Sleep apnea afflicts millions of adults. The word ‘apnea’ comes from the Greek apnoia a – “no” or “not”, and pneo/pnein – “air” or “breathing”. It literally means ‘no air’ or ‘not breathing’. The term is used to describe a medical condition wherein the afflicted person stops breathing for a brief period of time. Sleep apnea is simply the specific condition of apnea that occurs while sleeping.
There are two forms of sleep apnea – obstructive sleep apnea (OSA) and central sleep apnea (CSA). Of the two, OSA is much more common. It was once believed to be a rare occurrence, but the ability to test for it has uncovered the truth. Approximately 18 million adults in the United States are currently suffering from OSA today.
What is Obstructive Sleep Apnea (OSA)?
Obstructive sleep apnea happens when a person has a complete, or nearly complete, blockage of the airways that prevents airflow from passing through the nose and mouth during sleep. What causes said blockage? Any number of different things – enlarged tonsils, an elongated uvula, fatty deposits in the airway walls (note: everybody has fatty tissues in the airway walls), nasal congestion, and extra floppy tissue at the back of the palate. These are some of the main causes. OSA can occur in men and women, in the obese and the thin. Some people just happen to be born with unusually narrow airways. During sleep the muscles that line the airways, and usually work to keep things open, relax and allow things to get floppy.
Research has shown that some sufferers of OSA may stop breathing hundreds of times a night for brief periods. It is the act of sleeping that causes apnea to occur, so people with OSA usually wake themselves up gasping for air and then resume sleeping, often unaware of what is happening.
Since OSA sufferers are constantly waking themselves up they never get a chance to get any deep sleep. Their nights are long and restless, and generally unproductive which can lead to serious consequences. Ongoing daytime fatigue due to apnea can lead to failed careers, failed marriages, or even accidents at home, at work or while driving.
Medically speaking OSA can be life threatening. The body is constantly going through drops in oxygen and rising levels of carbon dioxide, has to work extra hard just to breathe and all this stresses the heart, and can lead to serious cardiovascular problems. Hypertension, heart failure and stroke have all been connected with sleep apnea.
Obstructive Sleep Apnea Symptoms
Most OSA sufferers don’t even realize how little sleep they’re getting. They just know that they feel lethargic and they’re tired all the time. This may lead them to the conclusion that they have insomnia. Unfortunately this could encourage them to try sleeping pills of some sort which only compounds the problem. Sleeping pills make your body relax the airways even further, and they also make it harder to wake up during apnea episodes.
So, how do you know if you have OSA? There are several key symptoms. Below this list I suggest a simple test.
The main symptoms are:
- Snoring – Not just any snoring, but extremely loud snoring (think chainsaws, foghorns, and bombing raids) interrupted by periods of silence (when the breathing stops) that are broken by loud or even exploding snorting or gasping sounds.
- Daytime sleepiness – OSA usually means excessive sleepiness. Again, not just sleepiness, but extreme sleepiness. You may find that you even fall asleep unexpectedly at various times of the day. You may also feel like you spend your days in a fog.
- Thick neck – Men with a neck circumference of 17 or more inches, or women with 16 or more are at a higher risk. Neck circumference is one of the strongest correlated factors in predicting someone has OSA.
- Weight gain – Not only does obesity contribute to OSA, but OSA can contribute to weight gain. Hormones that regulate appetite and weight are affected by chronic sleep deprivation. If you are overweight, or if you have suddenly started gaining weight even though you haven’t changed diet or exercise habits, this could be a warning sign.
- Hypertension and cardiovascular problems – More than half of OSA patients have hypertension! This is serious stuff people! Sleep is simply not a time of rest for the heart for folks with OSA. In fact it is stressful for the mind and body.
- Impaired cognitive abilities – memory, concentration, reaction time, ability to learn. All of these could be significantly impaired. This is not only because the person is sleepy. Studies show that permanent impairment to brain function can occur due to the oxygen deprivation associated with sleep apnea.
- Other medical problems – There is a strong association between OSA and type 2 diabetes, possibly due to disruptions in insulin levels and sugar metabolism caused by the apnea. Depression and headaches are also common related problems.
To determine whether you should be tested for sleep apnea, consider these points:
Snoring alone is not enough to indicate sleep apnea. If you snore most nights and the snoring is extremely loud, that is only an indicator.
More important is whether your spouse or other person notices that you stop breathing during the night. Even occasional stoppage of breathing should be a concern.
If you snore loudly and regularly, and either of these is true:
- you stop breathing during the night
- Your neck size is larger than 17″ for men and 16″ for women
If you are regularly extremely tired and lethargic during the day to the point of falling asleep at unexpected times just because you are inactive (for example sitting at your desk or at a red light), this could be caused by any number of sleep disorders. However, if along with this sleepiness you also:
- Have high blood pressure
- Have any other one symptom of sleep apnea mentioned above (in test 1)
If either test is true for you, you should get yourself in to be examined for sleep apnea right away. Remember, there are potentially life-threatening side effects if you do, so don’t delay!
Sleep Apnea Treatment
There are only two true cures of OSA. The first only works if your OSA is related to your weight. If it is, you can probably permanently stop your sleep apnea by losing weight. It may not be fun, but it will be worth it in the long run.
The other true cure of OSA is surgery, which I’ll discuss more in a minute.
Those who only experience OSA while sleeping on their back can shift to side sleeping and that will usually take care of the problem.
Sleep apnea sufferers should avoid all alcohol, sedatives and muscle relaxants, especially in the second half of the day.
A PAP machine is the most common method of treatment prescribed. PAP stands for Positive Airway Pressure. An air pressure device connects by a hose to a face mask that covers the nose. The continuous flow of air pressure into the nose keeps the airways open. This allows the wearer to breathe regularly throughout the night and to sleep normally. CPAP, or continuous positive air pressure, is the most commonly used type of PAP machine. It gives a consistent flow of air that does not adjust with breathing.
You may be thinking, “No way am I going to wear one of those space masks to bed!” You may be relieved to find out that CPAP has become a lot more comfortable in recent years. They are lighter, quieter and some even come with an option for warmed, humidified air.
Most people adjust to it quickly and without difficulty. The first time you wear it will likely be in the sleep laboratory so it can be adjusted to an appropriate air flow level. Long-term OSA sufferers usually say that the night in the sleep laboratory with their new CPAP was their best night of sleep they’ve ever had. Sleep laboratories are not like other labs. They are made to be relaxing, peaceful and comfortable with good quality beds, fluffy pillows, a serene setting, and a purring kitten to lie next to you. OK, I made that last one up.
Continuous positive airflow pressure may be a lifelong treatment for some people. You should experience the positive benefits the day after the first usage of the machine, meaning you will come out of the fog and realize you are alive for the first time. What’s more, many times CPAP reduces or completely eliminates hypertension.
Other OSA Treatments
Snoring is often treated using a dental device that extends the jaw and retains the tongue in proper position. They are also useful in treating mild to moderate cases of obstructive sleep apnea, yielding 50-70% success rates. They are easier to use and also less awkward than a CPAP machine, and easier for travel, too. You need to get such a device from your dentist so it is fitted properly. They can have a similar effect to wearing a retainer, so you want to make sure you don’t get one that will pull your teeth in weird directions.
Medications designed to stiffen the muscles around the airways have so far not been very successful. Other medications are sometimes used in conjunction with other treatments, antidepressants being the most common as they do have a mild positive effect on airway muscle tone.
Surgical Treatments for Obstructive Sleep Apnea
Unfortunately surgery for OSA does not have a high success rate. Some patients improve, most stay the same, and a few actually worsen. The problem is that the long air passages can collapse at many different points and surgery can only correct one point at a time. Never the less, it still may be worth considering as it is one of the only potential cures for OSA. Depending on which kind of correction is needed, and which surgery is used, some solutions are more effective than others:
Corrective Jaw Surgery – This moves the jaw (either upper or lower) forward to open the airway. It is a difficult procedure that requires extensive training on the part of the surgeon, but success rates as high as 90% have been reported.
Uvulopalatopharyngoplasty (try saying that one five times fast, or even once!) – UPPP has about a 40-45% success rate in treating OSA. For those that aren’t cured it may improve the situation enough that other surgeries or a CPAP can correct the problem the rest of the way.
Tracheostomy – This is rarely used today because it can seriously impair quality of life, though it is 100% successful in treating OSA. It involves making a small hole in the lower neck into the airway below the airway collapsing point. This is used only in life-threatening cases.
Other surgeries are sometimes used, but are not very successful. These included somnoplasty and palatal implants.
What is Central Sleep Apnea?
You might think of the brain as the central processing unit of the human body. It is the center for all communication throughout the body to maintain almost every system. Thus, central sleep apnea (CSA) is a kind of sleep apnea where the brain doesn’t send the necessary messages to control breathing during sleep. Similar to OSA, when the person stops breathing they wake up and are able to resume normal breathing – until they fall asleep again.
Central Sleep Apnea is not common, though it increases in prevalence as we age. People with heart failure, chronic lung disease, or neurological damage are at greater risk.
Loud snoring is not a symptom of CSA since the air pathways are not blocked. The diaphragm and chest muscles simply stop working.
CSA is usually treated by treating the underlying condition – heart failure, lung disease, etc. Some people only experience CSA when they are just beginning to fall asleep. In that case a mild sleeping pill may be prescribed.
In cases of central sleep apnea a thorough evaluation by a sleep specialist is performed to determine the root cause before deciding on a course of treatment.