often seen in nursing homes and among the ill.

Mixed Sleep Apnea: Some people experience long periods of obstructive sleep apnea interspersed with brief periods of central sleep apnea. This is called mixed sleep apnea.

Symptoms:

The two main symptoms of sleep apnea are:

1. You're very sleepy during the day.

2. You snore and have pauses in your breathing while sleeping.

Some other signs and symptoms of sleep apnea:

1. You have high blood pressure.

2. You're irritable.

3. You gasp or choke during sleep.

4. You're very tired (you have fatigue).

5. You're depressed.

6. You can't concentrate.

7. You have morning headaches.

8. You have memory problems/ memory loss.

Treatment:

In order to prevent the obstruction of the airway, which is the most common cause of sleep apnea, there is one treatment that is the best option. To keep the upper airway open, it is often necessary to support it with a constant flow of air delivered through a face mask worn while sleeping. This most common treatment is called Continuous Positive Airway Pressure, or CPAP.

Once it has been determined by a physician that this is the best treatment option, it is necessary to visit with a provider of durable medical equipment. The CPAP machine will be set with a prescribed pressure, and other equipment -- including a humidifier, hosing, and a personally fitted mask -- will be issued. It is important to find a mask that is comfortable, with minimal leakage when it is worn. Most individuals who use CPAP are able to tolerate it after a few weeks of regular use.

Although CPAP therapy is clearly the best option in moderate to severe sleep apnea, some individuals cannot tolerate it. In this case, other treatment options might be pursued, including:

1. Surgery to remove excess tissue in the throat.

2. Positional sleep aids (such as “sleep shirts” or wedges).

3. Dental devices to move the lower jaw forward.

4. Oxygen support (which is not usually sufficient alone).

Causes and Risk factors:

There are several factors that may predispose a person towards sleep apnea.

Gender: More men than women appear to have sleep apnea. Sleep apnea may be under-diagnosed in women. In general, older women have the same incidence as men their own age. A range of studies has reported apnea or hypopnea in between 9% and 24% of men and 4% to 15% of women.

Age: Sleep apnea affects people of all ages. Although it is most common in older adults, it has been reported in between 1.6% to 3.4% of children. Some experts believe that sleep disorder breathing may occur in as many as 11% of children. Interestingly, one study suggested that although prevalence of sleep apnea increases with age, its health consequences decline. In the study, apnea posed more of a threat to a person's health before age 45 than afterward.

Ethnicity: African Americans face a higher risk for sleep apnea than any other ethnic group in the United States.

Geography: According to one study, although urban dwellers are more likely to report disturbed sleep, particularly as a result of stress, rural dwellers have a significantly higher risk for apnea.

Obesity: Obesity, particularly having fat around the abdomen (the so-called apple shape), is a particular risk factor for sleep apnea, even in adolescents and children.

Immune abnormalities: High levels of certain immune factors are present in people with sleep apnea, including tumor necrosis factor alpha (TNF-alpha) and interleukin 6 (IL-6). Elevated levels of TNF-alpha can cause fatigue, shortness of breath, and weakness in the heart's pumping action. IL-6 and TNF-alpha may both play a role in obesity as well.

Body position: Body position greatly affects the number and severity of episodes of obstructive sleep apnea, with at least twice as many apneas occurring when a person lies face upward than when the person lies on his or her side. This may be due to the effects of gravity, which cause the throat to narrow when a person lies on the back.

Other medical conditions: Individuals with severe heartburn (Gastroesophageal reflux disease, or GERD) appear to be at higher risk for sleep apnea. Sleep apnea is also associated with higher rates of heart failure.

Smoking: Smokers are at higher risk for apnea, with heavy smokers (more than 2 packs a day) having a risk 40 times greater than nonsmokers.

Alcohol: Alcohol use has been associated with apnea.

Obesity or excessive weight gain is a primary risk factor. Additional tissue in the throat narrows the airway, which is then more easily blocked when the muscles are relaxed. Age and gender are also significant factors in sleep apnea. Aging is usually accompanied by a loss of muscle mass and if the muscles near the airways are more lax, it is easier for them to become blocked. Men seem more likely to experience sleep apnea, although it may be underdiagnosed in women.

Diagnosis:

Doctors diagnose sleep apnea based on your medical and family histories, a physical exam, and results from sleep studies. Usually, your primary care doctor evaluates your symptoms first. He or she then decides whether you need to see a sleep specialist.

Medical and Family Histories: Your doctor will ask you and your family questions about how you sleep and how you function during the day. To help your doctor, consider keeping a sleep diary for 1 to 2 weeks. Write down how much you sleep each night, as well as how sleepy you feel at various times during the day.

Your doctor also will want to know how loudly and often you snore or make gasping or choking sounds during sleep. Often you're not aware of such symptoms and must ask a family member or bed partner to report them.

If you're a parent of a child who may have sleep apnea, tell your child's doctor about your child's signs and symptoms.

Let your doctor know if anyone in your family has been diagnosed with sleep apnea or has had symptoms of the disorder.

Many people aren't aware of their symptoms and aren't diagnosed.

Physical Exam: Your doctor will check your mouth, nose, and throat for extra or large tissues. The tonsils often are enlarged in children with sleep apnea. A physical exam and medical history may be all that's needed to diagnose sleep apnea in children.

Adults with the condition may have an enlarged uvula or soft palate. The uvula is the tissue that hangs from the middle of the back of your mouth. The soft palate is the roof of your mouth in the back of your throat.

Sleep Studies: A sleep study is the most accurate test for diagnosing sleep apnea. It captures what happens with your breathing while you sleep.

A sleep study is often done in a sleep center or sleep lab, which may be part of a hospital. You may stay overnight in the sleep center.

Polysomnogram: A polysomnogram or PSG is the most common study for diagnosing sleep apnea. This test records:

1. Brain activity.

2. Eye movement and other muscle activity.

3. Breathing and heart rate.

4. How much air moves in and out of your lungs while you're sleeping.

5. The amount of oxygen in your blood.

A PSG is painless. You will go to sleep as usual, except you will have sensors on your scalp, face, chest, limbs, and finger. The staff at the sleep center will use the sensors to check on you throughout the night.

A sleep specialist reviews the results of your PSG to see whether you have sleep apnea and how severe it is. He or she will use the results to plan your treatment.

Medicine and medications:

No effective pharmacologic therapy for childhood obstructive sleep apnea (OSA) is recognized. Individuals with obstructive sleep apnea and hypersomnolence should have the underlying cause of their obstructive apnea addressed, rather than use stimulant medication during the day in an attempt to help stay alert.

Nocturnal supplemental oxygen is generally not advised as a primary treatment for obstructive sleep apnea. Although oxygen may blunt the degree of hemoglobin desaturation during sleep, it does not prevent sleep fragmentation, sleep deprivation, or associated autonomic stimulation during the obstructive episodes. Preoperative supplemental oxygen treatment has been reported to worsen obstructive hypoventilation in some children. Therefore, if oxygen is used as a bridge to more definitive therapy, the effect of supplemental oxygen should be documented during nocturnal polysomnography.

Intranasal fluticasone propionate (Flonase) administered daily for 6 weeks has been shown to ameliorate the frequency of obstructive events in children with documented mild-to-moderate obstructive sleep apnea caused by tonsil and/or adenoid hypertrophy by about one half. Intranasal corticosteroids have not been shown to decrease obstructive symptoms, eliminate the need for surgery, prevent oxygen desaturation, or shrink tonsil or adenoid tissue; therefore, if intranasal corticosteroids are used, the treatment is only temporary pending a more permanent solution. Systemic corticosteroids have not been shown effective and have no role in treatment.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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