About Sleep Apnea

Facts About..........Sleep Apnea
Revised by Dr. David James WHAT IS APNEA?

Breathing is the interchange of gases between the body and the medium in which it lives; more specifically, the taking in of oxygen, its use in the tissues, and the giving off of carbon dioxide, the waste. Simply put it inhaling and exhaling during which the lungs are provided with air through inhaling and the carbon dioxide removed through exhaling. Apnea means temporary cessation of breathing. Apnea, sleep apnea or obstructive sleep apnea is defined as "the cessation of breathing for 10 or more seconds while asleep.

The Greek word "apnea" literally means "without breath." There are three types of apnea: obstructive, central, and mixed; of the three, obstructive is the most common. In Obstructive apnea breathing is interrupted by a physical block to airflow. Obstructive sleep apnea (OSA) is caused by a blockage of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep.

Obstructive sleep apnea (obstructive sleep apnea) is cause by the closing of the upper airway while asleep. The uvula and soft pallet collapses on the back wall of the upper airway. Then the tongue falls backward, collapsing on the back wall of the upper airway, the uvula and soft pallet forming a tight blockage, preventing any air from entering the lungs. The effort of the diaphragm, the chest and the abdomen only cause the blockage to seal tighter. In order to breathe the person must arouse or awaken, causing tension in the tongue thereby opening the airway, allowing air to pass into the lungs.

Snoring

Most prominent symptoms are snoring, not breathing while asleep, excessive daytime sleepiness and obesity. Other symptoms include lack of concentration, forgetfulness, uncharacteristically irritable, anxiety, depression, mood and/or behavioral changes, morning headaches, disorientation at awakening and loss of sexual interest. What are the consequences of OSA? If OSA is not treated, serious health problems can occur, including:

• hypertension
• coronary artery disease
• heart attack
• stroke
• psychiatric problems
• impotence
• cognitive dysfunction
• memory loss

According to the National Institutes of Health, approximately 12 million Americans suffer from OSA, which is twice as common in men as it is in women.

So we see that Sleep apnea is very common, as common as adult diabetes. Risk factors include being male, over-weight, and over the age of forty, but sleep apnea can strike anyone at any age, even children. Yet still because of the lack of awareness by the public and healthcare professionals, the vast majority remain undiagnosed and therefore untreated, despite the fact that this serious disorder can have significant consequences.

In pure Central Sleep Apnea, the brain's control centers "forget" to breathe during sleep. The sleeper stops breathing, and then starts again. There is no effort made to breathe during the pause in breathing: there are no chest movements and no struggling, just stillness. After the episode of apnea, breathing may be faster for a period of time, a compensatory mechanism to blow off retained waste gasses and absorb more oxygen. In Mixed Sleep Apnea, both types of events occur. Regardless of type, the individual affected with sleep apnea is rarely (if ever) aware of having difficulty breathing, even upon awakening. Sleep apnea is recognized as a problem by others witnessing the individual during episodes, or is suspected because of its effects on the body.

While sleeping, a normal individual is "at rest", as far as cardiovascular workload is concerned. Breathing is regular in a healthy person during sleep, and oxygen levels and carbon dioxide levels in the bloodstream stay fairly constant. The respiratory drive is so strong that even conscious efforts to hold one's breath do not overcome it. Any sudden drop in oxygen or excess of carbon dioxide (even if tiny) strongly stimulates the brain's respiratory centers to breathe. In central sleep apnea, the basic neurological controls for breathing rate malfunctions and fails to give the signal to inhale, causing the individual to miss one or more cycles of breathing.

IS SNORING THE SAME AS SLEEP APNEA?

Snoring and sleep apnea are not the same thing

Mixed Apnea
Mixed apnea is a combination of central and obstructive apnea and is seen particularly in infants or young children who have abnormal control of breathing. Mixed apnea may occur when a child is awake or asleep.

 

Do you suffer from sleep apnea? Test yourself.

How likely are you to doze off or fall asleep in the following situations?

Choose the most appropriate number for each situation

• 0 = would never doze
• 1 = slight chance of dozing
• 2 = moderate chance of dozing
• 3 = high chance of dozing

 

• Sitting and reading
• Watching TV
• Sitting, inactive in a public place (theater, meeting)
• As a passenger in a car for an hour without a break.
• Lying down to rest in the afternoon
• Sitting and talking to someone
• Sitting quietly after lunch without alcohol
• In a car, while stopped for a few minutes in traffic

Scoring Total:
9 points or above = High chance that you suffer from sleep apnea

We recommend you to get a sleep study done in order to help determine what is keeping you from getting a restful sleep and how you can treat it.
Sleep apnea can and should be treated.

A blockage or narrowing of the airways in your nose, mouth, or throat generally causes obstructive sleep apnea (OSA). This usually occurs when the throat muscles and tongue relax during sleep and partially block the airway.
Sleep apnea can also occur if you have bone deformities or larger than normal tissues in your nose, mouth, or throat. For example, you may have large tonsils. During the day when you are awake and standing up, this may not cause problems. However, when you lie down at night, your tonsils can press down on your airway, narrowing it and causing sleep apnea.

Other factors that make sleep apnea more likely include being obese, using certain medicines or alcohol before bed, and sleeping on your back. OSA can occur in men and women of any age, but it is most common in obese, middle-aged men.

There is a strong relationship between weight and OSA. Your neck gets thicker as you gain weight. This increases the level of fat in the back of the throat, narrowing the airway. With more fat in the throat, your airway is more likely to be blocked. People with OSA are often obese and have a neck size of more than 17 inches. Many people with OSA also have high blood pressure.
Children with large tonsils may also have OSA.

Call your doctor if:

• You or your bed partner snores loudly and heavily and feels sleepy during the day.
• You notice that your bed partner stops breathing, gasps, or chokes during sleep.
• You sometimes fall asleep at inappropriate times, such as while you are talking or eating.
• Your child snores, has difficulty breathing while sleeping, sleeps restlessly, wakes up often, and is very sleepy during the day.

Symptoms, Signs and Sequelae

This section summarizes the clinical picture and consequences of obstructive sleep apnea syndrome.

As already mentioned, snoring is almost a uniform finding in an individual with this syndrome, but many people snore without having apnea. Snoring is the turbulent sound of air moving through the back of the mouth, nose and throat. The loudness of the snoring is not indicative of the severity of obstruction, however. If the upper airways are tremendously obstructed, there may not be enough air movement to make much sound. Even the loudest snoring does not mean that an individual has sleep apnea syndrome. The sign that is most suggestive of sleep apneas occurs if snoring stops. If it does, along with breath, while the persons' chest and body tries to breathe - that is literally a description of an event in obstructive sleep apnea syndrome. When breathing starts again, there is typically a deep gasp, and then the resumption of snoring.

Sometimes, elevated arterial pressure (commonly called high blood pressure) is a sequela of obstructive sleep apnea syndrome. When high blood pressure is caused by OSA, it is distinctive in that, unlike most cases of high blood pressure (so-called essential hypertension), the readings do not drop significantly when the individual is sleeping.[2] Stroke is associated with obstructive sleep apnea
In pure Central Sleep Apnea, the brain's control centers "forget" to breathe during sleep. The sleeper stops breathing, and then starts again. There is no effort made to breathe during the pause in breathing: there are no chest movements and no struggling, just stillness. After the episode of apnea, breathing may be faster for a period of time, a compensatory mechanism to blow off retained waste gasses and absorb more oxygen.

Diagnosis is made by a physician specially trained in sleep medicine. After a physical examination of the upper airway and an interview with lots of questions, if it is determined that you might have a sleep disorder, you will be asked to take a polysomnogram (sleep test). Most sleep centers and labs monitor 16 different sleep parameters including EEG, EKG, eye movement, chin movement, air flow, chest effort, abdomen effort, SaO2, snoring and leg movement. Each parameter serves to help the physician make a correct diagnosis. Tests are conducted in a sleep room much like a motel room. A technician will paste electrodes at certain points on your head, face, body and legs.

The most serious consequence of obstructive sleep apnea is to the heart. In severe and prolonged cases, there are increases in pulmonary pressures that are transmitted to the right side of the heart. This can result in a severe form of congestive heart failure (cor pulmonale). There is a special treatment for this condition.

Some treatments involve lifestyle changes, such as

• avoiding alcohol and medications that relax the central nervous system (for example, sedatives and muscle relaxants)
• losing weight
• quitting smoking.

Some people are helped by special pillows or devices that keep them from sleeping on their backs or oral appliances to keep the airway open during sleep. If these conservative methods are inadequate, doctors often recommend continuous positive airway pressure (CPAP), in which a face mask is attached to a tube and a machine that blows pressurized air into the mask and through the airway to keep it open. There are also surgical procedures that can be used to remove and tighten tissue and widen the airway, but the success rate is not high. Some individuals may need a combination of therapies to successfully treat their sleep apnea.

There are patterns of unusual facial features that occur in recognizable syndromes. Some of these craniofacial syndromes are genetic, others are from unknown causes. In many craniofacial syndromes, the features that are unusual involve the nose, mouth and jaw, or resting muscle tone, and put the individual at risk for obstructive sleep apnea syndrome.

Down Syndrome is one such syndrome. In this chromosomal abnormality, several features combine to make the presence of obstructive sleep apnea more likely. The specific features in Down Syndrome that predispose to obstructive sleep apnea include: relatively low muscle tone, narrow nasopharynx, and large tongue. Obesity and enlarged tonsils and adenoids, conditions that occur commonly in the western population, are much more likely to be obstructive in a person with these features than without them. Obstructive Sleep Apnea does occur even more frequently in people with Down Syndrome than in the general population. A little over 50% of all people with Down Syndrome suffer from obstructive sleep apnea (de Miguel-Díez, et al 2003), and some will be hooked to monitoring equipment that will record the entire night study. Most patients do not experience anxiety or difficulty in going to sleep. They are extremely sleepy and will be asleep in just a few minutes.
At the conclusion of the test the electrodes will be taken off and you will be free to go. A scoring technician will score your sleep study and the physician will review it. A day or two later you will meet with the physician to review your study. At that time you and the physician will determine the next course of action. Usually the sleep physician will recommend a second sleep test to determine if your sleep disorder can be treated with continuous positive airway pressure (CPAP). You will be fit with a CPAP breathing circuit, hooked up with the electrodes and put back in bed. While you are asleep the technician will adjust the CPAP pressure trying to eliminate all obstructive sleep apnea and snoring. A day or two later you will again meet with the physician and review you CPAP titration study. Usually you will be referred to an equipment provider that will supply the equipment and fit you with a regular breathing circuit. Then you will be on your way to a normal life.

Treatment

There are a variety of treatments for obstructive sleep apnea, depending on an individual's medical history, the severity of the disorder and, most importantly, the specific cause of the obstruction.

Most children with obstructive sleep apnea have the problem on the basis of chronically enlarged tonsils and adenoids. In these children, tonsillectomy and adenoidectomy is curative. The operation may be far from trivial, however, in the worst cases, in which growth is reduced and abnormalities of the right heart may have developed. Even in these extreme cases, however, the surgery tends to cure not only the apnea and upper airway obstruction - but to allow subsequent normal growth and development. Once the high end-expiratory pressures are relieved, the cardiovascular complications reverse themselves. The postoperative period in these children requires special precautions.

The treatment for obstructive sleep apnea in the case of adults with poor oropharyngeal airways secondary to heavy upper body type is varied. Unfortunately, in physicians advocate routine testing of this group (Shott, et al 2006). Obstructive sleep apnea is a serious complication that seems to be most frequently associated with pharyn-geal flap surgery, compared to other procedures for treatment of velopharyngeal inadequacy (VPI) [2]. In OSA, recurrent interruptions of respiration during sleep are associated with temporary airway obstruc-tion. Following pharyngeal flap surgery, depending on size and position, the flap itself may have an "obturator" or obstructive effect within the pharynx during sleep, blocking ports of airflow and hindering effective respiration [3] [4]. There have been document-ed instances of severe airway obstruction, and reports of post-operative OSA continue to increase as health-care professionals (i.e. physicians, speech language pathologists) become more educated about this possible dangerous condition [5]. Subsequently, in clinical practice, concerns of OSA have matched or exceeded interest in speech outcomes following pharyngeal flap surgery.

The most widely used current therapeutic intervention in physical interventions is positive airway pressure whereby a breathing machine pumps a controlled stream of air through a mask worn over the nose, mouth, or both. The additional pressure splints or holds open the relaxed muscles, just as air in a balloon inflates it.
There are several variants:

• (CPAP), or Continuous Positive Airway Pressure

• (VPAP), or Variable Positive Airway Pressure

• (APAP), or Automatic Positive Airway Pressure

A second type of physical intervention, a Mandibular advancement splint (MAS), is sometimes prescribed for mild or moderate sleep apnea sufferers. The device is a mouthguard similar to those used in sports to protect the teeth. For apnea patients, it is designed to hold the lower jaw slightly down and forward relative to the natural, relaxed position. This position holds the tongue farther away from the back of the airway, and may be enough to relieve apnea or improve breathing for some patients.

The FDA accepts only 16 oral devices for the treatment of sleep apnea. Oral appliance therapy is less effective than CPAP, but is more 'user friendly'. Side-effects are common but rarely is the patient aware of them.

Pharmaceuticals

Few drug-based treatments of obstructive sleep apnea are known despite over two decades of research and tests.
Oral administration of the methylxanthine theophylline (chemically similar to caffeine) can reduce the number of episodes of apnea, but can also produce side effects such as palpitations and insomnia. Theophylline is generally ineffective in adults with OSA, but is sometimes used to treat Central Sleep Apnea (see below), and infants and children with apnea.
When other treatments do not completely treat the OSA, drugs are sometimes prescribed to treat a patient's daytime sleepiness or somnolence. These range from stimulants such as amphetamines to modern anti-narcoleptic medicines. The anti-narcoleptic modafinil is seeing increased use in this role as of 2004.
In some cases, Aricept is prescribed to improve the memory of patients that do not sleep well.
In some cases, weight loss will reduce the number and severity of apnea episodes, but for most patients excessive weight is an aggravating factor rather than the cause of OSA. In the morbidly obese, a major loss of weight (such as what occurs after bariatric surgery) can sometimes cure the condition.

Neurostimulation

Many researchers believe that OSA is at root a neurological condition, in which nerves that control the tongue and soft palate fail to sufficiently stimulate those muscles, leading to over-relaxation and airway blockage. A few experiments and trial studies have explored the use of pacemakers and similar devices, programmed to detect breathing effort and deliver gentle electrical stimulation to the muscles of the tongue.
This is not a common mode of treatment for OSA patients as of 2004, but it is an active field of research.

Surgical intervention

A number of different surgeries are often tried to improve the size or tone of the patient's airway. For decades, tracheostomy was the only effective treatment for sleep apnea. It is used today only in very rare, intractable cases that have withstood other attempts at treatment. Modern treatments try one or more of several options, tailored to the patient's needs. Often the long term success rate is low, prompting many doctors to favour CPAP as the gold standard.

Nasal surgery, including turbinectomy (removal or reduction of a nasal turbinate), or straightening of the nasal septum, in patients with nasal obstruction or congestion which reduces airway pressure and complicates OSA.
Tonsilectomy and/or adenoidectomy in an attempt to increase the size of the airway.
Removal or reduction of parts of the soft palate and some or all of the uvula such as uvulopalato-pharyn-goplasty (UPPP) or laser-assisted uvulopalatoplasty (LAUP). Modern variants of this procedure sometimes use radiofrequency waves to heat and remove tissue.
Reduction of the tongue base, either with laser excision or radiofrequency ablation.
Genioglossus Advancement, in which a small portion of the lower jaw which attaches to the tongue is moved forward, to pull the tongue away from the back of the airway.
Hyoid Suspension, in which the hyoid bone in the neck, another attachment point for tongue muscles, is pulled forward in front of the larynx..
Maxillomandibular advancement (MMA). A more invasive surgery usually only tried in difficult cases where other surgeries have not relieved the patient's OSA, or where an abnormal facial structure is suspected as a root cause. In MMA, the patient's upper and lower jaw are detached from the skull, moved forward, and reattached with pins and/or plates.
Pillar procedure, three small inserts are injected into the soft palate to offer support, potentially reducing snoring in mild to moderate sleep apnea[7]
Special Situation- Surgery and Anesthesia in Patients with Sleep Apnea Syndrome.
Many drugs and agents used during surgery to relieve pain and depress consciousness remain in the body at low amounts for hours or even days afterwards. In an individual with either Central, Obstructive or Mixed Sleep Apnea, these low doses may be enough to cause life-threatening irregularities in breathing.
Surgery on the mouth and throat, as well as dental surgery and procedures, can result in postoperative swelling of the lining of the mouth and other areas that affect the airway. Even when the surgical procedure is designed to improve the airway, such as tonsillectomy and adenoidectomy or tongue reduction - swelling may negate some of the effects in the immediate postoperative period.

 

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