Copyright ©
1999 - 2000
CCSD
All Rights
Reserved
Disclaimer

Obstructive Sleep Apnea

Obstructive Sleep Apnea (OSA) is a very common sleep disorder. As the name indicates,it is a condition in which there is an obstruction to normal airflow during breathing, which only occurs in sleep and leads to episodes of struggling to breathe or apnea. An estimated 14 million Americans suffer from sleep apnea (at least 2-4% of the adult population), but it often gets dismissed as just heavy snoring. Instead, snoring could be a sign of OSA where episodes of struggling to breath can interrupt sleep over and over. As a result, people with sleep apnea frequently feel tired during the day because their rest is interrupted by this struggle to breathe. Surprisingly, many individuals with daytime sleepiness do not realize they are sleepy. They have come to think of chronic sleepiness as "normal". Struggling to breath and the associated strain on our system also puts individuals with OSA at risk for high blood pressure, heart failure and strokes. Thus, identifying patients with sleep apnea can lead to dramatic improvements in their quality of life and in their health. Identifying sleep apnea involves an appropriate medical history and testing of breathing during sleep. Early detection can prevent the grave consequences of OSA and is easily accomplished once the possibility of its presence in considered.

What is Sleep Apnea?

Sleep apnea is a condition where the flow of air during breathing decreases or is completely blocked during sleep. This occurs when the throat partially or completely closes. The throat is a very flexible tube, designed for swallowing and speaking, as well as breathing. There are many muscles along it which hold it open while we're awake. But for some people who are born with throats that may have a narrow opening, who gain weight and have excessive fatty tissue in their throats, or whose pharyngeal (throat) tissues are very collapsible. Sleep onset leads to the relaxation of these muscles and cause the soft tissues of the throat to collapse, partially or completely obstructing the airway.

If someone were to come over and cover your nose and mouth, then quite naturally you would struggle to breathe and wake up. That is almost exactly what happens with sleep apnea, with the choking occurring because of the internal collapse of the airway. People who have sleep apnea almost always snore heavily, although not everyone who snores has sleep apnea. Most patients do not realize they are snoring much less snorting and gasping and waking themselves up. The awakenings, called arousals, may only last a few seconds. Once the patient awakens and breathes again, they usually fall back asleep immediately and most of the time have no awareness that they ever woke up. But some people do wake up and experience a sensation that they have been choking. Even if you don't remember waking up, the pauses disrupt the rest that's so essential to good health.

These interruptions in air flow, which are considered apneic episodes if they last for ten seconds [3], can last as long as three minutes [4]. And they can occur from five times -- to over 100 times -- an hour [5]. Even in its milder forms sleep apnea can interrupt sleep and cause significant sleepiness.

In addition to loud snoring, telltale symptoms of sleep apnea include awakening un-refreshed by sleep and feeling sleepy during the day. Patients often don't realize they are sleepier than is normal - there's a tendency to accept the ability to nod off easily as "okay" or even desirable. To see if you're more sleepy than normal during the day, take a quick test (Epworth Sleepiness Test). Many patients awaken with morning headaches and dry mouths or throats. Bed partners can also provide important information about observed apnea, snoring and gasping. As we said, the patient more often than not has no awareness of what they are doing while asleep.

There is another form of sleep apnea, called central sleep apnea, which is more rare. In this case, the regulation of breathing is affected rather than a mechanical problem preventing breathing. This form of apnea is typically only seen in patients with congestive heart failure or other medical conditions. It too can lead to daytime symptoms and contribute to medical problems.

Why Sleep Apnea is Hazardous to Your Health

It is sometimes difficult to predict who has mild and who has severe sleep apnea. We generally define severity by the results of a sleep test in which breathing episodes have been measured, also called a polysomnogram. (PSG) There's not always a match between the severity of the case on such a test and the severity of the symptoms. Some patients have marked symptoms of daytime sleepiness. In many cases, they may find themselves falling asleep at the wheel. While most of the time these patients also have severe disease on testing, sometimes they don't. Other patients have relatively little in the way of severe complaints or symptoms but they may feel lethargic, irritable and have trouble concentrating during the day. Many people also have early-morning headaches. The lack of sleep can also cause depression, irritability, impotence, and learning and memory problems. On testing some of these patients turn out to have severe disease. Many studies have shown that people with sleep apnea are more likely to get into an automobile accident [6].

Even mild cases of sleep apnea can pose a serious threat to your health beyond that caused by a risk of falling asleep at the wheel. If left untreated over a period of time, sleep apnea puts intense stress on your body as it struggles to breathe every night. This can cause a slew of problems, and severely aggravate other conditions.

A very common effect of sleep apnea is high blood pressure. When you don't breathe for even a short period of time, it causes your body to produce a burst of adrenaline, which in turn causes sudden spikes in blood pressure. This can damage the heart and other organs, triggering strokes and heart attacks and greatly worsening congestive heart failure. The National Commission on Sleep Disorders Research estimates that 38,000 fatal heart attacks and strokes in the U.S. are caused by sleep apnea [7]. It makes people who are already heavy smokers or have heart problems that much more vulnerable.

Don't Blame it on Age - It Could be Sleep Apnea

Because sleep apnea tends to get worse with age, and is a problem that increases gradually rather than has a sudden impact, many people don't get diagnosed and treated properly. Oftentimes, problems that people attribute to the "aging process," such as poor memory, poor sleep and general fatigue, may have nothing to do with aging at all. Instead, they may be the side effects of sleep apnea. If you're in your 50s or 60s, you shouldn't assume that you're feeling old prematurely. By getting treatment for their sleep apnea, many people see a dramatic improvement in their quality of life.

Since most people don't realize that they have a snoring problem, it's important to get feedback. Your family and/or friends may be able to tell you if you snore or gasp alarmingly while you sleep. Alternatively, you can set up a tape recorder to record yourself overnight.

As we get older, it is also common to have patients complain about the need to urinate frequently at night. Many people don't put the two together, but if you find yourself getting up a lot in the middle of the night to use the bathroom, it could be triggered by sleep apnea. Sufferers of sleep apnea will get up to urinate after they've been awakened by their snoring or struggle to breath but because they are unaware of the apnea, they assume the awakening was due to the need to urinate. Once the apnea is corrected their frequent urination often disappears.

Another common sleep complaint is insomnia. While it is in fact the most common of sleep complaints, sometimes it is due to sleep apnea. The difficulty breathing and restless sleep leads to difficulty sleeping. Thinking that insomnia is the main problem, patients or their physicians may seek treatment for this, including the use of medication. However, taking sleeping pills may make the situation worse, since the pauses in breathing occur more frequently and last longer when you're more deeply asleep.

If you suspect that you have sleep apnea, it's important to consult a doctor. By monitoring your sleep overnight, while also measuring your breathing and heart rhythm, a specialist can make an accurate diagnosis.

Are You at Risk for Sleep Apnea?

Sleep apnea can affect people of any age, but most commonly shows up in middle age. In the U.S., about four percent of middle-aged men and two percent of middle-aged women have sleep apnea [2]. You're more likely to suffer from it if you are overweight but we have become more and more aware of how common the disorder may be in slim patients. There is a strong genetic component as well, so if there is a family history of severe snoring or symptoms suggestive of sleep apnea, your risk of also having it is greater. Sleep apnea can also be triggered by allergies, infections of the throat or sinuses, smoking or drinking excessively, or taking sedatives. Sleep apnea has also been linked to crib death, also known as sudden infant death syndrome.

What treatments are available for apnea and what should I do next?

The good news is that sleep apnea is treatable. While there's no pill you can take, there are a number of different treatment options, which have been used successfully to help people sleep quietly and soundly.

References
1. Principles and Practice of Sleep Medicine, edited by Kryger, Roth and Dement, 2000, pg. 869.
2. Ditto.
3. Ditto, page 940.
4. http://talkaboutsleep.com/disorders/apnea/apnea_intro3.htm
5.National Institutes of Health, "Facts About Sleep Apnea," 1995.
6.http://www.sleephealth.com/professional/protected/articles/Sleep%20Apnea%20References.htm
7. Revitalon text on sleep apnea.