Obstructive Sleep Apnea

Obstructive sleep apnea is regarded as one of the most serious sleep disorders. There are several types of sleep apnea, but the most common is obstructive sleep apnea. It can cause a person to stop breathing repeatedly during the night due to the throat muscles continuously relaxing and blocking the airway. The most common sign of obstructive sleep apnea is snoring.

Thankfully there are all kinds of treatments for obstructive sleep apnea (OSA). For example, a device using positive pressure can keep the airway open while the sufferer sleeps. Another example is using a mouthpiece that will push the lower jaw forward while a person sleeps. Surgery may be a necessity in extreme cases. 

Symptoms of obstructive sleep apnea

The problem with most of these symptoms is that you’re not likely to recognize them as easily. Your partner is likely to make you aware of them. What are some of the many symptoms?

• Problems getting up in the morning
• waking up and gasping for breath (feels like an asthma attack or being choked)
• snoring
• problems with sex
• restlessness during sleep
• irritability/grouchiness
• night sweats
• depression
• forgetfulness
• inability to focus or concentrate
• morning headaches
• sore throat or dry mouth upon waking up
• fatigue or daytime sleepiness.

The symptoms are not so evident in children, but may include the following: 

• odd sleeping positions
• pauses in breathing
• restlessness in bed
• grinding the teeth
• snoring
• sleepiness (often confused with laziness) at school
• school related problems
• behavioral or learning disorders
• night sweats
• drooling
• choking
• bedwetting.

If you or someone you love has any of the symptoms, it’s imperative to talk to a doctor to learn if they are associated with OSA and get treatment right away.

Why does obstructive sleep apnea occur?

Obstructive sleep apnea happens when the throat muscles relax too much to allow normal breathing. The muscles at the back of the throat support the soft palate, uvula, tongue, and tonsils.  

When these muscles relax, it causes the airway to narrow or close as you breathe. This can lead to inadequate breathing for 10 or more seconds. This causes oxygen levels in the blood to drop and carbon dioxide to rise. When the brain detects impaired breathing, it briefly wakes you up so that the airway can open. This awakening is usually so brief that you won’t remember it.  

You may wake up to gasping for air, choking, or snorting to restart breathing. The pattern can happen five to 30 times an hour all night long. And this can keep you from reaching the deep stages of sleep that your body needs in order to feel rested.

People who have OSA are often not aware that they have this sleep disruption. Many people think they’re getting a good night’s rest. 

Who is at risk of OSA?

Obstructive sleep apnea can affect anybody at any time. There are factors that can increase your risk of developing it, including:

Asthma – many researches show that having asthma also increases one’s chance of suffering from obstructive sleep apnea. 

Family history – if a family member suffers from OSA, other family members may be at increased risk. 

Gender – men are twice as likely to suffer from OSA as premenopausal women. However, women who have gone through menopause run a higher risk of OSA. 

Diabetes 

Smoking 

Chronic nasal congestion – people who suffer from chronic nighttime nasal congestion are twice as likely to suffer from OSA. The thought is that narrowed airways are the cause. 

Hypertension – high blood pressure (especially untreated) can lead to OSA. 

Narrow airway – genetics can play a part in OSA. If someone in your family has narrow airways, you may inherit them. If your adenoids or tonsils are too large, they can block your airway. 

Excessive weight – the majority of people with OSA are overweight or obese. Breathing is often obstructed by the fat deposits located around the upper airway. Medical conditions tied to obesity – hypothyroidism and polycystic ovary syndrome – can also lead to OSA. Does this mean that everybody who is overweight will have OSA? Not at all! Even thin people can suffer from the disorder. 

The complications of obstructive sleep apnea

It’s important to understand that obstructive sleep apnea is a very serious medical problem. What are some of the common complications associated with this condition?

Relationship problems

Bed partners are often sufferers of OSA as well, but only because of the loud snoring that emanates from their partners. It can keep them from getting a good rest and lead to problems in the relationship. They may find themselves sleeping in another room to get good sleep. 

Eye problems

According to various research there is a link between OSA and some eye conditions (e.g. glaucoma). However, some of these problems can be alleviated with treatment. 

Surgical and medication complications

Obstructive sleep apnea is also concerning for people who take certain medications or need to have surgery with general anesthetics. That’s because some medications, such as general anesthetics, narcotic analgesics, and sedatives, will relax the upper airway. This could make the OSA worse. After a major surgery you could experience even worse breathing problems and complications.

Tell your doctor before surgery that you suffer from OSA or have OSA-related symptoms. S/he may test you for it before the surgery takes place. 

Cardiovascular problems

When your blood isn’t getting enough oxygen, it can increase your blood pressure and put a strain on the body’s cardiovascular system. It’s not uncommon for OSA sufferers to be diagnosed with hypertension (high blood pressure). This also increases the chance of heart disease. 

The more serious the OSA, the higher the chance of suffering from coronary artery disease, heart failure, heart attacks, and strokes. 

OSA is also responsible for causing abnormal heart rhythms (also called arrhythmias), which can lead to lower blood pressure. If you have undiagnosed and untreated heart disease, these repeated multiple episodes of arrhythmias can raise the risk of sudden death. 

Daytime fatigue and sleepiness 

While you may not realize that you’re constantly waking up during the night from the OSA, it’s causing the body not to get the normal restorative sleep it needs to feel rejuvenated for the next day. If this happens, you may feel very sleepy the next day. You’ll be grouchy, and even little things may get on your nerves. 

You may have problems keeping focus on tasks. You may fall asleep watching TV or driving. It also increases your risk of having accidents at work. 

Children and adolescents who suffer from OSA may do poorly at school or be thought to have behavioral or attention problems. 

When it’s time to see a doctor 

It’s important to talk to a doctor if you or your partner notice any of the following issues:

• Snoring so loudly that it’s bothersome to you and the other members of your household
• gasping or choking for breath while sleeping, causing you to wake up
• recurrent pauses in your breathing in sleep
• being extremely tired and lethargic in the day, which can cause you to fall asleep while you’re driving, working, etc. 

Most people don’t see snoring as an issue, and not everybody who has OSA will snore. Always talk to a doctor about your snoring that interrupts the silence of the night. People who have OSA may snore louder when they sleep on their back and quieten down when sleeping on their side. 

If you’re constantly feeling tired and irritable, it’s time to see a doctor. If OSA is not the cause, the doctor can learn if you have another sleep disorder, such as narcolepsy. 

How is obstructive sleep apnea diagnosed?

The first thing the doctor will do is take a thorough history and do a physical exam. The first significant clues of OSA are snoring and the history of excessive daytime sleepiness. The doctor will examine your neck and head to see if there is anything physically wrong that can account for the sleep apnea. You will be asked to fill out a questionnaire about your sleeping habits, sleep quality, daytime drowsiness, etc. On top of that your doctor may conduct a series of tests such as:

Polysomnogram

If your doctor suggests a polysomnogram, it often means an overnight stay in a sleep study center or hospital. The test will be done through the night. While you sleep, the polysomnogram measures the activity of various bodily organs that are tied to sleep. The devices you’ll be hooked up to include:

• Arterial blood gas analysis (ABG)
• Pulse oximetry test – measures the changes in blood oxygen levels
• Electrocardiogram (EKG or ECG) – measures the heart rate and rhythm 
• Electromyogram (EMG) – measures muscle activity
• Electro-oculogram (EOM) – measures eye movements
• Electroencephalogram (EEG) – measures brainwaves.

Arterial Blood Gas (ABG)

For this study the doctor will draw arterial blood to measure the following:

• bicarbonate levels
• partial pressure of carbon dioxide
• partial pressure of oxygen
• oxygen saturation
• oxygen content.

With this test the doctor will get a clearer idea of the amount of carbon dioxide, oxygen, and the acid-base balance of your blood. This will also help him to know if your blood needs more oxygen. 

Pulse oximetry 

A pulse oximeter will be attached to a thin area of the body that has good blood flow (earlobe or fingertip). It uses red and infrared LEDs to gauge how much oxygen is in the blood. Oxygen levels will decrease during episodes of sleep apnea. A normal oxygen saturation level is between 95 and 100 percent. The doctor will interpret your results.

EKG measurement 

The 12-lead EKG will help the doctor find out if you have heart disease. If you have persistent high blood pressure, it can show up on the EKG. By monitoring and recording the heart rhythm and rate doctors can find out if there are cardiac issues while you suffer from sleep apnea. 

EMG measurement

Two electrodes will be put on your chin – one under and the other above the jawline. Two electrodes will also be placed on each shin. These electrodes will measure the activity in muscle movements. Since deep muscle relaxation is supposed to occur while you sleep, the EMG will note when your muscles move and relax while sleeping.

EOM and EEG measurements

For the EEG electrodes will be placed on your scalp, monitoring the brain waves before, during, and after your sleep. The EOM will keep track of your eye movements. Two tiny electrodes are placed one centimeter under the outer corners of both eyes. Movement is recorded when the eyes move from the center. 

These movements and waves give doctors some idea of the timing of each sleep phase – REM and nonREM (rapid eye movement). In the REM sleep phase you dream and have decreased muscle movement and tone. 

What treatments are suggested for OSA?

OSA treatments can range from lifestyle changes to surgery. Since OSA is a lifetime condition, lifelong treatments are necessary. 

Soft palate implants 

Soft palate implants are designed to stiffen the soft palate so that it doesn’t vibrate and cause an obstruction. The implants are placed in the soft palate while you’re under local anesthetic.  

The National Institute for Health and Care Excellence has deemed them safe, but there is little evidence of their effectiveness. However, they’re often advised where snoring has been tied to OSA.

OSA surgery 

Surgery for obstructive sleep apnea is considered the last resort and usually not as effective as the CPAP in treating and controlling the symptoms. There are also more risks associated with it. It’s only done when all other treatment options have failed and your quality of life is severely impacted. 

What are some surgical options to treat obstructive sleep apnea?

Uvulopalatopharyngoplasty – This is a very rare (and once popular) surgery where doctors remove the extra throat tissue to widen the airway.

Bariatric surgery – if you have been unable to lose weight, the doctor may perform a stomach reduction surgery to help you lose the weight and improve your sleep apnea. 

Tracheostomy – this is when a tube is placed into the neck for easier breathing even if you have blocked airways. 

Adenoidectomy – this is when the small lumps of tissue at the back of your throat (known as adenoids) are huge and blocking the flow of air while you sleep. 

Tonsillectomy – the doctor will remove the tonsils if they are too big and block the airway while you sleep.

Again, surgery is usually the last resort since the CPAP and other methods are considered far more effective in treating OSA symptoms. In some cases the use of a CPAP device is impossible after certain types of surgery. 

Mandibular Advancement Device (MAD) 

This device is not advised for severe cases, but can be useful if you cannot tolerate a CPAP device. The MAD device is a dental appliance – similar to the gum shield – that can be used in mild cases of OSA.

The MAD device is worn over the teeth while you sleep. It’s created to hold the jaw and tongue forward, increasing the space at the back of the throat and decreasing the chance of the airway narrowing that leads to snoring. 

When is a MAD device not advised?

• In severe cases of OSA
• bridgework
• crowns
• dental caps
• few or no teeth.

If you have any of the above, talk to a dentist before you this treatment of OSA. 

Have the MAD device fitted for you by a trained dentist who has experience treating sleep apnea. It’s possible that your insurance will pay for this, but in many cases you will need to pay out of your pocket. 

While you can purchase over-the-counter MAD devices on specialty websites, experts advise against them. A poorly fitting MAD device will worsen the symptoms. 

Continuous Positive Airway Pressure (CPAP)

CPAP devices are considered the most effective therapy for severe OSA cases. A CPAP device is a small pump that will provide constant compressed air supply via a mask covering the nose and mouth or only the nose. The compressed air keeps the airway open. 

The CPAP device can help reduce the symptoms of both tiredness and snoring while also decreases the risk of OSA complications (high blood pressure, strokes, etc.). 

There are side effects that can come with using the CPAP device:

• Headaches
• flatulence and stomachache
• pain in the ears
• problems with breathing through the nose
• nasal congestion, irritation, runny nose, etc. 
• discomfort from the mask.

When the CPAP device was first introduced, people often suffered from nasal and throat dryness. Today’s versions are much better, often equipped with a humidifier to address those issues. 

Many novice CPAP users may not feel comfortable with the device, but once used to it, they usually see an improvement to their symptoms. If the CPAP device you are using causes your problems, talk to your doctor or the treatment staff. It may be that a modification is needed. For instance, you could need a CPAP device that will start with a low amount of pressure and gradually increase the air supply as you sleep. 

Changes to your lifestyle

The first thing your doctor may suggest is making some lifestyle changes, such as losing weight if you are overweight or obese. S/he may suggest that you stop smoking or limit how much alcohol you consume, especially before bedtime. Your doctor may advise you against using sleeping tablets or sedatives to help you sleep. 

Researches and studies have shown that limiting alcohol, quitting smoking, and reducing weight can all help in alleviating the symptoms of OSA. Doctors are unsure of why quitting smoking can help with OSA, but even if it’s not suggested, it’s best if you do it for general health anyway. 

Another pragmatic way to alleviate symptoms of OSA is to sleep on your side instead of your back.

What to keep in mind about OSA…

If you or someone you love has OSA, it’s imperative to see a doctor. If you have any of the symptoms – daytime lethargy, sleeping problems, concentration issues, etc. – talk to the doctor about OSA and see what treatment options will be useful for you. There are many treatment options that can make living with the condition better and manage the symptoms. Your doctor will come up with a treatment plan that could include both therapy and changes to your lifestyle.