By Dr. Todd
Many factors make up the study of “disordered sleep”. Snoring & OSA (obstructive sleep apnea) are only two of them. Other possible problems include sleep deprivation, restless leg syndrome, narcolepsy, central sleep apnea, cardiac arrhythmias, cardiac ischemia, fragmented sleep, and neurological disruptions by prescription medications, alcohol, tobacco or caffeine.
OSA or the blockage of the upper airway preventing adequate ventilation is a continuum of disease from noisy breathing and snoring to hypopnea (under breathing) to mild, moderate, and severe sleep apnea.
Snoring alone is considered more of a socially disruptive problem (or “cosmetic” according to the medical insurance industry). It is disruptive to bed partners and can cause multiple arousals or fragmentation of sleep for the snorer as well as result in fatigue.
Sleep apnea becomes medically important because of the decrease in blood oxygen and subsequent brain and heart oxygen deprivation. This is felt to be a direct cause of thickening, high blood pressure & fatal heart attacks. The toll that sleep apnea may play on a person may effect their functional capacity in the workplace by decreased productivity, poor performance, and accidents on the job.
Risk factors for sleep apnea are obesity, thick short neck, large tongue for the size of the oral cavity, large tonsils, long uvula and soft palate, and nasal obstruction. Use of alcohol, sedatives, pain killers and a history of lung disease and low blood oxygen levels all worsen the effect of the OSA and the overall effects on the body.
Evaluation for and diagnosis of OSA begins with a history looking for symptoms of sleep apnea, snoring, snorting, or gasping for breath, failure to feel rested after a full night’s sleep, restless sleep, multiple night time awakenings for unknown reasons, night time perspiration or headaches upon awakening. Another likely indication of possible sleep problems is falling asleep at inappropriate times; such as during a conversation or while driving. Multiple factors are present in true sleep apnea.
A physical examination is done looking specifically at the upper respiratory tract anatomy for nasal obstruction, palatal, tonsil, base of tongue & supraglottic tissue collapse and narrowing of the airway, positioning of the larynx, hyoid, and jaw.
If the history and physical indicate possible sleep apnea, a sleep study is ordered. This test measures breathing, snoring, oxygen levels, heart function, brain waves and body movements while sleeping. From this test the measurements are reported as a number of respiratory disturbances, arousals and leg movements per hour; along with any oxygen desaturations occurring below 90%.
Based on the sleep study, patient history, and physical examination, recommendations are made for treatment options. Treatment is directed towards areas of abnormality found on physical examination, so this will differ from patient to patient. These may include CPAP (continuous positive airway pressure) or biPAP (bilateral positive airway pressure) via nasal, oral or full face mask devices and a CPAP machine. Surgery may consist of nasal (turbinate, septum, or nasal valve), throat (tonsillectomy, adenoidectomy, uvulophryngopalotoplasty, or lingual tonsillectomy) or neck (hyoid or laryngeal suspension) or jaw (maxillary or mandibular advancement or geniotuberical advancement) or tongue reduction surgical procedures individually or in combination.
Behavioral and lifestyle changes are important also. Weight loss and regular exercise, elimination of chemical depressants and stimulants, and regular sleep hours with good sleep hygiene are all important and will help towards the goal of restful and restorative sleep.