sleep apnea

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Sleep Apnea

 

Definition

Sleep apnea is a condition in which breathing stops for more than ten seconds during sleep. Sleep apnea is a major, though often unrecognized, cause of daytime sleepiness. It can have serious negative effects on a person's quality of life, and is thought to be considerably underdiagnosed in the United States.

Description

A sleeping person normally breathes continuouusly and uninterruptedly throughout the night. A person with sleep apnea, however, has frequent episodes (up to 400-500 per night) in which he or she stops breathing. This interruption of breathing is called "apnea." Breathing usually stops for about 30 seconds; then the person usually startles awake with a loud snort and begins to breathe again, gradually falling back to slep.
There are two forms of sleep apnea. In obstructive sleep apnea (OSA), breathing stops because tissue in the throat closes off the airway. In central sleep apnea, (CSA), the brain centers responsible for breathing fail to send messages to the breathing muscles. OSA is much more common than CSA. It is thought that about 1-10% of adults are affected by OSA; only about one tenth of that number have CSA. OSA can affect people of any age and of either sex, but it is most common in middle-aged, somewhat overweight men, especially those who use alcohol.

Causes and symptoms

Obstructive sleep apnea

Obstructive sleep apnea occurs when part of the airway is closed off (usually at the back of the throat) while a person is trying to inhale during sleep. People whose airways are slightly narrower than average are more likely to be affected by OSA. Obesity, especially obesity in the neck, can increase the risk of developing OSA, because the fat tissue tends to narrow the airway. In some people, the airway is blocked by enlarged tonsils, an enlarged tongue, jaw deformities, or growths in the neck that compress the airway. Blocked nasal passages may also play a part in some people.
When a person begins to inhale, the expansion of the lungs lowers the air pressure inside the airway. If the muscles that keep the airway open are not working hard enough, the airway narrows and may collapse, shutting off the supply of air to the lungs. OSA occurs during sleep because the neck muscles that keep the airway open are not as active then. Congestion in the nose can make collapse more likely, since the extra effort needed to inhale will lower the pressure in the airway even more. Drinking alcohol or taking tranquilizers in the evening worsens this situation, because these cause the neck muscles to relax. (These drugs also lower the "respiratory drive" in the nervous system, reducing breathing rate and strength.)
People with OSA almost always snore heavily, because the same narrowing of the airway that causes snoring can also cause OSA. Snoring may actually help cause OSA as well, because the vibration of the throat tissues can cause them to swell. However, most people who snore do not go on to develop OSA.
Other risk factors for developing OSA include male sex; pregnancy; a family history of the disorder; and smoking. With regard to gender, it has been found that male sex hormones sometimes cause changes in the size or structure of the upper airway. The weight gain that accompanies pregnancy can affect a woman's breathing patterns during sleep, particularly during the third trimester. With regard to family history, OSA is known to run in families even though no gene or genes associated with the disorder have been identified as of 2002. Smoking increases the risk of developing OSA because it causes inflammation, swelling, and narrowing of the upper airway.
Some patients being treated for head and neck cancer develop OSA as a result of physical changes in the muscles and other tissues of the neck and throat. Doctors recommend prompt treatment of the OSA to improve the patient's quality of life.

Central sleep apnea

In central sleep apnea, the airway remains open, but the nerve signals controlling the respiratory muscles are not regulated properly. This can cause wide fluctuations in the level of carbon dioxide (CO2) in the blood. Normal activity in the body produces CO2, which is brought by the blood to the lungs for exhalation. When the blood level of CO2 rises, brain centers respond by increasing the rate of respiration, clearing the CO2. As blood levels fall again, respiration slows down. Normally, this interaction of CO2 and breathing rate maintains the CO2 level within very narrow limits. CSA can occur when the regulation system becomes insensitive to CO2 levels, allowing wide fluctuations in both CO2 levels and breathing rates. High CO2 levels cause very rapid breathing (hyperventilation), which then lowers CO2 so much that breathing becomes very slow or even stops. CSA occurs during sleep because when a person is awake, breathing is usually stimulated by other signals, including conscious awareness of breathing rate.
A combination of the two forms is also possible, and is called mixed sleep apnea. Mixed sleep apnea episodes usually begin with a reduced central respiratory drive, followed by obstruction.
OSA and CSA cause similar symptoms. The most common symptoms are:
  • daytime sleepiness
  • morning headaches
  • a feeling that sleep is not restful
  • disorientation upon waking
  • poor judgment
  • personality changes
Sleepiness is caused not only by the frequent interruption of sleep, but by the inability to enter long periods of deep sleep, during which the body performs numerous restorative functions. OSA is one of the leading causes of daytime sleepiness, and is a major risk factor for motor vehicle accidents. Headaches and disorientation are caused by low oxygen levels during sleep, from the lack of regular breathing.
Other symptoms of sleep apnea may include sexual dysfunction, loss of concentration, memory loss, intellectual impairment, and behavioral changes including anxiety and depression.
Sleep apnea is also associated with night sweats and nocturia, or increased frequency of urination at night. Bedwetting in children is also linked to sleep apnea.
Sleep apnea can also cause serious changes in the cardiovascular system. Daytime hypertension (high blood pressure) is common. An increase in the number of red blood cells (polycythemia) is possible, as is an enlarged left ventricle of the heart (cor pulmonale), and left ventricular failure. In some people, sleep apnea causes life-threatening changes in the rhythm of the heart, including heartbeat slowing (bradycardia), racing (tachycardia), and other types of "arrhythmias." Sudden death may occur from such arrhythmias. Patients with the Pickwickian syndrome (named after a Charles Dickens character) are obese and sleepy, with right heart failure, pulmonary hypertension, and chronic daytime low blood oxygen (hypoxemia) and increased blood CO2 (hypercapnia).

Diagnosis

Excessive daytime sleepiness is the complaint that usually brings a person to see the doctor. A careful medical history will include questions about alcohol or tranquilizer use, snoring (often reported by the person's partner), and morning headaches or disorientation. A physical exam will include examination of the throat to look for narrowing or obstruction. Blood pressure is also measured. Measuring heart rate or blood levels of oxygen and CO2 during the daytime will not usually be done, since these are abnormal only at night in most patients.
In some cases the person's dentist may suggest the diagnosis of OSA on the basis of a dental checkup or evaluation of the patient for oral surgery.
Confirmation of the diagnosis usually requires making measurements while the person sleeps. These tests are called a polysomnography study, and are conducted during an overnight stay in a specialized sleep laboratory. Important parts of the polysomnography study include measurements of:
  • heart rate
  • airflow at the mouth and nose
  • respiratory effort
  • sleep stage (light sleep, deep sleep, dream sleep, etc.)
  • oxygen level in the blood, using a noninvasive probe (ear oximetry)
Simplified studies done overnight at home are also possible, and may be appropriate for people whose profile strongly suggests the presence of obstructive sleep apnea; that is, middle-aged, somewhat overweight men, who snore and have high blood pressure. The home-based study usually includes ear oximetry and cardiac measurements. If these measurements support the diagnosis of OSA, initial treatment is usually suggested without polysomnography. Home-based measurements are not used to rule out OSA, however, and if the measurements do not support the OSA diagnosis, polysomnography may be needed to define the problem further.
Both types of studies are usually covered by insurance with the appropriate referral from a physician. Without insurance, lab-based polysomnography cost approximately $1,500 in 1997, while overnight home monitoring cost between $500 and $1,000.

Treatment

Behavioral changes

Treatment of obstructive sleep apnea begins with reducing the use of alcohol or tranquilizers in the evening, if these have been contributing to the problem. Weight loss is also effective, but if the weight returns, as it often does, so does the apnea. Changing sleeping position may be effective; snoring and sleep apnea are both most common when a person sleeps on his back. Turning to sleep on the side may be enough to clear up the symptoms. Raising the head of the bed may also help. Opening of the nasal passages can provide some relief. There are a variety of nasal devices such as clips, tapes, or holders which may help, though discomfort may limit their use. Nasal decongestants may be useful, but should not be taken for sleep apnea without the consent of the treating physician.

Oxygen and drug therapy

Supplemental nighttime oxygen can be useful for some people with either central and obstructive sleep apnea. Tricyclic antidepressant drugs such as protriptyline (Vivactil) may help by increasing the muscle tone of the upper airway muscles, but their side effects may severely limit their usefulness.

Mechanical ventilation

For moderate to severe sleep apnea, the most successful treatment is nighttime use of a ventilator, called a CPAP machine. CPAP (continuous positive airway pressure) blows air into the airway continuously, preventing its collapse. CPAP requires the use of a nasal mask. The appropriate pressure setting for the CPAP machine is determined by polysomnography in the sleep lab. Its effects are dramatic; daytime sleepiness usually disappears within one to two days after treatment begins. CPAP is used to treat both obstructive and central sleep apnea.
CPAP is tolerated well by about two-thirds of patients who try it. Bilevel positive airway pressure (BiPAP), is an alternative form of ventilation. With BiPAP, the ventilator reduces the air pressure when the person exhales. This is more comfortable for some.

Surgery

Surgery can be used to correct obstructions in the airways. The most common surgery is called UPPP, for uvulopalatopharngyoplasty. This surgery removes tissue from the rear of the mouth and top of the throat. The tissues removed include parts of the uvula (the flap of tissue that hangs down at the back of the mouth), the soft palate, and the pharynx. Tonsils and adenoids are usually removed in this operation. This operation significantly improves sleep apnea in slightly more than half of all cases.
Reconstructive surgery is possible for those whose OSA is due to constriction of the airway by lower jaw deformities. Genioplasty, which is a procedure that plastic surgeons usually perform to reshape a patient's chin to improve his or her appearance, is now being done to reshape the upper airway in patients with OSA.
When other forms of treatment are not successful, obstructive sleep apnea may be treated by a tracheostomy. In this procedure, an opening is made into the trachea (windpipe) below the obstruction, and a tube inserted to maintain an air passage. A tracheostomy requires a great deal of care to prevent infection of the tracheostomy site. In addition, since air is no longer being filtered and moistened by the nasal passages before entering the lungs, the lower airways can become dry and susceptible to infection as well. Tracheostomy is usually reserved for those whose apnea has led to life-threatening heart arrhythmias, and who have not been treated successfully with other treatments.

Oral appliances

Another approach to treating OSA involves the use of oral appliances intended to improve breathing either by holding the tongue in place or by pushing the lower jaw forward during sleep to increase the air volume in the upper airway. The first type of oral appliance is known as a tongue retaining device or TRD. The second type is variously called an oral protrusive device (OPD) or mandibular advancement splint (MAS), because it holds the mandible, or lower jaw, forward during sleep. These oral devices appear to work best for patients with mild-to-moderate OSA, and in some cases can postpone or prevent the need for surgery. Their rate of patient compliance is about 50%; most patients who stop using oral appliances do so because their teeth are in poor condition. TRDs and OPDs can be fitted by dentists; however, most dentists work together with the patient's physician following a polysomnogram rather than prescribing the device by themselves.

Prognosis

The combination of behavioral changes, ventilation assistance, drug therapy, and surgery allow most people with sleep apnea to be treated successfully, although it may take some time to determine the most effective and least intrusive treatment. Polysomnography testing is usually required after beginning a treatment to determine how effective it has been.

Key terms

Continuous positive airway pressure (CPAP) — A ventilation system that blows a gentle stream of air into the nose to keep the airway open.
Genioplasty — An operation performed to reshape the chin. Genioplasties are often done to treat OSA because the procedure changes the structure of the patient's upper airway.
Mandible — The medical term for the lower jaw. One type of oral appliance used to treat OSA pushes the mandible forward in order to ease breathing during sleep.
Nocturia — Excessive need to urinate at night. Nocturia is a symptom of OSA and often increases the patient's daytime sleepiness.
Polysomnography — A group of tests administered to analyze heart, blood, and breathing patterns during sleep.
Tracheotomy — A surgical procedure in which a small hole is cut into the trachea, or windpipe, below the level of the vocal cords.
Uvulopalatopharyngoplasty (UPPP) — An operation to remove excess tissue at the back of the throat to prevent it from closing off the airway during sleep.

Prevention

For people who snore frequently, weight control, avoidance of evening alcohol or tranquilizers, and adjustment of sleeping position may help reduce the risk of developing obstructive sleep apnea.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Disorders of the Oral Region." Section 9, Chapter 105 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
Beers, Mark H., MD, and Robert Berkow, MD., editors. "Sleep Disorders." Section 14, Chapter 173 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Periodicals

Chasens, E. R., and M. G. Umlauf. "Nocturia: A Problem That Disrupts Sleep and Predicts Obstructive Sleep Apnea" Geriatric Nursing 24 (March-April 2003): 76-81, 105.
Chung, S. A., S. Jairam, M. R. Hussain, and C. M. Shapiro. "How, What, and Why of Sleep Apnea. Perspectives for Primary Care Physicians." Canadian Family Physician 48 (June 2002): 1073-1080.
Edwards, N., P. G. Middleton, D. M. Blyton, and C. E. Sullivan. "Sleep Disordered Breathing and Pregnancy." Thorax 57 (June 2002): 555-558.
Hisanaga, A., T. Itoh, Y. Hasegawa, et al. "A Case of Sleep Choking Syndrome Improved by the Kampo Extract of Hange-Koboku-To." Psychiatry and Clinical Neuroscience 56 (June 2002): 325-327.
Kapur, V., K. P. Strohl, S. Redline, et al. "Underdiagnosis of Sleep Apnea Syndrome in U.S. Communities." Sleep and Breathing 6 (June 2002): 49-54.
Koliha, C. A. "Obstructive Sleep Apnea in Head and Neck Cancer Patients Post Treatment … Something to Consider?" ORL—Head and Neck Nursing 21 (Winter 2003): 10-14.
Neill, A., R. Whyman, S. Bannan, et al. "Mandibular Advancement Splint Improves Indices of Obstructive Sleep Apnoea and Snoring but Side Effects Are Common." New Zealand Medical Journal 115 (June 21, 2002): 289-292.
Rose, E., R. Staats, J. Schulte-Monting, et al. "Long-Term Compliance with an Oral Protrusive Appliance in Patients with Obstructive Sleep Apnoea." [in German] Deutsche medizinische Wochenschrift 127 (June 7, 2002): 1245-1249.
Shiomi, T., A. T. Arita, R. Sasanabe, et al. "Falling Asleep While Driving and Automobile Accidents Among Patients with Obstructive Sleep Apnea-Hypopnea Syndrome." Psychiatry and Clinical Neuroscience 56 (June 2002): 333-334.
Stanton, D. C. "Genioplasty." Facial Plastic Surgery 19 (February 2003): 75-86.
Umlauf, M. G., and E. R. Chasens. "Bedwetting—Not Always What It Seems: A Sign of Sleep-Disordered Breathing in Children." Journal for Specialists in Pediatric Nursing 8 (January-March 2003): 22-30.
Veale, D., G. Poussin, F. Benes, et al. "Identification of Quality of Life Concerns of Patients with Obstructive Sleep Apnoea at the Time of Initiation of Continuous Positive Airway Pressure: A Discourse Analysis." Quality of Life Research 11 (June 2002): 389-399.
Viera, A. J., M. M. Bond, and S. J. Yates. "Diagnosing Night Sweats." American Family Physician 67 (March 1, 2003): 1019-1024.

Organizations

American Academy of Otolaryngology, Head and Neck Surgery, Inc. One Prince Street, Alexandria, VA 22314-3357. (703) 836-4444. http://www.entnet.org.
American Dental Association. 211 East Chicago Avenue, Chicago, IL 60611. (312) 440-2500. www.ada.org.
American Sleep Apnea Association. 1424 K Street NW, Suite 302, Washington, DC 20005. (202) 293-3650. Fax: (202) 293-3656. www.sleepapnea.org.
Canadian Coordinating Office for Health Technology Assessment. 〈www.ccohta.ca/pubs/english/sleep/treatmnt〉.
National Sleep Foundation. 1522 K Street, NW, Suite 500, Washington, DC 20005. www.sleepfoundation.org.

Other

American Sleep Apnea Association (ASAA). Considering Surgery for Snoring? 〈http://www.sleepapnea.org/snoring.html〉.
National Heart, Lung, and Blood Institute (NHLBI). Facts About Sleep Apnea. NIH Publication No. 95-3798. 〈http://www.nhlbi.nih.gov/health/public/sleep/sleepapn.htm〉.

apnea

 [ap´ne-ah]
cessation of breathing, especially during sleep. The most common type is adult sleep apnea. Central apnea in which there is failure of the central nervous system drive to respiration sometimes occurs in infants younger than 40 weeks after the date of conception.
adult sleep apnea frequent and prolonged episodes in which breathing stops during sleep. Diagnosis is confirmed by monitoring the subject during sleep for periods of apnea and lowered blood oxygen levels. Sleep apnea is divided into three categories: (1) obstructive, resulting from obstruction of the upper airways; (2) central, caused by some pathology in the brain's respiratory control center; and (3) mixed, a combination of the two (see above).
Treatment. Obstructive and mixed types are amenable to therapy. Since many sleep apnea patients are overweight, weight loss improves the symptoms. Central sleep apnea is the most difficult to control. Medications to stimulate breathing have not proven beneficial. Mechanical ventilation or administration of oxygen during the night may help some patients.

The most common treatment for obstructive sleep apnea is nasal continuous positive airway pressure, which the patient uses during sleep; the positive pressure exerted prevents the airway from obstructing. Another method that may be tried is a dental appliance to move the jaw forward during sleep. In the most refractory cases, such as when an anatomical airway obstruction can be demonstrated, surgery to remove it may be performed after consultation with a surgeon experienced in evaluating and treating such obstructions. Another treatment that is occasionally used is insertion of a special type of tracheostomy tube that can be plugged during the day for normal use of the upper airway and opened at night to bypass upper airway obstruction
central apnea (central sleep apnea) see adult sleep apnea.
deglutition apnea a temporary arrest of the activity of the respiratory nerve center during an act of swallowing.
initial apnea a condition in which a newborn fails to establish sustained respiration within two minutes of delivery.
late apnea cessation of respiration in a newborn for more than 45 seconds after spontaneous breathing has been established and sustained.
mixed apnea see adult sleep apnea.
obstructive apnea (obstructive sleep apnea) see adult sleep apnea.
primary apnea cessation of breathing resulting when a fetus or newborn infant is deprived of oxygen; exposure to oxygen and stimulation usually restore respiration.
prolonged infantile apnea sudden infant death syndrome.
secondary apnea a period of time following primary apnea during which continued asphyxia of the fetus or newborn, with a fall in blood pressure and heart rate, necessitates artificial ventilation for resuscitation and reestablishment of ventilation.
sleep apnea transient periods when breathing stops during sleep; see adult sleep apnea.

sleep ap·ne·a

central and/or peripheral apnea during sleep, associated with frequent awakening and often with daytime sleepiness. Compare: sleep-induced apnea.

sleep apnea

n.
Apnea caused by upper airway obstruction during sleep, associated with frequent awakening and often with daytime sleepiness.

sleep apnea

a sleep disorder characterized by periods in which respiration is absent. The person is momentarily unable to contract respiratory muscles or to maintain airflow through the nose and mouth. See also apnea, obstructive sleep apnea.

sleep apnea

A temporary cessation of breathing during sleep, usually lasting several secs; SA may be fatal if the person is asleep and stops breathing multiple times for ≥ 10 secs

sleep ap·ne·a

(slēp ap'nē-ă)
Central and peripheral breathing disorder during sleep, associated with frequent awakening and often with daytime sleepiness.

sleep ap·ne·a

(slēp ap'nē-ă)
Central and peripheral breathing disorder during sleep, associated with frequent awakening and often with daytime sleepiness.

apnea

1. temporary cessation of breathing.
2. asphyxia.

sleep apnea
transient attacks of failure of autonomic control of respiration, becoming more pronounced during sleep and resulting in acidosis and pulmonary arteriolar vasoconstriction and hypertension.

Patient discussion about sleep apnea

Q. Any advice on Fibromyalgia or Sleep Apnea? Hi there, any advice on Fibromyalgia or Sleep Apnea? Just been there for the test for both and they said ‘yes’. It looks like I have them. Just need to know what to expect. Thanks a bunch in advance.

A. untreated sleep apnea can:
Increase the risk for high blood pressure, heart attack, stroke, obesity, and diabetes
Increase the risk for or worsen heart failure
Make irregular heartbeats more likely
Increase the chance of having work-related or driving accidents

so here's a list of things you can do:
http://www.sleepapnea.org/resources/pubs/treatment.html

More discussions about sleep apnea