Sleep Apnea

Sleep apnea is a sleep disorder in which a person repeatedly stops breathing while asleep. These gaps in breathing, called apneas, are defined as lasting at least ten seconds, and can last many times longer. Sleep apnea is usually accompanied by snoring. Sleep apnea can occur in children, but this discussion pertains to adults.

There are three general categories of sleep apnea:

  1. Obstructive: Obstructive sleep apnea (OSA) occurs when there is collapse of the upper throat tissues, blocking the passage of air.
  2. Central: Central sleep apnea occurs with some problem in the central nervous system, most likely the brain failing to signal the respiratory muscles to function, causing a lack of respiratory effort.
  3. Mixed: Mixed sleep apnea occurs when there is a combination of obstructive and central apneas.

Regardless of the type of sleep apnea, individuals with this condition are rarely aware of having any breathing problem, even upon awakening.

Symptoms of sleep apnea may include:

  1. Snoring: Patients frequently have very loud and interrupted snoring, often associated with choking or gasps and may cause arousal from sleep. The snoring often occurs in a crescendo pattern, loudest just before the apnea. Snoring is more likely to occur when sleeping on your back (supine position). Bed partners are usually aware of the findings, but may elect to sleep in another room because of the noise.
  2. Excessive daytime sleepiness: Because of poor sleep quality at night, patients fall asleep during the day, often while performing routine activities such as watching TV, talking on the phone, or riding in a car. Usually, these brief episodes of sleep do not seem to relieve the overall sense of sleepiness.
  3. Morning headaches.
  4. Irritability and impaired mental or emotional functioning: These types of symptoms are directly related to interrupted sleep.

Risk Factors:

  1. Gender: In the US, men appear to have sleep apnea more than women, but it may be under-diagnosed in women, especially post-menopausal women.
  2. Age: Most commonly seen in adults aged 40 to 60 years.
  3. Ethnicity: In the US, African-Americans appear to have the highest risk for sleep apnea. Pacific Islanders and Mexican-Americans also have an increased risk but sleep apnea effects all ethnic groups.
  4. Physical Characteristics: (a) Obesity, especially the so-called “apple shape” (fat around the abdomen), is a particular risk factor for sleep apnea. But not all apneics are obese and not all obese persons have sleep apnea. (b) Having a large neck, especially with a circumference of 17 inches or more in men or 16 inches or more in women. (c) Having certain skull or facial characteristics, including a receding chin, large tongue, narrow upper jaw, or a stiffer and/or larger soft palate.
  5. Smoking: Heavy smokers are at increased risk compared to nonsmokers
  6. Alcohol: The studies are mixed but avoidance of alcohol is recommended for those with sleep apnea
  7. Medical Conditions: Diabetes Mellitus, Gastroesophageal Reflux Disease (GERD), and Polycystic Ovary Syndrome (PCOS).

Potential Adverse Effects of Sleep Apnea:

  1. Cardiovascular: (a) high blood pressure; (b) stroke; (c) heart failure; (d) coronary disease and heart attack; (e) atrial fibrillation
  2. Endocrine: (a) diabetes mellitus; (b) metabolic syndrome; (c) obesity
  3. Pulmonary: (a) pulmonary hypertension; (b) asthma (worsened symptoms or response to treatment)
  4. Neurological: (a) chronic headache; (b) seizures, including nocturnal epilepsy; (c) psychiatric, including depression or stress disorders; (d) loss of mental alertness; (e) nightmares
  5. Other: (a) liver disease; (b) high-risk pregnancy, including gestational diabetes and hypertension; (c) eye disorders, including glaucoma and conjunctivitis
  6. Non-medical: (a) automobile accidents; (b) disruption of relationship with bed partner

Diagnoses based upon:

  1. Medical and sleep history, including conditions that might be caused or worsened by sleep apnea
  2. Physical examination, including thorough head and neck exam
  3. Exclusion of other disease, including narcolepsy, depression, and chronic fatigue syndrome
  4. Polysomnography (sleep study): Clinically significant levels of sleep apnea are defined as five or more episodes per hour of any type of apnea

Treaments include:

  1. Nasal Continuous Positive Airway Pressure (CPAP), Bi-level Positive Airway Pressure (BiPAP), or Auto-titrating Positive Airway Pressure (APAP)
  2. Weight loss
  3. Cessation of smoking
  4. Avoidance of alcohol, particularly within 4 hours of bedtime
  5. Medications, including modafinil (Provigil)
  6. Oral appliance therapy, including Mandibular Advancement Device (MAD) and Tongue Retraining Device (TRD)
  7. Orthodontic treatment, including rapid maxillary expansion or pillar palatal implant
  8. Surgery, including uvulopalatopharyngoplasty (UPPP), laser-assisted uvulopalatoplasty (LAUP), tracheostomy, temperature-controlled radiofrequency ablation tongue reduction, maxillomandibular advancement (MMA) or hyoid advancement surgery
  9. Avoidance of supine sleep position

Resources:

  1. American Sleep Apnea Association
  2. National Center on Sleep Disorders Research
  3. National Sleep Foundation
  4. American Academy of Sleep Medicine