SLEEP APNEA INFORMATION FOR PATIENTS AND THEIR FAMILIES

Sleep apnea is a potentially very serious illness. Those who suffer from sleep apnea may stop breathing many times during each night’s sleep. The most common symptoms are excessive daytime sleepiness, trouble staying asleep and snoring.

The word, “apnea”, means a cessation of breathing. This may be due to a blockage in the upper
airway at the base of the tongue.

Anyone can develop sleep apnea at any age. It appears that men have sleep apnea more frequently than women until after menopause when women catch up to men in prevalence of sleep apnea. Once a person has developed sleep apnea, it usually remains as a lifelong problem.

There is no known cure, although in some cases weight loss and certain surgical procedures can provide complete relief of symptoms. In most patients, nasal continuous positive airway pressure (CPAP) is the treatment of choice (see below). In some cases, the symptoms begin gradually and may require years to reach their most serious level.

In a true case of sleep apnea, the occurrence of sleep alone is sufficient to induce repetitive episodes of apnea. In a true case of “sleep apnea”, the breathing of the person is entirely normal when fully awake. It is not a lung problem.

A physical examination of persons suffering from sleep apnea may or may not reveal characteristic physical abnormalities while they are awake. In addition, when they wake up they usually will not recall having experienced apneic periods while they were asleep. Therefore, the only means of detecting the condition is by examining/observing the person while he/she is asleep. Many cases have been diagnosed only after the sufferer’s spouse or bed-partner reported observing the apneic episodes.

OBSTRUCTIVE SLEEP APNEA:

There is an abnormal relaxation of the muscles of the tongue, throat and larynx during sleep. As a result, at the onset of sleep, the back of the throat is narrowed or completely collapsed and airflow is blocked. During the apneic episode, the diaphragm continues to contract rhythmically with a progressively greater effort against the closed airway until finally a partial or complete awakening or arousal occurs and normal breathing is resumed. These episodes are referred to as “apneic” events if the obstruction is complete or hypopneas if obstruction is partial. A form of partial or mild obstructive sleep apnea is known as the “upper airway resistance syndrome”.

SYMPTOMS WHILE ASLEEP:

If one observes a sleeping person who suffers from sleep apnea it will be noted that he/she may have a few or many, perhaps hundreds, of apneic episodes during a night’s sleep. The length of time that each apnea may last is from 10 to 190 seconds. In a typical case, sleep and the associated apneic periods are terminated by a partial arousal or a very brief awakening during which breathing resumes. After a few breaths, sleep deepens, breathing stops and the cycle repeats itself. This cycle continues over and over throughout the night. Most individuals who suffer from sleep apnea experience both long and short apneic periods during every night’s sleep.

Loud snoring is a common symptom. A history of snoring often precedes the development of other symptoms. The snoring occurs as the person begins to breathe at the end of each apneic period. Some sufferers are described as having a snorting or gasping respiration during sleep. A study of 12 persons suffering from sleep apnea revealed that their sleep was very agitated and frequently they moved around in an abnormal manner before they resumed breathing at the end of an apneic period. The movements ranged from simple “flapping tremors” of the hand and feet 2 to larger and sometimes quite violent movements of arms, legs, or even the entire body. Some individuals would suddenly sit up in bed, try to get out of bed and often succeed, try to walk, walk a little and then fall to the floor where they often would sleep for the rest of the night. All of these persons were difficult to awaken during apneic episodes, and, if suddenly awakened, they did not know where they were.

When sleep apnea occurs in children, it may cause bedwetting. Thus, the occurrence of bedwetting in a child who has been previously dry through the night is suggestive of the development of a sleep apnea syndrome. Bedwetting also occurs occasionally in adults with sleep apnea. Bedwetting episodes may occur more than once at night. Some adults awaken and feel the urge to urinate. Had they not been awakened by the apnea, they would have slept through the night to empty the bladder in the morning. Also, obstructive sleep apnea has been shown to increase the amount of urine produced by the kidneys.

SYMPTOMS WHILE AWAKE:

Those who suffer from sleep apnea may complain of insomnia. They often say that they are unable to get a night of continuous sleep. Although they are unaware of the apneic episodes, they are often aware that they are awaken frequently during the night and are unable to go back to sleep for some time. They also have many awakenings or arousals of which they are unaware. In one small study of such individuals, the number of awakenings ranged between four and six per night, each lasting between ten and sixty minutes. This, of course, also results in the person being tired during the day.

The primary symptom of which those who suffer from obstructive sleep apnea are usually aware, and the problem of which they most often complain, is excessive daytime sleepiness. Complaints such as, “I never seem to get enough sleep”, “I’m sleepy all day”, every day”, or “I’m always sleepy” are common. Although their nighttime sleep is very disrupted those who suffer from obstructive sleep apnea may be unaware of disturbance and feel their sleep is deep and continuous. People who are sleepy during the day should not drive vehicles or operate dangerous machines such as boats.

There are other problems characteristic of sleep apnea, which are sometimes reported by those who suffer from this disorder. For instance, early morning headaches or a very dry mouth are common complaints. (See summary list of symptoms at end of this article.) In addition, a slight disorientation sometimes occurs after awakening. This typically lasts for between 3 minutes to ½ hour. During the periods of disorientation, individuals usually have difficulties with their memories and they often given inappropriate answers to questions as if they did not hear or failed to understand what was asked. Many refer to this as a “foggy mind” state.

Apneic episodes cause other abnormal conditions to occur. For example, the oxygen content of the blood may decrease during apneic periods. This means that the heart, brain and other vital tissues are periodically deprived of needed oxygenated blood.

Furthermore, during the apneic episodes, there may be abnormalities of the heart and blood vessels. The blood pressure may rise sharply in both the pulmonary and systemic arteries and the heart slows (bradycardia) and may stop entirely (asystole) for as long as 5 to 8 seconds. These changes are temporarily reversed when breathing is resumed. Also, it is important to understand that the elevated blood pressure associated with sleep apnea may finally begin to remain elevated during the daytime when breathing is normal. Sleep apnea is the most commonly identifiable cause of hypertension.

Excessive daytime sleepiness is thought to be due to fragmentation or ruination of sleep caused by the arousals, which end apneas. Lack of oxygenation during sleep may affect brain function.

DIAGNOSIS:

When a person who is troubled by excessive daytime sleepiness or trouble staying asleep is also a heavy snorer, the diagnosis of sleep apnea should be considered. If the sounds of breathing during sleep are carefully observed, a characteristic cycle of heavy snoring followed by silence, and so-on repeatedly will be heard. A definitive diagnosis can only be provided by a specialized test known as polysomnography. This test is safe and not invasive or painful.

CAUSE:

Two thirds of patients with sleep apnea are overweight. The fat is deposited in the usual areas but also around upper airway and tongue causing narrowing and tendency to snore or obstruct. Some anatomical or structural abnormalities affecting the upper airway may be contributory such as a small jaw bone (mandible) or deviated nasal septum.

TREATMENT:

Rare cases of obstructive sleep apnea can be treated with medicine if it is mild and confined to REM-sleep.

In very, very severe obstructive type of sleep apnea, relief of the symptoms may require a relatively simple surgical operation, a tracheostomy, in which a hollow tube is inserted in the trachea through a small hole in the neck. The protruding end of the tube has a valve, which is closed when the person is awake. Thus, all during the day, the individual breathes and speaks normally through the nose and mouth. At night, the valve is opened so that air can flow through the tube directly to the lungs bypassing the sleep induced upper airway blockage. This procedure completely eliminates the apneas. Accordingly, it also eliminates the sleepiness and all other consequences of sleep apnea. A tracheostomy can be tolerated for many years or a lifetime. 

The only normal activity it prevents is swimming and talking while breathing through the tube. Tracheostomy is rarely needed today because nasal CPAP is so effective and safe. (See below) Nasal Continuous Positive Airway Pressure (CPAP) is the gold standard today. It involves the fitting of a custom-made mask or nasal pillows (inserts) which are applied to the patient’s nose during sleep. The mask is attached to a special pump which pushes air under a gentle pressure into the upper airway. The pressure of the air prevents the snoring and apneas. It works as a sort of pneumatic splint for the airway (see figure). Bed-partners enjoy the quiet and restful sleep provided when the obstructive sleep apnea sufferer uses nasal CPAP. Nasal CPAP gets rid of the excessive daytime sleepiness, trouble staying asleep and the snoring. It is almost 100% effective and is very safe.

In very select cases, oral appliances designed to fit on the upper and lower teeth in order to pull the jaw forward during sleep may be helpful by opening up the airway behind the base of the tongue. Healthy teeth are needed and the sleep apnea has to be mild.

In some cases of mild sleep apnea, which occurs mainly, when the sufferer is sleeping on his back positional therapy may be useful. This involves putting two tennis balls in a sock and sewing this to the back of the nightshirt.

Surgery such as radiofrequency ablation (microwave) or laser-assisted uvulopalatopharyngoplasty may be helpful for snoring or very mild obstructive sleep apnea. It is not safe or effective for more severe cases. Extensive oral-facial-maxillary surgery, e.g. to pull mandible forward, may be curative but has to be viewed as a last resort.

It has been shown that the only potential cure for obstructive sleep apnea besides radical facial maxillary surgery is weight loss if someone is overweight. A decrease of 10 to 20% body weight may be all that is needed, if the anatomy of the throat and nose is otherwise normal.

CAUTION REGARDING DRUG USE:

Drugs that depress the central nervous system may affect the upper airway muscles and breathing. The use of such drugs could lead to death if they sufficiently increased the number or duration of apneic episodes. This means that sleeping pills, tranquilizers, alcohol, narcotic pain killers or any similar drugs which have a depressing or sedating effect upon the central nervous system should be avoided or used only after careful consideration of their potentially deadly effect.

NOTE:

Regardless of the cause, excessive daytime sleepiness is not a trivial complaint. It can rob life of quality; create serious social, marital and business problems; and produce under-productive individuals. It may be dangerous and cause accidents.

Untreated sleep apnea may be associated with increased risk of heart attacks, heart failure, atrial fibrillation and strokes. It is the most common identifiable cause of high blood pressure (hypertension).

NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

SYMPTOMS:

Frequently the most useful information is obtained from family members or bed partners. The estimated frequency of these symptoms is listed.