Understanding Sleep Apnea so You Can Rest Assured
Authored by William C. Dement, M.D., Ph.D. and Robert Koenigsberg, CEO
Overview of Obstructive Sleep Apnea
Approximately 52 million Americans are victims of a sleep disorder called obstructive sleep apnea (OSA). Many millions more are predisposed and have a high risk of developing the illness. If you are an adult male, the odds are about 50/50 that your breathing is not normal when you are sleeping. It is imperative that anyone who might have this problem or is predisposed, or knows someone they care about who has the problem, should have the clearest possible understanding about it. If you struggle with OSA, contact one of our San Francisco Bay Area based offices to learn more today.
We have dedicated this section of the website to a crystal clear and detailed description of all aspects of obstructive sleep apnea. The section begins with an overview, which will introduce the reader to this important sleep disorder. During the next several weeks, we will be providing you with a more in-depth understanding of obstructive sleep apnea. Please check back to this section to view upcoming segments.
What is Obstructive Sleep Apnea (OSA)?
People with OSA experience recurrent episodes during sleep when their throat closes and they cannot suck air into their lungs (apnea). This happens because the muscles that normally hold the throat open during wakefulness relax during sleep and allow it to narrow. When the throat is partially closed and/or the muscles relax too much, trying to inhale will suck the throat completely closed and air cannot pass at all. This is an obstructive sleep apnea episode.
A cessation of breathing must last 10 seconds or more to be called an apnea. Obstructive apnea episodes can last as long as two minutes and are almost always associated with a reduction in the level of oxygen in the blood. When an individual is in the midst of an obstructive sleep apnea episode, as long as sleep continues, the apnea continues. It is only terminated and the victim's life is saved by waking up. This arousal instantly increases the activity of the muscles of the tongue and throat muscles that enlarge the airway. The victim will be able to breathe and to once again fill the lungs with life-giving oxygen. This cycle may be repeated hundreds of times a night while the sufferer has no idea it is happening.
What are the cardinal symptoms?
- Fatigue and tiredness during the day.
- Loud snoring; if the loud snoring is repeatedly punctuated by brief periods of silence or choking sounds, the individual is certain to have obstructive sleep apnea.
Other common features are:
- Small jaw, thick neck
- High blood pressure
- Restless sleep; the repeated struggle to breath can be associated with a great deal of movement.
- Depressed mood and/or irritability
- Reduced sex drive and impotence
- Snorting, gasping, choking during sleep
Not as commonly reported but may be present:
- Feeling that sleep is strangely unrefreshing
- Difficulty concentrating
- A dry mouth upon awakening
- Excessive perspiration during sleep
- Rapid weight gain
- Morning headaches
- Change in personality
- Memory lapses
- Intellectual deterioration
- Frequent nocturnal urination (nocturia)
- Confusion and severe grogginess upon awakening
- Particularly in young children, large tonsils and adenoids. There may be chest retraction during sleep (the sternum and the spaces between ribs pull unnaturally inward when trying to inhale)
How serious is OSA?
Depending on the degree of severity, OSA is a potentially life-threatening condition. Someone who has undiagnosed severe obstructive sleep apnea is likely to have a heart attack, a stroke, cardiac arrest during sleep, or a harmful accident. In addition, awakening to breathe hundreds of times in a single night causes the victim to become very sleep deprived. There is a constant risk of serious accidents such as falling asleep while driving as well as impaired function in the workplace and in personal relationships. All of the negative consequences of OSA increase as severity increases. Untreated OSA tends to progressively worsen and sooner or later will result in partial or complete disability and death.
If you suspect that you may have OSA, what should you do?
It is a sad fact that we are trying to remedy, but most health professionals are not well informed about OSA. It is therefore not very helpful to say, "If you suspect you may have OSA, consult your physician." Rather, you must first become as knowledgeable as possible about OSA yourself. You can also do a number of simple things that will convert your suspicions into certainty. The best first step is to involve your spouse or other family member. He or she can audiotape or videotape you while you are sleeping. The sounds and repeated silences and struggles to breathe are highly characteristic. When you have enough ammunition, make an appointment with your primary care physician specifically to get help for your OSA. Your spouse should accompany you if at all possible.
At this point, your physician should refer you for a diagnostic sleep study. These diagnostic tests can be carried out in the convenience of your own home or in a sleep disorders center. In either case, you should undergo an all-night sleep study. This test will absolutely prove the presence or absence of OSA, and perhaps more important, will yield a clear indication of the severity of your problem. The all night test is called a polysomnogram. The following functions are always continuously monitored: air flow, respiratory effort, blood oxygen level, snoring, and body position. Brain waves, eye movements, and muscle activity may also be monitored. The test involves no pain and is covered by insurance.
When done in your home, a special portable monitoring device is used and you are instructed in how to connect those sensors used for predominantly detecting OSA. When the test is performed in a sleep disorders center, you are monitored and observed by a sleep technologist, videotaped, and connected to a variety of sensors which are typically placed on your scalp, eyes, nose, finger, chin, chest, abdomen, and legs.
How is sleep apnea treated?
The most commonly prescribed treatment for obstructive sleep apnea is positive airway pressure (PAP). The PAP device delivers air pressure through a small nasal mask that the patient wears while sleeping. The pressure acts as an "air splint" which keeps the throat open eliminating obstructive apneas and allowing you to breathe normally all night long. Sleep becomes uninterrupted and restorative. For many patients, PAP therapy dramatically improves their daytime functioning as well as their general health. PAP is not a cure, but a noninvasive therapy for managing OSA.
Sleep apnea can also be treated surgically. However the costs and success rates may vary greatly depending on which procedure is chosen, the experience and skills of the surgeons. If you wish to consider surgical treatment of OSA, learning as much as you can about the various surgical procedures is very highly recommended. You must also be certain the surgeons are well qualified and have successfully treated many patients.
Surgical options include:
- Genioglossus Tongue Advancement
- Hyoid Suspension
- Somnoplasty (Radio frequency or RF procedure)
- Maxillomandibular Advancement
- Laser Assisted Uvuloplasty (LAUP)
- Uvulopalatopharyngoplasty (UPPP)
- Pillar Procedure predominantly for snoring
Finally, some patients try dental appliances. These appliances work by bringing the lower jaw forward to increase the size of the airway. This approach is usually reserved for milder/moderate cases of OSA or for individuals who snore but don't obstruct. There are a few well-designed studies that exist to show that these appliances work well long-term; however, patient compliance has yet to be carefully evaluated.
How does Positive Airway Pressure (PAP) therapy work?
For the last decade and a half, positive airway pressure (PAP) devices have been the most effective way of treating obstructive sleep apnea. To use the device, a small comfortable mask or nasal pillows are fitted over the nose leaving the mouth uncovered. Patients must sleep with their mouths closed, aided by a chin strap or a full face mask that covers both the nose and mouth; while the device gently blows air into the nose at a pressure slightly higher than the surrounding air pressure. Most people get used to it quickly, though some do not and require specialized coaching by experienced sleep professionals to become compliant. The therapy works 100% of the time if the patient is assisted in finding the correct mask and the right type of device for their disordered breathing. There exists a multitude of mask styles and sizes and it is very important that the right questions are asked to determine which type of mask will work best for a patient for the long term.
Although PAP is the general term used for these types of devices, there are four genres of devices that exist for different types of disordered breathing and for a patient’s type(s) of apnea. A CPAP device provides Continuous Positive Airway Pressure at a fixed pressure for both inspiration and expiration. An Auto PAP device is more comfortable for a patient than a standard CPAP because it responds to obstructive events on a breath by breath basis verses a constant fixed pressure and therefore provides lower pressures for the majority of the night and only higher pressures when patients are in REM sleep that occurs 20% to 25% of the night. A Bi-level device provides a higher inspiratory pressure than expiratory pressure to assist with work of breathing issues for severely obese patients or patients with specific medical abnormalities. Finally an Auto Servo Ventilator is the most sophisticated type of device and regulates the breathing pattern in patients suffering from central sleep apnea also termed complex sleep apnea.
Literally within minutes of achieving the correct PAP pressure to maintain an open airway, patients with obstructive and/or central sleep apnea start sleeping like people who have gone without sleep for many days. For the first week or so after starting to use the device, patients will spend a great deal of time in deep sleep. Patients often report that there is a dramatic increase of daytime alertness and energy in just a few nights on PAP therapy.
Nasal PAP is by now a very well established and safe treatment. Most insurance companies will cover the cost of leasing or purchasing a device. Today, thousands of PAP users are now happy after experiencing a dramatic positive improvement in their daytime alertness and energy level.
SleepQuest's sleep care professionals provide a unique service by spending an average of forty-five minutes setting you up with your PAP device and coaching you to wellness. We will work with you to help you determine which of the four genres of masks is best suited for your particular needs. We have found that a thorough in-service is required in order for you to have all of your questions answered, to teach you how the device operates, and to explain what we do to enable you to become compliant with your PAP.