A little night relief

Sleep apnea is a prevalent and potentially life-threatening condition that is often undiagnosed.

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By  Joanne Bladd Published  June 12, 2006

|~|sleep2.jpg|~|“It’s the job of healthcare providers to determine whether it is just habitual snoring or a sign of sleep apnea.”|~|Sleep apnea is a prevalent and potentially life-threatening condition that is often undiagnosed. According to estimates, 2% of adult women and 4% of adult men between the ages of 30 and 60 have the sleep disorder but, because of the lack of awareness by the public and healthcare professionals, the majority remain undiagnosed and untreated, despite its potentially serious health effects. And because sleep apnea is linked to obesity and aging, the disorder is on the rise worldwide.
People with sleep apnea repeatedly stop breathing, or their breath gets shallow repeatedly during sleep – sometimes dozens of times an hour, for ten or more seconds each time.
Untreated, sleep apnea may be associated with serious consequences, including coronary artery disease, stroke, insulin resistance, memory problems, weight gain, impotency, and headaches. Many studies have also linked it with high blood pressure. Untreated, sleep apnea may also impair job performance and increase the risk of automobile accidents.
Fortunately, sleep apnea is easy to diagnose and several effective treatment options exist. These include fitting sufferers with a device that provides continuous positive airway pressure (CPAP), undertaking lifestyle changes, and many surgical options. Sadly, many patients with sleep apnea don’t get the treatment they need because they tend to minimise their symptoms (chiefly snoring, and daytime dysfunction). Dr Nicolas Busaba, an assistant professor in the department of Otology and Laryngology at Harvard Medical School, believes doctors should be alert to underlying causes of sleeping problems.
“Patients typically seek medical care because their spouse or partner wanted them to because they are snoring,” he explains. “But it is the job of healthcare providers to determine whether it is just habitual snoring or a sign of sleep apnea.”

Recognising the problem
There are three types of apnea: obstructive, central, and mixed. Of the three, obstructive is the most common. People at highest risk of obstructive sleep apnea are those who snore loudly, have high blood pressure, have relatively narrow airways in their nose, throat, or mouth, are overweight, over age 40, and who have a family history of sleep apnea. While more men than women have the condition, Busba says, sleep apnea can strike anyone at any age.
As a result, healthcare professionals should ask any patient who snores about other
symptoms. If a patient reports making choking or snorting sounds during sleep, stopping breathing during sleep, feeling tired even after a full night of sleep, morning headaches, dry throat upon awaking, daytime fatigue or somnolence, mood swings, depression, attention deficit disorder/hyperactivity disorder (in children), difficulty concentrating, memory problems, or falling asleep while driving, it is important to refer
them to a sleep lab or sleep specialist or otolaryngologist for a diagnosis.

Diagnosing sleep apnea
A diagnosis of sleep apnea begins with a detailed history and physical exam, in which a patient’s mouth, nose, and throat are examined for extra or large tissues; for example, tonsils, uvula, soft palate, deviated nasal septum, etc. If it is determined that a sleep study or specialist is needed, it is also important to educate the patient about sleep apnea so that he or she understands that it is a serious condition.
A sleep study (an overnight exam, usually performed in a sleep laboratory) relies on nocturnal polysomnography to record brain activity, eye movement, muscle activity, breathing and heart rate, airflow, and oxyhemoglobin desaturation. It yields an apnea/hypopnea index (AHI), also called a respiratory disturbance index (RDI), that reveals the number of apneas and hypopneas (abnormally slow breathing) per hour of sleep. Fewer than five disturbances is considered normal, 5-20 is mild sleep apnea, 20-40 is moderate and more than 40 is severe.
“In addition to the AHI, it is important to look at the severity of oxyhemoglobin desaturation (percentage of oxygen in the blood) and to be on the lookout for evidence of arrhythmia,” Busaba explains. “If the AHI is less than 15 and the lowest oxyhemoglobin desaturation is more than 87%, one may consider this as very mild sleep apnea or habitual snoring.”
In such cases, a patient may only require counseling on weight loss and good sleep hygiene (sleeping regular hours, sleeping on their side, sleeping at least seven to eight hours a night, and avoiding sedatives and alcohol at bedtime). Standard procedures to treat snoring are appropriate in such instances.
New practice parameters published in February by the American Academy of Sleep Medicine also recommend oral appliances as a first-line treatment for snoring and mild-moderate obstructive sleep apnea. There are many types of oral appliances, but most help maintain an open and unobstructed airway in the throat by repositioning or stabilizing the lower jaw, tongue, soft palate or uvula.
If the AHI is more than 15 and the oxyhemoglobin desaturation is below 87%, especially if a patient has symptoms of cardiovascular problems or daytime dysfunction, CPAP or surgery should be considered.

Treating moderate-to-severe sleep apnea
Treatment is aimed at restoring regular nighttime breathing and relieving symptoms. Treatment will also help associated medical problems, such as hypertension, and reduce the risk for cardiovascular events and stroke.
The most common treatment for sleep apnea is continuous positive airway pressure (CPAP), an electronic device that delivers air into the airway through a nasal mask that keeps the lungs open by mechanically stenting the airway. The air pressure is determined at the time of the polysomnography, so that it is just enough to stop the airways from briefly getting too small during sleep.
While CPAP has been shown to be effective when used correctly, Busba notes that
compliance can be an issue. “Studies have shown that only half of the patients are
compliant enough, that they use the device for five hours per night, five nights a week or more.” he explains.
Sleep apnea will return if CPAP is stopped or if it is not used correctly. Some people may experience side effects including dry or stuffy nose, skin irritation on the face, stomach bloating, sore eyes, and headaches.

Surgery
If CPAP is not appropriate, Busaba says, surgery may be an option. “Typically, we try CPAP first, unless a clinical examination shows significant airway obstruction which is fixable by surgery.”
Patients who report no subjective improvement with CPAP, who are not compliant with CPAP, or have complications that prevent them from using CPAP are appropriate candidates for surgery. Options include uvulopalatopharyngoplasty, a surgery that removes the uvula, and part of the soft palate, with or without tonsillectomy; surgery that addresses the base of the tongue; mandible or hyboid bone surgery, tracheostomy (used only in severe sleep apnea); and maxillary mandibular advancement. Currently, there are no medicines available for the treatment of sleep apnea.

Promising avenues of research
“The main problem with diagnosing sleep apnea today,” says Busaba, “is that there is no test available that can determine the exact location or level of airway obstruction causing the sleep apnea.” However, researchers are working to develop such a test. Others are investigating the effects of strengthening the control of the pharyngeal muscle dilators and some advances in surgical correction are being explored.
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