Obstructive Sleep Apnea

What is Obstructive Sleep Apnea Syndrome?
The muscles that stiffen and open the throat tend to relax during sleep in normal children and adults. This relaxation leads to slight narrowing of the throat that does not cause any problem for most people. However, in peole with obstructive sleep apnea, this narrowing of the breathing passage is so great that breathing becomes difficuly, as if they were breathing through a floppy, wet straw. The brain senses that breathing is difficult and increases the effort to breathe. Eventually, this increased effort awakens the brain, which signals the throat muscles to become active again, which then reopens the breathing passage. With the breathing passage once more open, the effort to breathe decreases and the person goes back to sleep. This cycle of falling asleep, throat narrowing, raised effort to breathe and then arousal from sleep tends to repeat itself throughout the night, and can disturb sleep dozens to hundreds of times each night. Most of these awakenings are so brief that they are not remembered the next morning. An individual with this pattern of obstructed breathing, brief awakenings from sleep, and daytime symptoms is said to have Obstructive Sleep Apnea Syndrome.

What causes Obstructive Sleep Apnea Syndrome?
Since the throat muscles relax during sleep to some extent in everyone, many patients with sleep apnea have additional factors that contribute to their having the disorder. These include a smaller-than-normal jaw, large tongue, enlarged tonsils, or tissues that partially block the entrace to the breathing passage. Sleep apnea often occurs in overweight people, as it is thought that fatty issue in the neck affects the size or shape of the breathing passage. Sometimes several of these conditions are present in the same person.

Since obstructive sleep apnea is less frequent in younger women, a different throat structure or certain hormones may tend to protect them from having the disease, although in later years and especially after menopause the gap between the sexes narrows.

Alcohol, sleeping pills, and tranquilizers taken at bedtime also relax these muscles and can make the breathing passage more likely to close. Some people with sleep apnea may have worse sleep when they take a sleeping pill, or these pills can even be dangerous for them. If your health professional prescribes a sleeping pill for you, make sure that you tell him or her about any symptoms of obstructive sleep apnea syndrome you might have.

There is more than one pattern of abnormal breathing in obstructive sleep apnea syndrome. The breathing passage can narrow so much that no air can get through (apnea) or a bit less so that some air can pass (hypoapnea). In some patients, the narrowing may be so slight that the body can keep breathing normallly by increasing effort, but this may sill cause repeated awakenings (respiratory effort related arousals or upper airway resistance syndrome). It is thought that all of these events lead to the same consequence: repetitive disruption of sleep. Most sufferers will have a combination of the different types of abnormal breathing. In addition, the first two types of episodes may drop the level of oxygen in the blood, which can cause other symptoms.

If you have obstructive sleep apnea syndrome, you may not get enough oxygen during sleep and probably don’t sleep soundly. You may suffer from sleepiness that affects your work and/or social activities, and that could even lead to car accidents. Sleep apnea can also put you at risk for high blood pressure, heart failure, heart attack, or stroke. If you snore loudly on most nights, you should visit your health care professional. He or she may suggest evaluation at a sleep disorders center. Fortunately, sleep specialists are now able to diagnose and treat these breathing disorders during sleep. Proper treatment can prevent or reverse the potentially dangerous consequences of obstructive sleep apnea syndrome.

What are the warning signs of obstructive sleep apnea syndrome?
In adults:

  • Excessively loud snoring which can be heard rooms away
  • A pattern of snoring interrupted by pauses, then gasps, is a sign that breathing stops and restarts. Occasionally, patients will remember waking up short of breath or gasping, although usually there are many more stop-breathing episodes that are not recalled
  • Falling asleep at the wrong times, such as at work or while driving
  • Trouble concentrating, or becoming forgetful, irritable, anxious, or depressed
  • Morning headaches or nausea, frequent trips to the bathroom to urinate at night, and loss of interest in sex. Men may complain of impotence and women may have menstrual irregularities

These problems usually appear slowly and progress over many years, so that the patient may not recognize the symptoms. Sometimes the patient thinks the symptoms are just from getting older or are not serious. Family members, employers, or co-workers may be the first to recognize a pattern of excessive sleepiness and/or changes in mood or behavior, and should encourage a visit to a health care professional.

In children:

  • Being over-weight or having enlarged tonsils and/or adenoids
  • Certain birth defects that affect the size and shape of the throat, face, or chin, such as Down Syndrome
  • While asleep children with obstructive sleep apnea may snore or squeak, have difficulty breathing, or sleep fitfully
  • Daytime hyperactivity
  • Older children may seem sluggish and may perform poorly in school. Sometimes they are labeled “slow” or “lazy”
  • Some cases of sudden infant death syndrome (SIDS) may be due to sleep apnea, although how often this is true is still uncertain and research continues

Since it is not normal for a child to snore loudly every night, parents should report their child’s snoring to a health care professional.

If you seek help for a sleep problem, your healthcare professional will want to know your medical history and may talk with your bedpartner or other members of your household about your sleeping and daytime behavior. A healthcare professional who suspects obstructive sleep apnea syndrome will probably refer you to a sleep disorders center for evaluation. Experts there will ask detailed questions about your sleep and daytime symptoms, and may ask you to spend a night or two in the sleep laboratory to monitor your sleep. A night-time study will show if you have obstructive sleep apnea syndrome and will help define the best treatment.

On the night of the sleep study, you will be asked to arrive at the laboratory about two hours before your usual bedtime. Technologists will position tiny sensors at different points on your body to record your brain waves, muscle activity, leg and arm movements, heart rhythms, and other body functions during sleep. Each sleep disorders center has its own system of running tests, and several devices may be used to study the different patterns of breathing during sleep. These include a light mask that covers the nose and mouth, or small plastic prongs placed at the openings of your nose and/or mouth to measure the rate at which air enters and leaves your lungs. These tests help record whether and when breathing difficulties occur. Stretchy fabric bands may be placed around your chest and abdomen to measure the effort you make to breathe, and a device clipped to one of your earlobes or fingers would chart your oxygen level. Usually, there are no needles involved and the testing is not uncomfortable.

Your sleep may be studied during the day as well, through a series of naps offered at two-hour intervals. This study, known as the multiple sleep latency test (MSLT), measures daytime sleepiness. The test may also be used to look for other causes of sleepiness, such as brain disorder called narcolepsy.

Various types of x-rays and direct examination of your breathing passage are sometimes also used to provide a better picture of the throat in people with obstructive sleep apnea syndrome.

What happens if I am not treated for Obstructive Sleep Apnea Syndrome?
The most common complaint of people with sleep apnea is excessive sleepiness. The sleepiness is most often felt when the person is sitting still or not active, either physically or mentally. He or she may be unable to remain awake or to concentrate while reading or watching TV, even if they are interested in the material. Driving an automobile can often be difficult because of unwanted sleep, and people with obstructive sleep apnea have more automobile accidents due to dozing or inattention.

Untreated obstructive sleep apnea syndrome has other consequences for health and well-being besides sleepiness:

  • High blood pressure
  • Heart attack
  • Stroke
  • Depression

Medical science is learning that treatment ofobstructive sleep apnea can reduce or eliminate these risks. In many cases, the patient feels the benefits, such as reduced sleepiness and better mood, quickly after treatment begins.

If you are diagnosed with obstructive sleep apnea syndrome you may benefit from both general measures and specific treatments.

General Measures

  • Weight loss may help in the treatment of obstructive sleep apnea syndrome. Even small amounts of weight loss–20 lbs by a 200 lbs man would should weigh 165–may improve breathing during sleep, making sleep more restful and lessening daytime sleepiness.
  • Avoid alcohol within four hours of bedtime. Alcohol depresses breathing and makes obstructive sleep apnea syndrome episodes frequent and severe. Alcohol also appears to trigger obstructive sleep apnea syndrome in people who would otherwise merely snore.
  • Avoid sleeping pills. Sleeping pills depress breathing, relax the muscles of the throat, and generally make obstructive sleep apnea syndrome worse. Exceptions may be necessary for people who are bothered by frequent awakenings that are not due to obstructive sleep apnea syndrome episodes. Seek out a healthcare professional’s advice if you use sleeping pills and have obstructive sleep apnea syndrome.
  • Take all drugs with care. Medications prescribed for headaches, anxiety, and other common problems can affect sleep and breathing.
  • Sleep lying on one side or your stomach. Some people suffer from obstructive sleep apnea syndrome only when lying on their backs. Pillows placed behind the back or a tennis ball attached to the back of pajamas will prevents back-sleeping throughout the night.
  • Medications to relieve nasal stuffiness may be helpful in reducing snoring and may help obstructive sleep apnea syndrome slightly. The BreathRight® and Nosevent® nasal dilators and similar devices can also be used to reduce nasal obstruction. Consult your healthcare professional for advice.

Specific Treatments

Positive Airway Pressure (PAP): In this highly effective therapy, a light mask is worn over the nose during sleep. A small quiet air pump is attached to the mask with a long tube, so that air under pressure enters the nasal passages and into the throat. This gentle air pressure holds the throat open and allows normal sleep and breathing. Approximately 60 to 70% of patients who try PAP are able to continue to use it, while the rest find the mask too uncomfortable for various reasons. PAP masks come in all different sizes and shapes, since everyone’s face is a little different, and some even cover the nose and mouth.

There are also different types of PAP devices, with some made to change the pressure produced when breathing in or out (bi-level PAP) or in response to snoring and excessive narrowing of the throat. These different PAP devices were invented, in part, to help improve comfort, and may help certain patients. Common complaints of PAP treatment for obstructive sleep apnea include nasal stuffiness or congestion, dryness of the mouth or nose, mask air leaks, noise made by the PAP machine, sore dry or red eyes, skin irritation from the mask and/or straps and sensation of too much air pressure. If you experience any of these, make sure you tell your healthcare professional. In most cases, there are ways to prevent these symptoms so that you can use PAP comfortably.

Oral Appliances: Some obstructive sleep apnea patients are helped by oral appliances, devices that open the breathing passage by bringing the jaw or tongue forward or raise the soft palate. Patients with mild and moderate obstructive sleep apnea may especially benefit by using an oral appliance, while severe obstructive sleep apnea usually does not respond to this type of treatment. These devices sometimes cause excessive salivation, jaw pain, gagging, or dental problems.

Surgery: Physical problems that interfere with breathing during sleep can sometimes be corrected surgically. These problems include: enlarged tonsils or adenoids (common in children), nasal polyps or other growths, a deviated nasal septum, or certain sizes and/or shapes of the face, jaw, or soft palate.

Nasal operations alone that reduce nasal stuffiness may help snoring, but are usually not effective for obstructive sleep apnea. However, nasal surgery may be one part of an overall plan for surgical treatment of obstructive sleep apnea.

An operation known an uvulopalatopharyngoplasty (usually abbreviated UPPP) consists of removing excess tissue at the back of the throat that may be blocking the airway during sleep. Studies show that UPPP benefits up to half of patients with obstructive sleep apnea, and more research is underway to identify the patients most likely to be helped by this procedure. Some patients have reported side-effects of this surgery, such as a change in speech and the passage of liquids into the nose when swallowing. A modification of UPPP using a laser (Laser-assisted Uvulopalatoplasty, LAUP) is a less effective treatment for obstructive sleep apnea but can be effective for snoring. Somnoplasty or other techniques that shrink the tissue of the back of the throat or tongue using electrical currents, are being studied in hopes of improving the success of surgery at controlling obstructive sleep apnea. So far, these are still only thought to help snoring.

Other types of surgery have been developed to treat obstructive sleep apnea. Most of them aim to increase the size of the throat at the base of the tongue. These surgeries may involved cutting into the bones of the face and jaw in order to bring the jaw and face forward. In properly selected cases they are more effective than UPPP alone but they may also carry a greater risk of complications.

Patients with very severe, life-threatening obstructive sleep apnea syndrome may occasionally need a tracheostomy as treatment. The surgeon makes an opening in the neck and into the trachea (windpipe) and inserts a tube through which the patient breathes during the night, thus completely bypassing the breathing passage in the throat. The tube is kept closed and covered by clothing during waking hours, allowing normal speech and breathing.

Oxygen: Giving extra oxygen is not usually a good treatment for obstructive sleep apnea. Oxygen may be added to the PAP system, however, to correct for low oxygen levels due to existing lung or heart disease.

Medication: Most obstructive sleep apnea syndrome sufferers are not likely to received benefits from medication, although certain medications may help very mild cases of obstructive sleep apnea.

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