Sleep Apnea

Overview and Facts

Sleep apnea, a disruption of breathing while asleep, is a deceiving sleep disorder – 90% of people who have sleep apnea don’t know that they have it!  Although episodes of choking or gasping for air might occur hundreds of times throughout the night, you may not have any recollection of struggling for breath.

Usually it is the bed partner who first notices that the person is struggling to breathe. If left untreated, this common disorder can be life-threatening.

What happens when you have an episode of sleep apnea?

When you stop breathing during sleep due to sleep apnea, the balance of oxygen and carbon dioxide in the blood is upset. This imbalance stimulates the brain to restart the breathing process. The brain signals you to wake up so that the muscles of the tongue and throat can increase the size of the airway. Then, carbon dioxide can escape, and oxygen can enter the airway. These waking episodes are necessary to restart breathing (and to save your life), and you may not remember them, but they do disrupt your sleep and cause daytime exhaustion.

Obstructive Sleep Apnea (OSA)

OSA is the most common type of sleep apnea. It is caused by a breathing obstruction, which stops the air flow in the nose and mouth. The rest of this article discusses the causes, symptoms and treatments for OSA.

Central Sleep Apnea (CSA)

Central sleep apnea (CSA), less common than OSA, is a central nervous system disorder that occurs when the brain signal telling the body to breathe is delayed. CSA can be caused by disease or injury involving the brainstem, such as a stroke, a brain tumor, a viral brain infection, or a chronic respiratory disease. People with CSA seldom snore. However, while the causes of apnea are different in CSA and OSA, the symptoms and results are much the same – a deprivation of oxygen and poor sleep. The treatments for CSA include medications that stimulate the need to breathe and administration of oxygen.

Symptoms and Facts

Warning signs and symptoms of sleep apnea include:

• Frequent silences during sleep due to breaks in breathing (apnea)  
• Choking or gasping during sleep to get air into the lungs
• Loud snoring
• Sudden awakenings to restart breathing or waking up in a sweat
• Daytime sleepiness and feeling un-refreshed by a night’s sleep, including falling asleep at inappropriate times

Diagnosis

Sleep Centers – How sleep centers diagnose sleep disorders

If you suspect you may have sleep apnea, contact your doctor. You may need a referral from your doctor to visit a sleep center. If your physician refers you to a sleep center, the latest technology will be used to monitor you while you sleep. A sleep specialist will observe your sleep patterns, brain waves, heart rate, rapid eye movements and more using monitoring devices attached to your body. While sleeping with a bunch of wires attached to you might seem difficult, most patients find they fall asleep very easily.

The sleep specialist will analyze the results from your sleep study and design a treatment program if necessary. A sleep center can also provide you with equipment to monitor your activities (awake and asleep) at home.

Accredited Sleep Centers

The American Academy of Sleep Medicine provides a sleep center locator with information on finding a sleep center near you.

Treatment and Care

CPAP is the most widely recommended treatment for moderate to severe obstructive sleep apnea. CPAP entails wearing a mask-like device while you sleep, which provides pressurized air to prevent the airway from collapsing. Most CPAP units are the size of a tissue box and many now come with a built in humidifier for comfort.

While CPAP works very well in preventing apnea symptoms, many people find the apparatus uncomfortable and difficult to use. Luckily, recent advancements to CPAP technology have made these once cumbersome devices much lighter, quieter and much more comfortable. Recent refinements include options such as:

• “Bilevel PAP,” which switches from higher to lower air pressure during the exhalation, making breathing easier for some,
• “AutoPAP”, which uses an internal regulator that adjusts pressure rather than remaining at one fixed setting.

Different types of masks are available and can make using the device more comfortable
CPAP can cost $1000 or more – but they are usually effective when used correctly. Unfortunately, many people don’t receive proper coaching and guidance for using these breathing devices, and give up on them quickly.

The following tips may help you use CPAP more comfortably and successfully:  

• Take your time. Start by using your CPAP for short periods during the day. Use the “ramp” setting to gradually increase air pressure.
• Make small adjustments to the mask, tubing and straps to find the right fit. Soft pads are available to cover the straps and reduce skin irritation.
• Try masks of different sizes and types. A full mask might work better if you breathe through your mouth. A mask with nasal pillows should decrease nose discomfort. A mask with a chin strap will help keep your mouth closed and reduce throat irritation.
• Put your CPAP unit under the bed if the noise bothers you.
• Use a humidifier with the CPAP unit (or get a unit with a humidifier) to decrease dryness and skin irritation. Try a special face moisturizer for dry skin.
• Try a saline nasal spray or a nasal decongestant for nasal congestion.
• Keep your mask, tubing and headgear clean. Replace CPAP and humidifier filters regularly.
• Work with your doctor or sleep specialist to ensure the right fit and find the right settings on your CPAP unit.
• Find a support group or others who use CPAP to exchange tips and give and receive moral support.
• Use the CPAP consistently – every night and during every nap. This will make the adjustment easier and ensure maximum benefit.

Surgery can increase the size of your airway. The surgeon may remove tonsils, adenoids, or excess tissue at the back of the throat or inside the nose. Or, the surgeon may reconstruct the jaw to enlarge the upper airway.

Surgery may be an effective option for some, and can even provide permanent relief from symptoms. However, any surgery carries risks of surgical complications and infections, and in some rare cases, symptoms can become worse after surgery. If you have exhausted other apnea treatment options, you may want to discuss surgical options with your doctor or sleep specialist.

Living Your Life

The AWAKE support group program 

Q: What is A.W.A.K.E.?
The ASAA organizes a network of support groups known as A.W.A.K.E. (Alert, Well, And Keeping Energetic), composed of hundreds of mutual-help support groups in nearly all 50 states for people affected by sleep apnea.
Click here for more information

The ASAA  A.W.A.K.E. Network is composed of hundreds of mutual-help support groups in nearly all 50 states for people affected by sleep apnea. The Network, founded in 1988, is an integral part of the American Sleep Apnea Association (ASAA) and since 1990, the two have been partners in assisting patients, their families, and the healthcare community concerned with sleep apnea. Committed to the belief that the ASAA A.W.A.K.E. Network must be patient-centered, local A.W.A.K.E. members plan and implement each group’s activities so that they meet the needs of each individual group. Meetings, led by the A.W.A.K.E. coordinator, are held regularly and guest speakers are often invited to address the group. Topics may include advice on complying with CPAP therapy, legal issues affecting those with sleep apnea, weight loss, and new research findings.

FAQs

What is Obstructive Sleep Apnea?

Obstructive sleep apnea is a condition that exists, when the airway partially or completely closes during sleep.  This closing of the airway causes reductions in blood oxygen levels, severe sleep fragmentation, and excessive daytime sleepiness. 

The potential consequences of untreated obstructive sleep apnea include hypertension, coronary heart disease, myocardial infarction, pulmonary hypertension, congestive heart failure, stroke, neuropsychiatric problems, cognitive impairment, sexual dysfunction and injuries due to accidents.

What is the connection between Obstructive Sleep Apnea and Cardiac Disease?

Obstructive Sleep Apnea, a potentially deadly phantom, is the frequent stoppage of breathing caused by relaxed tissues in the throat during sleep.  Snoring is caused by vibrations of the relaxed throat tissues and is often the precursor or companion of sleep apnea.

People with Coronary Artery Disease whose blood oxygen level is lowered by sleep-disordered breathing may be at risk of ventricular arrhythmias and nocturnal sudden death.  CPAP treatment may reduce this risk.  Sleep disordered breathing, including apnea, may cause coronary artery disease and hypertension.

Some of the research suggests that sleep apnea may indeed be a cause of heart disease.

• Congestive Heart Failure affects 5 million Americans, about 10% of the adult population.
• 10% of men and 5% of women are estimated to have sleep apnea.
• In obstructive sleep apnea, often marked by snoring, the right side of the heart may suffer damage because it has to pump harder to support the extra effort of the lungs trying to overcome the obstruction to the airway. 
• Several obese patients with both obstructive sleep apnea and heart failure were treated with CPAP, the usual treatment for sleep apnea.  Marked improvement was seen with increased energy and lessened fatigue, lower blood pressure, and a more positive outlook as a result of treatment.
• Central apneas may cause high blood pressure, surges of adrenaline, and irregular heartbeats.  Central apnea occurs without snoring and is not caused by airway obstruction; rather it is caused by the failure of the brain to signal for a breath.

How can I find out if I have Obstructive Sleep Apnea?

Diagnosis is made on the basis of the clinical picture, patient, bed partner and/or family member reports snoring and an overnight polysomnogram.

What is a polysomnogram?

A polysomnogram is an overnight recording in a sleep lab of all of your sleep activities.  These activities include brain waves, muscle movements, eye movements, breathing through your mouth and nose, snoring, heart rate and pattern and leg movements.

Information is gathered using small disc called electrodes, belts that are placed around your chest and abdomen, a sensor that is placed on your finger and electrodes placed on your chest and a few on your face.

None of these devices hurt they all are designed to be as comfortable as possible.   The rooms at the sleep center are all private and decorated somewhat like a standard home or hotel bedroom.  Each room has a television and a bathroom.

If I have Obstructive Sleep Apnea what are my treatment options?

• CPAP Continuous Positive Airway Pressure
  The “Gold standard” treatment accepted by physicians who specialize in sleep medicine, is positive airway pressure.  This is so because it is the most effective when tolerated.  The CPAP consists of an air compressor, a tube, and a mask that covers the nose.  The compressor blow air into the airway this prevents the airway from collapsing when you are sleeping. This form of treatment can often provide immediate resolution of the OSA.
• Intra-oral Fixation Device – Also known as an oral appliance
  The Intra-oral Fixation devise is designed to gently move the lower mandible forward.  Studies have shown positive results in at least a subset of patients. This device is custom made by a dentist who specializes in the treatment of sleep apnea.  Once fitted the device must be adjusted to eliminate as many apnea events as possible.
• Surgery
  • Tonsillectomy – In children the problem is most often large tonsils that meet in the mid-line and block the airway.  If this is the cause a tonsillectomy will most likely resolve the OSA.
  • Repositioning the jaw – when the problem is caused by a jaw that is set back too far. (the long term effect of this procedure is not known)
  • LAUP Surgery – removal or shortening of the uvula, removal of tonsils, and sometimes shortening of the soft palate.  This procedure may eliminate snoring without preventing OSA.
  • Tracheostomy – the creation of an opening in the lower part of the throat, below where the airway collapses.  This opening is plugged during the day so that normal speech is possible, and open during the night so that normal breathing is possible.
  • Straightening of the septum, Turbinectomy and/or UPPP – These procedures may diminish the number of OSA events but may not resolve the condition completely.   These procedures have been shown to be effective in the resolution of primary snoring. 

My doctor told me to avoid exacerbating factors.  What are these?

Exacerbating factors are events or activities that contribute to the severity of your sleep disordered breathing. Some of these events or activities are listed below.

• Weight:
  Excessive weight brought about by sedentary life style, too many rich foods, or by medically related situations such as retention of weight after delivering a child or thyroid problems are probably the leading factors contributing to Obstructive Sleep Apnea.  In a large percentage of patients weight loss, aided by exercise if medical conditions don’t contraindicate doing exercise, down to ideal weight has reversed the process.
• Smoking:
  Cigarette smoking causes swelling of the mucous membranes in the nose, swelling of tissue in the back of the throat, and blockage of small vessels in the lungs.
• Alcohol:
  Alcohol causes too great of a relaxation of the airway during sleep.
• Organization of sleep and wakefulness across the week:
  There is two periods of sleep which, given the right circumstances, are especially vulnerable to the development of sleep-disordered breathing.  These are Stage 1 sleep, which should only occur when a person is first falling asleep but which can occur many times during the night is sleep poor; and REM sleep, which is the time when dreams most frequently occur.
• If a person, for instance, goes to bed at 10pm and awakens at 5am each workday, but then waits until several hours later to go to sleep and wake up on non-work days, both stage 1 and REM behave oddly.  This problem with REM and stage 1 is also true if on some days of the week a person just does not get enough sleep, and then on other days of the week they try to make up for it by sleeping longer.

  To prevent this try to go to bed and get up at the same time every day of the week.

Other factor affecting quality of nighttime sleep that can lead to apnea:

1. a disruptive bed partner
2. a baby or child waking you up
3. daytime stress or aggravation
4. sleeping during the day
5. excessive use of caffeinated products
6. room too hot or cold
7. ambient light
8. use of medications that effect sleep
9. Medical Problems:

Anything that leads to the blockage of the nose, the throat, or the lung potentially play a role in the development of sleep disordered breathing such as:

1. allergies to airborne particles such as pet dander
2. dryness in the nose because of a wood burning stove or other heat in your home
3. deviated septum
4. large tonsils
5. large adenoids
6. excessive amounts of fatty tissue
7. enlargement of some of the complex tissues at the back of the throat
8. lung problems related to childhood asthma through emphysema
9. can be a symptom that results from hypothyroidism
10. can be a symptom that results from diabetes

Assistance and Comfort

Sleep Apnea – Medications

Doctors generally do not suggest medicines for the treatment of obstructive sleep apnea (OSA). But medicine can help reduce daytime sleepiness when continuous positive airway pressure (CPAP) is reducing apneas-the number of times you stop breathing at night-but daytime sleepiness continues.^{13, 14}

Medication Choices

The U.S. Food and Drug Administration (FDA) has approved wakefulness-promoting medicines for people who are using CPAP but still have excessive daytime sleepiness:

Wakefulness-Promoting Medicines

What To Think About

People with sleep apnea who take wakefulness-promoting medicines should continue using CPAP to treat sleep apnea.

Resources

http://helpguide.org/life/sleep_apnea.htm

http://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea/

http://www.talkaboutsleep.com/sleep-basics/viewasleepstudy.htm

http://www.sleepeducation.com/essentials-in-sleep/cpap

http://www.sleepapnea.org/resources.html

Videos

https://www.sleepapnea.com/resources/videos/

http://www.mayoclinic.org/diseases-conditions/sleep-apnea/multimedia/obstructive-sleep-apnea/vid-20084717

http://www.mayoclinic.org/diseases-conditions/sleep-apnea/multimedia/cpap/vid-20084718