Sleep Apnea

Sleep apnea is a disorder in which breathing is disrupted during sleep. The brain will automatically restart the process, often without the subject's conscious awareness, but there is a physical toll. At minimum, sleep apnea results in daytime fatigue. At worst, it is associated with heart attack, high blood pressure, and stroke.

Definition

Sleep apnea is a serious, potentially life-threatening condition that is far more common than generally understood. First described in 1965, sleep apnea is a breathing disorder characterized by brief interruptions of breathing during sleep. It owes its name to the Greek word, apnea, meaning, "want of breath." There are two types of sleep apnea: central and obstructive. Central sleep apnea, which is less common, occurs when the brain fails to send the appropriate signals to the breathing muscles to initiate respiration.

Obstructive sleep apnea is far more common and occurs when air cannot flow into or out of the person's nose or mouth although efforts to breathe continue.

In a given night, the number of involuntary breathing pauses or "apneic events" may be as high as 20 to 30 or more per hour. These breathing pauses are almost always accompanied by snoring between apnea episodes, although not everyone who snores has this condition. Sleep apnea can also be characterized by choking sensations. The frequent interruptions of deep, restorative sleep often lead to early morning headaches and excessive daytime sleepiness.

In normal conditions, the muscles of the upper part of the throat keep this passage open to allow air to flow into the lungs. These muscles usually relax during sleep, but the passage remains open enough to permit the flow of air. Some individuals have a narrower passage, and during sleep, relaxation of these muscles causes the passage to close, and air cannot get into the lungs. Loud snoring and labored breathing occur. When complete blockage of the airway occurs, air cannot reach the lungs.

Early recognition and treatment of sleep apnea is important because it may be associated with irregular heartbeat, high blood pressure, heart attack, and stroke.

Sleep apnea occurs in all age groups and both sexes, but is more common in men (though it may be under-diagnosed in women) and possibly young African Americans. It has been estimated that as many as 18 million Americans have sleep apnea. Four percent of middle-aged men and 2 percent of middle-aged women have sleep apnea along with excessive daytime sleepiness. People most likely to have or develop sleep apnea include those who snore loudly and also are overweight, or have high blood pressure, or have some physical abnormality in the nose, throat, or other parts of the upper airway. Sleep apnea seems to run in some families, suggesting a possible genetic basis.

Symptoms

Often, the person who has obstructive sleep apnea does not remember the episodes of apnea during the night. The predominant symptoms are usually associated with excessive daytime sleepiness due to poor sleep during the night. Other symptoms include:

  • Loud snoring
  • Periods of not breathing (apnea)
  • Awakening not rested in the morning
  • Abnormal daytime sleepiness, including falling asleep at inappropriate times
  • Morning headaches
  • Weight gain
  • Limited attention
  • Memory loss
  • Poor judgment
  • Personality changes
  • Lethargy

Additional symptoms associated with this disease:

  • Leg Swelling (if apnea is severe)
  • Automatic behavior (performing actions by rote)
  • Hyperactive behavior, especially in children
  • High blood pressure

An estimated 18 million Americans have sleep apnea. However, few of them have had the problem diagnosed. Patients with the typical features of sleep apnea, such as loud snoring, obesity, and excessive daytime sleepiness should be referred to a specialized sleep center that can perform a test called polysomnography. This test records the patient's brain waves, heartbeat, and breathing during an entire night. If sleep apnea is diagnosed, several treatments are available. Mild sleep apnea frequently can be overcome through weight loss or by preventing the person from sleeping on his or her back. Other people may need special devices or surgery to correct the obstruction. People with sleep apnea should never take sedatives or sleeping pills, which can prevent them from awakening enough to breathe.

Causes

Certain mechanical and structural problems in the airway cause the interruptions in breathing during sleep. In some people, apnea occurs when the throat muscles and tongue relax during sleep and partially block the opening of the airway. When the muscles of the soft palate at the base of the tongue and the uvula (the small fleshy tissue hanging from the center of the back of the throat) relax and sag, the airway becomes blocked, making breathing labored and noisy and even stopping it altogether. Sleep apnea also can occur in obese people when an excess amount of tissue in the airway causes it to be narrowed. With a narrowed airway, the person continues his or her efforts to breathe, but air cannot easily flow into or out of the nose or mouth.

During the apneic event, the person is unable to breathe in oxygen and to exhale carbon dioxide, resulting in low levels of oxygen and increased levels of carbon dioxide in the blood. The reduction in oxygen and increase in carbon dioxide alert the brain to resume breathing and cause an arousal. With each arousal, a signal is sent from the brain to the upper airway muscles to open the airway; breathing is resumed, often with a loud snort or gasp. Frequent arousals, although necessary for breathing to restart, prevent the patient from getting enough restorative, deep sleep.

Because of the serious disturbances in their normal sleep patterns, people with sleep apnea often feel very sleepy during the day and their concentration and daytime performance suffer. The consequences of sleep apnea range from annoying to life threatening. They include depression, irritability, sexual dysfunction, learning and memory difficulties, and falling asleep while at work, on the phone, or driving. It has been estimated that up to 50 percent of sleep apnea patients have high blood pressure.

Risk for heart attack and stroke may also increase in those with sleep apnea. In addition, sleep apnea is sometimes implicated in sudden infant death syndrome.

For many sleep apnea patients, their spouses are the first to suspect that something is wrong, usually from their heavy snoring and apparent struggle to breathe. Coworkers or friends of the sleep apnea victim may notice that the individual falls asleep during the day at inappropriate times (such as while driving a car, working, or talking).

The patient often does not know he or she has a problem and may not believe it when told. It is important that the person see a doctor for evaluation of the sleep problem.

Diagnosis

In addition to the primary care physician, pulmonologists, neurologists, or other physicians with specialty training in sleep disorders may be involved in making a definitive diagnosis and initiating treatment. Diagnosis of sleep apnea is not simple because there can be many different reasons for disturbed sleep. Several tests are available for evaluating a person for sleep apnea. Diagnostic tests usually are performed in a sleep center, but new technology may allow some sleep studies to be conducted in the patient's home.

Polysomnography is a test that records a variety of body functions during sleep, such as the electrical activity of the brain, eye movement, muscle activity, heart rate, respiratory effort, airflow, and blood oxygen levels. These tests are used both to diagnose sleep apnea and to determine its severity.

The Multiple Sleep Latency Test (MSLT) measures the speed of falling asleep. In this test, patients are given several opportunities to fall asleep during the course of a day when they would normally be awake. For each opportunity, time to fall asleep is measured. People without sleep problems usually take an average of 10 to 20 minutes to fall asleep.

Individuals who fall asleep in less than 5 minutes are likely to require some treatment for sleep disorders. The MSLT may be useful to measure the degree of excessive daytime sleepiness and to rule out other types of sleep disorders.

Treatments

The objective of treatment is to keep the airway open to prevent apneic episodes during sleep. The specific therapy for sleep apnea is tailored to the individual patient based on medical history, physical examination, and the results of polysomnography. Medications are generally not effective. Oxygen administration may safely benefit certain patients but does not eliminate sleep apnea or prevent daytime sleepiness. Thus, the role of oxygen in the treatment of sleep apnea is controversial, and it is difficult to predict which patients will respond well. It is important that the effectiveness of the selected treatment be verified; this is usually accomplished by polysomnography.

For mild cases of obstructive sleep apnea, treatment often consists of using methods to avoid sleeping on one's back. For people with significant nasal congestion, a decongestant therapy may be prescribed. Patients with obstructive and central apnea should avoid central nervous system depressants such as alcoholic beverages, sedatives and narcotics. Weight loss and diet control are encouraged for overweight patients. Many serious cases of obstructive sleep apnea can be relieved by a treatment called nasal continuous positive airway pressure (nasal CPAP). Nasal CPAP uses a mask-like device and pump that work together to keep the airway open with air pressure during each inspiration. Surgery may benefit some patients by eliminating or reducing the narrowing of the airway due to anatomical defects.

Behavioral Therapy

Behavioral changes are an important part of the treatment program, and in mild cases behavioral therapy may be all that is needed. The individual should avoid the use of alcohol, tobacco, and sleeping pills, which make the airway more likely to collapse during sleep and prolong the apneic periods. Overweight persons can benefit from losing weight. Even a 10 percent weight loss can reduce the number of apneic events for most patients. In some patients with mild sleep apnea, breathing pauses occur only when they sleep on their backs. In such cases, using pillows and other devices that help them sleep in a side position is often helpful.

Physical or Mechanical Therapy Surgery

Some patients with sleep apnea may need surgery. Although several surgical procedures are used to increase the size of the airway, none of them is completely successful or without risks. More than one procedure may need to be tried before the patient realizes any benefits.

Some of the more common procedures include removal of adenoids and tonsils (especially in children), nasal polyps or other growths or tissue in the airway, and correction of structural deformities. Younger patients seem to benefit from these surgical procedures more than older patients.

Uvulopalatopharyngoplasty (UPPP) is a procedure used to remove excess tissue at the back of the throat (tonsils, uvula, and part of the soft palate). The success of this technique may range from 30 to 50 percent. The long-term side effects and benefits are not known, and it is difficult to predict which patients will do well with this procedure.

Laser-assisted uvulopalatoplasty (LAUP) is done to eliminate snoring but has not been shown to be effective in treating sleep apnea. This procedure involves using a laser device to eliminate tissue in the back of the throat. Like UPPP, LAUP may decrease or eliminate snoring but not sleep apnea itself. Elimination of snoring, the primary symptom of sleep apnea, without influencing the condition may carry the risk of delaying the diagnosis and possible treatment of sleep apnea in patients who elect LAUP. To identify possible underlying sleep apnea, sleep studies are usually required before LAUP is performed.

Tracheostomy is used in persons with severe, life-threatening sleep apnea. In this procedure, a small hole is made in the windpipe and a tube is inserted into the opening. This tube stays closed during waking hours, and the person breathes and speaks normally. It is opened for sleep so that air flows directly into the lungs, bypassing any upper airway obstruction. Although this procedure is highly effective, it is an extreme measure that is poorly tolerated by patients and rarely used.

Patients with deformities of the lower jaw may benefit from surgical reconstruction. Finally, surgical procedures to treat obesity are sometimes recommended for sleep apnea patients who are morbidly obese.

What is the prognosis?

Eliminating the obstruction usually reverses the commonly associated pulmonary and systemic hypertension and cardiac problems of obstructive apnea. Untreated, sleep apnea can greatly affect daytime functioning. Sleep apnea sufferers have a tendency to fall asleep during the day, a potentially deadly consequence of the disorder.

What research is being done?

Sleep apnea is currently one of the most active areas of sleep research. The National Institute of Neurological Disorders and Stroke has notified investigators that it is seeking grant applications in both clinical and basic sleep and wakefulness research, including neurological causes and consequences of sleep apnea. Research on sleep apnea is also funded by the National Heart, Lung, and Blood Institute and the National Institute on Aging.

Sources

  • American Psychiatric Association—Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised
  • National Heart, Lung, and Blood Institute, National Institutes of Health
  • National Institute of Neurological Disorders and Stroke, National Institutes of Health
  • National Sleep Foundation
  • National Institutes of Health—National Library of Medicine
Last reviewed 02/17/2015