With more than 18 million Americans suffering from it, sleep apnea has become a serious disorder, according to the National Sleep Foundation. Dr. Rosalind Cartwright states that couples struggling with sleep apnea have a high rate of divorce, and it is really not surprising; with snoring, daytime somnolence, decreased efficiency at work, and poor quality of life, sleep apnea can take a toll on interpersonal relationships. In this article, we will review what sleep apnea actually is, what the pathology behind the disease is, what are the types of sleep apneas, some controversies about the treatment, and some real-life stories. If you snore, or someone you know snores, then they could be suffering from sleep apnea. Read on to find out about the right way to deal with it.
What Is Sleep Apnea?
Sleep apnea is recognized as a cessation of breathing during sleep (for at least 10 seconds), secondary to upper airway collapse. This collapse of the airway can be partial, leading to snoring, or complete, leading to more serious apnea episodes.
Disrupted sleep episodes which range from a few times a night to hundreds of times, also attributes to daytime symptoms of sleep apnea like fatigue, poor concentration, and somnolence as the brain jump starts the body to breathe again. The collapse of the airway is rarely caused by a single factor; more commonly, there are multiple causes. Studying about the pathophysiology of the disease can help eliminate these causative factors which have an additive effect on the disease, and thus help combat sleep apnea.
Sleep apnea has garnered a lot of attention lately, since it has been found to be a risk factor for multiple high mortality diseases including systemic hypertension, stroke, and heart diseases. Until 1980s, this clinical correlate was overlooked by the medical community.
However, since then more and more people are treating it as a serious disorder with long term ramifications. The prevalence of sleep apnea is somewhat similar in developed as well as developing countries, with approximately 3-7% of adult males and 2-5% of women of general population involved, not only is the disease slightly more prevalent in obese people, but the overall disease burden is also underestimated due to the fact that even mild respiratory symptoms can have significant clinical impact.
Types Of Sleep Apnea:
The type of sleep apnea a person has depends on what type of airway collapse he is experiencing, and whether that collapse is complete or partial.
Sleep apnea is mainly of three types: obstructive, central and mixed. Let us discuss each type of sleep apnea individually:
Obstructive Sleep Apnea:
As the name implies, in this type of apnea, there is an obstruction to the flow of air. This obstruction can be caused by soft palate, tongue, or throat. When the airway collapses, it causes a myriad of events commencing with a drop in the oxygen level i.e. hypoxemia, with a simultaneous increase in the level of carbon dioxide in the blood that should have been exhaled. This causes sleep fragmentation and marked changes in the intrathoracic pressure i.e. pressure inside the chest increases, since the chest is moving trying to expel the air against a closed outlet.
Eventually the dropping oxygen in the body forces the brain to wake the body up in order to breathe; this is when the patient gasps and wakes up with a start. If this occurs more than fifteen times per hour, the diagnosis of sleep apnea can be made. Severity of the obstruction is linked to disease severity and the consequent risk for cardiovascular diseases.
Patients of obstructive sleep apnea can also have mild anatomical irregularities such as those associated with the nose i.e. deviated septum or swollen nasal passage, narrow throat and the falling of tongue in the throat; even a floppy uvula can cause an obstruction in the airflow and thus sleep apnea.
Central Sleep Apnea:
It is the least common type of apnea. It results due to problems in the nervous system; either the brain or the central nervous system suffers from a malfunction. As the person suffering from central sleep apnea falls asleep, the center in the brain that controls breathing stops working. Hence, the chest muscles do not receive signal from the brain to move. Consequently, the person has difficulty staying asleep as apnea promotes a disturbed sleep routine. Due to this reason apnea is often confused with insomnia. Many premature infants suffer from sleep apnea, however, many times this condition improves over time.
People with some heart conditions, cerebrovascular diseases like MS and congenital diseases are more susceptible to central nervous sleep apnea. Other conditions that trigger the attack include reaction to some medication, high altitude etc. An extension of this condition is sleep onset anxiety, in which the person is afraid to fall asleep. The anxiety results in the person to breath rapidly and deeply. As a result, the low carbon dioxide levels fail to stimulate the breathing reflex. Thus, the person is jolted awake. At times, the obstructed airway causes obstructive apnea, but it eventually results in central apnea. Although, treating with continuous positive airway pressure (CPAP) can alleviate the symptoms. The persistence of sleep apnea symptoms lead to enlargement of the heart, heart failure, respiratory and lung problems. The apnea can be diagnosed with the aid of analysis of medical and genetic history, and polysomnography-sleep study. The seriousness of the condition is directly proportional to the number of attacks in a night. Using such nuggets of information, the sleep specialists are able to prescribe a proper regimen for their patients.
This condition is an amalgam of both, obstructive and central apnea. Research has shown that in most cases, the symptoms of both condition are observed, however, one might be predominant, leading to mixed apnea. Another popular opinion is that when in case of obstructive apnea, if you are jolted awake and face subsequent wheezing, the carbon dioxide level falls and the symptoms of central apnea are observed, hence the diagnosis is that of mixed apnea. For patients suffering from mixed apnea, first the obstructive apnea is treated, and as the central apnea is caused due to the onset of obstructive apnea, its symptoms too abate alongside.
Symptoms Of Sleep Apnea
Since most of the times the symptoms for obstructive and central apnea are similar, it is rather difficult to diagnose the type of disease. A complete workup of sleep apnea starts with a sleep history, that is obtained either as routine workup, as evaluation for sleep apnea symptoms or in patient at risk of developing sleep apnea. The high-risk patients are people with obesity, cardiovascular disease like CCF (congestive cardiac failure), stroke, pulmonary hypertension, type 2 diabetes, atrial fibrillation, nocturnal dysrhythmias and high-risk driving population like truck drivers. The symptoms of sleep apnea include:
Choking or gasping at night
Dry mouth or throat upon waking
Tiredness on waking
The diagnosis of sleep apnea is often a challenge for the physician because the patient often is unaware that he has a sleep disorder. It is therefore, difficult for the patient to describe his symptoms. The table below shows some of the symptoms that help in the evaluation of a patient with sleep apnea:
A complete physical examination of the patient, with neurological, respiratory and cardiovascular evaluation is also needed, as most high risk patients suffer from diseases of the aforementioned systems. Other high risk cases include people with upper airway narrowing and obesity.
If the physician deems you a high-risk patient, then certain investigations can help establish the diagnosis. These include: polysomnography (PSG) or portable monitors for home testing. The latter is recommended in cases where in-laboratory PSG is not possible due to mobility issues, critical illness or safety issues. PSG can also be used to evaluate response to treatment.
Screening For Sleep Apnea
Having talked about the consequences of sleep apnea, a question of screening for the disease may arise in the mind of the reader. Since we screen for many other diseases, can’t we screen for something like sleep apnea in a high-risk patient as well?
The answer to that query has been provided by the US Preventive Services Task Force. The draft recommendation of the task force states that there is insufficient evidence right now, to support or oppose screening investigations for sleep apnea; people who are at risk or have concerns about sleep apnea should consult their clinicians, and the clinicians can order investigations if necessary to make the diagnosis. It is entirely possible that this recommendation may change in the future, however, as of yet, screening for sleep apnea has been ruled unnecessary in asymptomatic patients.
Do You Snore Deliberately?
Whilst snoring is a genuine manifestation of sleep apnea- a serious medical condition- many a times people use it as an excuse to present to their irritated spouses and goad them into investing in industrial strength ear plugs. However, in order that apnea does not get undue blame, research has shown that snoring alone doesn’t necessarily indicate apnea. The most authentic way of diagnosing apnea is when the patient is jolted awake at night alongside wheezing, i.e., no choking during sleep, no apnea, no excused snoring.
Sleep Apnea And The Brain
Being a multi system disorder, sleep apnea also has an adverse effect on the brain as well. However, the interplay between brain and sleep apnea are succinctly put, very complicated. The complex way in which sleep apnea underscores the subjective and objective emotional and cognitive health of the patient needs further study and evaluation in order to ascertain its role in the long term.
Prevalence of sleep apnea has increased in the past couple decades by almost 15-55%, and is still the most under diagnosed disease. Because of its association with obesity and cardiovascular disorders, sleep apnea has a great impact on public health in terms of high socio-economic burden as well as being a potentially modifiable risk factor for neurocognitive disorders—like dementia. Let us review some of the syndromic constellation and sequelae of this disease on the brain.
Changes Seen In The Brain
The changes in the brain begin as a consequence of sleep fragmentation, changes in the blood flow to the brain, decrease in the oxygen levels in the brain and a simultaneous rise in the carbon dioxide level. Such changes disturb the chemical environment of the brain, which is followed by some neural adaptive and maladaptive changes which eventually take a toll on the cognitive as well as the emotional health of the patient. These effects, however, are dependent on the idiosyncratic susceptibility and can vary from person to person. In some, the effect of sleep apnea can be severe but largely reversible, in others, the symptoms can be mild yet irreversible.
Sleep fragmentation can adversely affect the emotional health of an individual; it also causes daytime somnolence, irritability, decrease in productivity, seizure aggravation, cognitive decline, instability in interpersonal relationships, vehicular accidents. Data from recent studies and investigations so far has determined deficits in vigilance and attention, delayed memory disturbances, deficit in visuospatial and constructional abilities, and even psychomotor slowing. Language deficit is seen mostly in the younger patient group in whom neurodevelopment is an ongoing process. Because of the complexity of the disease process, it is still too early to find the exact nature between cognitive dysfunction and disease severity. Factors like hypertension, duration of disease, dysfunction on metabolic level, genetic susceptibility, inflammatory processes going on in the body etc. come into play.
Pathology Behind The Cognitive Disturbances
The basic pathology behind sleep apnea in simple terms is neuronal damage due to alteration in molecular signaling pathway. It seems that when one is getting insufficient sleep, there is decreased maintenance of the neurons in the brain. There is decreased neuronal excitability (the ability of the neuron to fire an impulse), decrease myelination (damage to the protective myelin sheath on the neurons) as well as misfolding of proteins in the cells. This puts the cells in the brain under constant oxidative stress which is damaging to them through the production of reactive oxygen species (ROS) and reactive nitrogen species, which are like tiny bombs for the cells.
Because of the changes on microscopic level, multiple interdependent factors like nutritional status, microenvironment antioxidant activity (combats ROS) and genetic makeup determine the extent of cognitive damage that sleep apnea renders. Oxygen deprivation also results in inflammatory changes in the brain as well as microarchitectural changes. Reactive gliosis, formation of new blood vessels, various synaptic changes and remodeling takes place in the brain as a sort of defense mechanism that is responsible for the cognitive symptoms. Sleep fragmentation and decrease in oxygen level in the body is also associated with an increase in the level of misfolded tau proteins as well as beta amyloid concentration in the cerebrospinal fluid (the fluid that bathes the brain and spinal cord). It should be noted that these tau proteins and amyloid deposition is the pathological cause behind Alzheimer’s disease as well, suggesting that sleep apnea patients show a higher incidence of cognitive decline and memory impairment.
Sleep Apnea And Emotional Health
There is an uncommonly high prevalence of emotional instability, depression and other mental health issues in sleep apnea patients. Since sleep is an important determinant of brain’s response to negative emotional events, a lack of it is definitely going to have an impact on the outcome of disease. In fact, sleep disturbance caused by sleep apnea, is greatly connected to major depressive disorder as well as post-traumatic stress disorder, even though the exact mechanism behind the disease process is still unclear. PTSD is related to insufficient restive sleep, while depression is associated with excessive restive sleep, which occurs as a rebound to sleep deprivation. In both scenarios, sleep apnea has an adverse impact on the disease, which starts a vicious circle of chronic anxiety and dysfunctional emotional memory.
Treatment And Its Effect On Brain
The effect of sleep apnea on the brain is further proven by the benefit that these patients received from a three month study of treatment with CPAP; these patients showed vast improvement in cognitive function overall. However, the damage to the brain that hypoxia (decrease in oxygen levels in the body) renders is not always reversible. For this reason, initiation of prolonged treatment might be needed to reverse the pathological process. Moreover, further study is needed to determine the stage at which treatment should begin so as to gain maximum benefit of therapy. Even in children, treatment showed an improvement in performance IQ and overall neurocognition.
Hereditary Association Of Sleep Apnea
It seems that genetic linkage has spread it wings far across the mundane world of eye color, hair color, and physical characteristics, to the extraordinary realm of sleep and sleep disorders as well. A review published by the National Institute of Health, takes into evidence the growing literature for the past three years that shows a significant hereditary association of sleep apnea. There can be multiple genetic loci found to be responsible for the disease. Factors such as obesity and increased body mass index, itself has a strong genetic determinant. Furthermore, linkage study of African American families, as well as twin study of daytime somnolence and snoring, have provided more evidence in favor of genetic component of sleep apnea.
Risks Associated With Sleep Apnea
As mentioned before, people suffering from sleep apnea are at high risk of certain cardiovascular, and cerebrovascular disorders. Let us have a look at some of these disorders.
1.Higher risk of myocardial infarction
Studies have shown that an association exists between worsening sleep apnea and heart condition. Heart attack or myocardial infarction, can occur in patients due to lack of oxygen supply to the body, and this is especially dangerous in situations of a preexisting cardiac condition. Moreover, it is not unheard of sleep apnea to react with heart medication, and worsen the oxygen supply situation.
2.Abnormal heart rhythms
As if heart attack was not enough, sleep apnea can also cause an arrhythmia, a disease in which the intrinsic electrical conduction system of the heart is disturbed, making the heart an inefficient pumping machine. It has been found that about half of atrial fibrillation (an abnormal rhythm of the atria of the heart) patients can benefit from treating their sleep apnea, proving that sleep apnea does infact have an association with hearth rhythms.
3.Risk of congestive heart failure
The heart woes of those suffering from sleep apnea are far from over. In patients with sleep apnea, the heart muscle is reduced to an inefficient pumping machine, putting the patient at risk for congestive heart failure.
4.Increased risk of stroke
In 2012, a panel of scientists at Experimental Biology Conference, discussing a study performed on mice, found that there is a decrease of almost 22% in the cerebral blood flow in mice induced with sleep apnea.
This reduction of cerebral blood flow is also a consequence of long standing sleep apnea in humans, which ultimately increases their risk of stroke and damage to the vessel wall.
5.Increased risk of depression
Sleep apnea patients suffer from tiredness, poor concentration, irritability and lack of sleep all the time. Over time, these symptoms combine to form an avalanche of stress and depression as productivity and energy levels decrease. There is a behavioral change in the patient rendering him incapable of performing as well as others, and an inability to relate to the peers. There is also a risk of having poor social life and an inability to have a good relationship with the partner. Eventually the stress level of the patient increases, allowing him to slip easily into depression.
6.Increase risk of accidents
Lastly, the lack of sleep and poor concentration make sleep apnea patient much more likely to succumb to fatigue or sleepiness while driving or operating heavy machinery. In either scenario, there is a high risk of getting into a fatal accident, injuring not only the patient but other innocent bystanders as well.
Diagnosis Of Sleep Apnea
The American Academy of Sleep Medicine (AASM)’s task force on adult obstructive sleep apnea, has constructed a clinical guideline for the evaluation of sleep apnea patients. It is recommended that questions regarding sleep apnea should be asked in routine physical examination; in case there is a suspicion of sleep apnea, a thorough sleep evaluation must be done, including history and physical exam, relevant investigations like sleep studies, and patient education. It must be noted that AASM recommends to classify the severity of sleep apnea before initiating treatment so that it is clear to the physician at the beginning of therapy if a patient is at risk of complications, as well as to establish how successful the treatment is.
Sleep apnea is more common in people who suffer from– due to no obvious reason- hypersomnia i.e. daytime drowsiness coupled with fatigue, loud snoring and anxiety. In his statement, the president of American College of Physicians, David Fleming, has emphasized on the importance of diagnosing sleep apnea as it is a ‘serious condition’. Patients who have unexplained daytime sleepiness are then prescribed a sleep study in order to ascertain whether there is a sleep disorder or not. Even though reliable investigation is present to diagnose the patients, clinical examination is still important; having a good clinical exam can help ‘select’ the patients for definitive testing. Sleep apnea is most accurately diagnosed by sleep studies; previously doctors used questionnaires to help make the diagnosis of sleep apnea, but this method fell short of making an accurate diagnosis or even help calculate the severity of the disease. There are many types of sleep studies; for sleep apnea, the two most accurate tests are the polysomnography and the home-based portable monitor.
Polysomnography, is conducted mostly in sleep laboratories, and it is important to carry out the test according to established standards, otherwise there is a chance of misdiagnosis. For instance, if the patient sleeps poorly, he may not experience any apnea; even a partial night’s sleep can underestimate the severity since deep sleep (in which apnea occurs) is achieved in the second half of the night.
Even though the name of this test is scary, the test is basically painless. The great thing about this test is that it distinguishes between different sleep disorders and even estimate disease severity. In the sleep lab, sensors are attached to the patient’s face, head, thorax, a finger and limbs whilst he/she sleep. These electrodes help record the patient’s sleep and lead to a computer which helps to translate this electrical signal into a graph-like form. A full night’s sleep is recorded and statistics like blood pressure, airflow, blood oxygen levels are continuously monitored and saved for the doctor to analyze. This data is used by the specialists, and the polysomnography compared to a normal recording to help diagnose apnea and its severity and prescribe regimen to remedy the condition.
However, since sleep laboratories are not very common, and those that exist are very expensive, home based portable monitors come into play. The American College of Physicians (ACP) recommends the latter for patients who do not have access to a sleep lab; moreover, according to ACP president, Fleming, the diagnosis of sleep apnea is in line with the High Value, Cost-Conscious Care Initiative of the ACP, thus proving that portable monitors is a cost effective method of diagnosis. Much like the polysomnography, these portable monitors also track the heart rate alongside airflow, oxygen levels in blood and movement of the chest (which shows if the patient is making conscious efforts to breathe). These stats then help the doctor in diagnosing a case of apnea.
It is also noteworthy that these tests are generally also prescribed to the patients who are more susceptible to sleep apnea. This includes patients suffering from genetic disorders, type II diabetes, hypertension, respiratory disorders and cardiovascular diseases.
The first course of action in diagnosis is making a chart of the number of times the symptoms of apnea have appeared; the number of times that sleep was interrupted in the night, the naps taken during the day to counter the fatigue thus caused, the loudness of snoring and number of gasps for breath (for which the help of another person might be required) and any family history of apnea. This data is essential to make diagnosis.
This is generally followed by a physical exam to ascertain if there is any anatomical indicator(s) of apnea. Patients with sleep apnea tend to have enlarged tissues around mouth, throat and nose. For children suffering from sleep apnea, enlarged tonsils are another indicator for the presence of disease. Also, for children, physical and medical history is sufficient for the diagnosis. Adults, on the other hand, need further testing i.e. sleep studies for a concrete diagnosis. The sleep studies basically determine the quality of sleep and how the body copes with the sleeping problems. These are much more conclusive and comprehensive and greatly enable the doctor in identifying the case of sleep apnea.
Mostly, the doctors rely on CPAP (continuous positive airway pressure) as the treatment of sleep apnea. CPAP uses slight air pressure to keep the airways open in order that the breathing isn’t halted when asleep and there is no subsequent gasping and disturbed sleep. In order to determine the presence and severity of apnea, a split-night sleep regimen is used, in which a portion of night is spent using CPAP, and some without it. When a case of apnea is established, the pressures of CPAP are altered in order to find the optimum pressure levels for the respective patient.
Treatment Of Sleep Apnea
The treatment of sleep apnea greatly rests on the causative agents. Broadly speaking, apnea can be treated with lifestyle modifications, use of breathing devices, and in severe cases, surgery might be recommended. Medicines, however, do not come into play. People suffering from sleep apnea are also at risk of having several other complications, for example, high blood pressure, early treatment diminishes the probability of having these secondary diseases like stroke, diabetes or CHD/heart diseases. The method of treatment is linked to the severity of apnea; those having mild form of apnea can be cured by lifestyle modifications and/or breathing devices, while those suffering from serious form of apnea might need surgery as well. If, however, the daytime sleepiness is not still abated even after the treatment, a more robust approach might be taken up by the doctor.
Obesity is one of the important factors that contribute towards sleep apnea. Taking measures to remedy it would undoubtedly have favorable impact toward alleviating apnea. Since those suffering from Type II diabetes, high blood pressure are cardiovascular diseases are more susceptible to have apnea, thus not letting their symptoms aggravate and keeping within optimum parameters would have profound impact in treating apnea. And so adequate measures should be taken in order to cure apnea and promote general well-being. For those patients who are obese, losing weight is imperative for fighting apnea.
Bariatric Surgery And Sleep Apnea:
Bariatric surgery is another option for the morbidly obese people; a recent research has found that bariatric surgery is associated with marked decrease in weight i.e. sustained for four years. In long term, this could certainly be of much benefit to the patient, in that it can help reduce the risk of developing cardiovascular disorders like hypertension, angina, heart attack, type II diabetes and sleep apnea. Thus, getting bariatric surgery could mean that the incidence potentially high socio-economically burdening diseases like hypertension, diabetes and MI would reduce greatly. According to the study, these people were 70 percent less likely to get a heart attack.
Another important step that should be adopted includes quitting smoking; respiratory health is very important, which isn’t possible with the habit of smoking. Alcohol and similar agents that induce stupor should be avoided as they hamper the breathing process during night by making it difficult to keep the throat open. Use of nasal sprays and similar medication can also be beneficial, as it keeps the nasal passageway open in order to promote airflow. Moreover, to keep the throat open at night, sleeping on the side rather than the back, and taking adequate measures to prevent rolling on the back. These precautionary measures can by supplemented with mouth pieces in case of mild sleep apnea. A special customized mouth piece can be made by a dentist/orthodontist. The piece helps adjust the jaws and the tongue in order to ensure that the airway remains open when asleep. The mouthpiece also helps to prevent snoring.
Surgery is another option to cure sleep apnea. It is basically done to broaden the air passageway that might be blocked due to the presence of extra tissue or due to the blockage caused by tonsils. Surgery works in multitude of ways; either the tissue is removed, shrunk or hardened, or the lower jaw is reset. The procedures that involve shrinking or hardening of the tissue present in the throat or the mouth are fairly simple; the doctor may use injections to shrink the tissue, whilst for hardening the tissue, a cut is made in the tissue to place some plastic in it. However, the surgery to remove the excess tissue needs anesthesia and is a less simple than the previously mentioned surgeries. In the aftermath of the surgery, pain persists in the throat for one or two weeks. Likewise, if tonsils are the culprit in blocking the airway, surgery is performed to remove them and clear the pathway for air in order to cure apnea. Tonsils more commonly pose a problem for in case of children. It is up to the doctor to either perform the surgery immediately or wait for the tissue to shrink on its own (which they do as children grow).
As mentioned previously, the most commonly prescribed remedy for apnea is CPAP (continuous positive airway pressure). It works by manipulating the air pressure; a mask is placed over the mouth or nose or both, and is connected to a machine that blows air into the airways. The pressure thus formed helps to keep the airway open so that the symptoms of apnea are not observed. The pressure of the air supplied is determined during the sleep testing, a technician adjusts the CPAP machine according to that pressure. However, the need to change pressure may arise. Also noteworthy is the fact that CPAP machine along with reducing snoring also reduces the number of nightly awakenings, the drops in oxygen levels in the blood and improves general sleep parameters. Adherence to treatment and constant use of the device is necessary to prevent recurrences.
Whilst the machine is godsend for patients with sleep apnea, it does have side effects. These range from dry/stuffy nose to irritation on the skin around the mouth, nose etc. to headaches. In case of ill fitted mouthpiece, many experience general discomfort along with bloating in the stomach. In such instances, it is better to visit the doctor- who can recommend nasal sprays and such to cure the dry nose or some ointment to prevent skin irritation-and a CPAP specialist- who can make a mask that is perfect fitting, or give instead a machine that adds moisture to the air to prevent dryness. There are multiple types and models of the CPAP machine and hence the patient has the option to choose a different machine if one doesn’t suit him/her. This adds versatility to the regimen, and prevents it from being completely abandoned if immediately the perfect fit- in terms of CPAP machine- is not found.
CPAP therapy is mostly a lifelong therapy; many companies have developed comfortable and durable CPAP machines in the last few years for the maximum comfort of the patient.
Unlike the CPAP machine, which makes it difficult for the patient to sometimes exhale against a positive pressure, a Bilevel PAP machine operates by providing two levels of pressure, a higher one during inhalation to keep the airway patent, and a lower one during exhalation so that the patient has no trouble sleeping. Even though it is more expensive that the PAP machine, it provides greater benefit to the patient in terms of adherence, and is better tolerated overall. It is also the preferred device in Chronic Obstructive Pulmonary Disease (COPD) patients.
Auto-titrating CPAP (Auto-CPAP) adjusts the pressure in accordance with what has been set by the operator and varies them to accommodate the postural change, stage of sleep and/or even nasal congestion.
These include mandibular advanced splints or MAS that fix in such a way that they put the jaw in a forward position so that the airway remains open. This device has mild side effects like dry mouth and excessive salivation, which can be dealt with easily. For mild to moderate sleep apnea, MAS is generally better tolerated and has better outcome than CPAP. Usually the patient feels more comfortable if the device is custom-made and thus fits him better.
Education Of The Patient:
This is perhaps the most important treatment protocol. Educating the patient about his disease can, not only ensure that there are lesser complications, but can also improve patient compliance and adherence to treatment. Educating the patient about things that makes apnea worse like smoking, weight gain, alcohol etc. can help him avoid them and thus ensure that his disease does not worsen.
CPAP Controversy And Sleep Apnea:
Even though we know that sleep apnea is a multi-system disorder, with cardiovascular system being commonly involved, several researches have come forward that debate whether CPAP has been successful in warding off these disorders or not. Research has shown that CPAP and usual care in sleep apnea patient were not successful in lowering the risk of serious cardiovascular events as opposed to people receiving usual care alone. Even though CPAP treatment helped reduce daytime somnolence, mood, general efficiency and quality of life, it had no impact in warding off the more serious consequences of sleep apnea. Multiple randomized trials were conducted to find what role CPAP could play in the prevention of cardiovascular events, but use of the latter, showed no difference in the overall cardiovascular end points over the years of follow up. However, better outcomes in adjusted analyses were seen in patient who were adherent to CPAP.
The limitation of trials like these could be the short mean duration of CPAP use, which in this case was 3.3 hours per night. Another issue that one might raise could be the timing of CPAP therapy, whether or not it is more effective in the second half of the night, as compared to early in the night.
Whatever the results at present may be, a larger trial needs to be held to find out the exact relation between cardiovascular events and sleep apnea. At the same time, for clinical practice, it is better than a trial of CPAP should be offered to sleep apnea patients who are symptomatic to improve their general wellbeing and quality of life. However, CPAP should not be offered in asymptomatic patient with an established cardiovascular disease solely to avoid future events. Ongoing trials can shed further light on this issue.
Central Sleep Apnea Treatment:
Hypoglossal nerve stimulation studies have found it to be a good treatment option for central sleep apnea. This nerve innervates the dilator muscles of the airway that can help keep the airway open. The electrical stimulation of this nerve can help promote patency of the airway as proven by an open-label clinical trial. Even though more research needs to be done to establish this as the treatment of choice, to date the US Food and Drug Administration has approved its use for central sleep apnea patients.
Sleep Apnea In Children
Most children suffer from symptoms of sleep apnea due to enlarged tonsils and adenoids (glands behind throat). Even though most symptoms occur secondary to severe obstruction, there are instances when even mild symptoms have proved problematic. Neuromuscular disorder, and craniofacial abnormalities in children, are other causes of airway obstruction and sleep apnea. According to the National Sleep Foundation, children with behavioral problems and learning issues are likely to have undiagnosed sleep apnea. Also, the American College of Chest Physicians has published a study, finding the probability that children with sleep apnea are twice as likely to have learning problems.
Children with sleep apnea usually exhibit the symptoms of fatigue, morning headaches, agitated behavior, nasal voice, failure to thrive, obesity, even show signs of attention deficit hyperactivity disorder (ADHD) and may suffer from metabolic or hormonal disorders.
At night they may:
-gasp, snort and stop breathing
-have disruptive sleep
-excessive sweating during sleep
-be restless or sleep in abnormal head positions
-long pauses in breathing
Sleep apnea has been found in almost 25% of children exhibiting ADHD; moreover, Judith Owens, MD, at National Children’s Medical Center in Washington, endorses proper sleep as an important factor in preventing childhood obesity.
According to Gary E. Freed, a pediatrics professor at Emory University School of Medicine in Atlanta, about 7-12 % of children snore, while only 1-3% of children suffer from sleep apnea disorder with a majority between the ages of 2 and 8 years. So even though you should be suspicious if your child mouth breathes, or snores at night, do not jump to conclusion but bring it up with your pediatrician and get the relevant investigations done.
Polysomnography is also the diagnostic tool used for investigating sleep apnea in children, as well as, assessment of severity of sleep apnea. Presently, pediatric home studies are not such reliable indicators of diagnosing sleep apnea. The American Sleep Apnea Association finds that most children with sleep apnea benefit from surgical removal of tonsils/adenoids. About 70-90% of the time it helps relieve the symptoms of sleep apnea in six to eight weeks. Apart from surgery, children may also benefit from positive airway pressure (PAP) with optimal pressure setting determined in the overnight sleep study. Other treatment options include:
-gastroesophageal reflux disease management
How To Live With Sleep Apnea
Even though sleep apnea is a serious disorder, an effective treatment plan can help ward off its more serious side effects—including hypertension, heart disease and stroke. The National Heart Lung and Blood Institute’s recommendations for sleep apnea include a regular follow-up with the doctor, compliance to treatment, weight loss and ongoing care with CPAP and frequent visits to the dentist for people using mouth piece.
For patients who are using CPAP, it is important that they are comfortable with their device; if a device is not working properly, you might need to switch to a different mask or even a new device. Also, it is important to learn how to care for your device, how to travel with it and knowing how and when to replace it.
According to the NHLBI, about half the sleep apnea patients are overweight. Weight control and a healthy lifestyle are therefore an integral part of treatment. Losing weight can help reduce sleep disruptions at night by improving the breathing index. Furthermore, exercise can help you sleep better by tiring you out.
Sleeping posture is a key to reducing sleep disruptions as well. The reason for it is that sleeping on the back can close up the throat, making breathing difficult. Sleeping on the side, on the other hand, helps to keep the throat open and breathing easier. Being sleep deprived also makes sleep apnea worse, therefore try not to take all-nighters if you have apnea.
You should know the dangers of operating heavy machinery over the course of your disease, and if you feel at any point that you might nod off, then it’s better to stay away from it. Before any surgical procedure, it is better to inform your doctor about your sleep apnea so that they can ensure that your airway remains patent.
Family members and bed partners are an integral part of sleep apnea diagnosis as they are usually the first ones to notice the symptoms. Family members should therefore ensure that appropriate medical help is sought, and that the patient follows the treatment plan. Most importantly, however, family should always provide emotional support to the patient.
Myths About Sleep Apnea
As mentioned before, even though it is a dangerous disorder, not many people think of it as a disorder, nor do they take the symptoms of the disease seriously enough. Despite the fact that more than 18 million Americans suffering from it, this disease has a lot of myths attached to it. According to the sleep experts of National Sleep Foundation, Some of the myths associated with snoring and sleep apnea include the following:
Snoring is just something the old people do: This is a completely wrong idea; even though snoring per se does not diagnose one with sleep apnea, it is a rather common symptom of it, especially if it is accompanied by day time somnolence. Furthermore, age has got nothing to do with snoring in as much as the disease onset does. Snoring can occur at any age, in both men and women, but commonly occurs after age 40. Moreover, postmenopausal women are likely to suffer from it than premenopausal women. While it can be harmless, it usually has a basis in a disorder like sleep apnea. It frequently has also been linked to hypertension lately.
Daytime sleepiness is an indicator of insufficient sleep: well, indirectly it may be an indicator of insufficient sleep, but we have to rule out the cause of insufficient sleep. In other words, sleep apnea may be the cause of a person not getting sufficient rest at night. When the airway of a sleep apnea patient gets blocked, his/her body gets insufficient oxygen, which prompts the brain to wake up the body to get that air, and a repeat of this cycle means that the brain and the body do not get sufficient rest. This results in excessive day time somnolence and an urge to sleep during the day.
Alcohol can be helpful: for a sleep apnea patient, alcohol usually aggravates the apnea. This is because of the relaxant effect of alcohol on the muscles of the throat that upon relaxing, close off the airway and worsen sleep apnea. Sleep medication also have the same effect; they relax the musculature of the airway enough to block it, and thereafter worsen the disease.
Obesity has no relation with sleep: it seems that obesity is related to every disease, and it is no less true for sleep apnea. Studies have found that imbalanced hormones due to sleep disturbances can lead to obesity and many other diseases. For obesity, the added disadvantage is that it also causes sleep apnea by preventing the chest muscles from expanding sufficiently during inspiration. Thus, a vicious cycle of sleep apnea ensues causing obesity, and obesity causing sleep apnea. It is therefore no surprise that losing weight is helpful in the treatment of sleep apnea.
Children are not affected by sleep apnea: as seen above, children are not unaffected by sleep apnea. About 1 in 10 children suffers from sleep apnea, and this may be evident by a poor academic record and poor performance at school.
Sleeping posture has no effect on sleep apnea: Lying on the back is more likely to result in a closed airway, both due to body weight and due to the effect of gravity. In such situations, it is better to sleep on the side, so that the airway can remain patent, and not worsen apnea.
Foods That Can Aggravate Or Reduce Sleep Apnea:
If you suffer from sleep apnea, the general guideline is to lose weight, stay away from smoking, drink less alcohol and avoid sleeping on the back. Apart from specific treatment devices like C-PAP, having a change in the dietary plan can also be helpful in warding off apnea spells. Incorporating vegetables and fruits in the diet is a given; apart from that, having a more balanced meal with whole grains, low fat dairy, and unsaturated plant oils can also prove helpful to the patient.
Being obese predisposes you to sleep apnea. According to Centers for Disease Control and Prevention, 70.7% of adult population of United States, over the age of 20 is overweight. This means that for optimal health it is important that people adopt healthier eating habits, with low carb intake, more exercise and more high protein food.
For people who suffer from sleep apnea, a dietary intake of foods that stimulate serotonin can be beneficial. Serotonin is a chemical in the brain that helps induce sleep. It is present in sufficient quantities in foods like cheese, turkey, milk, avocados and nuts. It is infact serotonin in the turkey that causes a wave of drowsiness after a thanksgiving dinner.
Avoiding relaxants like sleeping pills and alcohol can also help prevent apnea aggravation. At the same time, stimulants like caffeine can also worsen sleep apnea by sleep deprivation. At the end of the day, it is important to take everything in moderation and lead a more balanced lifestyle.