WHAT IS SLEEP APNEA
Sleep apnea is a very common sleep disorder that can occur at any age. From infants to the elderly, various presentations of abnormal breathing while sleeping can be seen. Sleep apnea syndromes define all these manifestations. Generally, these will fall into the categories of obstructive or central sleep apnea. Essentially, these are repetitive episodes where no airflow or significantly decreased airflow occurs. This will be associated with various degrees of drops in blood oxygen levels and sleep disruptions. In obstructive sleep apnea, an effort is being made to breathe but there is dynamic collapse/obstruction of the upper airway preventing airflow. In central sleep apnea there is an actual cessation of breathing effort resulting in a lack of airflow. Sometimes a patient will show both types. Severity is based on how often the events occur and on how low the oxygen saturation levels reach.
RISKS FOR DEVELOPING SLEEP APNEA
The incidence of sleep apnea increases with weight gain, and this represents the most common risk factor. Weight increases, particularly around the neck area, can promote the development of sleep apnea. Different anatomical variants of face and airway will increase the risk of sleep apnea even with normal weight. Most common examples would be retrognathia, where there is a recessed chin because of a posterior position of the mandible, and large tonsils, especially in children that can obstruct the airway. Strokes that affect the control of breathing can lead to sleep apnea. Medications that can be sedating and affect breathing can lead to sleep apnea, especially opiates that can cause very severe central sleep apnea even though awake breathing is normal. Smoking appears to increase the risk of sleep apnea as does alcohol intake. People with diabetes and hypertension may have an increased risk of having sleep.
The most common symptom of sleep apnea is complaints of daytime tiredness and or sleepiness. Sometimes this is described as fatigue. Waking up unrefreshed despite what seems to be adequate hours of sleep is also a major complaint. Awakening with morning headaches and dry mouth, trouble concentrating, and irritability are frequently described during the day. While sleeping, complaints of wakening up gasping, choking and panicking are not uncommon. Disturbing dreams and restless sleep are often noted. The bed partner of the patient with sleep apnea may also note problems; loud snoring and restlessness may seriously disturb the bed partner’s sleep. Actually observing the lack of breathing is also frequently noted. It is important to note that lack of symptoms and/or bed partner’s complaints does not always exclude the possibility of having sleep apnea.
There are multiple studies looking at the risks of untreated sleep apnea. Some of these risks have better validation than others. There is an increased risk of motor vehicle accidents in patients who have sleep apnea. In fact, this is so significant that frequently professional truck drivers will not be able to have a commercial driving license unless they can demonstrate effective treatment of underlying sleep apnea. The increase in risks is secondary to the increased risk of falling asleep and decreased ability to focus. Untreated sleep apnea may worsen diabetes, hypertension, heart arrhythmias, (especially atrial fibrillation), and congestive heart failure. Untreated sleep apnea may also increase the risk of having a stroke, a heart attack and may also increase mortality.
There are essentially two ways to diagnose sleep apnea and both require monitoring the patient while sleeping. One method is for the patient to have a home sleep study while the other is a sleep study at a sleep facility. The home sleep study measures less parameters and can fail in terms of reliable data much more often than study done at a sleep facility. However, the ordering physician will pick the appropriate study based upon the patient’s presentation. Generally, it is not difficult to make diagnoses of sleep apnea when the tests are done well.
The good news is that sleep apnea is a very treatable syndrome. The possible treatment options often depend on the severity of the sleep apnea, and the underlying health of the patient.
The most common and extremely effective therapy is the use of a device worn at night that can alleviate the upper airway obstruction, assist with breath support or both. Multiple options for nasal and oral interfaces allow the patient to select what is the most comfortable fit for their needs. There are many different devices with the most common being CPAP, AUTOPAP, BIPAP, BIPAPST and BIPAP AUTO SVC. Multiple options for nasal and mouth interfaces allow the patient to select the most comfortable for them. Dental appliances that are individually fitted for the patient when appropriate can be successful. These devices force the patient to bite with the lower jaw thrust forward opening the back of the airway. If weight is the cause of sleep apnea then significant weight reduction may markedly improve and occasionally resolve the patient’s sleep apnea. At times patients will exhibit sleep apnea in only one position which is primarily supine. Positional training is utilized and can be an effective solution.
Quitting smoking may improve sleep apnea. Elimination of alcohol can at times be curative in some individuals. Sedating medications can also improve sleep apnea. If opiates are the cause of sleep apnea elimination or a significant decrease in dose may resolve sleep apnea.
There are a number of surgical treatments for sleep apnea with various degrees of success. One of the most commonly used surgical procedures is tonsillectomy. Recently, a newer procedure called Inspire is being used. Essentially, this places two internal wires that assess breathing pattern and stimulate the upper airways muscles. There are multiple other surgical procedures with varying degrees of success depending on the upper airway anatomy.
It is very important that a specialist in Sleep Medicine treats the patient with sleep apnea so that the appropriate therapy is chosen. Close monitoring of the patient while on therapy is also best done under the direction of a Sleep Specialist.