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Sleep Apnea and Snoring

Introduction

In recent years the term sleep apnea has crept into common usage by the general public, as most magazines and newspapers have carried stories on the topic. The component of sleep apnea that most captures attention is the fact that it is often associated with loud snoring, a common complaint, and one that annoys a bedpartner. In its most common form, sleep apnea is associated with obstruction to airflow during sleep due to collapse of the upper airway at the back of the throat. It is therefore called obstructive sleep apnea. The majority of this discussion will center on this more common variety of sleep apnea, which when associated with symptoms of snoring and excessive daytime sleepiness is called obstructive sleep apnea syndrome. A less common form of sleep apnea, not associated with obstruction to airflow, is more commonly associated with neurological or heart disorders and is called central sleep apnea.

Who Gets Sleep Apnea?

Symptoms Associated with Sleep Apnea

Snoring

The symptoms of sleep apnea vary greatly in their intensity. There are some individuals who have severe sleep apnea and very few symptoms, or may not be aware of any symptoms at all, whereas other individuals may have very mild or even no sleep apnea and yet have loud and frequent snoring. Snoring that occurs with gasps or choking episodes is almost always associated with some degree of sleep apnea. Regular rhythmical snoring without any significant change in intensity is less likely to be associated with obstructive sleep apnea syndrome. When snoring occurs that is loud and interspersed with quiet episodes, this is almost certainly associated with the presence of obstructive sleep apnea. The quiet episodes are typically episodes of cessation of breathing that occur when the patient is unable to move air in or out of the lungs.

Apnea, which means cessation of breathing, typically occurs when the upper airway collapses and the person struggles to bring air into the lungs but is unable to do so until the upper airway opens. The presence of these apneic episodes during sleep is an important sign that always warrants further investigation. When even a few apneic episodes are evident, it usually reflects a more severe underlying condition. Often the apneic episodes will be noticed at the beginning of the night when they are less likely to occur, whereas in the middle of the latter half of the night the apneic episodes may become more severe and more frequent. In addition to snoring and apneic episodes during sleep, the other major symptom is excessive daytime sleepiness. Often it will come on very gradually so that the individuals themselves may be somewhat unaware of the severity of their sleepiness.

Other family members usually notice it. Not uncommonly, the affected individual will tend to doze or fall asleep when relaxing, watching television or when reading in the evening. Often the individual is not aware of having fallen asleep for a few minutes, but it may be evident to other family members. Of particular concern is excessive sleepiness when driving or in the workplace. Individuals with obstructive sleep apnea syndrome are five times more likely to have a motor vehicle accident than those without sleep apnea. Sleepiness may also cause inattention at work that may lead to work-related accidents. Tiredness and sleepiness leads to impaired school or work performance and can contribute to social embarrassment, memory and concentration difficulties, depression, impaired quality of life, and marital problems.

Nighttime Urination

Another symptom of obstructive sleep apnea syndrome is the need to urinate frequently during the night. The individual may awaken to go to the bathroom several times through the night, is often aware of having a dry mouth, and may get some water to drink at those times. Typically, the person with significant obstructive sleep apnea syndrome will be very tired upon awakening in the morning.

Symptoms in Children

Sleep apnea is common in children, particularly those with enlarged tonsils. Noisy breathing during sleep is often a feature, but children may or may not demonstrate excessive sleepiness. Some younger children will tend to be hyperactive rather than sleepy. Children with severe sleep apnea often assume irregular body positions in sleep and may tend to sleep on their knees in bed.

Upper Airway Obstruction

People with obstructive sleep apnea syndrome commonly will have some impairment of their nasal breathing ability. Some degree of deviation of the nasal septum is a common finding in patients with sleep apnea. Usually it is only mild or moderate and does not require any specific treatment. However, in some cases it may be severe and surgery on the deviation of the nasal septum may be required. In children, the presence of enlarged adenoids at the back of the nose and enlarged tonsils in the throat can contribute to the upper airway obstruction, thereby leading to sleep apnea. Removal of the adenoids or tonsils may be necessary. Patients with sleep apnea who have frequent nasal allergies or sinus problems should have these treated since reduction of the inflamed tissue in the nose will help prevent upper airway obstruction.

What Are the Long-term Risks of Sleep Apnea?

The lowering of the blood oxygen level can contribute to the development of heart irregularities (cardiac arrhythmias). The oxygen drop can also lead to an increased pressure in the blood vessels (veins) leading to the heart. Swelling of the ankles may be evidence of this increased pressure in these veins. In addition, blood pressure can become elevated due to the stress on the heart, and approximately 33% of people with sleep apnea have some elevation of their blood pressure (increased pressure in the arteries leading out of the heart). Furthermore, sleep apnea may worsen preexisting high blood pressure. Because of the cardiovascular effects, sleep apnea is known to be a cause of sudden death during sleep, although this is an uncommon occurrence.

Making the Diagnosis

When the typical symptoms are found, the diagnosis is usually obvious. However, all patients with the suggestion of having obstructive sleep apnea syndrome need to undergo appropriate diagnostic testing. Typically this involves sleeping overnight in a sleep laboratory, where the breathing can be documented with a test called a polysomnogram. Measurements are made of the airflow through the nose and mouth, abdominal and chest movements, as well as various heart performance measurements. Blood oxygen levels and electrocardiography (ECG) are usually measured during sleep, and sleep stages are also determined. Usually, sleep apnea is more severe during the REM stage, or dreaming stage, of sleep.

Some patients may have an assessment of their daytime sleepiness to help determine the severity of the apnea, or to exclude other disorders, such as narcolepsy. A daytime Multiple Sleep Latency Test (MSLT) is typically performed which measures the ability to fall asleep during the daytime and to see the type of sleep that occurs.

It may be necessary to perform an examination of the upper airway by passing a small flexible tube (nasoendoscope) into the upper airway. For some patients lung function tests may be necessary to determine the presence of lung disorders. Blood tests are performed which show the presence of an increased red blood cell count, due to the severe oxygen level lowering that occurs during sleep on a chronic basis.

Treatment

For those patients who are found to have only a minimal amount of breathing disturbance, loss of body weight, sleeping on one's side, or elevating the head of the bed may be measures that help to improve their condition. Patients should avoid sedative medications before sleep and avoid being sleep-deprived. Colds and allergies should be treated promptly and large meals should be avoided before bedtime. Smoking should be stopped.

Although there have been attempts to treat the disorder with medications, there are no medications which are routinely effective. Similarly, oxygen therapy has only a very minor role in the treatment of sleep apnea. The main form of treatment that is most effective and that will help eliminate all the symptoms of sleep apnea is the use of a continuous positive airway pressure device (CPAP). CPAP can be likened to a vacuum cleaner in reverse. It is a small pump that blows air through a tube to a mask that goes over the nose. The patient wears the mask at night during sleep and the flow of air prevents the upper airway from collapsing. The person is able to breathe in and out against the very low flow of air that goes into the upper airway. The CPAP stops the upper airway obstruction, and as a result, the snoring, gasping and choking stop. The patient sleeps more soundly, is not tired upon awakening, and the daytime sleepiness resolves. CPAP is the most widely used treatment for sleep apnea syndrome. A modification of the CPAP device involves the ability to adjust the pressure of the airflow as the person breathes during sleep. The pressure can change when the person is inhaling or exhaling. These devices, one of which is known as BIPAP, make it easier for the person to breathe out against a lower pressure of air. They are typically used for patients with the more severe forms of obstructive sleep apnea syndrome, who often require very high pressures of air flow.

Certain oral appliances can be helpful. These are likened to the bite plate that is often used during sports. Such a device holds the lower jaw slightly forward, thereby preventing narrowing of the airway behind the tongue. A large number of different oral appliances are available and need to be fitted by a dentist in consultation with a sleep specialist. The oral appliances are not as effective as CPAP. However, for individuals who are unable to tolerate CPAP an oral appliance may be a useful alternative, although it may not completely eliminate the sleep apnea.

Surgical Treatments

A variety of surgical treatments have been proposed. Although surgery was more popular some years ago, the improvement in the CPAP devices has caused surgery to be considered a secondary form of treatment for most patients. For patients who have been shown to have a minimal degree of sleep apnea and for whom snoring is a major concern, removal of tissue at the level of the soft palate may be helpful. Various new procedures have been developed, called laser uvulopalatopharyngoplasty surgery (LAUP) and radio frequency palatoplasty. At this time these procedures are not indicated as a first line treatment for people with significant sleep apnea syndrome. However, in people unable to tolerate nasal CPAP they may be useful alternative treatments, although they are less likely to cure the sleep apnea. Some surgical treatments such as removal of adenoids and tonsils may be very helpful, and they are usually the first lines of treatment for children. Nasal surgery generally is less effective at relieving sleep apnea, although it may sometimes be recommended in a patient who is unable to use CPAP effectively because of severe nasal obstruction. Although tracheostomy (the surgical creation of a direct opening from the front of the neck to the trachea) was previously used to treat sleep apnea, it is rarely performed except in the most severe patients because of its severe complications, both socially and medically

Conclusion

Obstructive sleep apnea syndrome is a common disorder that can cause tiredness, fatigue and sleepiness during the daytime and can be associated with loud snoring at night. Because of the potential for accidents due to sleepiness, and the risk of cardiovascular complications, it is an important condition that needs to be treated effectively. A variety of treatment options are available; however, a clear diagnosis established by a sleep specialist is important before undertaking any treatment direction. Weight loss is important for all patients. However, weight loss alone is rarely enough as it is not always successful and it may delay utilizing appropriate treatment. The most common form of treatment is by means of the CPAP device, which is tolerated well by the majority of patients who require its use. The advantages of effective treatment are the loss of snoring and gasping, the improvement of daytime sleepiness, and the elimination of potential cardiovascular complications.