Sleep Apnea

Sleep apnea is a sleep disorder.  A sleep disorder (somnipathy) is any disruption in your sleep pattern that interferes with your normal physical, mental, social and emotional functioning.

According to the National Heart, Lung, and Blood Institute (NHLBI), sleep apnea occurs when the upper airway becomes blocked repeatedly during sleep, reducing or completely stopping airflow.  This is known as obstructive sleep apnea (OSA). If the brain does not send the signals needed to breathe, the condition may be called central sleep apnea.

There are several causes of sleep apnea.  Some people get it because of their physical structure and others get it due to a medical condition, such as obesity, large tonsils, endocrine disorders (e.g., hypothyroidism), neuromuscular disorders, heart or kidney failure, certain genetic syndromes (e.g., cleft lip or cleft palate), and premature birth.

There are many risk factors for sleep apnea, including

• Aging
  • Fatty tissue buildup in the neck and tongue
• Unhealthy lifestyle habits
  • Alcohol
  • Smoking
  • Unhealthy eating and lack of physical activity
• Family history and genetics
  • Inherited
  • Structural development of the face and skull
• Race or ethnicity
  • More common among blacks, Hispanics and Native Americans

Some of the most common signs of sleep apnea include:

• Reduced or absent breathing (apnea events)
• Frequent loud snoring
• Gasping for air during sleep

Some of the most common symptoms associated with sleep apnea include:

• Excessive daytime sleepiness and fatigue
• Decrease in attention, vigilance, concentration, motor skills, and verbal and visuospatial memory
• Dry mouth or headaches when waking
• Sexual dysfunction or decreased libido
• Waking up often during the night to urinate

Women tend to have more issues with headaches, fatigue, depression, anxiety, insomnia and sleep disruption.

Yes, symptoms of sleep apnea are different for children as compared to adults.  Children may experience:

• Bedwetting
• Asthma exacerbations
• Hyperactivity
• Learning and academic performance issues

Children are also more at risk for sleep apnea if they have enlarged tonsils and adenoids.

If sleep apnea isn’t treated, it may increase your risk for the following disorders:

• Asthma
• Atrial fibrillation
• Cancers (pancreatic, renal, and skin)
• Chronic kidney disease
• Cognitive and behavioral disorders
• Diseases of the heart and blood vessels
• Eye disorders (glaucoma, dry eye)
• Metabolic disorders (glucose intolerance, type 2 diabetes)
• Pregnancy complications (gestational diabetes, gestational high blood pressure)

Sleep apnea can also cause your body to be in a chronic state of inflammation. This happens because your blood oxygen levels drop due to OSA, so your body and brain trigger the fight or flight response. This, in turn, increases your blood pressure and heart rate and wakes you from sleep so that your upper airway can open. During sleep, these cycles of decreased and increased blood oxygen levels can cause inflammation that may contribute to the buildup of plaque in blood vessels (atherosclerosis), which can increase your risk of heart attack or stroke. Chronic inflammation can also damage the pancreas and lead to type 2 diabetes.

Your doctor may diagnose sleep apnea based on your medical history, a physical exam, and sleep study results. Your medical history review will include questions about the signs and symptoms of sleep apnea you may be experiencing; whether you have a family history for sleep apnea or another sleep disorder; whether you have risk factors for sleep apnea; and whether you have experienced any complications from untreated or undiagnosed sleep apnea.

Your physical exam will involve your doctor looking for signs of other conditions that increase your risk for sleep apnea, including obesity, large tonsils, narrowing of the upper airway, or a large neck circumference (>17” for men or >16” for women is considered large).  Additionally, your doctor may look at your jaw size and structure, the size of your tongue, and your tongue’s position in your mouth, as well as your lungs, heart and neurological systems to see whether you have developed any complications of sleep apnea.

Your sleep study can be done at home or at a sleep center.  The study records the number of episodes of “slowed or stopped breathing,” and the number of central sleep apnea events detected in an hour.  The study also monitors blood oxygen levels and brain and heart activity during sleep. Results of your sleep study can tell your doctor if you have mild, moderate, or severe sleep apnea based on the number of sleep apnea events you have within an hour. They can also help determine the type of sleep apnea you have, obstructive versus central sleep apnea.

If you have obstructive sleep apnea (OSA), your sleep test results will show an increase in breathing muscle activity when muscles try to open an obstructed upper airway.  If you have central sleep apnea, sleep study results show decreased activity in chest muscles, which can lead to periods of slowed or no breathing. OSA is more common than central sleep apnea.

Not everyone who snores has sleep apnea.  But anyone who snores loudly, nightly and has other symptoms, like pauses in breathing at night or daytime sleepiness, should talk to a doctor to rule out sleep apnea.

Based on the information gathered during your consultation, your doctor may order the following additional tests to rule out other medical conditions that can cause sleep apnea:

• Blood tests
  • Check levels of certain hormones (e.g., thyroid, growth, DHEAS)
  • Rule out hypothyroidism, acromegaly, and polycystic ovary syndrome (PCOS)
• Pelvic Ultrasound
  • Examine ovaries and detect cysts
  • Rule out PCOS

Patients with OSA have a variety of treatment options available to them to help them manage their condition. Your doctor will recommend the best option that helps you maintain an open airway during sleep. Usually, these recommendations depend on the type and severity of your sleep apnea.

Mild cases of sleep apnea can be medically managed, and may include one or more of the following recommendations:

Healthy Lifestyle Changes

• Eat a heart-healthy diet
• Limit alcohol intake
• Aim for a healthy weight
• Get regular physical exercise
• Develop healthy sleeping habits
• Quit smoking

Sleep Positioning Pillows

• Anti-snoring pillows
• Support side sleep
• Supports the position of the head for optimal airflow

Mouthpieces/Oral Appliances

• Worn while you sleep
  • Custom fit device
  • Mandibular repositioning mouthpiece
  • Tongue retaining device
• Molded to an individual patient’s anatomy
• Designed to keep the lower jaw in the forward position
• Help to mitigate the backward compression of the tongue base on the oral airway
• Visit a dentist or orthodontist for fittings

Continuous Positive Airway Pressure Device (CPAP)

• Sleep with a mask that opens the airway with forced air
• Resist the collapse associated with OSA
• Use facial pillows to wear with masks for added comfort

If you have severe OSA that does not respond to medical management or your OSA is due to a visible obstruction to the upper airway, you may need surgery.

Fortunately, there are several possible surgical procedures that could be done to help you with your OSA, some of which include:

Pillar Procedure

• Minimally, invasive, FDA-approved treatment for mild to severe OS
• Performed in an office setting under local anesthesia
• Minimal post-procedure discomfort or downtime
• Involves the placement of small implants into the soft palate to create stiffening and to minimize the soft tissue collapse associated with obstruction.

Tonsillectomy

• Tonsil are organs located at the back of the throat
• Enlarged tonsils lead to obstruction of the oral airway
• More common in children than in adults
• Involves surgical resection of enlarged tonsils

Uvulectomy

• The uvula is the “punching bag” in the back of the throat
• Enlarged or elongated uvula may contribute to OSA
• Involves surgical resection of the uvula
• Usually done in conjunction with other procedures, like the Pillar Procedure or Tonsillectomy

Inspire Treatment

• FDA-cleared treatment for moderate to severe OSA
• Performed as an outpatient procedure under general anesthesia
• Involves placement of an implantable, neurostimulation device
• Placed under the skin of the neck and chest through three small incisions
• Delivers mild stimulation to key upper airway muscles
• Keeps the airway open when patients sleep

Ultimately, effective treatment of OSA depends on proper diagnosis and location of the anatomic source of the problem.

If you think you have signs and symptoms of sleep apnea, please contact CT Sinus Center at (203) 574-5997 for evaluation, diagnosis, and treatment recommendation.