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Sleep apnea

sleep apnea, sleep apnea symptoms
Sleep apnea, also spelled sleep apnoea, is a sleep disorder characterized by pauses in breathing or periods of shallow breathing during sleep1 Each pause can last for a few seconds to several minutes and they happen many times a night1 In the most common form, this follows loud snoring2 There may be a choking or snorting sound as breathing resumes As it disrupts normal sleep, those affected are often sleepy or tired during the day1 In children it may cause problems in school or hyperactivity2

There are three forms of sleep apnea: obstructive OSA, central CSA, and a combination of the two called mixed OSA is the most common form1 Risk factors for OSA include being overweight, a family history of the condition, allergies, and enlarged tonsils4 In OSA, breathing is interrupted by a blockage of airflow, while in CSA breathing stops due to a lack of effort to breathe People with sleep apnea are often not aware they have it Often it is first observed by a family member1 Sleep apnea is often diagnosed with an overnight sleep study5 For a diagnosis of sleep apnea, more than five episodes an hour must occur7

Treatment may include lifestyle changes, mouthpieces, breathing devices, and surgery1 Lifestyle changes may include avoiding alcohol, weight loss, stopping smoking, and sleeping on their side Breathing devices include the use of a CPAP machine8 Without treatment sleep apnea may increase the risk of heart attack, stroke, diabetes, heart failure, irregular heartbeat, obesity, and motor vehicle collisions1

OSA affects 1-6% of adults and 2% of children36 It affects males about twice as often as females3 While people at any age can be affected it occurs most commonly among those 55 to 60 years old13 Central sleep apnea affects less than one percent of people9 A type of central sleep apnea was described in the German myth of Ondine's curse where when asleep the person would forget to breathe10

Contents

  • 1 Signs and symptoms
  • 2 Risk factors
  • 3 Mechanism
  • 4 Diagnosis
    • 41 Oximetry
  • 5 Classification
    • 51 Obstructive sleep apnea
    • 52 Central sleep apnea
    • 53 Mixed apnea
  • 6 Management
    • 61 Continuous positive airway pressure
    • 62 Surgery
      • 621 Nasal obstruction
      • 622 Pharyngeal obstruction
      • 623 Hypopharyngeal or base of tongue obstruction
      • 624 Multi-level surgery
      • 625 Potential complications
    • 63 Other
      • 631 Neurostimulation
      • 632 Medications
      • 633 Oral appliances
      • 634 Nasal EPAP
      • 635 Oral pressure therapy
  • 7 Epidemiology
  • 8 Prognosis
  • 9 History
  • 10 See also
  • 11 References
  • 12 External links

Signs and symptomsedit

People with sleep apnea have problems with excessive daytime sleepiness EDS, impaired alertness, and vision problems11 OSA may increase risk for driving accidents and work-related accidents If OSA is not treated, people are at increased risk of other health problems, such as diabetes Even death could occur from untreated OSA due to lack of oxygen to the body12 Moreover, people are examined using "standard test batteries" in order to further identify parts of the brain that may be adversely affected by sleep apnea,11 including those that govern:

  • "executive functioning", the way the person plans and initiates tasks11
  • paying attention, working effectively and processing information when in a waking state11
  • using memory and learning11

Due to the disruption in daytime cognitive state, behavioral effects may also be present These can include moodiness, belligerence, as well as a decrease in attentiveness and energy13 Another symptom related to sleep apnea is sleep paralysis, the fear of which can sometimes lead to insomnia These effects may become intractable, leading to depression14

There is also evidence that the risk of diabetes among those with moderate or severe sleep apnea is higher15 There is also increasing evidence that sleep apnea may also lead to liver function impairment, particularly fatty liver diseases see steatosis13161718 Finally, because there are many factors that could lead to some of the effects previously listed, some people are not aware that they have sleep apnea and are either misdiagnosed, or just ignore the symptoms altogether11

Risk factorsedit

Sleep apnea can affect people regardless of sex, race, or age However, risk factors include:

  • being male
  • excessive weight
  • an age above 40
  • large neck size greater than 16–17 inches
  • enlarged tonsils or tongue
  • small jaw bone
  • gastroesophageal reflux
  • allergies
  • sinus problems
  • a family history of sleep apnea
  • deviated septum19

Alcohol, sedatives and tranquilizers may also promote sleep apnea by relaxing throat muscles Smokers have sleep apnea at three times the rate of people who have never smoked20

Central sleep apnea is more often associated with any of the following risk factors:

  • being male
  • being older than 65 years
  • having heart disorders such as atrial fibrillation or atrial septal defects such as PFO
  • stroke

High blood pressure is very common in people with sleep apnea21

Mechanismedit

When breathing is paused, carbon dioxide builds up in the bloodstream Chemoreceptors in the blood stream note the high carbon dioxide levels The brain is signaled to wake the person sleeping and breathe in air Breathing normally will restore oxygen levels and the person will fall asleep again22

Diagnosisedit

Sleep apnea may be diagnosed by the evaluation of symptoms, risk factors and observation, eg, excessive daytime sleepiness and fatigue but the gold standard for diagnosis is a formal sleep study polysomnography, or sometimes reduced channels home based test A study can establish reliable indices of the disorder, derived from the number and type of event per hour of sleep Apnea Hypopnea Index AHI, or Respiratory Disturbance Index RDI, associated to a formal threshold, above which a patient is considered as suffering from sleep apnea, and the severity of their sleep apnea can then be quantified Mild OSA Obstructive Sleep Apneas ranges from 5 to 149 events per hour, moderate OSA falls in the range of 15–299 events per hour, and severe OSA would be a patient having over 30 events per hour

Despite this medical consensus, the variety of apneic events eg, hypopnea vs apnea, central vs obstructive, the variability of patients' physiologies, and the inherent shortcomings and variability of equipment and methods, this field is subject to debate23 Within this context, the definition of an event depends on several factors eg, patient's age and account for this variability through a multi-criteria decision rule described in several, sometimes conflicting, guidelines2425 One example of a commonly adopted definition of an apnea for an adult includes a minimum 10 second interval between breaths, with either a neurological arousal a 3-second or greater shift in EEG frequency, measured at C3, C4, O1, or O2 or a blood oxygen desaturation of 3–4% or greater, or both arousal and desaturation

Oximetryedit

Oximetry, which may be performed over one or several nights in a patient's home, is a simpler, but less reliable or accurate alternative to a formal sleep study polysomnography In one study, normal overnight oximetry was highly sensitive and so if normal, sleep apnea was considered unlikely26 In addition, home oximetry may be effective in guiding prescription for automatically self-adjusting continuous positive airway pressure27

Classificationedit

There are three types of sleep apnea OSA accounts for 84%, CSA for 04%, and 15% of cases are mixed28

Obstructive sleep apneaedit

Main article: Obstructive sleep apnea Screenshot of a PSG system showing an obstructive apnea No airway obstruction during sleep Airway obstruction during sleep

Obstructive sleep apnea OSA is the most common category of sleep-disordered breathing The muscle tone of the body ordinarily relaxes during sleep, and at the level of the throat the human airway is composed of collapsible walls of soft tissue which can obstruct breathing Mild occasional sleep apnea, such as many people experience during an upper respiratory infection, may not be significant, but chronic severe obstructive sleep apnea requires treatment to prevent low blood oxygen hypoxemia, sleep deprivation, and other complications

Individuals with low muscle tone and soft tissue around the airway eg, because of obesity and structural features that give rise to a narrowed airway are at high risk for obstructive sleep apnea The elderly are more likely to have OSA than young people Men are more likely to suffer sleep apnea than women and children are, though it is not uncommon in the last two population groups29

The risk of OSA rises with increasing body weight, active smoking and age In addition, patients with diabetes or "borderline" diabetes have up to three times the risk of having OSA

Common symptoms include loud snoring, restless sleep, and sleepiness during the daytime Diagnostic tests include home oximetry or polysomnography in a sleep clinic

Some treatments involve lifestyle changes, such as avoiding alcohol or muscle relaxants, losing weight, and quitting smoking Many people benefit from sleeping at a 30-degree elevation of the upper body30 or higher, as if in a recliner Doing so helps prevent the gravitational collapse of the airway Lateral positions sleeping on a side, as opposed to supine positions sleeping on the back, are also recommended as a treatment for sleep apnea,313233 largely because the gravitational component is smaller in the lateral position Some people benefit from various kinds of oral appliances such as the Mandibular advancement splint to keep the airway open during sleep Continuous positive airway pressure CPAP is the most effective treatment for severe obstructive sleep apnea but oral appliances are considered a first line approach equal to CPAP for mild to moderate sleep apnea according to the AASM parameters of care34 There are also surgical procedures to remove and tighten tissue and widen the airway

Snoring is a common finding in people with this syndrome Snoring is the turbulent sound of air moving through the back of the mouth, nose, and throat Although not everyone who snores is experiencing difficulty breathing, snoring in combination with other risk factors has been found to be highly predictive of OSA35 The loudness of the snoring is not indicative of the severity of obstruction, however If the upper airways are tremendously obstructed, there may not be enough air movement to make much sound Even the loudest snoring does not mean that an individual has sleep apnea syndrome The sign that is most suggestive of sleep apneas occurs when snoring stops

Other indicators include but are not limited to: hypersomnolence, obesity BMI >30, large neck circumference 16 in 410 mm in women, 17 in 430 mm in men, enlarged tonsils and large tongue volume, micrognathia, morning headaches, irritability/mood-swings/depression, learning and/or memory difficulties, and sexual dysfunction

The term "sleep-disordered breathing" is commonly used in the US to describe the full range of breathing problems during sleep in which not enough air reaches the lungs hypopnea and apnea Sleep-disordered breathing is associated with an increased risk of cardiovascular disease, stroke, high blood pressure, arrhythmias, diabetes, and sleep deprived driving accidents36373839 When high blood pressure is caused by OSA, it is distinctive in that, unlike most cases of high blood pressure so-called essential hypertension, the readings do not drop significantly when the individual is sleeping40 Stroke is associated with obstructive sleep apnea41

It has been revealed that people with OSA show tissue loss in brain regions that help store memory, thus linking OSA with memory loss42 Using magnetic resonance imaging MRI, the scientists discovered that people with sleep apnea have mammillary bodies that are about 20 percent smaller, particularly on the left side One of the key investigators hypothesized that repeated drops in oxygen lead to the brain injury43

Central sleep apneaedit

Main article: Central sleep apnea Screenshot of a PSG system showing a central apnea

In pure central sleep apnea or Cheyne–Stokes respiration, the brain's respiratory control centers are imbalanced during sleep Blood levels of carbon dioxide, and the neurological feedback mechanism that monitors them, do not react quickly enough to maintain an even respiratory rate, with the entire system cycling between apnea and hyperpnea, even during wakefulness The sleeper stops breathing and then starts again There is no effort made to breathe during the pause in breathing: there are no chest movements and no struggling After the episode of apnea, breathing may be faster hyperpnea for a period of time, a compensatory mechanism to blow off retained waste gases and absorb more oxygen

While sleeping, a normal individual is "at rest" as far as cardiovascular workload is concerned Breathing is regular in a healthy person during sleep, and oxygen levels and carbon dioxide levels in the bloodstream stay fairly constant Any sudden drop in oxygen or excess of carbon dioxide even if tiny strongly stimulates the brain's respiratory centers to breathe

In central sleep apnea, the basic neurological controls for breathing rate malfunction and fail to give the signal to inhale, causing the individual to miss one or more cycles of breathing If the pause in breathing is long enough, the percentage of oxygen in the circulation will drop to a lower than normal level hypoxaemia and the concentration of carbon dioxide will build to a higher than normal level hypercapnia In turn, these conditions of hypoxia and hypercapnia will trigger additional effects on the body Brain cells need constant oxygen to live, and if the level of blood oxygen goes low enough for long enough, the consequences of brain damage and even death will occur However, central sleep apnea is more often a chronic condition that causes much milder effects than sudden death The exact effects of the condition will depend on how severe the apnea is and on the individual characteristics of the person having the apnea Several examples are discussed below, and more about the nature of the condition is presented in the section on Clinical Details

In any person, hypoxia and hypercapnia have certain common effects on the body The heart rate will increase, unless there are such severe co-existing problems with the heart muscle itself or the autonomic nervous system that makes this compensatory increase impossible The more translucent areas of the body will show a bluish or dusky cast from cyanosis, which is the change in hue that occurs owing to lack of oxygen in the blood "turning blue" Overdoses of drugs that are respiratory depressants such as heroin, and other opiates kill by damping the activity of the brain's respiratory control centers In central sleep apnea, the effects of sleep alone can remove the brain's mandate for the body to breathe

  • Normal Respiratory Drive: After exhalation, the blood level of oxygen decreases and that of carbon dioxide increases Exchange of gases with a lungful of fresh air is necessary to replenish oxygen and rid the bloodstream of built-up carbon dioxide Oxygen and carbon dioxide receptors in the blood stream called chemoreceptors send nerve impulses to the brain, which then signals reflex opening of the larynx so that the opening between the vocal cords enlarges and movements of the rib cage muscles and diaphragm These muscles expand the thorax chest cavity so that a partial vacuum is made within the lungs and air rushes in to fill it
  • Physiologic effects of central apnea: During central apneas, the central respiratory drive is absent, and the brain does not respond to changing blood levels of the respiratory gases No breath is taken despite the normal signals to inhale The immediate effects of central sleep apnea on the body depend on how long the failure to breathe endures At worst, central sleep apnea may cause sudden death Short of death, drops in blood oxygen may trigger seizures, even in the absence of epilepsy In people with epilepsy, the hypoxia caused by apnea may trigger seizures that had previously been well controlled by medicationsverification needed In other words, a seizure disorder may become unstable in the presence of sleep apnea In adults with coronary artery disease, a severe drop in blood oxygen level can cause angina, arrhythmias, or heart attacks myocardial infarction Longstanding recurrent episodes of apnea, over months and years, may cause an increase in carbon dioxide levels that can change the pH of the blood enough to cause a respiratory acidosis

Mixed apneaedit

Some people with sleep apnea have a combination of both types; its prevalence ranges from 056% to 18% The condition is generally detected when obstructive sleep apnea is treated with CPAP and central sleep apnea emerges The exact mechanism of the loss of central respiratory drive during sleep in OSA is unknown but is most likely related to incorrect settings of the CPAP treatment and other medical conditions the person has44

Managementedit

Treatment often starts with behavioral therapy Many patients are told to avoid alcohol, sleeping pills, and other sedatives, which can relax throat muscles, contributing to the collapse of the airway at night45 As sleep apnea is worse for many people when they are on their back, sleeping on the side is often advised

Possibly owing to changes in pulmonary oxygen stores, sleeping on one's side as opposed to on one's back has been found to be helpful for central sleep apnea with Cheyne–Stokes respiration33

Continuous positive airway pressureedit

Person using a CPAP mask, covering only nose CPAP machine with two models of full face masks See also: Continuous positive airway pressure

For moderate to severe sleep apnea, the most common treatment is the use of a continuous positive airway pressure CPAP or automatic positive airway pressure APAP device4546 These splint the person's airway open during sleep by means of pressurized air The person typically wears a plastic facial mask, which is connected by a flexible tube to a small bedside CPAP machine47

With proper use, CPAP improves outcomes and appears to decreases the risk of death due to heart disease48 Evidence suggests that CPAP may improve sensitivity to insulin, blood pressure, and sleepiness495051 Long term compliance, however, is an issue with more than half of people not appropriately using the device48

Although CPAP therapy is effective in reducing apneas and less expensive than other treatments, some people find it extremely uncomfortable Patients complain of feeling trapped, having chest discomfort, and skin or nose irritation Other side effects a patient may experience are dry mouth, dry nose, nosebleeds, sore lips and gums12 Many patients refuse to continue the therapy or fail to use their CPAP machines on a nightly basis, especially in the long term52

Surgeryedit

Illustration of surgery on the mouth and throat

Several surgical procedures sleep surgery are used to treat sleep apnea, although they are normally a third line of treatment for those who reject or are not helped by CPAP treatment or dental appliances Surgical treatment for obstructive sleep apnea needs to be individualized to address all anatomical areas of obstruction

Nasal obstructionedit

Often, correction of the nasal passages needs to be performed in addition to correction of the oropharynx passage Septoplasty and turbinate surgery may improve the nasal airway

Pharyngeal obstructionedit

Tonsillectomy and uvulopalatopharyngoplasty UPPP or UP3 are available to address pharyngeal obstruction

Uvulopalatopharyngoplasty A pre-operative, B original UPPP, C modified UPPP, and D minimal UPPP

The "Pillar" device is a treatment for snoring and obstructive sleep apnea; it is thin, narrow strips of polyester Three strips are inserted into the roof of the mouth the soft palate using a modified syringe and local anesthetic, in order to stiffen the soft palate This procedure addresses one of the most common causes of snoring and sleep apnea — vibration or collapse of the soft palate It was approved by the FDA for snoring in 2002 and for obstructive sleep apnea in 2004 A 2013 meta-analysis found that "the Pillar implant has a moderate effect on snoring and mild-to-moderate obstructive sleep apnea" and that more studies with high level of evidence were needed to arrive at a definite conclusion; it also found that the polyester strips work their way out of the soft palate in about 10% of the people in whom they are implanted53

Hypopharyngeal or base of tongue obstructionedit

Base-of-tongue advancement by means of advancing the genial tubercle of the mandible, tongue suspension, or hyoid suspension aka hyoid myotomy and suspension or hyoid advancement may help with the lower pharynx

Other surgery options may attempt to shrink or stiffen excess tissue in the mouth or throat; procedures done at either a doctor's office or a hospital Small shots or other treatments, sometimes in a series, are used for shrinkage, while the insertion of a small piece of stiff plastic is used in the case of surgery whose goal is to stiffen tissues45

Multi-level surgeryedit

The Stanford Center for Excellence in Sleep Disorders Medicine achieved a 95% cure rate in people with sleep apnea by surgery54 Maxillomandibular advancement MMA is considered the most effective surgery for people with sleep apnea,55 because it increases the posterior airway space PAS56 The main benefit of the operation is that the oxygen saturation in the arterial blood increases56 In a study published in 2008, 933% of surgery patients achieved an adequate quality of life based on the Functional Outcomes of Sleep Questionnaire FOSQ56 Surgery led to a significant increase in general productivity, social outcome, activity level, vigilance, intimacy, and intercourse56 Overall risks of MMA surgery are low: The Stanford University Sleep Disorders Center found 4 failures in a series of 177 patients, or about one out of 44 patients57 However, health professionals are often unsure as to who should be referred for surgery and when to do so: some factors in referral may include failed use of CPAP or device use; anatomy which favors rather than impeding surgery; or significant craniofacial abnormalities which hinder device use58 Maxillomandibular advancement surgery is often combined with genioglossus advancement, as both are skeletal surgeries for sleep apnea

Potential complicationsedit

Several inpatient and outpatient procedures use sedation Many drugs and agents used during surgery to relieve pain and to depress consciousness remain in the body at low amounts for hours or even days afterwards In an individual with either central, obstructive or mixed sleep apnea, these low doses may be enough to cause life-threatening irregularities in breathing or collapses in a patient's airways59 Use of analgesics and sedatives in these patients postoperatively should therefore be minimized or avoided

Surgery on the mouth and throat, as well as dental surgery and procedures, can result in postoperative swelling of the lining of the mouth and other areas that affect the airway Even when the surgical procedure is designed to improve the airway, such as tonsillectomy and adenoidectomy or tongue reduction, swelling may negate some of the effects in the immediate postoperative period Once the swelling resolves and the palate becomes tightened by postoperative scarring, however, the full benefit of the surgery may be noticed

A person with sleep apnea undergoing any medical treatment must make sure his or her doctor and anesthetist are informed about the sleep apnea Alternative and emergency procedures may be necessary to maintain the airway of sleep apnea patients60

Otheredit

Neurostimulationedit

Diaphragm pacing, which involves the rhythmic application of electrical impulses to the diaphragm, has been used to treat central sleep apnea6162

In April 2014 the US Food and Drug Administration granted pre-market approval for use of an upper airway stimulation system in people who cannot use a continuous positive airway pressure device The Inspire Upper Airway Stimulation system senses respiration and applies mild electrical stimulation during inspiration, which pushes the tongue slightly forward to open the airway63

Medicationsedit

There is limited evidence for medication but acetazolamide "may be considered" for the treatment of central sleep apnea; it also found that zolpidem and triazolam may be considered for the treatment of central sleep apnea, but "only if the patient does not have underlying risk factors for respiratory depression"46 Low doses of oxygen are also used as a treatment for hypoxia but are discouraged due to side effects646566

Oral appliancesedit

An oral appliance, often referred to as a mandibular advancement splint, is a custom-made mouthpiece that shifts the lower jaw forward and opens the bite slightly, opening up the airway These devices can be fabricated by a general dentist Oral appliance therapy OAT is usually successful in patients with mild to moderate obstructive sleep apnea6768 While CPAP is more effective for sleep apnea than oral appliances, oral appliances do improve sleepiness and quality of life and are often better tolerated than CPAP69

Nasal EPAPedit

Nasal EPAP is a bandage-like device placed over the nostrils that utilizes a person's own breathing to create positive airway pressure to prevent obstructed breathing70

Oral pressure therapyedit

Oral pressure therapy utilizes a device that creates a vacuum in the mouth, pulling the soft palate tissue forward It has been found useful in about 25 to 37% of people7172

Epidemiologyedit

The Wisconsin Sleep Cohort Study estimated in 1993 that roughly one in every 15 Americans was affected by at least moderate sleep apnea7374 It also estimated that in middle-age as many as nine percent of women and 24 percent of men were affected, undiagnosed and untreated737475

The costs of untreated sleep apnea reach further than just health issues It is estimated that in the US the average untreated sleep apnea patient's annual health care costs $1,336 more than an individual without sleep apnea This may cause $34 billion/year in additional medical costs Whether medical cost savings occur with treatment of sleep apnea remains to be determined76

Prognosisedit

A 2012 study has shown that hypoxia an inadequate supply of oxygen that characterizes sleep apnea promotes angiogenesis which increase vascular and tumor growth, which in turn results in a 48 times higher incidence of cancer mortality777879

Historyedit

The clinical picture of this condition has long been recognized as a character trait, without an understanding of the disease process The term "Pickwickian syndrome" that is sometimes used for the syndrome was coined by the famous early 20th century physician, William Osler, who must have been a reader of Charles Dickens The description of Joe, "the fat boy" in Dickens's novel The Pickwick Papers, is an accurate clinical picture of an adult with obstructive sleep apnea syndrome80

The early reports of obstructive sleep apnea in the medical literature described individuals who were very severely affected, often presenting with severe hypoxemia, hypercapnia and congestive heart failure

The management of obstructive sleep apnea was improved with the introduction of continuous positive airway pressure CPAP, first described in 1981 by Colin Sullivan and associates in Sydney, Australia81 The first models were bulky and noisy, but the design was rapidly improved and by the late 1980s CPAP was widely adopted The availability of an effective treatment stimulated an aggressive search for affected individuals and led to the establishment of hundreds of specialized clinics dedicated to the diagnosis and treatment of sleep disorders Though many types of sleep problems are recognized, the vast majority of patients attending these centers have sleep-disordered breathing Sleep apnea awareness day is April 18 in recognition of Colin Sullivan82

See alsoedit

  • Obesity hypoventilation syndrome
  • Congenital central hypoventilation syndrome

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External linksedit

Classification
  • ICD-10: G473,P283
  • ICD-9-CM: 32723, 78057
  • MeSH: D012891
External resources
  • MedlinePlus: 000811
  • eMedicine: ped/2114


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