Sleep Apnea and its Treatment

1. What issleepapnea?
Sleepapneaisa serioussleepdisorderthatoccurswhena person’sbreathingisinterruptedduring
sleep.People withuntreatedsleepapneastopbreathingrepeatedlyduringtheirsleep,sometimes
hundredsof timesduringthe night.
There are twotypesof sleepapnea:obstructive andcentral.Obstructive sleepapneaisthe more
commonof the two.Obstructive sleepapneaoccursas repetitive episodesof complete orpartial
upperairwayblockage duringsleep.Duringanapneaepisode,the diaphragmandchestmuscles
workharder as the pressure increasestoopenthe airway.Breathingusuallyresumeswithaloud
gasp or bodyjerk.These episodescaninterfere withsoundsleep,reduce the flow of oxygentovital
organs,and cause heart rhythmirregularities.
In central sleepapnea,the airwayisnotblockedbutthe brainfailstosignal the musclestobreathe
due to instabilityinthe respiratorycontrol center.Centralapneaisnamedassuch because itis
relatedtothe functionof the central nervoussystem.
A
B
Who getssleepapnea?
Sleepapneaoccursinabout 25 percentof menand nearly10 percentof women.Sleepapneacan
affectpeople of all ages,includingbabiesandchildrenandparticularlypeople overthe age of forty
and those whoare overweight.Certainphysical traitsandclinical featuresare commoninpatients
withobstructive sleepapnea.These includeexcessiveweight,large neck,andstructural
abnormalitiesreducingthe diameterof the upperairway,suchas nasal obstruction,alow-hanging
softpalate,enlargedtonsils,orasmall jaw withan overbite.The figuresbelow illustrate the upper
airwayinnormal sleep(A;personislyingonback,face up) andin obstructive sleepapnea(B).The
arrows indicate complete obstructioninthe backof the throat.
What causessleepapnea?

2. Obstructive sleepapneaiscausedbya blockage of the airway,usuallywhenthe softtissue inthe
rear of the throatcollapsesduringsleep.Central sleepapneaisusuallyobservedinpatientswith
central nervoussystemdysfunction,suchasfollowingastroke orinpatientswithneuromuscular
diseaseslikeamyotrophiclateral sclerosis.Itisalsocommoninpatientswithheartfailure andother
formsof cardiac andpulmonarydisease.
What are the symptomsof sleepapnea?
Oftenthe firstsignsof OSA are recognizednotbythe patient,butbythe bedpartner.Many of those
affectedhave nosleepcomplaints.The mostcommonsymptomsof OSA include:
Snoring
Daytime sleepinessorfatigue
Restlessness duringsleep
Suddenawakeningswithasensationof gaspingorchoking
Dry mouthor sore throatupon awakening
Intellectual impairment,suchastrouble concentrating,forgetfulness,orirritability
Nightsweats
Sexual dysfunction
Headaches
People with central sleepapneamore oftenreportrecurrentawakeningsorinsomnia,althoughmay
alsoexperience achokingorgaspingsensationuponawakening.
Symptomsinchildrenmaynotbe as obviousandinclude:
Poorschool performance
Sluggishnessorsleepiness,oftenmisinterpretedaslazinessinthe classroom
Daytime mouthbreathingandswallowingdifficulty
Inwardmovementof the ribcage wheninhaling
Unusual sleepingpositions,suchassleepingonthe handsandknees,orwiththe neckhyper-
extended

3. Excessive sweatingatnight
Learningandbehavioral disorders
Bedwetting
What are the effectsof sleepapnea?
If leftuntreated,sleepapneacanresultina numberof healthproblemsincludinghypertension,
stroke,arrhythmias,cardiomyopathy(enlargementof the muscle tissueof the heart),congestive
heartfailure,diabetes,andheartattacks.Inaddition,untreatedsleepapneamaybe responsible for
jobimpairment,work-relatedaccidents,andmotorvehiclecrashesaswell asacademic
underachievementinchildren andadolescents.
How issleepapneadiagnosed?
The diagnosisof sleepapneaisrelativelystraightforward,basedonsleephistoryandanovernight
sleepstudycalledapolysomnogram.Polysomnographyisperformedinasleeplaboratoryunderthe
directsupervisionof atrainedtechnologist.Duringthe test,avarietyof bodyfunctions,suchasthe
electrical activityof the brain,eye movements,muscleactivity,heartrate,breathingpatterns,air
flow,andbloodoxygenlevelsare recordedatnightduringsleep.Afterthe studyiscompleted,the
numberof timesbreathingisimpairedduringsleepistalliedandthe severityof sleepapneais
graded.In some cases,a multiplesleeplatencytestisperformedonthe dayafterthe overnighttest
to measure the speedof fallingasleep.Inthistest,patientsare givenseveralopportunitiestofall
asleepduringthe course of a day whentheynormallywouldbe awake.If youhave symptomsof
sleepapnea,yourdoctormayask you to have a sleepevaluationinasleepdisordercenter.
What are the treatmentsforsleepapnea?
Conservative treatments—Inmildcasesof sleepapnea,conservative therapymaybe all thatis
needed.Overweightpersonscanbenefitfromlosingweight.Evena10 percentweightlosscan
reduce the numberof apneiceventsformostpatients.Individualswithapneashouldavoidthe use
of alcohol andsleepingpills,whichmake the airwaymore likelytocollapse duringsleepandprolong
the apneicperiods.Insome patientswithmildsleepapnea,breathing pausesoccuronlywhenthey
sleepontheirbacks.Insuch cases,usingpillowsandotherdevicesthathelpthemsleepinaside
positionmaybe helpful.People withsinusproblemsornasal congestion(suchpeopleare more likely
to experience sleepapnea) shoulduse nasal spraysorbreathingstripstoreduce snoringand
improve airflow formore comfortablenighttime breathing.Avoidingsleepdeprivationisimportant
for all patientswithsleepdisorders.
Mechanical therapy—Continuouspositive airwaypressure (CPAP) isthe preferredinitialtreatment
for mostpeople withobstructive sleepapnea.WithCPAP,patientswearamaskover theirnose
and/ormouth.An airblowerforcesairthroughthe nose and/ormouth.The air pressure isadjusted

4. so that itis justenoughtopreventthe upperairwaytissuesfromcollapsingduringsleep.The
pressure isconstantand continuous.CPAPpreventsairwayclosure while inuse,butapneaepisodes
returnwhenCPAPisstoppedorit isusedimproperly.Otherstylesandtypesof positive airway
pressure devicesare available forpeople whohave difficultytoleratingCPAP.
Mandibularadvancementdevices—Forpatientswithmildsleepapnea,dental appliancesororal
mandibularadvancementdevicesthatpreventthe tongue fromblockingthe throatand/oradvance
the lowerjawforwardcan be made.These deviceshelpkeepthe airwayopenduringsleep.A sleep
specialistandprosthodontist(withexpertise inoral appliancesforthispurpose) shouldjointly
determine if thistreatmentis bestforyou.
Surgery—Surgical proceduresmayhelppeople withsleepapnea.There are manytypesof surgical
procedures,some of whichare performedasoutpatientprocedures.Surgeryisreservedforpeople
whohave excessiveormalformedtissueobstructingairflow throughthe nose orthroat,suchas a
deviatednasal septum, markedlyenlargedtonsils,orsmall lowerjaw withanoverbite thatcauses
the throat to be abnormallynarrow.These proceduresare typicallyperformedaftersleepapneahas
failedtorespondtoconservative measuresandatrial of CPAP.Typesof surgeryinclude:
Somnoplasty—A minimallyinvasive procedure thatusesradiofrequencyenergytoreduce the soft
tissue inthe upperairway.
Uvulopalatopharyngoplasty(UPPP)—A procedurethatremovessofttissueonthe backof the throat
and palate,increasingthe widthof the airwayatthe throat opening.
Mandibular/maxillaryadvancementsurgery—Asurgical correctionof certainfacial abnormalitiesor
throat obstructionsthatcontribute tosleepapnea.Thisisaninvasive procedure thatisreservedfor
patientswithsevere sleepapneawithhead-face abnormalities.
Nasal surgery—Correctionof nasal obstructions,suchasa deviatedseptum.